YOUNG ATHLETES SPECIALISE FAR TOO EARLY, AND LITTLE VARIATION INEVITABLY LEADS TO INJURY.

– Damien Van Tiggelen –

PROFESSOR/REHABILITATION SCIENTIST

Damien Van Tiggelen is a rehabilitation scientist and head of the Centre for Physical Medicine & Rehabilitation at the Queen Astrid Military Hospital (Brussels). Moreover, he has been a visiting professor at the Faculty of Medicine & Health Sciences (UGent) since 2013. He earned his doctorate in Motor Rehabilitation & Kinesitherapy in 2009 with the thesis “Prevention of Patellofemoral Pain in Military Recruits”. Prevention of sports injuries of the lower limb is his field of research. He is leading this research both among military staff and hockey players.

Professor Van Tiggelen, does sport, and hockey in particular, pay sufficient attention to injury prevention?

Athletes and coaches are becoming increasingly aware of the importance of prevention, but still not enough attention is paid to it. Prevention is of course not ‘sexy’ and often comes down to boring exercises with no connection to the athlete’s preferred sport. Moreover, the athlete does not see any immediate effect. Injury prevention is not a goal in itself, better performance is. And those two aspects are obviously linked. Therefore, the link with performance should be made clearer. Preventive exercises also put the athlete in situations which often lead to acute injuries, which will allow the athlete to anticipate the movement. In hockey, for example, changes of direction and sprints when the athlete is already tired are a risk of ligament or muscle injuries. This is what we refer to as “graded exposure”. In this treatment strategy painful movements are performed and built up step by step. This approach is based on the fact that pain and pain increase do not automatically result in damage the body.

What could be improved in terms of injury prevention and at what level?

A lack of infrastructure in Belgian hockey is certainly an issue. You need both the space and the time for appropriate preventive exercises. And there is certainly also room for improvement in terms of awareness-raising. The federation has been keeping a record of injuries since 2013, but unfortunately many still remain under the radar. Insurance companies have a very good picture of sports accidents, but injuries due to overexertion do not feature in claims. Most sports injuries have a ‘dormant’ origin and do not, or only rarely, appear in these tables. However, they are no less important for the sport and the athlete himself, who will sometimes end up in a slump for years. At club level, I also see some changes happening in the coming years. We have been researching injuries in hockey for about five years and have a good idea of the sport-specific adaptations in the athletes. Together with Dorothée Gaeremynck - Medical-Paramedical Coordinator of the Belgian Hockey Federation - we screen the young athletes of the BeGold programme every year. Covid-19 did put a stop to it this year, but if the financial resources can be found, we will certainly continue. Once we can roll out customised programmes, this will also have an impact at the club level.

What injuries are most common among (young) hockey players and to what extent do they differ from other sports?

Every sport has its typical injuries and hockey is no different. Hockey is what we call an ‘invasive game’, short sprints, pivoting and intensive movements. The rotations of the trunk and limbs in deep flexion are typical for hockey. I think young athletes specialise in a certain sport too early. They sometimes play hockey three or four times, without making time for other sports. Little variation inevitably leads to injuries. In some sports we see that the federation intervenes, like in baseball. The number of pitches per week is limited for young children. However, it is still premature to introduce something similar for hockey. The data to substantiate this is simply not available yet. In hockey, we see two types of injuries: acute and overuse injuries. The former include muscle tears and sprains, while overuse injuries are chronic and gradual in nature. A distinction can also be made between men and women (or boys and girls). Men often suffer from injuries to the hamstrings, as in football, and other muscle injuries. They typically occur during the preparation or at the end of the season, when fatigue starts to affect athletes. Ankle injuries are common in both sexes, while traumatic injuries to the knee (anterior cruciate ligament) are more of a problem in girls. However, this is not typical for hockey alone. Acute injuries also include traumatic injuries caused by the ball or the stick. Most accidents happen in ‘D’, where the ball may be hit upwards towards the goal and where the concentration of players in certain phases of play is high. These include injuries to the face (including teeth) and to the fingers. As far as overuse is concerned, there are also differences between the two sexes. Boys are more likely to suffer from femoroacetabular impingement (FAI) - where there is an entrapment at the level of the hip joint between the edge of the femoral head and the hip socket. They are also more likely to be affected by Sever’s disease. The calf muscles at the back of the lower leg consist of two large muscles. Both muscles attach to the heel bone via the Achilles tendon. In persons whose skeleton is not yet fully developed, there is a growth disk where the Achilles tendon attaches to the bone. Every time the calf muscles tighten, the muscles pull on the Achilles tendon. It cannot stretch much, which puts a great deal of strain on the growth plate of the heel. If the tension is too great/strong or is carried out repeatedly for a long time, the growth plate can become irritated. This can result in pain and sometimes a bone-like protrusion at the back of the heel. Girls are more likely to suffer from patellofemoral problems, i.e. pain around the kneecap. A combination of (partly unknown) factors, with overloading as an important component, causes this symptom. Treatment is often long-term and consists of rest and exercise therapy. Girls are also more prone to shin splints, a collective term for various irritations of the shin. The most common variant is an inflammation of the bone membrane near the shinbone. You can get it through overexertion or bad shoes, for instance.

A generic or individual approach, that is often the key question... Which do you prefer?

The generic approach is good for athletes who have no history of injury, which is so-called primary prevention. The advantage of a generic programme is that it does not require much preparation, it is easy to learn and easy to apply. But even in this generic approach, it is necessary to differentiate between the sexes. In addition, certain age groups also have certain needs. Our research has shown, for example, that hip mobility decreases significantly in boys in the U18 age group compared to the U16, something we do not see in girls at all. There again, strength of the quadriceps and core (back and abdominal muscles) appear to be more important. With these scientific findings, ‘semi-tailored’ programmes based on gender and age can be created. This is already a step in the right direction.

An individual programme is better but requires a lot of time and resources. It requires thorough anamnesis (feedback from the athlete) and examination. Moreover, adequate follow-up is necessary, because today’s needs are not necessarily the same as next season or even next month. Therefore, the screening we have been able to conduct so far also has its limitations. You could compare it with a photo. You may look good in the photo, while the photo is not exactly what you want it to be. This is also true of screening and testing. It is a snapshot. The very striking deviations are significant, but the subtle ones are much less so. An individual programme must take into account previous injuries and, in particular, their underlying cause. We know that the most significant risk factor for an injury is a prior injury.

What role does good monitoring play in all this?

Constant monitoring of an athlete is a vital step in injury prevention. Injuries are caused by an imbalance between the imposed load and the athlete’s capacity. Both of these factors vary constantly, which makes it all very complex. Sports performance is largely dependent on four pillars: physical fitness, mental resilience, nutrition and hydration, and - last but not least - rest and recovery. These four pillars fluctuate constantly: a bad night’s sleep, stress at work, a bad meal, and so on. Scientific literature speaks of internal load and external load. The latter is measured using, for example, GPS systems (total distance walked, metres per minute, etc.). The internal load is indicated by the athlete by subjectively evaluating internal load. The body does not like acute peaks in load. Many or high peaks often lead to injuries. If you run an untrained marathon, chances are that, in addition to a medal, you will also be taking home an injury as a souvenir. We are currently working on developing a system where this monitoring is not only reserved for the top athletes of the premier league or national team. A pilot project is now underway in a Belgian club.

Are athletes sufficiently aware of the importance of injury prevention ?

I think that the awareness is growing. Unfortunately, injury prevention is still too often limited to a warm-up and some dynamic stretching. The coaches should be the ambassadors of awareness-raising in the first place, because players just do what they are asked to do. Coachesand parents should encourage youth players to play (totally) different sports in the off-season, so that they are exposed to a variety ofmovement. This will not only enhance their skills and game intelligence, but will also prevent injury.

What are common ‘mistakes’ in injury prevention ?

Athletes often do the exercises they are good at, not the ones that are necessary for them. In addition, I regularly see programmes which are too analytical and have not much to do with the sport. This is not actually wrong, but if it does not translate into something functional, it makes little sense and compliance is not great. Hockey is a running sport, where the majority of the time is spent standing on one leg and where stability of the lumbopelvic region is important for efficient running (and less injuries). However, the transfer to functional movement is not obvious. Hamstring injuries are often sustained when the athlete is accelerating or reaching maximum speed. So part of the prevention will also have to consist of these incentives. If, for example, you constantly train on half a hockey pitch, you will never reach the maximum speed you can achieve during a match.

You mentioned recurring injuries earlier. What can be done to avoid these ?

As I said, the greatest risk of injury is a previous injury. If the rehabilitation is only symptomatic, the risk of relapse is real. We have not yet discovered the secret formula to completely avoid recurring injuries, but it is important to identify the cause of the initial injury. Why does the biceps femoris always rupture in the preparation, why always in November or in February? Why do girls always suffer from those annoying patellofemoral problems? Identifying all the contributing factors requires not only a good scientific knowledge of the injury, but also a thorough knowledge of sport and the athlete’s environment. Proper monitoring of the athlete also allows timely identification of when the load/capacity balance is about to get out of control. You see, all this is a very interesting, but also a complex process. A real challenge!

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