Injury Screening or Risk Management? – Marrying Data With Experience

Screening – Who’s responsibility is it??

This is a brief overview of musculoskeletal screening from the perspective of a first team physiotherapist working in the real world of professional football at League 2 where resources are limited. This is certainly not an in depth academic review. Instead, the aim is to stimulate debate and challenge the true purpose of screening our athletes.

Musculoskeletal screening in football is a very contentious subject possibly due to its inability to predict injury (McCall et al 2015). In addition to this, there is an ever-growing body of empirical literature that reports there has been no decrease in the incidence of injuries over the past decade in professional football despite the introduction of musculoskeletal screening (Ekstrand et al 2011). However, this is in contrast to a Premier League club who recently reported at an international conference in London that they have significantly reduced soft tissue injuries as a result of their screening methods. So why is there a discrepancy between the science of screening and screening in practice? Where does screening originate? What is the most effective screening method? Who should take responsibility for reducing injury incidence?

Screening: – A historical perspective

Medical screening has been undertaken for many years; for psychiatric disorders, syphilis and other diseases. Half a century ago, it was used primarily to keep unsuitable people from joining military service. Screening within professional football takes its cues from the principles of medical screening although the focus is on sporting injuries rather than idiopathic disease.

Screening Models:

Wilson & Jungner (1968) proposed a criteria that is widely considered as the benchmark for disease screening (Figure 1). These authors are often credited as pioneers for developing the modern principles of screening. Most of the points identified remain relevant to screening in football.

1. The natural history of the condition should be well understood
2. There should be a detectable early stage
3. Treatment at an early stage should be of more benefit than at a later stage
4. A suitable test should be devised for the early stage
5. The test should be acceptable
6. Intervals for repeating the test should be determined
7. Adequate health service provision should be made for the extra clinical workload resulting from screening
8. The risks, both physical and psychological, should be less than the benefits
9. The costs should be balanced against the benefits

Figure 1: Wilson & Younger (1968)

Application to Musculoskeletal Screening

Van Mechelen et al (1992) adapted Wilson and Junger’s approach and proposed a simple model to help “prevent injury”. This model emphasized that an understanding of the aetiology of injury and the risk factors were essential, prior to implementation of corrective strategies. Following this, the Translating Research into Injury Prevention Practice (TRIPP) (figure 3) framework was developed. In addition to Van Mechelen’s model it included athlete compliance and the assessment of risk taking behavior, which may predispose a footballer to injury (Finch, 2006).

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Figure 2: Four step sequence of injury prevention research

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Figure 3: Modified TRIPP Framework (Finch, 2006)

Risk Management and screening:

Musculoskeletal screening in football falls under the remits of risk management. This is the overall process of assessing and controlling risks and should be implemented as part of a best practice management system by critiquing one’s own current practice and using epidemiological studies (enable you to make evidence-based decisions) to assess a player’s ability to safely participate in training and games (Fuller & Drawer, 2004). The primary aim of screening is to identify risk factors (a condition, object or situation that may be a potential source of harm), estimate and evaluate the amount of risk associated with that factor as illustrated in Fuller & Drawer’s model below (Figure 4). A very good example of this would be the ongoing work by the FA and other sports governing bodies on cardiac screening of athletes to prevent sudden cardiac death.

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Figure 4: Risk Management (Fuller & Drawer, 2004)

Musculoskeletal Screening in Football

Musculoskeletal screening is very mechanical in nature and effectively is simplified into a set of numbers on an excel sheet at the end of the process. In contrast, injuries are complex, multi dimensional, and despite significant advancement in research and clinical screening tests capable of predicting future injury, the causative factors and pathophysiological processes of soft tissue injuries remain largely unclear. Although screening methods are being continuously scrutinised in order to establish a more extensive range of clinical indicators to predict injury, some clinicians might argue that it is currently of little value to screen players prior to participation due to the lack of clinical utility. In essence, this is because screening tests are very poor at predicting injury. For example, those who score badly may remain injury-free whilst those who score well may still suffer injury.

In reality, we as clinicians are continuously screening our players at every patient contact, which includes “corridor consultations”. If you were to only screen players according to the models discussed in this review, it is this author’s opinion that you may be missing out on valuable information, which may affect decisions on readiness to train and play. Soft skills, the ability to interpret subtle cues when interacting with a patient, although very difficult to quantify, play a vital role when assessing risk. It could be argued that going with your “gut feeling” has as much evidence behind it as any single clinical predictive test, just a thought!!! Of course I am not suggesting that we throw the baby out with the bath water, but maybe a more sensible approach would be to marry the science (objective data) with the art (experiential experience), in other words integrating an evidence-based approach into practice. It would take a very brave clinician to knock on the manager’s door and request that a player be removed from training on his GPS or heart rate data alone. A more holistic view when analyzing this data may increase its accuracy on assessing readiness to train and play.

We need to accept that there will always be a risk of injury involved in football, and unless we remove the player completely from training and playing we will not be able to eliminate the risk. It is a contact sport, which places extreme physiological and psychological demands on the player. Therefore, it would be unreasonable to think that we can mitigate for all the risks involved and that we can successfully prevent any injuries through screening. Consequently, it might be a better strategy when screening players to identify what the risk is and if it is an acceptable level of risk? To put it simply we need to think more in terms of utilizing a risk reduction approach rather than an injury prevention strategy. Preventing injury and reducing risks are not the same. Effective screening to identify the risks may impact on injury rates but this is not a certainty.

In my opinion this paradigm shift is long over due. As frontline clinicians working in professional football we need to educate all those involved about risk management rather than injury prevention. We need to involve players, managers, coaching staff and stakeholders in the process of risk management. Risk management needs to be a shared concept within your club rather than being your sole responsibility. “Framing” the risks involved in a positive manner to the players, managers, stakeholders and supporters in an open and honest fashion and educating them about their role in injury reduction is an extremely challenging communication skill, which should not be underestimated. How we communicate the risks involved can have an enormous impact the views/concerns of the recipients of the information. We need to educate players and coaches that we are “risk aware” rather than “risk averse” as medical practitioners are sometimes portrayed.

In conclusion, there are various methods for screening players and many authors have acknowledged that there is no particular musculoskeletal screening method, which is better than another for predicting injury. How you choose to screen your players will reflect your current playing squad, resources, facilities, manpower etc. In principle, the choice of screening method should be evidence based, reliable, specific and repeatable. Ideally objective-screening methods should form part of a wider holistic process, which takes into account the player as a person rather than being used in isolation to mechanically evaluate risk. There is no right or wrong way to screen, however, it might be prudent to critique your own screening philosophy to ensure it is fit for purpose to assess the risks involved at your club. This is not an easy process and even with the best risk management system there is no guarantee that you will reduce your injury rates, but at the very least you should be able to successfully determine what your risk factors are, who is affected by them and if the risks involved are acceptable. Reducing the injury burden should be a shared responsibility between all the parties involved in the club and should not lie only at the feet of the clinician. Players, managers and other stakeholders all have a role to play in managing risk. In essence, as long as you communicate the limitations of screening as a predictor of injury and are not naďve enough to think you can prevent injury, you shouldn’t go too far wrong.