PHOTO CAPTION: An athlete performs a lower body exercise while his physical therapist observes his technique. The COVID-19 pandemic has shortened off-season and pre-season training programs as well as limited access to facilities. Both factors can increase the injury rates in the upcoming fall, winter and spring sports seasons.

The current environment is a challenging one. There have been significant disruptions this year to the academic calendar as well as interruptions and modifications to the typical athletic calendar; all due to the COVID-19 pandemic. For example, specific sports typically played in one season are being rescheduled to a different time of the year, while other sports are playing this fall utilizing appropriate health and safety regulations for athletes, coaches, and spectators.

The standard routine of pre-season training, daily and weekly practices, and a season of competition has now been changed because of COVID-19 concerns. As athletes return to their sport of choice, it is important for the clinician to recognize the multitude of factors at play currently, including the physical, psychological, and social factors, and their potential impact on the patient or athlete. It is imperative for the physical therapist to provide support for these individuals, including physical treatment provided in clinical settings to address specific injuries, education about proper off-season and pre-season training programs, and utilization of relationships within the community to educate individuals, teams, and organizations as needed.

Practice and Pre-Season Get Shorter

Participation in youth and high school sports is growing nationally, rising from approximately 4 million participants in the 1970s to an estimated total of greater than 7 million in 2005 and continuing to grow.1 The benefits of participation in sport are well-documented, including promotion of health and wellness, encouraging social interaction between peers, and improving personal mood and behaviors. However, with this growth of athletic participation there is a growing volume of injuries across multiple sports. This trend is observed among males and females and between all ages.

Knowles reviewed injuries at the high school level of an individual state over a 3-year period and noted an annual medical cost of $9.9 million, with a significantly higher amount for the total comprehensive cost—nearly $140 million.2 In the 2005-’06 school year, approximately 1.4 million injuries occurred nationally at a rate of 2.4 injuries/1,000 athlete exposures (AE; ie, practices or competition).1

The highest injury incidence rates for males are in ice hockey, rugby, basketball, soccer, football, and wrestling, while the highest rates for females occur in basketball, ice hockey, gymnastics, running, and field hockey.3,4 Football demonstrates the highest injury rate at 4.36 injuries/1,000 AE.1 Additionally, there is typically a higher rate of injury occurring in competitive games compared to practice, as well as higher rates occurring when the athlete is in a fatigued state.1,5,6 Research also generally indicates higher injury rates during the earlier parts of the season and then a gradual decline throughout the competitive season.7,8

A Reckoning with the Competitive Load

Due to the current environment, with a modified or non-existent practice and pre-season schedule, restricted facility access during the spring and summer months to perform appropriate training before the season, and potential to immediately ramp up the competitive load, there is a potential for an increase in total injury rates in the upcoming fall, winter, and spring sport seasons. Discussions with physicians at a local orthopedic practice, along with individuals working in the collegiate and professional settings in various sports, indicate a concern for higher injury rates in all sports, particularly for this upcoming season and for the following year due to the interruption in typical training schedules. In the upcoming months, there will be a primary role for the physical therapist to advise individuals about appropriate treatment to injuries, as well as with creation and implementation of appropriate off-season/pre-season training programs.

The International Olympic Committee (IOC) consensus statement on load in sport and injury risk provides an excellent quote about the risks of competing and practicing in a fatigued state5:

“At an athlete level, inappropriate loading can increase injury risk by impairing factors such as decision-making ability, coordination, and neuromuscular control. Fatigue from training and competition leads to reduced muscular force development and contraction velocity. In turn, this can increase the forces imposed on passive tissues, adversely alter kinetics, kinematics, and neural feedback, reduce joint stability, and thus contribute to increased risk of acute and overuse injuries.”

Sport-Specific Interventions

When an injury occurs to an athlete, it can generally be stratified into several different areas: an acute injury caused by sudden trauma, such as a ligament sprain, muscle strain, contusion, or fracture; an overuse injury occurring over an extended period of time, such as a tendonitis in the rotator cuff in the tennis player or a lower-body stress fracture in the distance runner; or a catastrophic injury, often occurring to the athlete’s head or neck area involving an injury to the brain or spinal cord, as well as the threat of severe cardiac involvement.

Another potential injury concern is the occurrence of a concussion to the athlete. This most commonly occurs in contact sports such as football, ice hockey, and rugby, but is an injury that can occur in any sport or activity. Although many times unreported or undiagnosed, it is estimated that concussions account for 5-13% of all injuries reported in high-school athletes.9 Specific interventions provided by the physical therapist will be guided by the nature of the injury and on an individualized basis, keeping in mind appropriate tissue healing time periods. For example, a more aggressive treatment philosophy may be provided to the starting senior quarterback on the football team who suffers a grade I ankle sprain the week before the playoff game against a rival, versus the sophomore baseball pitcher with a partial tear of the UCL ligament.

Within the soccer population, there is significant support for performance of an eccentric strengthening program to reduce frequency of hamstring strain,10 while performance of the “Thrower’s 10” or other upper body strengthening program and utilization of an off-season interval throwing program may assist with reducing injury rates within baseball and softball players. For all sports, it is imperative for the physical therapist to provide appropriate interventions, both in-season and during off-season training, to address active injuries within athletes and prevent a potential increase in injury rate during the upcoming seasons.

Strategies for Reducing Injury Risk

While it may be impossible to completely eliminate the injury risk of sport, there are different ways to reduce the frequency and severity of injuries. For instance, incorporation of a targeted pre-season exercise program can strengthen musculature, improve balance/proprioception, and improve endurance of athletes to reduce injury rates in various sports. Specifically, focused training programs show the ability to reduce risks of lower extremity, knee, and ankle injuries, including ACL tears and ankle sprains.6 Incorporation of core and lumbar spine strengthening programs also demonstrate positive outcomes by beginning with basic neuromuscular control of local stabilizing musculature, advancing with stabilization exercises to promote co-contraction between local and global muscles, and ultimately challenging the athlete with dynamic functional movements to reflect real-world demands.11

Another strategy to reduce injury rates includes addressing external factors, such as proper utilization of appropriate protective equipment (helmets, mouth guards, bracing/taping, etc). Appropriate understanding of the sport’s rules, such as proper tackling posture in football, may also assist the physical therapist with controlling potential injuries by identifying higher-risk individuals. For this year’s upcoming seasons for various sports, it is also important for the physical therapist to be aware of the threat of calendar congestion, referring to the accumulation of competitive events over a shorter period of time, with the majority of available data suggesting an increased risk of injury with more competitive events.5

Multiple well-respected sports medicine physicians, physical therapists, and athletic trainers advocate for a period of rest in-between sports or in-between seasons. In fact, according to the IOC statement on youth athletic development, “a break in training and competition is often therapeutically essential, and ultimately more beneficial to the athlete, than trying to maintain the usual routing and consequently inhibit recovery of an injury or acute illness.”6 In the coming seasons, the physical therapist may have to take a more central role in conversations with coaches, players, and families to educate about proper rest periods and preventing excessive participation when appropriate.

Therapists Can Lead the Way

It is important for the physical therapist to work collaboratively with athletic trainers, physicians, and other stakeholders like parents and coaches to provide the highest-quality care to the injured athlete. Opportunities currently exist for physical therapists to grow relationships with local teams, schools, and other organizations to provide appropriate interventions, both in a clinical setting and on the field. Typically, this may involve providing treatment to athletes or education to teams in the form of an injury prevention program. In today’s environment, this may also include assisting with creation of health and safety guidelines and guiding competitive scheduling and load management to help manage overall workload for individuals and teams.

In addition to the physical treatment of these athletes and patients, due to the various external stressors currently facing individuals including the uncertainty of games and practices amid the continued COVID-19 pandemic, the physical therapist’s role should also include psychological training to help progress them back to their field of competition. By striving to provide high-quality care to patients across the total spectrum of care, the physical therapist can assist patients and athletes with returning to their peak level of performance. RM

Andrew L. Hutchinson, PT, DPT, SCS, is an outpatient orthopedic and sports physical therapist with ATI Physical Therapy in Birmingham, Alabama. He is a guest lecturer with the American Sports Medicine Institute, functions as a clinical instructor and mentor to physical therapy students and clinicians, and is involved with direct treatment of high school, collegiate, and professional athletes in the community. Hutchinson graduated from the University of St. Augustine for Health Sciences and has been practicing since 2011. For more information, contact [email protected].


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