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Injury prevention

For more powerful safety messages, focus on adverse outcomes not risk factors

11 Mar, 14 | by Caroline Finch


Cross Fertilising British Journal of Sports Medicine (BJSM) and Injury Prevention (IP)


An interesting paper, by Morrongiello et al., in the most recent issue of the Injury Prevention Journal (Volume 20, Issue 1) presents the results of a study that investigated the nature of images that should be used for powerful safety messages. The context was safety messages aimed at parents of young children. For each message, two images were provided – one that depicted the risky scenario itself (i.e. focussed on the injury risk factors) and the other on type of injury that would occur (i.e. the adverse health outcome). For example, one image showed a toddler near a flight of stairs, the other showed a head injury resulting from a fall down those stairs. The study concluded that images depicting negative consequences, which then evoked negative emotions, were considered much more powerful safety messages than comparable injuries just alerting viewers to the presence of hazards and risk factors.

These findings of are in accordance with the principles of maximising consumer value and understanding consumer motivations as outlined in our editorial in the BJSM on the need for social marketing for injury prevention messages.

Whether or not such findings would also apply to athletic populations is unknown. Intuitively, parents of child athletes could well be influenced by such negative messages. But would negative outcomes also apply to adults who govern their own injury prevention behaviours during the sport they play and have prevailing beliefs that injury would not happen to them?

Some of our recent research into the attitudes of coaches and sports trainers in relation to concussion management in Australian football and Rugby League, has highlighted the dimension of concept of“moral regret” as a key motivator for change. Essentially, this means that coaches and sport trainers who feel that they would be letting down players by compromising their health/playing futures if they did not use concussion management guidelines are more likely to use them. We recommend capitalising on this regret aspect to promote correct concussion management in the future – a strategy that implicitly builds on messages relating to the chances of negative adverse outcomes, not injury risk per se.


Caroline Finch is an injury prevention researcher and Head of the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Federation University Australia located in Ballarat, Victoria, Australia. She specialises in two areas: (1) sports injury surveillance and research methodologies and (2) implementation and dissemination science applications for sports injury prevention. She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and the Statistical Editor for Injury Prevention; both journals are published by the BMJ Group. Caroline can be followed on Twitter @CarolineFinch.

Injuries will decide the English Premier League Title (once again!)

27 Aug, 12 | by Karim Khan

Guest Blog by Peter Brukner (@PeterBrukner)


What will determine who will win the 2012-13 Premier league title?

Money, manager, quality of squad – all these factors are obviously important, but in the end when you look at the teams that have top quality squads – and I would probably include Man City, Man United, Chelsea, Arsenal and Tottenham in that list – then the biggest single factor will be the injury record of these clubs.

One only has to look back at last season to see how important injuries were in deciding the eventual winner. Here are the stats on the top eight teams in last year’s Premier League (courtesy of the excellent website


If we compare the two Manchester clubs, Manchester City had a fraction of the games missed compared to United. Remember United had a number of long term injuries to key players Nemanja Vidic, Darren Fletcher and Anderson.

There is no doubt that had there been parity, or anywhere near parity, between the two with injuries, then the title would have gone to United once again.

Are injuries just a matter of bad luck or can they be prevented?

There are a lot of factors that can influence injury rates. These include the number of games played, the type of training and the age of the players. If players have to regularly play twice a week (e.g. Premier League and Champions League matches), then they are more likely to be injured. Those clubs with greater depth in their squads who can afford to rotate players and reduce the game load should be in a better position to reduce injuries.

The last but by no means least factor is luck. The majority of injuries are probably not preventable and are the inevitable result of the physical demands placed upon players in the Premier League.

However there is a particular group of injuries that may be “preventable”.

Clubs generally divide their injuries into muscle and tendon injures such as hamstring, groin, calf and achilles problems, and other direct contact injuries. Most clubs now pay particular attention to reducing the number of those muscle and tendon problems. There is considerable evidence now that a comprehensive injury prevention program can significantly reduce muscle and tendon injuries.

Getting managers and players to embrace the concept of injury prevention has been a challenge for club medical and fitness staff. Managers will always tell you how keen they are on injury prevention (a “no-brainer”), but actually getting them to allocate part of the precious time spent at the club to prevention is another matter. It amazes me that players earning £100,000 per week are not expected to commit additional time other than the 1-2 hours on the training ground to matters such as injury prevention.

When I arrived at Liverpool two years ago I was told by numerous people that we would never get the players to embrace a culture of injury prevention and spend the time on the necessary exercises to achieve that. However the opposite has been the case and once the players realised the benefit of what we were proposing, they fully embraced the change of culture. By the end of last season, most were in the gym doing their personalised injury prevention programs every day.

There is unfortunately a culture among Premier League clubs of not asking the players to do anything they don’t want to do. The challenge for club fitness and medical staff is to convince players and management that a little time and effort spent on prevention will be more than worthwhile by the end of the season.

Should clubs be making their medical and fitness departments a higher priority?

It makes sense from a business point of view that when you have extremely valuable assets (the players), one should look after those assets as well as possible. It is an interesting point to note that Chelsea, Liverpool and Man City, three clubs which had significantly lower injury rates than the other top clubs last season, have all invested heavily in their medical and fitness staff in the past few seasons, allocating more resources and recruiting high quality personnel.

One thing for certain is that once again this season injuries will play a major role in determining the Premier League title and clubs will be paying more and more attention into ensuring that their players get the best medical, physiotherapy and fitness advice to reduce the number of games missed by key players through injury.

Related Articles

J W Orchard. (2009) On the value of team medical staff: can the “Moneyball” approach be applied to injuries in professional football? Br J Sports Med 2009;43:13 963-965  (viewed over 3000 times) 

Arnason A, et al. 2004. Physical fitness, injuries, and team performance in soccer. Med Sci Sports Exerc. Feb;36(2):278-85.

Eirale, C et al. Low injury rate strongly correlates with team success in Qatari professional football Br J Sports Med bjsports-2012-091040Published Online First: 17 August 2012  (not free – Online first for subscribers and BJSM member societies)



Dr Peter Brukner (@PeterBrukner) is an Associate Editor of BJSM and an Australian sports medicine physician, author and media commentator living in Liverpool, UK. Currently working with Sky Sports News and one of the sports physicians working with the Australian cricket team.

Reposted with permission from Peter Brukner’s website  – a site for provocative and insightful sport and exercise medicine columns. Follow @PeterBrukner on Twitter.

BJSM invites your comments on Twitter using the #EPL hashtag or @PeterBrukner to help us follow the conversation.

We need to promote protective equipment differently

31 Jul, 12 | by Caroline Finch

Cross Fertilising Injury Prevention’ journal (IP) and BJSM                           



Protective sports equipment can prevent serious injury (McIntosh et al, BJSM, 2011). Why then doesn’t everyone use it?

Behaviour change theory tells us that, first, attitudes need to be right. But if people do not support protective equipment they will not use it.

A paper by Ruedl et al in the June 2012, Volume 18 (3) issue of Injury Prevention has categorized differences in why some people do and do not wear ski helmets. What differentiated the two groups most was a “subjective disadvantage” attitude in which users had much more positive opinions about helmet design factors such as their stylishness, ability to keep the head warm, non-restriction of vision, non-effect on hairstyles, cost and weight. In contrast, there was a negative association between helmet use and “safety awareness” attitudes, with the more safety conscious skiers being more likely to wear helmets.

As I read this paper, I was struck by the similarity of these ski helmet findings to those we found for protective eye-wear use in squash a decade ago (Eime et al, Sports Medicine, 2004). An additional observation from our work was that the non-users who were so critical of the design and wearability features of protective eye wear were also those who were more likely to have never tried it.  So preconceived opinions about protective equipment are a barrier to even trying it in the first place. By framing the issue within the socio-ecological framework for behavior change, we were able to successfully design and implement a promotion campaign aimed at addressing this particular belief, as well as others (Eime et al, BJSM, 2005).

Many sports have challenges towards maximising protective equipment use, especially (but not exclusively) when they do not introduce regulation mandating it.  We’d like more people to use it but that means convincing those with negative attitudes about it to change their behaviours.  In other words, we need to improve how we market protective equipment to those most likely to benefit from its use.

We argued in a very recent BJSM editorial, the way forward must be for injury prevention experts to learn from our social marketing colleagues (Newton et al, BJSM, 2012).  Imagine the power of a truly viral safety campaign that leads to demonstrably higher rates of appropriate protective equipment. What a dint that would make on injury rates!



Caroline Finch is an injury prevention researcher from the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Monash Injury Research Centre, Monash University, Australia.  She specializes in both injury surveillance and implementation and dissemination science applications for sports injury prevention.  She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and a member of the Editorial Board of Injury Prevention; both journals are published by the BMJ Group.  Caroline can be followed on Twitter @CarolineFinch

Safer bicycling. Better roads? More helmets? Increased legislation and enforcement?

23 May, 12 | by Caroline Finch


Last month in a BMJ blog, Domnhall Macaulay stated “Cyclists deserve our support; we need to address the risks of riding on the road and make cycling safer.” In one of my earlier BJSM blogs, I also pointed out that bicycling safety has long been a research and action goal of many injury prevention experts. The April 2012 issue of Injury Prevention contains several new papers, from Canadian injury prevention researchers, that each address some aspect of bicycling safety and injury.

Mecredy et al report data from a national survey of Canadian school-aged children about their injury experiences. The survey included a particular focus on the built environment and street connectivity close to the neighborhoods where they lived. A key finding was that children living in neighborhoods with poor connectivity reported more injuries and this was largely attributable to bicycling injuries. In fact, more than half of all physical activity related injuries that occurred on streets were associated with bicycling. The authors use these findings to argue for the design of safer streets, with more consideration given to separating bicycles from other forms of traffic.

There are varying approaches towards encouraging or supporting the use of cycling helmets globally. These range from mandatory road rules to educational campaigns aimed at voluntary uptake to little or no focus. In Toronto, legislation requires all cyclists under the age of 18 to wear helmets but older cyclists can choose whether or not to wear one themselves. It is not surprising, therefore, that the observational study by Page and colleagues has reported an overall bicycling helmet wearing rate of only 50%. Of course, children were much more likely to wear helmets than adults were (but not exclusively so). But females were also more likely than males to do so and helmet wearing rates were also highest in commuter cyclists. (The researchers also observed other types of recreational riders and found the use of helmets to be even lower in people who used scooters, inline skates and skateboards.) The authors recommend that the mandatory cycle helmets laws be extended to adults to increase helmet-wearing rates and that the legislation be more enforced across all age groups.

Irrespective of whatever actions are implemented to improve the environments or safety behaviors of bicyclists, high quality, reliable data is needed to evaluate the impact of these preventive strategies. Many bicycling-related injuries are treated in emergency departments (EDs) and therefore injury surveillance conducted at this place of treatment has the potential to contribute to ongoing population-level evaluation efforts. As demonstrated by Karhaneh et al, the use of International Classification of Disease (or ICD) codes specifically developed for bicycling injuries can be used reliably and accurately in the ED setting, confirming the value of ED data for bicycling injury surveillance. Unfortunately, the same could not be said for the other group of physically-active road users, the pedestrians.

There is no doubt that bicycling is a very healthy active pursuit that is to be encouraged. However, as with all other forms of physical activity, if injury risks are not kept to a minimum then bicycling will be unsustainable as a long-term population physical activity promotion strategy, particularly in countries which do not have the road infrastructure to support safer cycling. In terms of active road users, bicyclists have received the greatest safety research attention to date and are likely to still do so. But this is still good news, because strategies to improve safety for cyclists (particularly improved road infrastructure and driver behaviors) are also likely to benefit other non-motorised users of roads (pedestrians, runners, skateboarders, in-line skaters and the like) too.



Caroline Finch is an injury prevention researcher from the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Monash Injury Research Institute, Monash University, Australia. She specialises in implementation and dissemination science applications for sports injury prevention. She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and a member of the Editorial Board of Injury Prevention; both journals are published by the BMJ Group. Caroline can be followed on Twitter @CarolineFinch

An introduction to physiotherapy issues in groin pain

2 May, 12 | by Karim Khan

By Helen Millson (M.Phil.Sports Physio UCT)


Well-known FIFA sports physio Mario Bizzini called groin pain “The Bermuda Triangle of Sports Medicine?” (1) with good reason! There is little consensus on groin pain management. The key is the Correct Diagnosis – Easier said than done! This blog introduces key issues for more junior sports clinicians.


What is Groin Pain?

Undergraduate training often fails to emphasise the two joints in the pelvis –   the hip joint and also the pubic symphysis are at the centre of many movements. (2)  As a clinician, try to assess how the patient’s functional movement influences both the hip and the pubic symphysis. What causes pain and where?  Try to understand the entire kinetic chain with its related function to the pelvis / groin / hip. Then perform relevant clinical tests as well as sports-specific functional tests.

The cause of groin pain is a ‘million dollar question’…….

The diagnosis is mostly by exclusion not inclusion. Osteitis Pubis (OP) diagnosis is no longer an accepted term. This may be a normal response to overload and may lead to bone stress reaction, and then possibly joint and disc degeneration. Increased signal of bone marrow oedema may be a precursor to the development of groin pain. It may or may not correlate with clinical symptoms. (3) As a clinician, consider prevention and reducing load when there are early groin pain symptoms or radiological changes (MRI) of excess load.

And what of the Adductor muscles? (4)

In soccer players with groin pathology, adductor dysfunction is a more frequent MRI finding than “osteitis pubis”. Both entities are mechanically related and frequently coexist.

Specific strengthening of all Adductor muscles is one of the main goals for preventing and managing groin / hip pathologies.

However, one must not be single minded and should take into account other structures including Ligamentum Teres tears (5), Ilio Psoas (6), Greater Trochanter (7), Rectus Abdominus (8), Pelvic floor muscles (9) and Gluteus muscle function (10).

Then consider Radiologists with their preferred way of imaging.

Although radiological investigations are important, most studies tend to agree that experienced clinical judgment remains a critical element in the diagnostic pathway. (11)

A few groin / hip tests have been well documented and are valuable for diagnosis. (12)

What about the treatment options?

There is consensus in the literature that non- surgical treatment should always be applied before surgery is considered. However, the time span differs in the studies.

The rehabilitation protocols show gradual progression based on objective functional and clinical markers over a reasonable time frame.

In my experience, it is of value to always have pre-season specific baseline tests (Musculo-Skeletal evaluation).

The rehabilitation can take anything from 3 – 12 weeks depending on the actual diagnosis e.g. if it is an overload problem, one would “actively rest” the athlete until they are able to fully function symptom free in their respective sport.

One should address the local strength first, followed by functional strength with the entire global perspective taken into account.

Reassessment criteria to judge progress and assess next level of activity with objective markers are essential in order to increase the rehabilitation appropriately.

Of course, at an elite sports level, one is mostly not given this time-frame to do conservative rehabilitation!

Post-operative rehabilitation programmes varies from 10 days – 12 weeks.

This depends on the type of surgery, the specific demands  and………the very different requirements of the Surgeon involved!

And surgery:

•   No consensus as to an ideal operating technique

•   Serial patient outcome measurements are needed to base intervention success on factors other than return to sports activity.

• Operate on asymptomatic side, as it has been suggested that 40% progress to bilateral?

There is also on-going controversy regarding the prevalence of a True Hernia, with many different surgical implications. (13)


Then on to the discussion regarding hips…….

The prevalence of radiographic hip abnormalities in elite soccer players is considerable. (15)

One must identify the relationship between these radiographic abnormalities and the clinically symptomatic pathologies.

A battery of tests should be utilised to improve the accuracy of the clinical reasoning.

Hip joint restriction often precedes the development of chronic groin injury and may be a risk factor for this condition.

One must also remember that the Acetabular Labrum and Ilio-Femoral Ligament are vital for normal hip mechanics and excessive removal of either in surgery can be detrimental.  (16)

As our understanding of FAI and chondral injuries and their causes grows, future efforts will focus on prevention.

Future research is required to determine the extent to which physio intervention aimed at improving hip kinematics would be effective in treating individuals with labral injuries



•   The challenge lies between ascertaining the Anatomical diagnosis vs. Pathological diagnosis vs. Functional diagnosis – the interaction of the three will influence prognosis and management, whereas identification of one alone will give a bias in one direction.



•     In spite of minimal EBM, it seems the most pertinent point is that many of the groin /hip pathologies can be averted by thorough and specific pre-habilitation, bearing in mind the entire kinetic chain and addressing total function around the pelvis above and below.



1)    Bizzini M. “Warm: Up the Bermuda Triangle of Sports Medicine?” in BJSM 2011.

2) William Meyer, FA Conference London Dec 2011

3)  Paajanen H. 2009. “Sports hernia” and osteitis pubis in an athlete. Duodecim. 125(3):261-6.

4)  Wiktorsson-Möller, Oberg , Ekstrand , Gillquist,1983. AJSM; Lynch SA, Renström PA.1999. Sports Med; Orchard et al., 2005. Clin J Sport Med; Cunningham et al. 2007; Phillipon 2009; Lloyd 2009; Thorborg 200; Crow 2010; Gilmore 2011; Davis et al, 2011; Connell 2011; Schilders 2012 and many others.

5)  Botser IB, Martin DE, Stout CE, Domb BG. 2011. Tears of the ligamentum teres: prevalence in hip arthroscopy using 2 classification systems. Am J Sports Med. Jul;39 Suppl:117S-25S.

6)   Hölmich P. 2007. Long-standing groin pain in sportspeople falls into three primary patterns, a “clinical entity” approach: a prospective study of 207 patients. BJSM. Apr;41(4):247-52; discussion 252. Epub 2007 Jan 29.

7)  Steinbrueck A, Hocke S, Heimkes B. 2011.Apophyseolysis of the greater trochanter through excessive sports: a case report. Am J Sports Med. Jan;39(1):195-8.

8)  Connell D, Ali K, Javid M, Bell P, Batt M, Kemp S. 2006. Sonography and MRI of rectus abdominis muscle strain in elite tennis players. Roentgenol. AJR Am J. Dec;187(6):1457-61.

9)  Ruth C. Lovegrove Jones, Qiyu Peng, Maria Stokes, Victor F. Humphrey, Christopher Payne, Christos E. Constantinou. Mechanisms of pelvic floor muscle function and the effect on the urethra during a cough. Eur Urol 2010;57:1101-10.

10)  Graham RB, Costigan PA, Sadler EM, Stevenson JM. 2011. Local dynamic stability of the lifting kinematic chain. Gait Posture. Oct;34(4):561-3; Philippon MJ, Decker MJ, Giphart JE, et al.2011. Rehabilitation exercise progression for the gluteus medius muscle with consideration for iliopsoas tendinitis: an in vivo electromyography study. Am J Sports Med. Aug;39(8):1777-85. Epub 2011 May 12.

11) Garvey JF. 2011. Computed tomography scan diagnosis of occult groin hernia. Hernia. 2011 Dec 14.

12)  Delahunt  et al. Man Ther. 2011; Anthony Hogan, FA Conference London 2008; Pers Holmlich, BJSM 2004, BJSM 2007; Mallarias, Hogan et al BJSM 2009; James Moore Rehabilitation Chapter in Prof Haddad Book –  “The Young Adult Hip in Sport”. To be published 2012.

13)  Connell DG…. Patient care – crunch time. Br J Gen Pract. 2009

14) Gerhardt et al, AJSM 2011

15) Myers AJSM 2011

Blog by Evert Verhagen: Taking one step backwards to jump forward – the case with ankle sprains

25 Apr, 12 | by Karim Khan

Guest blog by Prof @EvertVerhagen


It is well known that ankle sprains are the most common sports and physical activity (PA) related injury. It has also been clearly documented that athletes who experience an ankle sprain have a higher risk of re-injury within 1 to 2 years post-injury. This increased injury risk after an initial ankle sprain is generally thought to be caused by a proprioceptive impairment in the ankle due to trauma to mechanoreceptors of the ankle ligaments after an ankle sprain. Partly based on this rationale, neuromuscular training (NT) is widely used for rehabilitation after an ankle sprain, and is thought to improve proprioception by re-establishing and strengthening the protective reflexes of the ankle. However, despite a vast number of studies pointing towards the preventive effectiveness of NT, use of NT in practice does not seem to pick up. This leaves a high rate of ankle sprain recurrences that potentially can be prevented.

Consider the research cycle as postulated by Tugwell et al. [1] (Figure 1). In general this cycle states that effective prevention of injuries is the result from a sequence of seven translational steps, ranging in content form fundamental to practical. The first step is identifying the burden of disease and the seventh is evaluating a program that provides, by implementation, health benefits in the real world. If one substitutes ‘disease’ with ‘ankle sprains’, gaps arise in this translational research cycle. With regards to ankle sprains and NT there is an abundance of knowledge of step 1 (burden of disease) [e.g. 2-4] and  a vast knowledge base on steps 4 (effectiveness) and 5 (cost-effectiveness) [5]. However, etiological (causation) and efficacy evidence is lagging behind, and implementation knowledge and program evaluation is completely lacking.

Figure 1 The research cycle of Tugwell et al.[17] In this model, there are seven distinct steps. The first is identifying the burden of disease and the seventh is evaluating the implementation of a program that provides health benefits in the real world (e.g. a prevention program for ankle sprains).

In my opinion, to push preventive in practice forward we require a more integrated and translational approach to bridge the gaps between on the one side effective preventive measures and the underlying working mechanisms, and on the other side between effective preventive measures and true injury prevention in every day practice (Figure 2). We need to take one step backwards in order to jump forward.

Recently we finished the 2BFit study, a RCT on the effectiveness of an 8 week unsupervised NT program for the prevention of recurrent ankle sprains [6,7]. This particular program was a further elaboration from a previous study we conducted [8,9]. In two studies this neuromuscular training program has now been proven (cost)effective for the prevention of ankle sprain recurrences. I dare to state that based on available evidence we now have an epidemiologically sound effective preventive NT program that can be used to unravel preventive pathways as well as effective prevention in practice.


Figure 2 A schematic description of the proposed translational approach with a (cost) effective preventive measure as the starting point of fundamental and implementation goals.

Therefore, in a laboratory setting we can specifically study changes induced by the program in recently injured athletes, as compared to healthy athletes. This will provide information on which etiological factors are positively affected, which specific exercises of the program induce this effect, and the required frequency and duration of exercises for the NT program to be effective. The latter is required as the current effective NT program is a container of different exercises targeting strength, proprioception and agility in an 8 week program prescribing 3 exercise sets per week. Not surprisingly full compliance to prescribed program was low, even in controlled studies. Through this approach, fundamental knowledge will provide guidance to specify the NT program to it’s bare essentials and decrease user-burden while retaining full effectiveness. This will give us an effective and useable intervention message to be implemented.



  1. Tugwell P, Bennett KJ, Sackett DL et al. The measurement iterative loop: a framework for the critical appraisal of need, benefits and costs of health interventions. J Chronic Dis 1985;38:339–51.
  2. J Hootman, R Dick, J Agel Epidemiology of Collegiate Injuries for 15 Sports: Summary and Recommendations for Injury Prevention J Athl Tr 2007;42(2):311–319.
  3. Le Gall F, Carling C, Reilly T. Injuries in young elite female soccer players: an 8-season prospective study. Am J Sports Med 2008;36(2):276-84.
  4. William GF, Yard EE, Dawn C. Epidemiology of lower extremity injuries among U.S. high school athletes. Acad Emer Med 2007;14(7): 641-5.
  5. Verhagen E, Bay K. Optimising ankle sprain prevention: a critical review and practical appraisal of the literature. Br J Sports Med. 2010;44(15):1082–1088.
  6. Hupperets M, Verhagen E, Van Mechelen W. Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ 2009;339:b2684.
  7. Hupperets M, Verhagen E, Heymans M, et al. Potential savings of a program to prevent ankle sprain recurrence: economic evaluation of a randomized controlled trial. Am J Sports Med 2010;38(11):2194–2200.
  8. Verhagen EALM, Van Tulder M, Van der Beek AJ, et al. An Economical Evaluation of a Proprioceptive Balance Board Training Program for the Prevention of Ankle Sprains in Volleyball. Br J Sports Med 2005:39(2);111-115.
  9. EALM Verhagen, AJ van der Beek, JWR Twisk, LM Bouter, R Bahr, W van Mechelen. The Effect of a Proprioceptive Balance Board Training Program for the Prevention of Ankle Sprains. Am J Sports Med 2004:32;1385-1393.



Evert Verhagen is an Assistant Professor at the EMGO Institute for Health and Care Research at the VU University Medical Center, Amsterdam, the Netherlands.  You can follow him on Twitter @EvertVerhagen

Injury prevention in high level snowboard: A need to return to first principles?

17 Apr, 12 | by Karim Khan

 Guest blog by @CarolineFinch

In the recent BJSM blog Is high level snowboard too dangerous to allow your children to participate? Prof Engebretsen raises an important question, namely how to prevent injuries in a sport where pushing the extremes of physical performance in challenging and harsh environments is both an individual athlete and sporting organisation goal.[1]

Most recent advances in sports injury prevention have tended to focus directly on the athletes, themselves, with the aim of making them more resilient to the injury risks they are faced with in their chosen sport. I wonder if, for sports such as snowboarding where most injuries result from acute energy exchange beyond the body’s tolerance, it is time to go back to first principles for injury prevention and revisit the application of Haddon’s 10 countermeasure strategies.[2] In this hierarchy of injury control, “Make what is to be protected more resistant to damage from the hazard” is only the eighth strategy. There are seven higher order control strategies that could (and should) be applied to also reduce injury risks and hazards.

Engebretsen [1]also queries whether leaders of the sport really have true awareness of the risks in elite snowboarding. The fact that so little ongoing attention seems to have been given to identifying and implementing solutions meeting many of the higher-order Haddon countermeasure strategies would seem to support this. Interestingly, a recent blog by Laura Robinson at also queries whether “sports officials’ tendencies to put the fight for new viewers by making the sports more dangerous and exciting” are more favoured than the safety of the athletes of snow sports.[3]

We published a review of the evidence for preventing snowboarding injuries in 1999, with the main focus on recreational participants of this sport as it was still a very new activity in Australia.[4] At that time, the sport was considered similar to other snow sports and so most safety advice was derived from that for more general snow/ski safety. One of our conclusions was:

“the rapid international growth of the sport has not been matched by a detailed epidemiological evaluation of the injuries specific to snowboarding or of the countermeasures to prevent them” (page 118).

It would seem that the situation has not changed that much. All sports injuries occur within an ecological context in which multiple levels of the sports delivery system interact with the physical environments in which sports are undertaken and the specific characteristics of the athletes who participate in them.[5] This applies equally well to high performance and professional sport as it does to the more recreational forms. Future safety gains for snowboarding, as indeed other sports, will only be achieved if all stakeholder groups:

  1. are engaged and united from the outset;
  2. share common goals for the ongoing development of the sport;
  3. prioritise the safety of their athletes; and
  4. jointly invest in the development, implementation and evaluation of cost-effective injury prevention solutions according to Haddon’s hierarchy of control as translated to this sport.


1.         Engebretsen L. Is high level snowborrd too dangerous to allow your children to partcipate? Posted 1/03/2012.: BJSM blog – social
media’s leading SEM voice; 2012.

2.         Haddon WJ. Energy damage and the 10 countermeasure strategies. 1973;13:321-31.

3.         Robinson L. Faster, Higher … Deader. Posted 23/03/2012.; 2012.

4.         Finch C, Kelsall H. Preventing snowboarding injuries – what is the evidence? 1999;6:117-26.

5.         Finch CF, Donaldson A. A sports setting matrix for understanding the implementation context for community sport. Br J
Sports Med. 2010;44:973-8.



Caroline Finch is an injury prevention researcher from the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Monash Injury Research Centre, Monash University, Australia.  She specialises in implementation and dissemination science applications for sports injury prevention.  She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and a member of the Editorial Board of Injury Prevention; both journals are
published by the BMJ Group.

Caroline can be followed on Twitter @CarolineFinch

Sports injuries are freak accidents – or are they?

10 Apr, 12 | by Caroline Finch

 Guest Blog by @CarolineFinch

Cross Fertilising ‘Injury Prevention’ journal (IP) and BJSM

Compared to many other health issues, it seems that it is not hard to get media stories about sports injury into our daily newspapers.  What seems to be hard, is the coupling of such stories with positive injury prevention messages.

An interesting paper in the February 2012 18(1) issue of Injury Prevention reports an analysis of US new stories and their use of the phrase “freak accident” in the reporting of injury events. The Editor’s Choice paper by Smith et al identified 250 human injury stories over a 5-year period that used this phrase. The vast majority of stories (61%) related to injuries sustained by professional athletes and these mainly focussed on the nature or impact/outcome of the injury. Only 9% of the professional athlete injury news stories contained any clear prevention content.


This study is consistent with the findings from an Honours student project I supervised in 2009 (Sarah Hester, University of Ballarat).  We undertook a daily hand check of three Victorian (Australian) newspapers and identified 3215 media stories mentioning injury or injury-death and recorded the context in which those injuries occurred.  We also found the majority of stories to relate to injuries in sport (64% of the total) and hardly any of these mentioned injury prevention at all (<1%) (unpublished data).

There is ample anecdotal evidence that many people believe sports injuries to be an inevitable consequence of participation in sport.  It is not surprising that this view is common if the popular media fails to mention prevention, either directly or indirectly, in their stories.  The term “freak accident” just reinforces any belief that injuries in sport cannot be prevented and further implies that they are the result of just bad luck.  Public health orientated injury experts have long argued against the use of the term “accidents” because of the connotations of this word, and its use has been banned in BMJ journals since 2001.  Readers of the British Journal of Sports Medicine (BJSM) also well know that sports injuries in result from a combination of factors, and are certainly not freak events with no aspect of predictability or preventability.

Perhaps it is time for sports injury prevention researchers and sports medicine practitioners to actively work towards also have the word “accident” banned from all popular media coverage of sports injuries in both professional and recreational athletes. 

As long as major attitudinal barriers to sports injury prevention such as “there is nothing I can do to reduce my risk of injury in sport” and “of course everyone who plays sports get injured” prevail, all of our broad-based population efforts to implement injury prevention programs will largely fail.  Rather than just talking about the impact of injuries in terms of a need for ongoing medical treatment and time away from sport, we should also be routinely providing journalists and the media with simple messages about how the same sorts of injuries could be prevented in the future. What a better situation it would be for a future media analysis to find a strong reporting theme relating to guaranteeing lifelong participation in sport precisely because injury prevention is inevitable.

Success stories:

The AMSSM Annual Meeting (April 21, 2012) opens with a keynote session on Injury Prevention. It includes international sports injury prevention stars including Roald Bahr (Norway), Per Holmich (Denmark), Mark Saffron (US) and Martin Schwellnus (SA)

BJSM publishes 4 Sports Injury Prevention Themed issues annually. These are called the ‘IPHP’ issue of BJSM – Injury Prevention and Health Protection. You can find the archive of IPHP issues here


Caroline Finch is an injury prevention researcher from the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Monash Injury Research Centre, Monash University, Australia.  She specialises in implementation and dissemination science applications for sports injury prevention.  She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and a member of the Editorial Board of Injury Prevention; both journals are published by the BMJ Group.  Caroline can be followed on Twitter @CarolineFinch

Born to run or shoes are made for running? Adding science to the strident debate.

27 Mar, 12 | by Karim Khan

Guest blog by George Murley

There is an increasingly strident debate on the use of minimalist/barefoot versus traditional sports footwear in running, and there appear to be advocates for both sides who believe there is no need for a rational discussion.

Screen shot from: The Barefoot Professor - by Nature Video

The debate appears to have escalated following publications by Richards and colleagues (2008) ‘Is your prescription of distance running shoes evidence-based?’ and later by Lieberman and colleagues (2009) ‘Foot strike patterns and collision forces in habitually barefoot versus shod runners’ and McDougall’s book — ‘Born to Run.’

The main issue in this very messy debate seems to be whether ‘some’ barefoot/minimalist shoe running is beneficial. This is related to the first vertical impact force, minimalist shoes are meant encourages a forefoot strike and  decrease this force, which in turn dampens the first vertical impact force. This however has some individuals suggesting that running barefoot may lead to injuries related to loading of the Achilles and direct impact of the forefoot. A second part of the argument is that footwear is supposed to weaken foot muscles whereas barefoot running challenges muscles and presumably leads to stronger/hypertrophied muscles that in turn have a positive effect of function.

Clinically we are primarily interested in the effect on injury.  There are strong views and some limited evidence supporting arguments about the relationship between the first vertical impact force and injury.  One perspective is that first vertical impact force causes injury whereas others argue injury is related to the ‘active’ forces of push off.

There are a ton of unanswered questions:

Does athletic shod or unshod running affect injury risk?

How does shod and unshod running interact with comfort and performance?

Which biomechanical parameters are related to injury risk?

Does footwear or unshod running reverse biomechanics parameters related to injury risk?

What is important is that clinicians and scientists approach this debate in a reasoned and calm way as there may be merit in both sides of the argument. Having only one perspective and fighting amongst ourselves is not necessarily going to help answer the questions or help the sportspeople make informed decisions about their footwear.



Podiatry Arena (extensive blogging on this issue)


Simon Bartold’s presentation


Lieberman et al (2010) ‘Foot strike patterns and collision forces in habitually barefoot versus shod runners’ published in Nature’s International Weekly Journal of Science

The Barefoot Professor: by Nature Video


Author Chris McDougall’s book — ‘Born to Run’


Richards et al (2008) ‘Is your prescription of distance running shoes evidence-based?’ published in the British Journal of Sports Medicine


Related BJSM Blog

To Strike or Not to Strike? That’s not the only question (for running and injury prevention)



Dr George Murley is a Podiatrist who graduated from La Trobe University with Honours in 2002. He then commenced teaching at La Trobe and completed his PhD related to the effect of foot posture and foot orthoses on lower limb muscle activity. Dr Murley was awarded the Stephen Duckett Higher Degree Research Prize for best PhD thesis in the Faculty of Health Sciences in 2010.

Bicycling opportunities and injury risk–both are about exposure

8 Mar, 12 | by Caroline Finch

Guest blog by @CarolineFinch

Cross Fertilising ‘Injury Prevention’ journal (IP) and BJSM

One of the most researched areas in road safety and injury prevention is that of bicyclist safety. In fact, my own initial foray into injury prevention research in the early 1990s was as a member of the team that evaluated the population-level impact of the first mandatory bicycle helmet wearing law (1). The topic of bicycle helmet effectiveness remains a topic of much debate despite much evidence that they are effective if worn correctly. Bicycling is also a major focus of current active transportation and physical activity research.

The February 2011 issue of Injury Prevention includes several papers relating to bicycling injury that are of relevance to anyone interested in increasing this form of physical activity. The first paper, by Poulos et al. presents the protocol of study that aims to describe the incidence of crashes, near-misses and injury rates in relation to bicyclist exposure factors including the time and distance travelled and the type of road infrastructure used. As the authors point out it is not fully obvious which type of bicycling infrastructure provides overall best safety gains and this needs further research. They cite the example that paths that are designed to protect bicyclists from road traffic, but which enable sharing by bicyclists and pedestrians, may in fact increase total injury rates due to collisions with pedestrians in which either type of oath user is injured. The study plans to recruit people who self-identify as active bicyclists and then to conduct two-monthly follow-up surveys with them to collect information about their bicycling habits and injury experiences.

Another paper in the same issue, by Ackery and colleagues, describes a case-control study of bicyclist deaths in the USA e documented as part of the well-established national Fatality Analysis Reporting System. This system includes all fatal crashes involving a motor vehicle on public roadways and so the bicyclist injuries were all the result of a collision with a motor vehicle. The study explored a range of exposure factors such as travel time of day, posted speed limits, and the type of vehicle collided with in both fatal cases and controls who were non-bicyclist road deaths. The most significant finding was that a disproportionately high proportion of the bicyclist deaths, compared to controls, involved larger and more expensive vehicles. The authors concluded that transportation policy should consider strategies to separate bicyclists from other very large road users.

The first French case-control study of helmet wearing and bicyclist injuries is described in a paper by Amoros et al. All study participants were recruited from a road trauma registry, with cases being bicyclists with a head injury and the control being bicyclists without head or neck injuries. Exposure to particular road infrastructure at the time of injury was collected in terms of the crash setting being on an urban or rural road and the type of road (as being major, local, or “off”). Evidence from this study is in support of the protective benefits of helmets.

As with all areas of physical activity promotion, there is a very clear and strong overlap with injury prevention. The bicycling context provides a graphic example of how increased exposure to a given ideal behaviour (e.g. in terms of duration of activity), can also increase the risk of adverse outcomes such as injury. Injury researchers have long known this and have a history of well-developed robust methods for measuring bicyclist exposure (e.g. in (1)). The success of active transportation as a physical activity will depend on there being suitable safe infrastructure and environments for the bicycling to occur in and the amount of bicycling (or exposure to positive physical activity) that ensues will be directly related to this. Conversely, increased exposure to hazards within those same environments, whether due to longer amounts of accumulated time spent bicycling or bicycling in settings with particularly high traffic volumes or poor road conditions, can lead to increased risk of bicycling injury. Active transportation policy developments will need to consider the provision of infrastructure to protect and support the needs of all road users, including those who wish to use it for their physical activity benefits, rather than just as a means of getting from a to b.

Additional reference
(1) Cameron MH, Vulcan PA, Finch CF, Newstead SV. Mandatory bicycle helmet use following a decade of helmet promotion in Victoria, Australia – an evaluation. Accident Analysis and Prevention. 1994, 26:325-337.

Caroline Finch is an injury prevention researcher from the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Monash Injury Research Centre, Monash University, Australia. She specialises in implementation and dissemination science applications for sports injury prevention. She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and a member of the Editorial Board of Injury Prevention; both journals are published by the BMJ Group. Caroline can be followed on Twitter @CarolineFinch.


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