General prevention of injuries in sports

Top-level, primarily professional athletes, most of whom had one or more injuries, which my colleagues and I treated, or the athletes themselves managed to intervene to reduce symptoms before the competition. Since then, I’ve repeated it many times, more as a tasteless joke or merely as an observation of what happens in the environment of an average sports physiotherapist or any sports worker.

Intense or professional sports activity inherently aims to push individual physical capabilities to their limits or beyond. This very fact places the athlete’s body at risk of injuries. And they happen. Then we treat them. We return the athlete to training. Then we treat the same or another injury. And so it goes on endlessly.

Among these injuries, there are those that cannot be prevented, or at least not entirely (traumas), and those whose prevention should be the most important part of sports physiotherapy (overuse syndromes). To quote an excellent and passionate sports doctor I had the opportunity to work closely with: “Every injury of an athlete is a defeat of our profession.”

The entire field of injury prevention in sports today is very broad, encompassing a large number of subspecialties in medicine and sports science in a broader sense, and is an industry worth billions of euros. At the same time, this same field is a domain where half-information reigns, unscientific approaches, alternative medicine, bombastic promises, enforcement of “protocols” of prevention that are supposed to work for all athletes, even though they are very different in every respect, simple advice aiming to solve complex problems, supplements that promise what isn’t possible even in fairy tales, recovery systems promoted by famous athletes and coaches, without scientific basis or understanding of their effects, and much more that doesn’t fit into this small text.

At its core, injury prevention is simple. Its task is to prevent the athlete from developing cumulative damage to their movement system that will result in an injury. The dominant lever of this endeavor is the manipulation of training load and rest. Proper nutrition and sufficient hydration are prerequisites here.

All other procedures from today’s vast universe of preventive and “preventive” measures and actions are merely additions that can increase the success of prevention by a percentage point or two but cannot achieve almost anything on their own. That’s the truth, no matter what you find on the internet, social media, or other parts of this electronically connected World, where, as usual (just like in real life), the loudest are those who know the least. By offering you simple solutions to complex problems, they play on the ancient evolutionary card in all of us, which is that one problem must have one, preferably simple, solution, and even better if it can be applied to everyone in need. If the procedure or method is expensive, then its “aura” of effectiveness becomes even more intense.

In this cacophony of information, half-information, and often complete misinformation, even someone like me, with broad experience and knowledge, struggles to navigate. I can only imagine what it’s like for athletes, their parents, coaches, and even less experienced physiotherapists or doctors. When you add to this the understanding that the world of professional sports is a big business, and the need for profit by every actor involved is a fact, the image of the jungle becomes denser.

Yet, the simple fact is that the most effective methods of injury prevention are cheap or free and easily applicable with some cooperation within the sports medical team, which should consist of the coach, strength and conditioning coach, physiotherapist, and doctor.

Not diminishing the significance of the progress in my profession over the past decades, and consequently a deeper understanding of physiological and pathological processes, alongside the development of new technologies and diagnostic and treatment methods, I feel the need to tell a little story about injury prevention from the distant 1990s, which, I think, illustrates everything written so far quite well.

It was the winter of ’96 when, as a young and relatively inexperienced physiotherapist, I was working multiple jobs, one of which was as a therapist in a local basketball club. At that time, the coach of a women’s volleyball club, training in the same hall, approached me and asked for help because they were facing a serious problem with injuries.

At midseason, out of a total of 8 players on the starting lineup, 6 were injured to the extent that they couldn’t even train, let alone participate in matches. This was before the libero position was introduced. I agreed. The work was intense. The results were good, and the girls finished as runners-up in the Croatian championship and cup.

Shortly after the end of the competitive season, I was invited for a meeting with the coach and the club president, where they offered me a position to continue working with them. I said I would, but on one condition. What condition? When I say the training is over, the training is over!

The coach, otherwise a kind man with a heart bigger than himself, turned pale and barely managed to contain his reaction, saying that he couldn’t accept that because training and everything happening during it was under his exclusive authority.

Very calmly, I explained that in the previous months, I had witnessed situations where almost all the injuries occurred during training, never during matches, and always at the very end of the session when the intensity spiked suddenly as the players grew more fatigued. This imbalance between the coach’s demands and the players’ capabilities created injuries that we treated for days, sometimes weeks. Without this change, my role in the club would be almost meaningless.

After a brief consideration (and a healthier shift in facial color), the coach, who later became a good friend, agreed to the condition. I’m certain he only agreed because he thought I’d never actually use this authority to end training.

During the third training session of the new season, it became evident that the players were exhausted on one hand, while the coach was becoming increasingly anxious on the other. This drove the coach to add more complexity to the training demands, which couldn’t be executed well due to fatigue. This fueled his frustration, prompting him to escalate the physical demands even further—precisely the reason for the majority of injuries in the previous period.

I approached the coach, calmly and quietly, and requested that we end that part of the training and allow me to conduct an injury prevention exercise program with the players during the remaining time. A dramatic pause followed. He understood that if he rejected my request, I would leave the club, and they really needed a capable physiotherapist. However, if he accepted, he’d have to swallow his frustration, perhaps a bit of pride, and certainly some of his ego. To his credit, he chose the latter.

In the following weeks, together with him and the strength and conditioning coach, we established protocols that combined simple methods like extended warm-ups before training, identifying fatigue in individual players before training began and adjusting their load accordingly, creating personalized conditioning plans for each player alongside individual prevention programs tailored to their needs and current condition, simple stretching and relaxation exercises, and self-diagnosis of body conditions after training.

Each member of the sports medical team was responsible for one of these tasks, and I coordinated all of them. As mutual trust grew among everyone involved (players, coach, strength coach, club management), internal resistance weakened, and communication within the club improved.

This open communication allowed further enhancement and personalization of preventive measures and their application monitoring.

I must note that the financial situation in the club at that time was far from ideal, and the medical bag with just a few items was all we had. But we possessed something far more valuable: teamwork unburdened by the need to be right, focused instead on doing what was necessary and required. The following two seasons were the only ones in the history of that club where no player missed an official match due to injury. Since volleyball is a non-contact sport and trauma is rare, the absence of overuse syndromes clearly signified the success of this injury prevention model. And yes, these were the two most successful seasons in the club’s annals, measured by sporting results.

Sometimes, in life and in our profession, the most valuable things are free. But the results can be real and significant, just as they were in this story.

Over time, my private practice grew, and I could spend less and less time at the training sessions of “my” volleyball players. This led to a gradual increase in injuries and new absences from official matches in the seasons that followed.

Although even today, decades later, I am still connected to the same club, treating its current players, the memories of those two wonderful years, with all their benefits, give me the right to say that implementing injury prevention in elite and professional sports is possible and easy, almost banally simple.

The prerequisites are just a bit of knowledge, some experience, and a lot of communication within the sports medical team and the team itself with the athletes.

The moment that communication becomes poor, difficult, frustrating, or impossible, injury prevention also becomes impossible, and no aspect of modern science or technology can save it.