Many factors that have a bearing on injury rates are the direct responsibility of the athlete. The athlete should be aware of the factors that are under their control, which include the following: general health, conditioning, adequate recovery, proper rehabilitation of old injuries, psychological stressors, appropriate nutrition, and education. With an understanding of these factors, the athlete can take an active role, with the help of the team physician, trainer, and/or coach, to correct and enhance areas of opportunity.

Any athlete who wishes to participate in organized sports should be required to go through a PPE. The primary goal of this PPE is to help maintain the health and safety of the athlete during athletic participation. The medical history is the key element of the PPE, as it can identify most problems that may affect the athlete. For this reason,
it is important that the athlete completes the historical questionnaire accurately, with a parent’s review for a minor, before the examination.

Any preparticipation screening should answer these questions: (a) Is this candidate mature enough to compete in the sport or sports for which the screening is being done? (b) Is this person in adequate physical condition to compete in the sport? (c) Does this candidate have any increased potential for injury? (d) Does this person have medical problems that may be a cause has disqualification from competition? The team physician is doing him/herself? and the athlete an injustice if all of these questions cannot be answered following the examination.

It is the athlete’s responsibility to be physically fit to begin competition or training. Being “in condition” means the athlete is equal to the neuromuscular demands and has the necessary strength and stamina for his/her sport (1).

Percent body fat and lean body mass can help determine an athlete’s level of conditioning and can be determined in any number of ways (2). Skinfold analysis, which is performed with a hand held caliper, is a simplistic way to measure body fat. It provides a reasonable estimate of body composition. Hydrostatic (under water) weighing is one of the most accurate ways to determine body composition (3), but is more involved, requiring a tank, weighing scale, and the ability of the athletes to perform a maximal expiration and hold their breath under water while the weight is being recorded (4,5). Most coaches and trainers will use the skinfold analysis to establish the athlete’s body composition. Those figures, along with periodic weighing, should be used to guide weight loss practices or weight maintenance.

Warm-up exercises are designed to prepare the body for exercise, prevent injury, and enhance the athlete’s performance (6,7). A good warm-up program consists of both general exercises that should be performed by all athletes and specific exercises that are targeted for the specific sport of the athlete, as well as specific position exercises (e.g., goalkeeper as opposed to field player warm-up in soccer).

General warm-up exercises should begin with large muscle groups, such as the quadriceps and hamstrings, as these are the main areas to which blood flow will be redistributed. Jogging and stationary biking are two such exercises often used. After the general warm-up, the athlete can begin more specific exercises for the particular activity they will soon undertake. For example, a swimmer should concentrate on further warming up the muscles, joints, tendons, and ligaments of the upper extremities, particularly the shoulder. A soccer player should concentrate on the lower extremities. Table 8.2 outlines some of the benefits of warm-up exercises. The whole warm-up session should last anywhere from 15 to 30 minutes, but may vary depending on the sport involved. The intensity may also vary, but at minimum it should produce an increase in heart rate and mild sweating. It is important not to warm up too early. There should be no more than 5 to 10 minutes between the end of warm-up and the beginning of the competition.

Flexibility refers to the ability to move a specific joint through a full range of motion and is an important component in any good conditioning program. The flexibility of a joint is limited by the tightness of its connective tissue. Therefore, the goal of improving flexibility through stretching is to improve joint mobility.

There are several forms of stretching: static, dynamic, ballistic, and proprioceptive neuromuscular facilitation (PNF). Static stretching is performed by slowly moving into a stretched position and holding the pose for 15 to 30 seconds. Each stretch should be performed three to four times/session. The athlete should assume a pose that will allow him/her to feel the tissue elongation and not feel pain or discomfort.

Dynamic stretching involves maximal joint motion secondary to muscle contraction. It involves controlled swinging of the limb with the athlete gradually increasing the distance, speed, or intensity without going past his/her range of motion. Ballistic stretching involves quick bouncing movements where momentum is used to achieve greater range of motion. This type of stretching does not allow the muscle tendon unit enough time to fully adapt to its stretched pose and can increase the chance of injury (8). Therefore, this technique is NOT recommended.
Interestingly, there are multiple studies showing that static, dynamic, and ballistic stretching may all aid in improving performance measures such as range of motion and muscle strength (9).

PNF stretching combines passive stretching with isometric contraction to attain increased flexibility. It is performed by alternating contraction and relaxation of the agonist and antagonist muscles. For example, if the hamstring is the target muscle, it is gently stretched by a partner, contracted isometrically against resistance (usually the partner), relaxed and then stretched further in the same range of motion. The disadvantage of PNF is that it requires a partner and there is a tendency to overstretch. Some basic stretching guidelines are listed in Table 8.3. Of note, there are reports of acute stretch injury wherein specific mechanisms of stretching may be associated with muscle strain and discomfort (8). Knowledge of proper stretching techniques and awareness of an athlete’s level of conditioning may decrease the incidence of such injury.

For a guide to inappropriate stretches, please consult Figure 8.1. In addition, there are multiple studies that find that static, dynamic, and ballistic stretching may all aid in improving performance measures such as range of motion, muscle strength, etc. (40).

Strength is the ability to produce maximal force in a single muscular contraction. Power (P) is the ability to exert maximal amount of work (w) rapidly over time (t). Both of these elements are key in enhancing performance, preventing injuries, and recovering from injuries.

There are 3 types of resistance training that can be utilized to enhance strength and power: concentric (positive work), eccentric (negative work), and isometric (static work) (10,11). In concentric training, the muscle contracts as it shortens in length against a resisting force. The resistance can be in the form of the athlete’s own body weight, free weights, weight machines, or rubber bands. Concentric exercises can be either isotonic or isokinetic. Isotonic exercises are those in which the resistance load is constant, thereby providing constant muscle tension throughout the range of motion of the exercise. Isokinetic exercises are performed on specialized machines, which are set at a fixed speed but variable resistance to accommodate the athlete.

Because isokinetic exercises require the use of specialized machines, isotonic concentric exercises are most commonly used in strength and power training. Examples of isotonic concentric exercises include dumbbell curls, machine leg extension exercises, and bench press.

In eccentric training, the muscle lengthens as the origin and insertion of the muscle separate during isotonic contraction. Eccentric training can be used to prevent musculotendinous injuries as well as to rehabilitate old injuries (12). Proper use of eccentric exercises is advocated, as misuse can cause delayed muscle soreness and tendinosis (13). An example of an eccentric exercise is slowly lowering the arm during the negative phase of a biceps curl.

Proprioceptive training is especially important following an injury, and assists in preventing injury recurrence (14

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