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We read the recent systematic review on the prevalence, incidence and risk factors for overuse injuries of the wrist in young athletes and agree with the conclusion that age and early specialisation (early training commencement) are risk factors for injury.1 The study highlighted training intensity as a risk factor for overuse injuries. Given changes in training loads precede the onset of injury in cricket,2 football (soccer)3 and Australian football,4 we consider that overuse injuries can be considered errors in training load prescription and labelled as such. Care should also be taken with broadly labelling training intensity as a risk factor as moderate training loads are protective against injury Gabbett's ‘training injury prevention paradox’.5 ,6 High training loads may predispose to injury in some tissues more than others;2 they can protect against injury when coupled with small magnitude changes in training loads.6
We have included a case study of an athlete diagnosed with intersection syndrome (twice) to illustrate this definitional issue of ‘overuse’ injury in the wrist. Figure 1 below shows daily ‘internal’ training loads (RPE × minutes, ‘exertional minutes’) and acute:chronic workload ratio7 recorded by the athlete across a 65-day period in which two wrist injuries occurred. While on face value it appears that overuse, that is, a higher than average load was the major precursor, note the periods of low relative training load preceding the injury. These may represent a period of tissue deconditioning. Figure 2 highlights that the wrist injuries occurred in a low training load period relative to other periods throughout the year. Should the definition of overuse injuries be recast to also consider the underuse component of the patient loading history?
In this example the training environment has not been conducive in preparing the tissue for the demands of the sport. The important clinical relevance of this is that labelling these injuries as ‘overuse’ may encourage athletes to reduce their training unduly, thus exposing their tissues to deconditioning3 or an inconsistent loading pattern2 which have been associated with injuries. The implications for clinicians are that subjective examination should explore not only supranormal training load but also periods of low/no load and the trajectory from this to injury presentation. Gabbett has written that ‘high training workloads alone do not cause sports injuries: how you get there is the real issue’;8 and our case may illustrate the same. We call for our field to avoid the term ‘overuse’ injury and replace it with ‘training load error’ injury.
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