Load Monitoring and Injury

Prevention

Lloyd Leach
Sporting year schedule of the elite athlete or sports team:

• Rest?
• Recovery?
• Free time?
• Off-season?
• Just as the one competition or season ends the
next one quickly follows, with the players
either competing in international tournaments
or engaging in training at the start of the next
season.
Can we think about training loads
differently?
• Most high performance coaches would agree
that optimal athletic performance requires
adequate quality preparation as well as
athletes remaining injury and illness free.
• New scientific enquiry is providing a clearer
understanding of the link between
preparation (training), injury and success.
Can training loads protect or
lead to injury?
• Training loads have the potential to protect
from or increase risk of injury/illness in
athletes. Both low and high training loads
are associated with increased likelihood of
injury when compared to moderate chronic
loads, which can protect athletes from
injury.
‘U-shaped’ relationship between
training loads and risk of injury
• The mistake would be not to adjust training
load prescription in the light of the known
risks of training underloading or overloading.
What do we need to know about
‘training load errors?
• Training load errors are known to expose
athletes to increased risk of injury.
• It is acknowledged that errors might occur as
the boundaries are pushed to reach peak
athletic performance.
• Acceptance of some risk is part of high
performance sport.
• However, athletes who are properly informed
can make better decisions and avoid known
training load errors associated with injury risk,
such as under-loading or overloading.
What do we need to know about injuries and
illnesses, and their relationship to performance
and success?

• Most coaches acknowledge that injuries or

illnesses are detrimental to performance.
• Current research evidence links an injury-free
and illness-free player to sports success, and
links increased injury burden to sporting
failure.
• Loading in sport, then, appears to be a
concept that, at the very least, should be
constantly monitored, when considering
injury risk and recovery, and for avoiding
often costly rehabilitation.
• Load monitoring of players provides a
smart early detection mechanism and
early response mechanism for identifying
players at risk of injury and/or illness.
• Essentially it requires a good player
information management system (PIMS)
Data Instruments
• Questionnaires
• GPS
• Smartphones
• Pedometers and Accelerometers
• Gyroscopes

• These instruments are customised to the

players and coaches needs for
performance enhancement
Player Information
• Player identity code (anonymity and confidentiality)
• General health
• Medical (incl. injury information)
• Dietary information
• Physical fitness
• Skill proficiency
• Wellbeing
• Mental state
• Physiological information (HR, lactates, VO2)
• Training load and GPS information
• N.B.: player compliance
Requirements
• Trained staff who know how to use the
equipment
• Experienced staff who add value to the
enterprise
• Knowing what technology is available as
well as the updates and changes
• Having the resources to stay at the ‘cutting
edge’ of technological advancements
What is a training load?
• In general, a training load (or more commonly
called an overload) refers to the total amount of
exercise (inclusive of training and matches)
imposed on a player which, if physiologically
functional and tolerable, will induce a positive
adaptation on the player’s body and, thereby,
enhance sport performance subsequently, with
minimal or no negative side-effects, such as
over-reaching, overtraining, chronic fatigue,
‘burnout’, injury, illness, etc.
Optimal tissue loading will be situated in
between the following:
• Minimum load required to improve performance.

• Maximum load required before tissue injury/overload.

• at opposite ends of the spectrum, no
loading will lead to poorer performance,
whereas excessive loading will lead to an
increased risk of injury.
• With every sport, there is a need to
understand the specific loading
requirements of not only that sport, but
also the athlete’s individual capacity.
• ‘Training load’ is broadly separated into
two categories: external and internal.
External Load
• This describes the work performed by an
athlete that is quantified externally. For
example, the distance covered by a
swimmer.
• It can also include the duration, intensity
and other available measurements as well.
Internal Load
• This describes measurements of the
athlete’s perception of effort for a given
external exercise stress.
• The most common method of quantifying
internal load is a rating of perceived
exertion (RPE) or heart rate response to a
stimulus (the training impulse score,
TRIMP).
• Internal load measurements should include
both exposure (for example, distance or time)
and the athlete’s effort (perceived or
measured).
• The most commonly applied measure for this
measurement is multiplication of activity
duration and sessional RPE, i.e.,
• IL = 90 min x 15 = 1350 AU
• Consider the concept of perceived exertional
minutes (PEM) as an alternative, i.e., only
active exercise time multiplied by RPE, i.e.,
• IL = 40 min x 15 = 600 PEM
• Internal load quantification should include
all activities that the athlete completes, not
only sport-specific skill training. For
example, capturing cross training and
strength training sessions as well as sport-
specific sessions will provide a more
complete picture of the athlete’s load.
Total Load
• So, it becomes important to quantify the
total workload an athlete performs by
measuring both internal and external loads
relevant to their sport, as each quantifies
different parameters. Partial (incomplete)
capture of workload may lead to only
partial quantification of injury risk.
• Internal loads may be the only feasible
method of total load in many sports.
Absolute Training Load
• ATL is the total of all training sessions
performed within a specified period, such
as a single day or one week.
• When this is totalled across a seven-day
period, it is referred to as an ‘acute training
load’.
• Both low and very high acute training
loads have been associated with
increased risk of injury.
• However, moderate-to-high workloads can
protect against injury.
Relative Training Load
• RTL is the change in training load over a
specified time frame relative to an
historical training load.
• This is expressed as a percentage, such
as change from week-to-week or week-to-
month.
• A widely accepted method of quantifying
this is ‘training stress balance’ (TSB).
Training Stress Balance
• This has recently been renamed in the
scientific literature as the ‘acute-to-chronic
workload ratio’ (ACWR) which indicates
exactly what is being described: the ratio
of the most recent week (acute load) and
the average of the previous four weeks
(chronic load).
• It is important to quantify both the absolute
and relative training load as, together, they
determine both athlete training capacity
and injury risk.
• Similarly, an injury-inducing overload occurs
when the training load imposed has exceeded
the player’s ability to cope or adapt (also
called maltraining or incorrect training) and,
thereby, results in injury or maladaptation
(incorrect adaptation).
What exactly is a loading injury?

A loading injury occurs when training load

has exceeded the bodies ability to adapt.
Key principles of load management:

1. Establish moderate chronic training loads

and ensure these are maintained.
Why?
• Moderate to high training loads protect
from injury if achieved in a safe manner.
There is a linear increase in training load from weeks 1-6 for
safety, and may represent situations such as an athlete
returning from injury or a planned rest (such as a holiday).

Weeks 7-14 (green bars) is an example of an athlete

maintaining a moderate to high training load.
2. Be aware that injuries can occur up to
one month later .
Why?
• Injury risk may be elevated for up to four
weeks after an acute spike in training load, in
a latent period.
• Generally speaking,
– muscle injuries occur 1-to-2weeks after training
load errors,
– tendons within three weeks, and
– bone between three and four weeks
• Therefore, knowing what athletes have completed in the previous
four weeks, one can predict the likely outcome in the subsequent
four-weeks.
• The purple bars depict a large week-to-week change - training load
error
• The boxed area is the period of heightened injury risk (latent
period).
• The red bar represents injury.
• The orange bars are rehabilitation and return to training safely.
3. Minimise large week-to-week fluctuations
Why?
• Large changes (acute spikes) in training
load increase injury risk for up to one month
after the spike.
Three examples highlight this principle
• Example 1: if the recovery week training load is too
low (purple bars), it may expose the athlete to
increased risk of injury on returning to normal
training (pink bars).
• Example 2: If an athlete is already
performing moderate-to-high training loads
(green bars), a large spike in load (purple
bar) presents a substantial risk for injury (red
bar).
• Example 3: If an athlete is performing
moderate-to-high loads (green bars), they are
protected from injury by safe fluctuations in
training load for situations such as recovery
weeks and holidays (light green bar).
4. Establish minimum and ceiling thresholds
of safety
Why?
• Establishing a minimum training load
ensures the achievement of minimum
training standards and reduced risk of
injury.
• Establishing a ceiling or maximum training
load also prevents overtraining and reduces
risk of injury.
• The yellow dotted lines on the two graphs
below depict minimum and ceiling thresholds
for an athlete. The graph below shows that
high variation of training loads that are above
and below the minimum (light purple) and
ceiling (dark purple bars) increase injury risk.
Note!

• Variation in training loads from week-to-

week is important.
• However, when determining injury and
illness risks, it’s the magnitude of variation
that is important.
Dose-Response Relationship
• Studies have reported a positive relationship
between training loads and injury rates,
suggesting that the harder athlete’s train the
more injuries and/or illnesses they will sustain.
• Consequently, the prevention of training-load
related soft-tissue injuries has been relatively
simple: if training loads exceeded a planned
‘threshold’, athletes were then ‘managed or
trained away’ from potential injury – and training
load decreased subsequently
• So, to date, the prevention of soft-tissue
injuries related to training-load has been
relatively simple: if training loads exceeded a
planned ‘threshold’, then the athletes training
load was decreased accordingly.
• However, it is probable that if training loads
are continually reduced a secondary
complication of detraining may develop.
• There is evidence which suggests that
insufficient training may also lead to increased
injury risk.
• A study showed that athletes who performed
<18 weeks of pre-season training prior to
sustaining an initial injury were at increased
risk of sustaining a subsequent injury.
• Similarly, athletes with poorly developed
physical fitness were also at increased risk of
sustaining injury.
(Gabbett, BJSM, 2016, 0:1-9)
• Conversely, athletes who completed more
than 80 per cent of their planned training
weeks were seven times more likely to
achieve their season goal. This showed as
an 86 per cent successful season.
Key Message
• Ensuring athletes reach minimum standards
of physical fitness, coupled with scientific
monitoring of training loads to avoid
overtraining and excessive fatigue, offers
coaches a ‘best practice’ approach to
minimise injuries.
• Most elite clubs have a limited number of
available athletes, therefore, the challenge for
coaches involved in conditioning is to design
and deliver individual and specific training
programmes that are based on sound
scientific principles.
• Progressively challenging training loads (note,
not excessive) should be prescribed to
determine:
a)which athletes are most susceptible to injury
under physically stressful situations (these
athletes most likely won’t tolerate the intensity
and fatigue of regular competition), and
b)which athletes are not susceptible to injury
under physically stressful situations (these
athletes are more likely to tolerate the
intensity and fatigue of regular competition).
• Training programmes must be physiologically and
psychologically appropriate to allow athletes to
cope with the demands of competition.
• exposing the brain to hard physical work and
fatigue on a regular basis appears to improve the
body’s ability to cope with fatigue
• physically intense training improves physical
fitness but, equally important, it also increases
the mental resilience of players.
• Regular, intense training promotes both
physiological and neural adaptations that
permit athletes to tolerate the physical and
mental demands of regular, intense
competition.
• Physically (and mentally) unfit athletes are
more likely to pace themselves, as a self-
preservation and protection strategy.
• If athletes have not been exposed to hard
physical work on a regular basis, the brain
instructs the body to stop exercise earlier to
prevent exhaustion.
• This highlights the importance of knowing
the individual capacities of the various
athletes very well , and knowing how their
bodies are being stressed differently, as
well as how each one responds differently
to their teammate.
• What training indices need to be monitored for
reduced injury risk?
• The load monitoring method needs to be
appropriate and sensitive enough to measure
the subtle and often “silent” changes in
training variables.
• If carefully applied, such load monitoring
mechanisms may even help identify players at
increased risk of sport injury for preventive
intervention.
Acute vs. chronic training load
• It is important to closely monitor over time
the athlete’s acute load (data collected over
7 days), as well as chronic load (4-week
cumulative data).
• This information can be used to quickly
identify any spikes in training load, and
allow for close monitoring and adjustment.
Practical Implications
• Some of the injury risk relates to a lack in
specific muscle conditioning than merely
cumulative loading
• This suggests that it is possible to mitigate
some of the injury risk through
– targeted pre-season specific conditioning
– Graded transition from pre-season training to early
season competition.
– Functional movement screening of athletes to
identify those at risk.
Thank you
Conclusion
• High acute workload in cricket fast bowlers
may lead to a somewhat delayed
increased risk of injury up to 3 to 4 weeks
after the acute overload, possibly via a
mechanism of damaging immature (repair)
tissue.
Clinical Relevance
• Fast bowlers in cricket are the players
most prone to injury, therefore, cricket fast
bowling workloads require scrutiny not just
for managing acute injuries, but also for
preventing injuries in the next month.
Practical implications
• Injury rates for male cricketers at the elite level
are fairly constant and predictable, with fast
bowlers being far more frequently injured than
the other positions.
• Acute increases in match workload for bowlers,
such as playing in back-to-back test matches and
enforcing the follow-on in test matches, are
associated with a greater risk of bowling injury.
• Increasing match scheduling (over a10-year
period) has probably contributed to the
increasing injury prevalence (Orchard, 2006)
• A greater risk of injury in the second innings of
first class matches (compared to the first
innings)
• A greater risk of injury in the second game of
back-to-back matches
Measuring patterns of sport-specific
fatigue
• In knowing the position-specific demands
of each player, this would include
measuring time spent in each ‘training
zone’ or specific components of
performance.
• There may be certain times of the year
when training and game performance are
more physiologically demanding on certain
tissues
• This may help the medical staff to identify
patterns of neuromuscular fatigue, as well
as bone stress, or indications of sub-
optimal physical conditioning of one or
more players.
• The appropriate management of athlete
training load is recommended as a crucial
step to prevent injuries by increasing an
athlete’s ability to train uninterrupted.