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An injury prevention pyramid for elite sports teams
  1. Philip Alexander Coles
  1. Correspondence to Philip Alexander Coles, Performance and Medicine, San Antonio Spurs, 1 Spurs lane, San Antonio, Texas 78240, USA; pcoles{at}

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There are numerous factors that influence injury rates in elite sporting teams, and many of them are intricately related. To achieve sustained success in decreasing injury rates, we must understand not only each of those potential factors in isolation, but also the relationships that exist between them. Rarely is one session, or one event, the true isolated cause of an injury. Typically, there has been a confluence of many events over time, which has led to the pivotal point where one event then simply becomes ‘the straw that broke the camel’s back’. The ‘High Performance Unit’ should take the lead in responsibility for preventing injuries, but for them to achieve long-term success,they must collaborate closely with coaches, management and the players themselves, in creating an integrated approach to preventing injuries. While there may be significant debate about the relative influence of individual factors on injury rates, there should be little debate that each of the factors discussed in the following model will have some effect. For sustained success, it is more productive to think of each factor as a building block in a pyramid, as opposed to an independent entity. Although this does not mean that addressing one aspect in isolation cannot be effective in the short term, it recognises if you do not have the foundation blocks right, then your likelihood of achieving consistent and long-lasting success is decreased. We should also be aware, that the culture of an organisation as a whole, and the psycho-social influences on each individual player within it, can have a modifying effect on the model at every stage.1

Player recruitment / List management

The first building block in the injury prevention pyramid for elite sporting teams is player recruitment and / or list management. Ultimately, if you recruit or maintain a list of players who are either not suitable for the stress of the competition you are playing in, or the style you want to play, then you will struggle to achieve a consistently low injury rate.

The idea that some players are more inherently durable is much debated. It is generally accepted, however, that one of the best predictors of future injury is past injury.2 This means that if you recruit or maintain a list of players with a long and consistent history of injury, the chances are increased that your future injury rates will be high. Of course with the correct management you may be able to improve the on past record of an individual, and unfortunately, it is not as simple as just looking at the history of availability in isolation. With some injuries, there are known risk factors that make it more likely to be recurrent,3 so clearly the examination of a player’s history has to be looked at in that context, while at the same time considering how a player’s age may interact with any risk factors for future recurrence. Technical and tactical knowledge is also required at this point, as how a player has been used in the past, compared with how they will be used in the future, can also have a modulating effect on risk. The recruitment of a specific player may also have a knock-on effects for other players within the squad, as it may change either the tactical approach of the team as a whole or the tactical use of other individual players. The team culture and individual support mechanisms around individual players are other components which should also be considered as modulating factors for future injury risk. Team management should be involved here to add some background intelligence on how the change in environment may affect a player, as although less objective, this may also have a relationship on their ability to cope with new level of physical stress they will now be under.

The upshot of this is that although every team and every competition is different, having the right mix of players for that specific team is the first building block to developing a squad that is going to have consistently lower injury rates. Developing a thorough and integrated approach to recruitment, which is of course driven by coaches or management, but includes the high-performance staff, is vital to achieve this. The high-performance unit should provide specific information that is factored into the ultimate decision of the coach or general manager as to whether or not to recruit or retain each player within a squad.

Load management

The second building block in the pyramid is load management. Irrespective of their inherent durability or physical qualities, there is a maximum level of load that each individual player will be able to tolerate, at any given point in time. If they are pushed beyond that level, they will break down. This is why managing load is one of the foundation blocks of the system. The high-performance staff’s role is to identify and increase this level in each individual, while ensuring that the coaching staff understand it, and factor it into their plans. This field has grown exponentially over the past few years, and it will continue to do so as more reliable, valid and practical measures are understood. There are highly debated theories about which are the key metrics for assessing training load and injury risk, but whichever is your preference, there is an established need for a gradual increase in training loads until you get players accustomed to a level which is above the maximum that will be required of them in competition, without exposing them to acute spikes in those loads along the way.4

Typically, load management predominantly references training loads, as it is far easier to manipulate training loads than those from within competitions, where tactical concerns and the need for success will dominate a coach’s thinking. In sports with long pre seasons to prepare, management of those training loads can set up the season for success, or otherwise, in terms of injury prevention.5 Once a season is started, however, player recovery and preparation often takes precedence over athletic development, and while load management is just as vital in this, the approach may need to be different. In sports such as NBA Basketball, where the game to training ratio is so biased towards games and the pre season is so short, the great majority of load management has to occur from within competition. This of course makes integration between the coaching and high-performance staff even more vital to success. Great coaches have always used their experience and intuition to influence their load management, even if it was done subconsciously. Although coaches will always need those skills, the high-performance unit can now offer more reliable and objective data to support this decision-making. It should be realised, however, that most of the actual content in terms of in season player load will still be coach driven. So while the high-performance staff may have expertise in terms of how much load different players can tolerate, if they are not working hand in hand with the coaching staff, they are unlikely to be successful in preventing injuries.

Traditionally, some coaches have shied away from involving the high-performance staff in session planning because of either a lack of understanding, or a fear of loss of control. Conversely, others have possibly deferred too much responsibility to high-performance staff, who can overstep the boundaries of their role. Part of the high-performance manager’s role is to educate and advise the coaches on load management, while minimally interfering with their level of control over the actual content in season. They should also help coaches to understand that while more efficient players are created by training with game-specific methods, occasionally specific deficits must be dealt in isolation. Advance planning and shared information are the two vital components of this relationship. If coaches plan in advance, the high-performance manager may be able to see potential risks in overloading and can pre warn the coach. Equally, they are also able to identify potential loading deficits, and can encourage either increases in load or plan appropriate strategies to address those deficits with top up work.

Athletic development—quality strength and conditioning

If you have good player list management, and good load management, you have a good base to be successful in injury prevention. To improve as a team, however, you may need to operate at a higher physical level; and when trying to achieve that higher level while simultaneously having fewer injuries, your athletic development program becomes vital. The next building block is, therefore, quality strength and conditioning programmes, which lead to an overall improvement in the athletic qualities of the individuals in your squad.

In many ways, it is the ‘chicken and egg argument’ as to whether movement patterns need to be corrected before strength is added or vice versa, and there are reasonable points to be made in support of either theory. In my experience, however, many elite athletes remain durable even without ideal movement patterns, but few who remain durable with insufficient strength or conditioning levels, and there is strong research support for the benefits of strength and conditioning in preventing injuries.6 Ultimately, individuals who are not strong enough, or not fit enough, to cope with the demands of their sport will eventually break down. The high-performance team should invest heavily in planning and reviewing their programs to ensure they achieve objective success for every individual player in terms of athletic development.

Figure 1

The injury prevention pyramid

Having a good athletic development programme is absolutely vital in making the most out of the possibilities you are provided with by the effectiveness of the first two building blocks in the pyramid. It should be understood, however, that if the first two blocks are not solid, then the best strength and conditioning program in the world, will not ‘save’ a club from bad injury statistics. Having said that, teams that have set up solid foundations, and do manage to improve their player’s individual athletic qualities, will see an improvement not only in their internal injury statistics but, importantly, also in their physical performance measures and ultimately their results.

Movement efficiency

Efficient movement patterns go hand in hand with improved athletic development. Its position in the injury prevention pyramid is likely to be debated, as some would argue that without moving in the most efficient way, a player can never truly use the strength he or she has, let alone improve it further. Inefficient movement patterns are also thought to lead to an increased risk of injury, which isreasonable from a theoretical standpoint. The alternate argument remains that the first step should be ensuring every athlete is strong enough, and fit enough to cope, and then the focus can turn to ensuring they use those qualities safely and efficiently. In a holistic approach of course, concurrent time should be spent to improve each player’s individual movement efficiency, and teaching that is a skill many physical therapists and strength coaches possess, so it should certainly be a significant component of all professional team’s injury prevention strategies.

Structured injury prevention programmes

There is good evidence that some structured injury prevention programmes can decrease the time loss to ‘preventable injuries’ by around 30%.7 If you have built a solid base to your injury prevention pyramid, these results may be slightly exaggerated however, as many of the components included in them will have already been covered in your athletic development and movement efficiency programs. The real benefit to these structured programs is that they promote compliance. Even in a professional team environment, compliance can still be an issue, but in any environment where staffing and/or time with athletes is limited, they become more important and more effective. The simplest way to consider it is this: proprioception training decreases risk of ankle sprains,8 and eccentric hamstring exercises decrease the risk of hamstring strains;9 but in both cases that is only true if they are done consistently enough to achieve the adaptations required. If they are included in a warm-up such as the FIFA 11+ prevention program, it can help to ensure that the whole team completes the minimum required amount to achieve success. In an adequately supported professional team, if you can achieve the same exposures in a more individualised and targeted way, you can perhaps achieve even better results, without the risks of boredom, and poor quality of performance, which can be associated with repeated team programs. If, however, compliance is an issue, or there is simply an inability to get individual exposures completed because of the schedule, then structured team programmes become a valuable option to add to your programme. If considering adding these to your programme, some time must be spent to ensure both players and coaches realise their importance. This will greatly improve initial compliance, while it is then up to the longer-term results of the programs to ensure longer-term compliance. These programs should be considered the ‘icing on the cake’ for a professional team, which are used to supplement the building blocks of the pyramid below.

Injury assessment and rehabilitation

Assessing what level a player can function at with an ongoing injury, or progressing a player to return to play after an injury, naturally sits towards the top of the pyramid as they are only relevant after an injury has already occurred. Nonetheless, the way these situations are managed has a significant effect on your ability to prevent future injuries, and your season-long availability statistics. The medical staff within the high-performance unit take the lead in responsibility for this level of the pyramid, but as is the common theme, all staff contribute some level of influence. Deciding if a player can manage to play on with an injury, or when a player returns to play post-injury, is one of the most difficult questions in sports medicine. There is an interesting decision-making tree outlining this process that is worthwhile to read,10 but the reality is that every situation is unique and must be treated that way. The exact same injury (on a physiological basis) may require different rehabilitation techniques and time frames between different players, or even within the same player on different occasions. The final decision on return to play should be reached after significant consultation between the medical experts, the players themselves, and the coaches, who each have a role to play in those discussions.

Whenever a player is progressing through the stages of rehabilitation, there is always a level of risk that must be accepted, as they step up to an increased level of load. How aggressive you can be in pushing them forward depends on the level of risk that the medical staff, the coaching staff and the player, are all willing to accept. So while the physiological time frames for healing must be respected, individual psycho-social influences, team culture, and coaching philosophies should also be considered, and although the time frames to any particular game can never dictate the return, it might be a consideration in the level of risk that that is deemed acceptable by all.

Increasing the involvement of coaching staff through the process of injury assessment, management and rehabilitation, can also decrease the emotional responses that can occur should an injury setback occurs. Too often in these situations, the backlash or emotional responses that are a fairly natural response from a player, coach or manager will not only negatively affect that players' further progression or future responses, but may also spill over into negative effects on other players. While understanding that the medical staff should take responsibility of a player’s health and well-being in all their recommendations, ultimately, the player, the coach and the medical staff have to work together to create a shared responsibility for the management path, and an accepted level of risk in each individual case.


All of the building blocks of the injury prevention pyramid as described to this point are under our control, and improving each of them, particularly if done in a systematic way from the base upwards, will consistently decrease a club’s injury rates. Clubs can, and therefore should, be held responsible for their injury rates and while ultimately responsibility for that within a club lies with the high-performance unit, there must also be recognition from the coaching staff and management, as well as players themselves, that they also have a significant influence. In reality, if all sections of a club are not working together in a fully integrated program, the chances of success are slim. Still, as in most aspects of life, no one can honestly say everything is completely under our control, and as much as experts in high performance may like to dismiss it, luck may still play a small part. All injuries should be considered on a continuum from ‘not preventable at all’ at one end, to ‘completely preventable’ at the other end, and the reality is that while most injuries exist somewhere towards either end, no injury is ever truly at either extreme. Our recruitment, load management, athletic development and medical programmes will always have an ability to mitigate risk; and over time, the better programmes will no doubt show better results, but there can certainly be cases where teams have had very few injuries despite not having great programmes in place. Alternatively of course, if you are pushing athletes hard to achieve elite physical goals, injuries can still occur, even in the best of systems. In the longer-term, however, the better your systems are, and the more integrated all the staff across a club are in implementing those, the less injuries there will be, and the more consistent your team’s success will be.



  • Contributors There were no other contributors to this article.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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