It's About Preparing People, not Preventing Injuries

ACL injuries do not happen in a void. People sustain injuries when their infrastructure is unable to manage a specific set of physical circumstances. To describe the mechanism of the injury without the context of the person and their level/type of sport, is to miss valuable insight.

In sport, we prepare the person, to the best of our understanding, to meet the physical demands of that sport. We do not just work to prevent one particular injury; we prepare athletes to navigate the total sport physical environment. By "we" I mean the coaching and support staff -- specifically the athletic development staff. 

Athletic development (AD) coaches prepare athletes through the development of physical literacy and movement competencies via movement progressions. It is more than strength, power, agility; it is the acquisition of knowledge, skills, abilities and behaviors to manage themselves within the entire sporting environment. At the higher levels of sport, AD coaches coordinate with dietitians and sport psychologists to give athletes the most comprehensive toolbox possible to perform at the highest level of potential.

It has come to my attention that the concept of athletic development, often called by the more traditional name strength & conditioning (S&C), falls outside of the language and body of knowledge of the physical therapy (sports medicine) world. This is the silo effect: the creation of artificial boundaries of professional knowledge and expertise.  

One group uses movement within a medical model; the other uses it in a performance model. In most athletic departments and sport organizations, these two groups struggle to integrate and build a united team behind the team. Separate spaces and equipment, language, modes of dress and identity reinforce the professional divide.

Physical therapists and other medical professionals (athletic trainers, sports med MDs) continually produce research trying to demonstrate the effectiveness of "X injury prevention program." This is a medicalization of the situation: apply a special intervention "X", created by our special knowledge of the body, to reduce the risk of "Y" injury. Injuries are a disease; here is your prophylactic.

Many of these studies conclude that "X" is better than nothing (or a control group that does next to nothing). In sport and fitness, it is generally understood that a range of interventions can bring about an improvement in fitness in untrained populations. Something done with even the slightest consistency can bring about improvement in fitness -- the ability to negotiate the physical environment of sport without injury for a short amount of time. With each peer-reviewed, published study or study review, the physical therapy world pats themselves on the back for another successful study on injury prevention. 20 min, three times a week and boom, you are inoculated.

But it is not about stopping any one type of injury or single negative consequence; it is about developing a positive state of being-- the necessary state of physical, emotional and cognitive being required to navigate the daily world of sport, through a process of education and a progression of physical experiences. 

This is a preparedness approach, not a prevention approach. If the physical therapy profession wants to address injuries, we need to step out of the medical model of prevention and step into the performance model of preparedness.

Every injury is a case study N = 1 -- an opportunity to learn. To do better, we must not look at the injuries alone; we have to look at each athlete, that athlete's training history, their specific physical competencies or lack thereof, and the quality of that individual's infrastructure given their level / frequency of competition with regard to the sport. 

The focus must turn to appropriate physical preparation to meet the demands of the developmental level of the athlete and their specific sporting situation. In addition to better investment in physical infrastructure, we must advocate for better parental and coach management of the athlete's sporting environment (frequency of competitions & number of competitions in relation to time devoted to development).

Medicalization and reduction of this work to "guidelines" and "prevention programs" removes the human context and leaves us with toothless generalizations buried in flowery academic language. It ignores the vast body of knowledge of other disciplines. 

With specific regard to ACL injuries and the application of exercised-based rehabilitation, we do not need more research. We have the knowledge and methods of how to use movement to return to athletic normal, using athlete-centered, developmentally appropriate movement progressions. We base these progressions on developing physical literacy, building movement competencies and understanding the demands of sport. This work comes from Physical Education and Athletic Development -- fields that study the structured use and role of movement in normal human development & physical health.

Just as Atul Gawande looked to the field of aviation to implement checklists in surgery, physical therapists need to embrace knowledge and methods from physical education and athletic development to improve our understanding and use of exercise programming. Physical therapy, as a profession, has lost its way with regard to the mastery of therapeutic exercise. We are still arguing about OKC vs CKC exercises and are as distracted as ever by BFR, Blazepods and the use of stroboscopic glasses. In the meantime, gravity and the ground continue to win the ACL injury war. 

As a profession, we need to identify, observe and report on experienced clinicians who are successfully implementing the tools and methods of athletic development into their ACLR / LE rehab programming. The knowledge is there. It needs to be collected, disseminated and included in professional training.

This is not a rejection of "evidence-based" information. It is an acknowledgement that meaningful methods and tools exist outside of RTCs and meta-analyses. Rehabilitation and return to sport are processes, not singular procedures that can be examined with traditional clinical trials. 

There is no "one best sequence of exercises" for an ACLR. There is only the course of action that is appropriate for that athlete, playing that sport, at that level of competition, in that clinic with that available space and equipment; meeting the person where they are. This requires human judgement on a day-to-day basis and the management of real-world challenges of implementation. It requires an understanding of "athletic normal" movement, along with the spaces, language, tools and progressions that support the return to a state of athletic normal.

As physical therapists, we begin the process of doing better by turning the mirror on the competence of the clinician and asking ourselves if we are using the best available information and capable of implementing it in our environment. We need to step outside of the ivory tower and into the gym to watch expert coach-clinicians guide patients through an entire case of return to sport, day-to-day, week-to-week, month-to-month. This work looks much more like a physical education class or an athletic development coaching session than a doctor's office visit or a lab experiment.

We need to boldly and openly eliminate low-value (over-medicalized) work, distractions from the latest modality and sacred professional cows that take up valuable time and resources. We must create space and time to integrate knowledge of PE/AD principles into our professional understanding of exercise programming, and work to make it widely acknowledged and utilized. We must move from a mindset of prevention to a mindset of preparedness. We fail the people under our care when we fail to break out of our self-imposed professional silos.