General Prevention Principles of Injuries

Fig. 4.1

The figure of four, an example of static stretching

Static stretching increases range of motion (ROM) and can also decrease musculotendinous stiffness, even during short-duration (5–30 s) stretches [73].

A systematic review by Kay and Blazevich has showed that longer stretch durations (60 s) are more likely to cause a small or moderate reduction in performance; however, a static muscle stretching totalizing 45 s can be used in pre-exercise routines without risk of significant decreases in strength-, power- or speed-dependent task performances [34].

Ballistic stretching consists of repetitive bouncing movements at the limit of range of motion using the stretched muscles as a spring which pulls out from the stretched position. This particular stretch increases ROM but also is associated with reduced muscle strength and can cause injury. This should be done with extreme caution and after pondering many factors (age, physical condition, experience) of the considered individual.

Proprioceptive neuromuscular facilitation stretching is a reflex activation and inhibition of agonist and antagonist muscles, resulting in increased range of motion. This stretching method can furthermore be subdivided into passive and active techniques. In the passive techniques, the target muscle is placed into a position of stretch followed by a static contraction. The muscle is then passively moved into a greater position of stretch [13]. In the active technique, the final passive stretch is exchanged by an active contraction of the antagonist, which stretches the target muscle [13]. Both PNF methods produce an ROM improvement decreasing stiffness of the tendon structures [36].

4.2.4 Cooling Down

Cooldown phase consists in gentle exercises after vigorous physical activity. It should include 5–10 min of slow cardio activity (jogging or walking) followed by 5–10 min of static stretching exercises.

This phase is recommended because it has been observed that cooling down helps in the removal of lactic acid, decreasing muscle soreness [16].

Cooling down also brings quickly the body from an exercise state back to a state of rest. It reduces heart and breath rates, gradually cools body temperature and restores to baseline the physiological systems (Fig. 4.2).

Fig. 4.2

(a, b) A CrossFit class during the cooling down phase

4.3 Way of Living

4.3.1 Nutrition

Not only an adequate diet improves athletes’ performance but every single athlete’s aspect of life can benefit from a good nutrition programme.

An athlete’s energy need and nutrient requirement depend on various individual factors as weight, height, age, sex and metabolic rate and on the type, intensity, frequency and duration of training.

Every athlete or coach must calculate the adequate calorie and essential nutrient intake, according to the type of training, to reach good performances and to maintain good health.

Ideally, athletes need to take 60–70 % of their total calories from carbohydrate, and the remaining calories should be obtained from proteins (10–15 %) and fats (20–30 %).

Like the general population, it’s a good practice that calories and nutrients come from a wide variety of foods on a daily basis, as reported in the food guide pyramid [21].

4.3.1.1 Carbohydrates as Fuel

Carbohydrates are the precursor needed to form muscle glycogen stores necessary for the physical exercise. If the glycogen stores level drops down, like during an endurance exercise, high intensity cannot be maintained and the athlete will feel exhausted.

For this reason, the right consumption of carbohydrates is important during the pre-workout and post-workout and also during exercise in some cases.

Before exercise, a proper meal is necessary to maintain optimal level of blood glucose for muscles. Carbohydrate intake before exercise can help to restore suboptimal liver glycogen stores, which the athlete will use during prolonged training and competition.

The pre-workout meal should be high in carbohydrates, not rich in fat, and readily digestible. Current researches suggest that 1–4 g of carbohydrate per kilogramme of body weight should be consumed 1–4 h before exercise [56]. High-fat or high-protein food should be avoided for their long gastric emptying time.

During an endurance exercise (longer than 90 min), muscles run out of glycogen, and they begin to take up glucose from the blood stream. Supplies of blood glucose can be drawn from liver glycogen, but with the persistence of the exercise, liver glycogen stores can be depleted and blood glucose level drops down. In these conditions, the athlete will note local muscular fatigue and will have to reduce his exercise intensity and in some cases it is possible to observe typical hypoglycaemia symptoms. The available evidence suggests that athletes should take in 25–30 g of carbohydrate every 30 min during an endurance exercise to maintain an adequate blood glucose level [14]. This amount can be obtained through either carbohydrate-rich foods or fluids during training (sports drink or energy bars).

After exercise, muscle glycogen that has been used must be resynthesised. It has been demonstrated that when carbohydrates (about 100 g) are consumed immediately after exercise, glycogen resynthesis can be faster [32]. It is also possible to obtain a more efficient glycogen resynthesis rate by adding protein to the post-workout meal. The reason for this improvement is that proteins can produce a greater insulin response and therefore activate glycogen synthase [71]. The current recommendations are to consume around 100 g of carbohydrates within a 30-min window postexercise to maximise muscle glycogen synthesis.

4.3.1.2 Proteins

The protein requirements do vary with the type and intensity of exercise performed and the total amount energy consumed. Several studies suggest that individuals who exercise at a higher intensity have a greater protein need [42, 61].

It has also been shown that the protein need depends on the energy intake; in fact, if calories from carbohydrates are insufficient, proteins will be used as an energy source, therefore increasing the need of protein intake [9].

Even if high-level athletes require a higher protein intake, being western diet often hyperproteic, general population doesn’t need a protein supplement. This means that if the caloric intake is adequate, athletes don’t need more proteins than the rest of the population.

Consuming more proteins than the amount that body can use should be avoided. When athletes follow diets that are high in protein, they can compromise their carbohydrate status and therefore affect their ability to train and compete at peak performance.

The unjustified large use of protein or amino acid supplements, common in some sports, can lead to dehydration, loss of urinary calcium, weight gain, and stress to the kidney and liver [59].

4.3.1.3 Fat

Fat also provides energy for exercise. Fat is the most concentrated source of food energy and supplies more than twice as many calories (9 kcal/gm) by weight as protein (4 kcal/g) or carbohydrate (4 kcal/g). Fat is the major, if not most important, fuel for light- to moderate-intensity exercise. Although fat is a valuable metabolic fuel for muscle activity during longer-term aerobic exercise, no attempt should be made to consume more fat.

However, it has been demonstrated that athletes who consumed a lower-fat, higher-carbohydrate diet had significantly more power and speed because of their higher muscular glycogen level [58].

4.3.1.4 Drugs

Athletes can easily fall under pressure because their performance is constantly being judged and evaluated. In addition, today at all levels, a certain number of athletes wants to win at all costs. Consequently, there is a big interest among some athletes in investigating drugs that may enhance performance. Those athletes believe that certain drugs may increase athletic performance and consider their use despite the well-known long-term health hazards.

One of the most common substances being abused by athletes is anabolic steroid. These chemical derivatives of testosterone are used by athletes to increase muscle mass, which improves strength and power. What sportsmen overlook are the long-term side effects of anabolic steroids including liver cancer, prostate cancer, abnormal sperm production and some psychological changes like aggressive and violent behaviour [70].

Another traditional doping agent is erythropoietin (EPO) that can increase blood cell count. Having more red blood cells to carry oxygen, athletes aerobic capacity is improved and fatigue delayed. EPO injections increase haematocrit level, which may cause a heart overload. This is particularly dangerous when the heart rate slows down, such as during sleep. The increased thickness, or viscosity, of the blood increases the risk of blood clots, heart attacks and strokes.

At last, weight loss drugs are frequently taken by athletes to lose weight quickly to make a particular weight classification. Currently, the most common drug being used to lose weight fast is the ephedra. This product is commercialised as a dietary supplement for the purpose of weight loss. These compounds increase heart rate, constrict blood vessels (increasing blood pressure) and expand bronchial tubes (making breathing easier). Their thermogenic properties cause an increase in metabolism, thus leading to an increase in body temperature.

The use of this substances can cause potentially fatal side effects, including stroke, heart attack, seizures, or severe mental disorders.

4.3.2 Sleep Hygiene

Although the function of sleep is not fully understood, it is generally accepted that it is necessary to recover from previous wakefulness and prepare for functioning in the subsequent wake period.

Sleep deprivation can have significant effects on athletic performance, especially submaximal, prolonged exercise [49].

Compromised sleep may also influence learning, memory, cognition, pain perception, immunity and inflammation [11]. Furthermore, changes in glucose metabolism and neuroendocrine function as a result of chronic, partial sleep deprivation may result in alterations in carbohydrate metabolism, appetite, food intake and protein synthesis [60].

Data from some studies which investigated about the effect of sleep on performance suggest that increasing the amount of sleep in athletes may significantly enhance performance.

Mah et al. [39] instructed six basketball players to obtain as much extra sleep as possible following 2 weeks of normal sleep habits. Faster sprint times and increased free-throw accuracy were observed at the end of the sleep extension period. Mood was also significantly improved, with increased vigour and decreased fatigue. The same research group also increased the sleep time of a group of swimmers to 10 h per night for 6–7 weeks and reported that 15-m sprint, reaction time, turn time and mood were improved [39].

Moreover, athletes suffering from some degree of sleep loss may benefit from a brief nap, particularly if a training session is to be completed in the afternoon or evening. Following a 30-min nap, 20-m sprint performance was increased (compared to no nap), alertness was increased and sleepiness was decreased. In terms of cognitive performance, sleep supplementation in the form of napping has been shown to have a positive influence on cognitive tasks. Naps can markedly reduce sleepiness and can be beneficial when learning skills, strategy or tactics if compared to sleep-deprived individuals [48]. Napping may be beneficial for athletes who have to routinely wake early for training or for competition and for athletes who are experiencing sleep deprivation [67].

Athletes should focus on utilising good sleep hygiene to maximise sleep time. Strategies for good sleep include:

The bedroom should be cool, dark and quiet. Eye masks and earplugs can be useful, especially during travels.
Create a good sleep routine by going to bed at the same time and waking up at the same time.
Avoid watching television in bed, using the computer in bed and avoid watching the clock.
Avoid caffeine approximately 4–5 h prior to sleep (this may vary among individuals).
Do not go to bed after consuming too much fluid as it may result in waking up to use the bathroom.
Napping can be useful; however, generally, naps should be kept to less than 1 h and not too close to bedtime as it may interfere with sleep [24].

4.4 Mental Constitution

The practice of sport, particularly at higher levels, is not devoid of perils. One of these perils is the lesion. Most of the lesions suffered by athletes are caused by the high demands of the competitive sport: attaining great results in a short time period, lack of psychological preparation, growing physical loads, disrespect of the adaptation time that the body needs to adapt to progressively higher demands, etc. [17].

We cannot say that there is a particular type of personality more prone to be injured [57, 68] because the research so far has failed to prove that particular personality characteristics are associated to injuries. However, a sensation-seeking person can be more willing to practise higher-risk sports such as skiing, motorbike, escalade, etc. The probability of these sports that cause lesions is higher than others [17], and his practitioners having consciousness of this must take more precautions without putting in question his achievements. According to Malina et al. [40], we can divide the risk factors for lesions in internals and externals. In the first category, we can put physical factors, problems of structural alignment, lack of flexibility, lack of muscular strength, a poor capacity development, behaviour factors, lesion history and variations associated with the maturity. In the external risk factors, we must consider inadequate rehabilitation from a previous injury, training errors, game conditions, equipment, mixture of age groups, trainer’s behaviours, parenting behaviours and the sports organisation.

What we say to the athletes with whom we work is that a physical injury always implies a psychological one also! So, if we treat a lesion from the physical side, we must treat it also from the psychological point of view. And with the advantage of some psychological techniques such as mental imagery, it can accelerate the recuperation time [68].

And, as the advances in sports medicine allow to an extraordinary reduction of the recuperation times, more and more important is the role of the psychological recuperation especially if we talk about professional sport where the athlete is a “financial investment” and must be fully recovered.

Initially, the researchers agreed on a five-stage process (similar to the one occurring in grief): after an injury, the athlete passes by different stages: immediately after the lesion the negation phase: “this has not happened to me”. After he gains consciousness, the rage phase succeeds: “why me?” Then he starts seeking reasons for suffering the injury, and if he surpasses all these phases with success, the fourth stage is depression. Finally, the last phase is acceptance. The time an athlete spends in each of these phases and the velocity which he passes through each depends on his personality and the support he receives from the others [25]. Now the common understanding is that the injury experience is not so rigid and ordered. So, we can talk about three general categories of responses [65]:

Injury-relevant information processing: the injured athlete gathered information related to the injury and recognises the negative consequences.

Emotional upheaval and reactive behaviour: as soon as the athlete realises that he is injured, he experiences a set of emotions such as shock, disbelief, denial, isolation and self-pity.

Positive outlook and coping: it’s when the athlete accepts the injury and deals with it starting coping efforts, has a good attitude and is relieved to see progression in his recuperation.

Athletes can also display other reactions [47]:

Identity loss: his self-concept as athlete becomes diffusing because of the effects of the injury.

Fear and anxiety: the thoughts about reinjuring and the worries about their recuperation and if some teammate replaces them are overwhelming. And all these can increase because normally an injured athlete has plenty of time.

Lack of confidence: as an injured athlete can’t practise and play, they can lose confidence in their abilities.

Performance decrements: because of the diminished confidence and the lost practice time, athletes can experience performance decrements when they return to practice and competitions.

The consequences of an injury are not only in terms of pain and suffering but also in self-esteem, quality of life, stress and anxiety, anger, treatment compliance issues, depression, concentration and attention problems, mood alterations, sleep disturbance, and alterations in cognitive processes and directly or indirectly, through all these effects, can affect relationships.

Fortunately, today, the traditional thinking of considering a lesion a mere biological problem has been surpassed, and the role of the psychological factors and their treatment is widely recognised.

We can divide the psychological intervention on injuries in two stages: prevention and rehabilitation.

At the preventive level, psychologists can intervene in athletes at injury risk: the ones with negative life stresses, an increase in daily hassles, previous injuries and poor coping resources [8]. Moreover, if an athlete experiences anger and aggression during a competition or has competitive trait anxiety, the risk of injury increases. “The combination of stress history, poor coping resources and personality factors results in what theorists call an elevated stress response. This involves increased muscle tension, increased distractibility, and a narrowing of attention so that the athlete is not as aware of or responsible to critical events or cues. Prolonged exposure to stress also changes the body’s endocrine system, making a person more susceptible to illness and slowing down the healing process” ([8], pp. 218).

Palmi [46] talks about three risk factors, the medical–physiological, psychological and sports related, and consequently suggests four intervention strategies:

Improving the basic information given to the athlete about the risk factors, the best preparation and the habits to prevent injuries.

Learning psychological resources to reduce the probability of injuries such as relaxation after finishing hard training sessions.

Planning the training and the competition with realistic goals adapting to his own condition and in order to avoid overtraining.

Improving technical resources because how much an athlete is ready to do a task is less the probability to get injured.

On the rehabilitation side, a psychologist intervention can address these aspects:

Establish a good relationship of confidence with the athlete.
Educate the athlete about the injury and the recovery process.
The athlete must accept his responsibilities in the treatment trying to actively seek information about the lesion and what he can do in order to recover as soon as possible.
The athlete must define clear, specific and realistic goals with a time frame in a short, medium and long term for the rehabilitation process and for the return to practices and competition.
The athlete should know how to get support from friends, family, teammates and trainers.
The athlete must work mentally in his recovery process taking consciousness of his attitude towards the injury and building positive self-talk about the recovery process, and if he can’t practise physically, he can mentally rehearse and practise.
The athlete can’t isolate himself from friends and family.
Teach the athlete how to cope with the possible setbacks.

The other sports medicine personnel involved in the rehabilitation process can act in order to [68]:

Educate and inform the athlete about the injury and recuperation process
Use appropriate motivation
Demonstrate empathy and support
Have a supportive personality (warm, open and not exaggerate confident)
Foster positive interaction and customise training
Demonstrate competence and confidence
Encourage the athlete’s confidence

4.5 Expectations of the Athletes and the Environment

One of the toughest things for an injured athlete to manage is with the self-expectations and also with the expectations from the others (family, trainers, managers, teammates, supporters and friends) about his recovery and returning to the practices and competitions.

One of the most important words we say to the injured athletes we work with is patience. Patience is very important for the athlete not to return too early and get reinjured but also to all the people around him who is important to the recovery process.

One athlete who is capable of working all the points mentioned earlier in the previous topic and who has a team of sports medicine personnel involved and is knowledgeable and has patience is far more near to recover well and return to his previous level of achievement or better!

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