[Physio Discussed] Injury prevention: what actually works? with Adam Loiacono and Dr Nicol Van Dyk

In this episode with Adam Loiacono and Nicol Van Dyk we discuss the topic of injury prevention. We explore:

• What is injury prevention?
• Prevalence of injuries in different sports
• The future of injury prevention
• Individuality within injury prevention
• What the current evidence supports
• Tapping into patient’s motivation for rehabilitation and prehabilitation
• Injury prevention protocols – what role do they play?  
• Return to play protocols
• The role of screening with athletes

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Nicol van Dyk is a trained physiotherapist and performance health researcher. He was Awarded the Ad Astra Fellowship in the School of Public Health, Physiotherapy and Sport Science in 2024 after four years with the Irish Rugby Football Union as Medical Research Lead. He relocated to Qatar in 2013, while continuing to provide clinical care for athletes he formed part of the Aspetar Injury and Illness Prevention programme at the Aspetar Sports Medicine Hospital. In 2018 Nicol completed his PhD in Health Sciences at Ghent University, Belgium titled “Risk factors for hamstring injuries in professional football players.”

Adam Loiacono has over 15 years of experience providing top-tier rehabilitation and performance training to professional & youth athletes. His career includes reaching the NBA Finals with the Phoenix Suns in 2021 and the MLS Cup with the New England Revolution in 2014. Adam is a distinguished member of an elite group of physical therapists, holding the prestigious board certification as a Sports Clinical Specialist (SCS) through the American Physical Therapy Association - a credential achieved by only 10% of physical therapists in the United States. 

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Our host is @James_Armstrong_Physio from Physio Network

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Transcript

Introduction

SPEAKER_00 0:04

Welcome to Physio Discussed, the podcast where we explore the conversations shaping modern physiotherapy, sports performance, and rehabilitation. Today's episode is centered around one of the biggest topics in elite sport and sports medicine: injury prevention. But rather focusing on the simple protocols or checklist style approaches, this conversation really explores the complexity, uncertainty, and realities of working in high performance environments. Joining me are Adam Loyacano and Nicole van Dijk. Adam is a sports physiotherapist and performance practitioner with extensive experience working in elite sport, particularly around rehabilitation, return to performance, and integrating rehab into real-world sporting environments. Nicole is an internationally recognized sports physiotherapist and researcher whose work has helped shape modern thinking around hamstring injuries, injury risk, and return to play in elite athletes. Throughout this episode, we discussed why injuries like hamstring strains continue to persist despite decades of research, and whether injury prevention has become overly reductionist, and how difficult it is to predict injury risk in chaotic sporting environments. We also explore the limitations and the pros of screening, the challenge of recreating true sporting demands during rehabilitation, and the balance between objective data, athlete feedback, and coaching context when making return-to-play decisions. A big theme running through this conversation is the research and real-world practice, including why many previous prevention strategies struggle to create meaningful changes at population level and what clinicians should actually prioritize both in elite sport and everyday clinical settings. This ended up being a really honest and thought-provoking discussion around uncertainty, complexity, and what meaningful injury prevention might actually look like in modern sport. You're gonna love this one, there's loads to take away. I advise you to grab a pen and paper and a cup of your favourite hot drink and join us in this fabulous discussion. I'm James Armstrong and this is Physio Disgust. Adam, Nicole, it is great to have you onto the Physio Disgust podcast. Today we're gonna be talking about a very broad topic of injury prevention. We're gonna get stuck right into that today. I'm sure listeners come across this an awful lot. Nicole, I'm gonna come to you. We were talking just off air for want for a better word, before we started recording about that term, injury prevention.

What is injury prevention?

SPEAKER_00 2:43

So can we zoom out a little bit before we start delving into the nitty-gritty of injuries and whether or not we can prevent them? What do you what are we thinking about that term injury prevention?

SPEAKER_01 2:54

If we zoomed out and think about prevention as a whole. So what do we mean when we talk about prevention and healthcare? In a general sense, we usually talk about removing exposure, right? Like that's what we do. So we don't we we tell everybody to stop smoking, everybody wears a mask, everybody gets the vaccine. So we're trying to remove that exposure to the potential agent that causes the disease, the condition, or you know, the injury. But in sport and exercise, we really don't can't do that. You know, it's tied to that exposure. So we can't tell everybody to stop smoking. We're trying to figure out exactly how many cigarettes can you smoke before you tear a hamstring, right? That's a very different world we live in. So I think we really have to get away from that idea that you know prevention is somehow this like this hill we need to get to. I think injuries are just part of sports, you know, and like we need to accept that in a very real way, and that we need to build, and physiotherapists are fantastically placed to work across that whole spectrum. You know, if we think about primary prevention, secondary prevention, and tertiary prevention, so we can even break that up into everybody gets something, we're screening for a specific intervention or tertiary prevention, as in rehab and return to play, and the ability to prevent reinjuries or other or subsequent injuries. So I really do think we've reframed that narrative. And a lot of that has to do with management. So, you know, if we think about the old Van Mechelen model, everybody's seen it, the risk of injury sequence. That's really a research model. But what we're trying to do is understand those elements into those programs that will help athletes be robust, be resilient, and able to handle the stress or the load that's placed upon them. And that's really, I think, a better place for us to try and get to. I mean, if you think about hamstring injuries, right? So I did a bit of math and um we look after the United Rugby Championship injury surveillance. And just at our data from last season, the odds of an hamstring injury is about two to 23. Right. So for every two times it happens, there's about 23 times it won't. That's pretty low odds. They don't actually happen that often, even, you know, but it's in our mind, it's in our space, and we need to try to like reframe that, I think, a little bit in something we have to manage, athletes we have to build and make resilient, and then deal with it when it happens.

SPEAKER_00 5:07

Boom was talking at sort of uh creating a fear avoidance of injury rather than actually accepting that it's part and parcel of challenging bodies to compete at that highest level and how to become resilient and manage those injuries. Yeah, uh indeed.

SPEAKER_01 5:21

You know, I think I'm not saying we should just not we should just accept the status quo, but I do think there is a level of that's actually been proven to be quite successful. Hamstring injuries is a great example in a way, right? Because people kind of know, and if you've lived through the last two decades, it's the most common injury we see almost across all track and field-based sports. Now, it wasn't always, you know, like what would you know what do you want to guess what the most common injury was before hamstrings about two decades ago? Uh I won't keep you in suspense, right? Ankle sprains. I was gonna say ankles. I was gonna say ankles. Yeah, because like if you're old enough like me, you'll remember that ankle sprains was a big deal, and we had the real trouble. And then what happened, right? Conditions got better, pitches got better, equipment got better, and we and you know, like to give ourselves a little credit, we actually did a pretty good job in terms of prevention, rehab, and protective interventions. So, you know, I'm not sure if the same will happen for hamstrings or not, but I do think that we kind of forget that as the support is now, the demands on players is just enormous. You know, like if football is a great example, the amount of football an elite player plays now. Now, the funny thing about that is in the 70s it was about the same, but it didn't play every match at the same intensity that they do now. You know, like now it's and we demanded of them. So there's a real push in terms of player load, player welfare. Fifth pro has really been very like an active voice in trying to say, hey guys, we need to just think about this, and I think that is probably where we'll see the greatest effect.

SPEAKER_00 6:49

Absolutely. Adam, and from your point of view, you know, working in elite performance environments,

Complexities of injury occurence

SPEAKER_00 6:56

do you think sometimes we're trying to solve injuries or prevent them? And an actual fact when reality in sports far more chaotic and context-driven?

SPEAKER_02 7:06

I agree with Nicole here that they're just a part of sport. And the other thing that Nicole talked about, like going from the 70s to now, like across a lot of different sports, you know, I think back from like the 2010s to 2020s and European football to then even the NBA over the last seven, eight years, just the intensity of play has gone up. Yet have we really changed or upgraded how we approach the prevention or management of injuries? And then also the match congestion of NBA and NHL here in the United States used to be the epitome of that playing on average three to four games every seven days. But now with the multiple fixtures, the multiple tournaments, the I mean, this year being a World Cup year, I mean, your best players in the world are going to play 18 months straight with no real offseason. And so you think about not only is it intensity, it's volume, there's just a lot of things in elite sport that no matter how good your programming is, you're just fighting an uphill battle. And that's part of like the business and entertainment aspects that come in elite sport that, you know, people try to make money, they want to get paid more. So if you want to get paid more, you gotta play more games, right? But you it is much more, to your point, chaotic and nuanced than just saying, hey, hamstring injuries are number one most common injury in elite football, elite soccer. You know, here's this program, and you're not gonna get hurt. It's just not that simple. I wish it was. But it's just very complex and chaotic. And, you know, there's an interesting perspective like on hamstring, too, is like some heard some people in the sprint and trap community talk about how hamstring injuries are also a neurological injury, right? You think about the demands on a hamstring, crossing the hip, crossing the knee, an elite athlete having to be exposed to the high velocities of sprinting. And then you layer that with fatigue or match congestion. Now all of a sudden, was it really a structural biomechanical issue, or was it really that split second neurologic input? And all of a sudden, like that just happened to be the thing that gave.

SPEAKER_00 9:16

So we're almost oversimplifying it by using an anatomical point to blame for injury in some respects.

SPEAKER_02 9:22

Yeah. I mean, I've come to appreciate, you know, when you're dealing with professional athletes or elite level athletes, they almost all have something that goes when they're under stress or load. You know, and some sports have it more consistent across a certain tissue type, right? In basketball players, maybe it's tendonopathies, in soccer players, maybe it's hamstrings or calves, in hockey players, it's growing, in baseball players, it's an elbow, right? Like just the tissue that gets exposed the most when fatigue sets in or load sets in, that's the tissue, that's the signal, that's the thing we want to point to and say, yep, that's what's wrong. When in actuality, it's a much more complex puzzle. Not something it can't be solved or can't be managed, but the myopic viewpoint of an anatomical structure being, yep, that's what we have to fix. You can have success approaching it that way, albeit it may in the end be incomplete at best.

SPEAKER_00 10:22

I suppose it links really nicely back to what Nicole said about where we looked at the word prevention in healthcare, where we try to then limit exposure. Well, what we've already got out of our chat today so far is that in actual fact we're seeing the opposite happening. We're seeing more exposure, more intense exposure. And then to try and limit the injury, we're looking at a far more, far more complex approach to injury reduction management, or whatever, whatever we're we're calling it. It's a really broad thing we're looking at rather than just a tissue that we're gonna focus on.

Risk management program

SPEAKER_01 10:55

If I jump back in there just for a second, I mean, uh, you know, like the problem is the solution, right? So we you need to train, you need to run fast. And so to run fast, you need to run. So what do we do? We make athletes stronger and faster. And guess what they do? They run faster, they push harder. They're not going to stay at the same level. Their performance goes up, but with that, the risk goes up. And that's really what we're doing. It's a risk management program. So for young practitioners and any practitioner worth their salt, I mean, Adam and I will have bitten our like really like teeth many times. Like, just like please get through this next session, because then I know you'll get through the game. And you know, that's kind of where I think a lot of that lands is you just kind of have to accept the risk, mitigate against it as as well as you can. But then, and then maybe we'll get back to this, but it's really about the person. So we're yet to get there, but a poor night's sleep and a bad slice of pizza will probably tear your hamstring way more often than a 5% reduction in your eccentric strength. So, you know, it's that holistic view, and we're reductionists because it's easy. You know, Martin Boucher is on this crusade that we should stop looking or like hang our hats on our high-speed running exposure. He's not wrong in many ways, right? It's just easy to look at GPS because it was the technology that got there first, and it's the thing that's easy to gauge. Now, I'm not saying we throw it out, that's it's not an either-or situation either. Also, it's definite incorporating these different components. And man, I don't know how to do that, like other than looking at the individual in front of you. And again, you know, I think physios are pretty phenomenal at exactly that.

SPEAKER_02 12:27

It's much more complicated in the team sports versus an individual sport because there's so much, there's so much more that goes into that chaos on the field, right? Like basketball is 10 players playing in the smaller space, soccer is 22 playing in a larger space, you know, style of play, tactical decisions, individual differences, right? It's it's we love to solve problems, like the Nintendox Physios and healthcare practitioners, great. We love to solve problems, create solutions. The reality is, you know, the N equal one rings true so much in risk management and quote unquote injury prevention. And it's so hard to replicate some of these programmings across different athletes because you can have everyone do the same program and some get hurt, some don't. And then they do the same program next year, and the ones that got hurt did it, or the ones that didn't. And it's hard to say which one is with Nicole's point, like that slice of a pizza and that that sleep, you know, not to say we need to stop doing what we're doing, but elite sport and team sports really is difficult to pinpoint exactly what was the thing that led to an injury, and it's just understanding what are the general principles and qualities that we know are beneficial for athletes to help reduce that risk, whether that's high-speed running exposure or densities of high-intensity efforts, or it is absolute strength, or it is metrics on force plates or isokinetic, right? There are things that the rehab space has figured out for return to play. Take those principles, apply it to a healthy athlete, and then at best, you try to manage everything else. Well no, accepting that injuries are going to happen. And hopefully they don't happen all at once. But more than not, you know, a team will get put through the ringer at some point during the season.

SPEAKER_00 14:11

Absolutely. So

What works in injury prevention?

SPEAKER_00 14:13

I suppose what really quite good to get into now is maybe contradictory to what we've said already, but what can we do? So, what is there out there that we can not necessarily hang our hat on, but start leaning towards that that might help us mitigate some of those risks? We've said that actually we need to manage them, accept them as part and parcel of elite sport, and I think as general recreational sport as well. But what can we do to try and support athletes to mitigate, reduce the more the chances of injury that can be avoided? If that makes sense.

SPEAKER_01 14:50

You know, like to to to first kind of lean into those different narratives, right? So there's me, there's we, and there's the, right? If I can put it like that. So there's my story. So it's we we've appreciated, I think we need to get back to case studies, man. Like we don't publish them anymore. They're so useful, right? To compare against. And then we have so much data now on the individual that we can build a profile. I'm lucky enough to be part of a longevity platform called Cascade Health, and we have elite athletes on our profile too, where we're really trying to build this holistic picture, but of you, right? Of the person. And so that's a really important part. If you have the ability and the resources and the data and the tech, you know, there's some real value in understanding the patterns and trends associated with a person. You know, what are the habits? What are the things we can look out for? And then you have to figure out what to pay attention to, right? Like, what is the things to pay attention to? That's hard. And in the whoop kind of like wearable world we live in now, sometimes there is a lot of noise, right? And we we need to understand that better. Um, but certainly that helps. And then I think at the Wii level, so if you if you don't have that, but you have a team and you could even if you're looking at their exposure as a whole, you know, like that's helpful. And understanding where are we really pushing, where are we pulling back, why are there these gaps? Can we make something around a team effort in terms of exposure, even as a very simple metric, right? That we know is helpful, and maybe we have comparisons for that. And then maybe at the the the level, I maybe I've switched them around, but I'll inter I'll intertwine them. It's like we know that uh Nordics work, man, just do them. You know, like everybody has to do Nordics, and they don't just work to prevent injuries. We have fantastic work from Denmark and Germany. They make you stronger, they make you faster, they help your performance, right? And so does a lot of those exercises. And that should be our focus, right? We're gonna make you faster, stronger, we're gonna protect your ability to participate, whether you're elite or not, in the sport you love. And that's why we're doing these exercises baked into your program, not as this standalone feature, you know, that you do at the end of a session or you know, nobody wants to do that. I don't do that. Do you guys run? Hopefully, we have some runners on the podcast. I bet you 99% of people don't stretch before they run. I don't. And I know, I know I wish I should, but I couldn't be bothered preventing something that hasn't happened. Right? And that's I think we have to understand that our athletes feel the same way. So if we program it for performance, for participation, for protection, potentially, I think we're in a way better space.

SPEAKER_00 17:24

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SPEAKER_02 17:50

It's funny you say, like, if you know how do you implement something that hasn't happened

Patient adherence to injury prevention programs

SPEAKER_02 17:54

yet. I often find some of the athletes that have the highest compliance and best participation in a weight room or in a performance program are ones that have endured some type of surgery because they understand what it took to get them back. And then they had an appreciation for every little detail that they had to undergo. I mean, I'm working with a female soccer player right now, she's on her second knee surgery, and she is an absolute rock star. She knows exactly what to expect. She's like, Yep, I know this is gonna suck. I have to do this, but she's so much better, having unfortunately had to endure it before. But you get an athlete that's never endured something like that before, or an athlete that you're trying to get compliance in the weight room to work on these things that are beneficial, like you said, like the Nordics. But until they, you know, that's life's greatest teacher, failure, right? Until you fail, until you I hate to use the word sufferers, you know, endure some level of trauma. It's hard to emotionally invest into something if you've never felt it or understood it before. And so I'm glad I'm as soon as you said that, I said, man, I gotta call this out because I see it day in and day out. Some of the best performers in the weight room and participation are those that have just unfortunately had to endure some struggle beforehand. And that bleeds right into an appreciation for understanding, hey, I need to hit these benchmarks in my prevention program, not as the means of it's the holy grail. If I do this one thing, I'm never gonna get hurt. But if I hit these minimum standards, it's almost like from a, you know, you send your car to the mechanic. Like you know they're gonna go through that 100, 200 point checklist just to make sure every individual part is where it needs to be. That's not saying you're not gonna get in a car accident. That's not saying something's gonna break down, but they're reducing your risk of something happening. Same thing for us. Like if you there is value in that mechanistic myopic view of okay, Nordics are only for hamstrings, but they also can translate to sprinting, they can translate to performance. Not saying if you do Nordics, you don't, you're not gonna not get a hamstring injury, but more likely than not, yeah, probably gonna reduce your risk. And so from a practical side, my viewpoint, having lived in both the rehab and performance world, you have to have an appreciation that there are minimum standards of strength, range of motion, power, tendon stiffness that should be majority of athletes hitting, regardless of sport, you know, almost like that general physical preparation, if you will. And I love the boom of longevity and some of these influencers talking about VOT Max and Nexa scans and grip strength or relative body mass list lifted on a squat, right? It's all super important if you pull back that and say, hey, if this is good for everybody to be quote unquote healthy and live longer, shouldn't we kind of take the same perspective and say, regardless of sort, regardless of who you are, like these are the things that we know just help improve your overall health span? I would imagine, and I'm led to believe the same is true for performance, probably just at a higher level, if you will, or a higher standard. And that's how I've approached this idea of injury prevention and risk mitigation and say, listen, there's I gotta check the boxes, I gotta make sure these baselines are here. And I know even if we hit all of these, there's still that integration piece that could lead to an injury. Like, is the driver half asleep today? Was there someone else on the road not paying attention? Was there a banana peel around on the corner like Mario Kart? I don't know. But there's those things that that could potentially just throw a wrench in the system and really cause that injury, no matter how much you know you invest into preventing or managing

Role of communication in injury prevention/rehabilitation

SPEAKER_02 21:43

it.

SPEAKER_01 21:43

Yeah, and just to counterbalance that, right? Sorry, James, like we're going, we're riffing here, right? But like, I mean, I think we want to give a shout out to structured programs from the part. Like the FIFA 11 Plus, right, works incredibly well at an amateur youth level because there's no structure there or people are resource poor. So it's a wonderful warm-up program that we now have pretty good, you know, lab results. And it works. You know, there's others like that, I think that rugby and other sports have experimented with. So I want to give a shout-out to that because I think there is value in those structured programs. And if we look at like some of the Olympic work, there's an over like in the last two, maybe three decades, there's about a 50% drop in injuries overall, right? Like if you look at the UEFA data and the elite club study in Europe and in soccer or football, there's a around a 50% drop in incidence. Hamstrings have kind of stayed the same. And so proportionally they've got a bigger share of the pie now. And people kind of like tag onto that headline. But we've overall, so I think you know, like there is we're not saying that we are not successful, and it's holding that tension between that risk mitigation piece and then managing this stuff when it happens that I think is really important. So I just I think it's important you just mentioned that in the wonderful work that a ton of really amazing people have done.

SPEAKER_00 23:01

Yeah, definitely. And so it's we it we are seeing reductions. That's an interesting stats there, Nicole, that you've mentioned there, that actually overall that we're seeing a good reduction in injuries, but actually hamstrings are staying the same, therefore they appear to be that greater problem, as it were, and a solution needing to fix. I'd like to go back a couple of bits there, Adam, that you talked about. I thought that linked really nicely into when an athlete's previously been injured and had to go through that hard, arduous rehab that is often needed to return them to play, that they then have that understanding and then tend to be better at understanding and engaging in quote unquote the the injury prevention side of things. That also then links Nicole into what you were saying about the you. So understanding the individual's needs for certain elements of conditioning and what they need to reduce their in incidence of injury, would you say?

SPEAKER_01 24:00

Yeah, but uh Carly McKay, Dr. Carly McKay from Calgary has written a great book. I don't think it's got a lot of tension, but it's actually pretty cool. The mental side of sports injuries, not the title, like I think we can argue about the title because it sounds like it's outside like of sports, but this idea that you know, if you build an understanding, a resilience, appreciation for, then you really are in a good sh in good shape to you know not only endure when injury happens, you know. Phil Glasgow, who's the head of performance support of the IRFU, that's a great way of saying it. Rehab is training in the presence of injury. I mean, that reframing is so helpful to athletes, right? It's like, oh, okay, we're still looking for a stimulus to drive an adaptation to get you back, right? We're looking for performance, you're looking for that extra bit of strength, speed, whatever. And when you're injured, you're looking for healing and good healing and recovery. And so I think that is a really important part of uh, as Adam said, that appreciation, how we build those narratives for athletes leaning into their context. Why are we doing this season? Do you need a contract? Do you want to press your folks? You know, you've just had a kid and you want to like make sure there's a like really understanding what's the motivator behind doing your re at five in the morning. I mean, that's a big part of this. And when once you tap into that, everything else is just a little bit easier. I think that is a big part of it.

SPEAKER_02 25:21

Not much more to add other than the the motivation side of it. I have found a great success in communicating and educating enough as to the why behind certain things or helping athletes connect. Like, hey, there's a reason why we're doing A, B, and C in a training program today, because it ties to what you're supposed to be doing on the field today or on the court. It's not coming from a place of I'm trying to tell you how smart I am. It's I've learned that when they can appreciate and connect the dots themselves, they're more barred in rather than just showing up and being told what to do and blindly executing something with no real understanding of it. Now, don't get me wrong, there are some athletes that prefer that they don't want to think they just trust you. That's there are those. But more often than not, you I have been able to have better intent, better effort, better quote unquote buy-in by just helping drip those breadcrumbs along, if you will. Say, like, this is the reason why. And here's where it's going. Maybe not today, but maybe you know in a couple of weeks. And then there's like, oh, okay, now I understand the importance of this exercise that I don't like to do, or hey, I hate doing, or I don't understand why this is like we have to do this. It's not related to my sport. Like, there's not a ball on my feet or a ball in my hand. Why am I doing this? Adam makes no sense. And it's like, oh, no, no, no. Let's tie it back to something that is meaningful to you. And like Nicole said, maybe it's something off the quarter, off the field, right? Like, there's all those little things that come down to the, if you will, the art versus science, right? You need both. You can't have one without the other.

SPEAKER_00 26:47

You also

Return to play protocols and testing

SPEAKER_00 26:48

mentioned, Adam, you brought in the tub subject of return to play. I thought we can't have this podcast without talking about return to play. And to tee it up, we're also going to talk about screening later on as well. And we've got to have that in there. But return to play protocols, testing. What are your thoughts around that? How useful they are, and any tips, I suppose, for listeners on your advice on what you should or maybe not be doing.

SPEAKER_02 27:12

I liken this to, you know, everyone has it, everyone nowadays has a has a smartphone. You know, here in the United States, almost everyone has an iPhone. And so you get on you get on maps and you plug in your destination, you get anywhere from two to four routes to get there. Some are longer, some are shorter. Protocols and return to play plans are exactly that. They tell you where your starting conditions are, and they show you options to get you to the end. Now you can get on that drive and all of a sudden there's a car accident. Now you got to pivot and take a detour. Or there's actually not a wreck anymore, and it's actually faster. And so you can adapt. But the protocols are a starting point. They shouldn't be the holy grail or everything that you should be doing because to Nicole's point, you have to go to n equals one. And I'm a huge supporter of the idea like agile periodization or scrum project management, right? Like you're constantly embedding testing within your rehab, within your training plans, so that you're getting real-time feedback. I think this is what's great about the world of sports science and the performance community is they're constantly collecting data from on pitch or on court to help inform the coaches of, hey, that was too much, that was too hard. And you're like, they're making adjustments for the next day. Well, the rehab and physio space can do the same thing rather than saying, hey, here's your four-week block, and we're not going to look at anything until four weeks later. It's like, no, can you embed a little bit to kind of give you that understanding of your progress? So then you know within you can kind of maybe take, you know, a little detour around this back road, or maybe you can bypass this person on the left-hand side and go a little bit faster. And so it's a it's this combination of you need those protocols to start somewhere. And like to Nico's point, there's been a lot of great people that have helped write a lot of those protocols. And then to the N equals one, well, once you get rock and roll and you're two, four, six weeks in, like that protocol got you where you need it to, but now you have to individualize it based on what you're seeing in real time. And then you maybe can go faster, maybe you can go slower, but it all comes down to your ability to constantly evaluate within sessions and between sessions, not just these simple benchmarks of every two, four, or six weeks. It's how can you make those micro adjustments along the way? And I'll put the disclaimer and say, I know that's challenging in the private space. I know it's a lot more pragmatic in the team environment when you have multiple touch points. But if you're in the private space and in a clinic or in not a team environment, can you leverage some of your exercises as just check-in points? Like I'm gonna look at this particular set as a means of how are we doing? Or I'm going to embed a force plate testing as part of our program today, just to hey, let's just see how you're doing. Let's just see where we're at, rather than only looking at a snapshot on one particular time.

SPEAKER_01 29:58

And Matt, we used to get that question all the time, right? Like, what's your criteria for return to play? It's like, well, you know, at the end of our react, we do this. They've usually done a period of sports-specific training by then. And then in stage three, we do this, in stage two, we do this, in stage one, it's this. And you earn the right to progress. A lot of these criteria now have adapted that criteria-based progression, which I think is the way to go with respect to biological healing. I mean, it's a great Arsen Wenger quite maybe a good thing to name Arsen Wenger after Arsenal won the Premier League thanks to um to Man City draw last night. But you know, he was asked about all this recovery innovation and like ice baths and beat reduce and whatever. And he was like, if you have a muscle injury, it takes 23 days. It took 23 days 30 years ago. So there's that, right? There's a biological healing process we will never get away from. But we are optimizing rehab by having these criteria-based progressions and treating the person clinically in front of you, right? So that's absolutely crucial. And then I then I think the the key pieces that Adam alludes to there too is getting back to your performance, right? We know now that I can get you back to playing. That doesn't mean you're back where you were. And so how do I get you back there? And a lot of that is not maybe just strength-based. I mean, that there is lots of the mental side of sport that comes into that too. And there's a story building around that. But yeah, I think it's absolutely crucial that we look beyond single muscle, single metric, single measure, and that we build all those components as much as you can into that return to performance piece. And I again, like we're talking about elite athletes, it's true for everybody, right? So, and we all like you know, we all have that data now to kind of lean into. So if you're running your own private practice somewhere and you have athletes at your practice, like get their Strava profiles, check what they did before they got injured. Strava's actually added a physio section to their workflow now. So you can load your rehab sessions on the platform. I mean, how great is that? So I think there's a lot of advantages we can take when we're planning out that journey, as Adam said, through for the athletes up to where they need to be. And then I think, really importantly, beyond that, like some fantastic, just genius work from Michael Kiar and Abigail Mackey in Denmark showing that at 30 days post-muscle injury, the cells are still active on the membrane, right? Like there's still healing processes happening. Most of our hamstring injuries are back by then. So our job isn't done when they go back. Our job is to make sure that when they go back, they go back and they keep whatever they need, and then they build into those routines, those habits, hopefully healthy habits to maintain that. And they're way more willing to participate in that in the future.

Does previous injury increase risk of injury?

SPEAKER_00 32:36

I'm gonna ask a question now. This is something personal, but it often comes up into my mind and a question I have around when you often hear that the greatest risk of a particular injury is having that injury before. Do you sometimes think or ever think that statistic is there because that return to performance hasn't actually been put into place and they've been returned to play, and then, like you said, there, they've just been left to carry on. And maybe it wasn't quite finished.

SPEAKER_01 33:03

But no, you're right. Like, I mean, I think there's a caveat to that, right? So we've seen it twice. When I was in Qatar and my work was on risk factors for hamstring injuries in football, in our first paper, around four seasons, previous injury risk factor, significant result, boom. Second paper, two seasons gone. No, no previous injury risk factor, no, no significant finding. Like, where did this go? Like, how is that possible? But at the same time, in this very controlled environment at the Qatar Stars League, almost everybody got rehab in our rehab uh randomized controlled trials. Whether you were in the intervention or the control group, you got a pretty good deal, right? Like you got a really good rehab program. We saw that in volleyball in Norway with Professor Roald Barr and his team as well, where ankle sprains as a previous injury risk factor just disappeared. So if you do a really good job in rehab, it's actually possible to mitigate that risk way down. You know, but but a part of that is when you return, now we don't always have control over that. Like sometimes there's loads of reasons, contextual reasons, why an athlete may take that risk. So communicating that, understanding that this is a risk, there is a higher chance. We've got to do this because it's the final, and you may never play again and let's go. Sure, right? Like who wouldn't do that? But at the same time, even beyond that, making sure that our athletes do get back to what they need or have that adaptation that they need. I mean, that's the other really big thing. Adam talked about it in the rehab part two, right? And I think it's true across Nikolai Bernstein's blacksmith experiment from the 1930s. So you looked at blacksmith and where they hit with their hammer, right, as they as they do the motion. And the the variability in their movement is insanely high, but they hit the same point every time, right? So that expert kind of level ability to build programs for our athletes that have loads of adaptability in them, but we're hitting what we need. I mean, that is the mark of a truly great process. And and that takes some time. I think you've got to admit that that takes time and experience to build, but boy oh boy, your athletes will thank you every time, right? It there's just so much value in that. And it's needed very often to have that adaptation and ability to adapt in the program.

SPEAKER_02 35:14

Yeah, I love the variability conversation there. I mean, nothing, I think nothing also supports that more than like the concept of early specialization in sport versus generalization uh and sport when it comes to you know who becomes world class in the end. Uh, I think you know, David, David Epstein has written about that in his book range quite extensively. There's been numerous studies and people looking into that. And so I think it just goes back again, you know, the blacksmith versus, you know, the blacksmith study versus early specialization, it just goes to show that rigidity within anything is not going to be beneficial. And that's where the variability in the motor learning, the programming, just the adaptation, it all just takes time. Um, and that's where this idea of return to play, return to performance, return to sport, choose your budget blur. I feel like everyone has a different, you know, dogma of which one should be used, or like, oh, return to sport is not the same as return to play or performance. At the end of the day, like you're what we're trying to do is just get you back to where you were at previously at minimum. And then depending on who you are, where you're at in your career, who you what you want out of your career, do you want to be better? Are you trying to be not have this happen again? Are you trying to just survive this season? It's not as clear-cut as we want it to be. And so I just share that perspective of yeah, that pie in the skies we all want everyone to be performing better than they were pre-injury. But sometimes the reality is just getting them back to on the field on the court to be able to do things that they need to as part of a professional job or as part of a personal goal. Sometimes that's good enough. And I think we have to be willing to accept that good enough is sometimes acceptable.

SPEAKER_00 36:57

Ever wished you could see how experts treat real patients of theirs? With case studies by Physio Network, you can. Watch presentations where top clinicians break down real life patient cases step by step, showing how they assess and treat even the trickiest of conditions. It's the best way to improve your clinical reasoning and build confidence in the clinic. Click the link in the show notes to start your free trial today. I want to talk about screening

Screening for injuries

SPEAKER_00 37:24

because it's something that we hear about a lot. And in terms of a way to prevent teams getting more injuries or individuals becoming injured. What are your thoughts around how useful screening is? Is it as useful as some think? Can it be used in a good way? And do you think it's sometimes overused? Adam, let's start with you. We'll go on that. Absolutely, it's it's useful.

SPEAKER_02 37:48

How else are you gonna know if something's going awry? As I look I liken this to, you know, you go and get your routine physical from your physician, they look at the labs. They're not saying they're gonna change anything right away. They're just simply saying, well, let's take a look under the hood, see how you're doing. Let's, you know, do we need to intervene on anything? So the screens, I view them as just a way to let's have a formal assessment that's consistent, that we can measure against, that we can look for potential yellow flags. I wouldn't even call them red flags. And then you cross-reference that against some standard that you believe in. Now, there's a lot of standards out there that I feel are well established. If we think, you know, we've been talking about hamstrings a lot. So let's say part of your screening tool is lumbopelvic complex and hip internal, external rotation, straight leg raise, and then you're looking at Nordic, you know, eccentric strength on a Nordic, and we have our standards and thresholds. Well, if you are sufficient within those standards and thresholds, great. This isn't a priority for your program anymore. Let's go look somewhere else. And so that's how I look at screens as a means of I'm not using a screen to say I'm going to fit you into this box and say you have to have all of these key things and be within all of this. I think there's a bandwidth that we have to be willing to accept because it is an entire system. And usually, you know, body shapes, archetypes, positional demands, training age, training history, chronologically, all those things add this variability to allow bandwidth to exist. And we have to look at that and say, what's our tolerance to that bandwidth being smaller or larger? And then leaning into what we has been established from great practitioners, great researchers, great clinicians, as hey, this is what we believe the standard should be. You know, I think a great example of this is if you're in team sports as a baseball pitcher. If you're in track and field, it's a sprinter. We know there is an acceptable range of motion, biomechanics that are gonna be beneficial to both those activities. But when you consider baseball pitchers have a variety of different arm lengths, different heights, sprinters, you look at Usain Boltz, who is six foot plus, to say someone that's five foot six, five foot eight, they're gonna have different bandwidths within that screen, if you will, based on the skill they have to do. But we've established that acceptable bandwidth. And that's where I lean into how I look at screening tools, whether it's movement, performance, return to play. Like to me, that's how I implement and utilize those on a day-to-day basis.

SPEAKER_01 40:26

Yeah, I think the utility is the question, right? So for a long time, screening was kind of associated with prediction. And so we had programs like the FMS, it's really broad value, right? But at a broad level, like you can't dig into details there. It's not gonna give you more than at that overview, and it certainly won't predict. So we I think we've moved away from the idea that I'm gonna find the athlete that will get injured and then I'm gonna focus on him and he won't, right? By the way, that's the problem with this stuff for us, right? We can't go to the coach at the end of the season and I look at all these athletes, look at all these injuries that I prevented. You know, like I need a bonus. Like we only get the pressure when there's a lot of injuries in a team, like some of the premier clubs at the moment. But screening is valuable, certainly from the data that we've collected. You know, looking across our program when we when I was in Qatar at the Ask Law Sports Medicine and Orthopedic Hospital, so we can't predict who will get injured, but about one in every three players had a musculoskeletal issue we followed up on that wasn't reported before we did the screen. Now, some of it was really simple, a bit of advice, some of it was an additional test, some of that subclinical pathology. So screening is really valuable in that sense, detecting current issues, understanding where you are with what you have. So you had an ACL two years ago, a year ago, you had a HAMI. Where are we in that process and in that profile and understanding how you're doing overall, I think is really valuable. And all the other bits, right? Building those relationships with athletes, monitoring those trends and little signals within all the noise you know you have on a daily basis can be really, really valuable. So I think there is an enormous reason why we need to continue screening programs. And it's another way in which we can serve it, serve our communities, right? Outside of the elite environment and make sure we are providing them with ways in which they can lean into prevention in a way that's really meaningful. So I'm a big fan, and I think that's the key now is having these programs that are tailored to what your team, your situation, or your athlete may need and what they're trying to achieve.

Can we predict injury?

SPEAKER_00 42:25

In sense you think that actually keeping track of where athletes are throughout the season, for instance, can that lead to us being able to potentially see where someone might become more prone to injury?

SPEAKER_02 42:38

Yes and no. Yes, in the sense that you can look at pattern recognition, and if I see these sets of variables, the last time I saw this, X happened. And I've been in situations where we've made decisions on player and say, you know what, A, B, and C last time was at this threshold, and something there was a negative outcome. And then I've been in the exact same situation, and A, B, and C was there. We had a negative outcome, but that didn't happen the second time through because it's so individualized and context specific that it does make it challenging to be able to say with absolute certainty like something is going to happen. But I think it comes back to everything we've talked about so far, is just the level of risk and tolerance around those decisions when you have that data. And the screening allows you to get that consistent data collection to then be able to over time speak with potentially more confidence in those situations. That's where we're leaning into when we consider the ability to manage within a season by just seeing it work and not work and not on anyone's fault or anyone did something wrong. It's just that's just what happened.

SPEAKER_01 43:52

If we look at a big medical screening program, so let's think about breast cancer, right? So mammograms as a screening tool is incredibly Incredibly effective to detect cancer. But the intervention for a positive mammogram is pretty heavy, right? You're potentially getting a mastectomy. Now we could cure breast cancer tomorrow if all 13-year-old girls got double bilateral total mastectomies. But that's a pretty horrible world to live in, and that would be a massive expense. I mean, we don't have the money to do that. So, but our what's our interventions? Our interventions are pretty simple, they're pretty cheap. You know, there's single-leg hops and naudic exercises and warmups. I mean, we really should lean into our interventions as a whole. So I'm not saying you need to do screening before you get an intervention, and not in our world, for sure or not. But screening adds that next level of understanding where I can intervene. How can I make you better? And again, tying that into you as a holistic performer, right? Like, where do we make sure that we're addressing everything we can? The other thing that I think we should also differentiate is overuse injuries versus index injuries or acute injuries. So Ben Clarsten and the folks at the OSDRC developed the overuse questionnaire. And you look at the data from Norway, it's not a perfect tool, right? But there's really good ways to then look at those trends. So when does your tendonopathy, like that you're dealing with and you're managing, become an issue? When is it painful? And when do you keep it like below the surface so you can actually do what you need to do? So there's also that that ability to look at chronic ongoing issues that athletes deal with from a monitoring perspective, even with something as simple as the OHCRC tool, that's really useful in terms of a screening program.

SPEAKER_00 45:30

Brilliant, brilliant. Right, we're coming in towards the end of our time now. So I thought it'd be really nice now to come to each of you to give some pearls of wisdom to the listeners now and to kind of sum up this.

Key Takeaways

SPEAKER_00 45:45

If you were to give listeners some real key takeaways in terms of uh their perspective of injury, we're gonna call it injury prevention, and things to take away into clinic. What would you say to newly qualified and experienced clinicians listening? Adam, we'll start with you.

SPEAKER_02 46:04

In terms of injury prevention, that sounds great. The reality is you're trying to manage a bunch of variables and lower their risk. So if the young clinician has to really understand who's in front of you and what the demands are once they're trying to get back to what they're doing, and reverse engineer that and understand what are the constituents or the parts that can help this person be successful, and then create your checklist of what am I going to evaluate these parts again to just determine if I feel confident that they that this part, this muscle, this joint, this range of motion, this movement is adequate enough where it's no longer a threat to injury. And then you you start to create your hierarchy of what's most important on a priority list for your athlete, for your individual. And then that helps you write that n equals one program. And if you have someone coming in for the first time and you don't have that longitudinal data, you don't know what to do with them, well, then you can lean on to the to the mass studies and the generalizations and these programs that we've come out with. Like, for example, the FIFA 11 Plus. Well, if you're a soccer player, what do we know? Probably need to do the Nordics, probably got to do some Copenhagens, probably got to work on some single-leg hops, right? And that just is the starting point. And then as you start to work with them and evaluate them more, you can refine it a little bit. So to summarize there, it's understand where you're going, break it down into digestible tasks or exercises or interventions, if you will, and then lean into the general data or the normative data. Excuse me, that was the word I was looking for, the normative data to help you start somewhere, and then you just refine it as you go.

SPEAKER_01 47:53

One of my favorite quotes, right, is from Mike Tyson. Right. So everybody's got a plan until they get punched in the face. I think that's so true. So when I think injury prevention, I'm thinking, how do I create robustness and resilience in the in this person that I'm helping, right? How do I make you able to take the punches and to get up when you get hit? Right. That's really, I think, where we should be putting that injury prevention frame into risk management and robustness. I really like the idea of that. So I'm going to encourage folks to really consider how they reframe their approach to injury prevention in that way. There's two things. It's still evidence-based practice, you know. So there's still those three components, right? There's the research, and we need more of it. And we need clinicians to drive that. The gap is that we're still waiting for people doing their master's or PhD, and I'm one of them, to finish their degrees before, like we need clinicians and clinics and teams to drive that, and it's happening. So that's the one thing. And then I think that there's your experience. Don't discount how valuable it is to do this on a day-to-day basis and lean into that intuition you build as a clinician. And then there's the player preference, it's the individual, it's the human in front of you. And make sure you're always attaching your program, your prevention, your implementation to that person and their needs. You know, and then I think complementary to that, or I want to plug my friend David Clancy. He's written this wonderful book called Essential Skills for Physiotherapists. And it's just absolutely about how we build those real skills, to use the Seth Godin term, in terms of interacting with patients, with players, with individuals, empathy, listening, wisdom, charisma. You know, those are the things that will help you absolutely excel in whatever you're doing as a physiotherapist, certainly injury prevention.

SPEAKER_00 49:42

Marvelous. Adam, Nicole, thank you so, so much for your time today. It's been a very broad subject, which I think we've really unpicked quite nicely today with some things that listeners can put into practice and certainly start thinking about in terms of that term injury prevention. Adam, Nicole, thank you so much. Um I'm sure we'll no doubt have you on the podcast again in the future. Thank you, Jeff. Thank you.