Using an ‘evidence based approach’ to help build long and healthy careers for elite basketball playe
Updated: Apr 13
Preface by Janx…..
This past year Jamie was the team Physio for our U18 State team for South Australia that I was also the Head Coach for. Jamie was outstanding in his role and really helped the team perform. I also value that staff are liked and build positive, professional relationships with athletes as I feel this helps them feel comfortable, enjoy their experience and therefore perform better. Jamie was very well liked and respected by athletes and staff alike, whilst been very professional and demanding of the athletes when it was in their interest for him to be. During National Championships I heavily lean on staff to undertake their areas of expertise with excellence and demand that. I want our experts to be a part of the team and offer their expertise and advice at will. Jamie certainly exceeded expectations. He took a holistic approach to athlete support from diet, fluid intake, sleep, schedules etc. Of course there was the standard work of the physio including pregame warmups, massage to support recovery, injury diagnosis, post-game recovery, treatment etc. etc. I felt we had one of the best in the field in Jamie and in the occasional down time I really appreciated to getting to know him, how motivated and driven he is, his passion for his work and his time with the Milwaukee Bucks.
PICTURED: Jamie with Milwaukee Bucks Medical Staff in 2016. Pictured on left also is former Norwood Flames junior who has just returned from a fulltime stint with the Milwaukee Bucks for a couple of years, Tim Oleary.
Post-our tournament it was not surprising he has taken part in Australian Boomers Camp and more recently the Emerging Boomers World University games campaign and I could not be more happy for Jamie.
Jamie holds a degree in sports science from the University of South Australia, completing it in 2003. He continued on after completing his initial degree to complete his Physiotherapy degree again at the University of South Australia in 2006. Since becoming a practicing Physio he began also honing his skills and having some involvement with local Australia Rules Football teams, having been a football player himself where he played reserves level SANFL for the North Adelaide Football Club over 4 seasons. He then started to branch out into other sports, being involved with state level junior triathletes for team South Australia at multiple National Junior Championships.
However, talking to him he is a huge basketball fan and so that is why he has begun to get more and more aligned to basketball. Along with this, Jamie now co-owns a private physiotherapy practice, and has in 2015 started his Masters in Sports Physiotherapy. This helped him to work with the Port Adelaide Football Club (SANFL), after completing a placement as part of his Masters studies. He also performed a short stint with the Milwaukee Bucks (NBA) as part of his study, and it was during this placement that he realised that he wanted to pursue a career in high performance basketball, with a goal to reach the heights of the NBA. In pursuit of this dream he has just worked at Boomers camp (Australian Mens Basketball Team), prior to their 2017 Asia Cup success, as well as performing a locum role at the Australian Institute of Sport (AIS) with the Basketball Australia Centre of Excellence programs and the Global NBA Academy program.
With Jamie rapidly rising in the basketball world in his field of expertise, also having seen him in action first hand, I cannot wait to read his insights on helping our athletes build a long and successful career.
This blog IS heavy reading. It is a well researched paper that provides insights into risk and workload management. It provides statistics on how these areas can help your teams win but also improve your athletes longevity in the sport, something elite junior and senior coaches should want to see. It is a great read for elite coaches, sports trainers, physios and of course athletes to gain insights from someone that we feel is am expert nationally in the field. For us coaches this information helps us understand what Physios and Medicos are talking about better and will help us better understand their language.
Over to Jamie.....
In recent years sports such as Soccer, AFL and Rugby have been pushing the boundaries in Sports Science and Sports Medicine. Strength and Conditioning and field/court training has moved from a model of pure performance enhancement to including injury prevention strategies. Gone are the days of just working players as hard as possible to increase strength, aerobic capacity and skill development, as we now know that by doing this we are flirting with causing injuries. You may think, so what, athletes get injured, they heal, then move on. However, recent evidence tells us that the more injuries a team has, and the more games/trainings missed by players, then the likelihood of success of that team is reduced. The same goes in vice versa, the teams with low injury rates have a higher chance of success. The greatest recent example of this was Leicester City’s English Premier League win in the 2015-16 season. Going into the season the club were 5000-1 to win the title, going on to defy the odds, and many believe it is due to the low number of injuries, therefore allowing their best players to be available for selection more than any other team. They had only 19 injuries for the season, and only 8 injuries lasting more than 14 days. Powerhouse teams like Liverpool and Manchester United finished outside the top 4 that season, below their expectations, recording significantly more days lost to injury, while Newcastle United finished on top of the injury stats and were duly relegated (see table below). Maybe one of the smaller NBA teams is possible of emulating Leicester City’s performance, and challenge the big money teams for a championship? It would seem even more important that these smaller teams invest in keeping their athletes playing as many games as possible, to make up for the lack of budget to lure the world’s best players.
So, what about basketball?
At the end of the 2016-17 regular season the teams with the 3 best records (Golden State, San Antonio and Houston) finished in the bottom 5 for games lost to injury. While the 3 teams with the greatest games lost to injury (Miami, Philadelphia and New Orleans) did not make the playoffs (see table below). Coincidence? Maybe, maybe not!
So how much of this is just good/bad luck, and how much is due to good interventions of the Sports Science/Medicine teams?
This is hard to know, as we do not entirely know what the team’s medical staff implement as measures of injury prevention. Furthermore, a study performed in European soccer concluded that Injuries had a significant influence on performance and these findings stress the importance of injury prevention to increase a team's chances of success (Hagglund et al., 2016). Another study performed in the NBA concluded that a healthy roster is important for increasing winning performance (Podlog et al., 2014). So, if we have evidence that injury prevention programs reduce injury rates, and evidence that low injury rates increase success, it is easy to see why Soccer and AFL teams are placing such a large influence on equipping their teams with adequate staff to carry out these measures to try to ‘safe-guard’ their players. More and more research is therefore being performed to help us continue to understand what prevention models are going to have the biggest impact on reducing injury rates. However, it must be said that most of these studies are being performed in Soccer and AFL, with a lack of research being performed in basketball. The NBA seems to be catching on however, with teams starting to employ Sport Science and Medical staff from Australia and the UK, where most of this research is being performed, and where these professionals have been plying their trade implementing these programs.
Large amounts of good quality evidence around injury prevention programs and load monitoring has been published over the past decade, allowing medical staff to implement these strategies. Let’s look at specific injury prevention programs. Firstly, we cannot call this ‘injury prevention’ as we cannot completely prevent injuries, therefore ‘reducing injury risk’ is a term that seems more fitting. The FIFA 11+ is an injury prevention model that was developed as a means to try to reduce injuries in soccer. It is a 20-minute exercise program designed to be performed as a warm-up program to training and involves strength, balance, proprioception, agility and jumping/landing exercises in an attempt to improve neuromuscular control. A number of studies have been performed on this program and a systematic review and meta-analysis by Thorborg et al. (2016) showed that the FIFA 11+ prevention programme reduces the top four most prevalent football injuries: hamstring, hip/groin, knee and ankle injuries by 60%, 41%, 48% and 32%, respectively. Another study in female youth soccer players compared an injury prevention program including jumping, agility and balance exercises Vs a standard warm-up that involved static stretches only, showing that the injury prevention program reduced injuries by 38% (Marshall et al., 2016). Smaller studies have been done in basketball, concluding that injury prevention programs reduced ankle sprains by 81%, low back pain by 78% and knee sprains by 65% (Riva et al., 2016). Therefore, it should become common practice among basketball teams, at all levels, to implement similar basketball specific exercises to a warm-up before every training and game. This could include around 10-15 minutes of non-ball exercises, followed by ball specific exercises to reach the required minimum 20 minutes. For example, non-ball exercises can include; walking lunges, forward and lateral hopping, single leg balance exercises, change of direction running, and jump/land exercises. Netball Australia have also designed an injury prevention program which is focussed on reducing knee injuries, however no research has been published yet on this program, but as it is a court based sport similar to basketball, many of these exercises can be used by basketball teams. The exercises are based on the examples I have provided, and the Netball Australia website can be a great source for more information.
So specific warm-ups help generally help reduce injury rates, great…. Do we stop there? Not at all. Research also tells us that the biggest risk of injury is having a previous injury. For example, if an athlete has had a previous hamstring strain, then they are more likely than their teammates to sustain another hamstring strain. The same goes for other muscles strains, athletic groin pain, ankle injuries, and the list goes on. Therefore, pre-season screening for these injuries and their associated physical limitations has become an important part of a medical team’s protocol. However, screening has caused a lot of debate recently, as we must be careful to not put all of our time and energy into certain screening measures and implementing prevention programs that do not have great evidence, and evidence that is applicable to the individual sport. Medical staff can get carried away with spending a lot of time on screening, which has possibly become the case in certain sports. Certain generic functional movement screening protocols have been found to be poor predictors of identifying potential injury risk, although they have become very popular in certain sports. So, what do we screen and how do we know what to target? As I have stated the biggest risk of future injury is having a previous injury. Then, understanding what injuries are most prevalent within a given sport, and what injuries cause the greatest time lost to injury, will enable medical staff to try to identify ‘at risk’ athletes and therefore implement individual athlete prevention strategies that are evidence based. That is, injuries that have research showing that implementing a specific protocol can reduce the risk of injury. At the end of the day there is always risk, no matter how good the prevention strategy, but reducing the risk gives the best chance of a healthy team roster.
So what injuries are the most prevalent in basketball and what injuries cause the greatest time/games lost?
A review of 17 years of NBA injury statistics showed that ankle injuries were the most prevalent injuries, totalling 14.7% of all injuries with 13.2% being lateral ankle sprains (Drakos et al. 2010). Not only are these injuries common, but they have high recurrence rates with 70% of first time ankle sprains leading to chronic ankle instability (Gribble et al. 2016) which commonly leads to surgical repair. We can also identify who is at risk of an ankle injury through targeted screening, as multiple studies have shown that deficiencies in tests such as the Star Excursion Balance Test (SEBT) identified athletes at a higher risk of injury, and therefore implementing appropriate interventions can reduce risk (remember we cannot completely prevent!) ankle injuries (Attenborough et al. 2017, Plisky et al. 2010). Therefore, adding the SEBT to a pre-season screening can be a beneficial addition to a basketball team. A systematic review (Doherty et al. 2016) also showed that implementing an exercise rehab program after an ankle injury including strength, balance and proprioceptive exercises can reduce re-injury by around 50% and therefore reduce the risk of developing chronic ankle instability, showing the need for proper rehabilitation measures post injury. During my short stint at the Australian Institute of Sport, working with the NBA Academy, we would screen new athletes into the program. Any basketballer who showed a reduction in the Star excursion balance test would carry out a 12-week balance program, which included daily exercises for around 10 minutes, designed to improve balance and proprioception to therefore reduce injury risk.
PICTURED: Star Excursion Balance Test – Standing on the junction of the Y, reach out to the 3 points as far as possible with the opposite leg, without losing balance. The ratio of distance reached to leg length has been shown to identify ‘at risk’ athletes.
The prevalence of muscle injuries is high in sports, but what many people and athletes don’t know is that many measures can be put in place to identify those at risk and reduce injury and re-injury rates. A lot of the evidence focusses on hamstring strains as it is the most common type of muscle strain injury in sport, with it being reported as the 4th most prevalent injury overall in the NBA, followed by adductor (groin) strains as 5th (Drakos et al. 2010). A lot of research on hamstring strain injuries has been carried out over the past decade, mainly due to the high incidence rates in sports involving high speed running, such as football and soccer, but as I have mentioned there is also a high incidence in basketball. The research tells us that reduced eccentric hamstring strength, and reduced muscle fascicle length are risk factors for hamstring strain injuries (Opar et al. 2015 & Timmins et al. 2015). Eccentric strength is the strength of the muscle while lengthening, essentially the opposite of lifting a weight therefore lowering the weight. What we also know is that we can measure, screen and monitor this eccentric strength via the use of a Nordboard, and we can increase eccentric hamstring strength and fascicle length via a hamstring injury prevention program including Nordic hamstring exercises by between 70-85% (Petersen et al. 2011 & Mjølsnes et al. 2004). This exercise is also included in the FIFA 11+ program that I mentioned earlier, but typically is performed post training with 2 sets of 5 repetitions and progressed over 10 weeks to 3 sets of 10 repetitions. Rapid increases in high speed running has also been associated with increased risk of hamstring strain injuries (Duhig et al. 2016), which I go into more detail later in regards to load management. Similar studies have also shown reduced hip adductor/groin strength is associated with acute and chronic groin injuries, and that these can be reduced with identifying ‘at risk’ athletes, and therefore implementing prevention programs.
PICTURED: Jamie performing Nordboard testing on an Aussie Rules athlete. The athlete performs a Nordic hamstring exercise while on the Nordboard, which gives feedback on eccentric strength.
Over the past decade or so sport science has become widely and extensively used in professional sport, and rightly so. There is a mountain of evidence that training load is associated with injuries and injury risk. Basically, increasing your training load too quickly has an increased risk of injury, however having high training loads can also prevent injuries. Confused???
It has been shown that both high and low acute to chronic workload ratios are associated with a higher risk of injury (Hulin & Gabbett, 2014 and Blanch & Gabbett, 2015). So, what does this mean???
Training load = The total amount of training/game load that an athlete performs.
Acute load = The total training load for a given week (or other nominated short time frame)
Chronic load = The average acute loads over the past 4 weeks (or other nominated longer time frame)
So how do we work out training load???
Training load is generally achieved via adding or multiplying internal workload and external workload.
Internal workload = How hard an athlete has worked that session. Usually via heart rate measure or more easily via RPE (Rate of perceived exertion). Basically, after each session the athlete’s rates how hard/easy the session was from 0 to 10.
External workload = How much work the athlete has done. This is calculated via GPS measures or more easily via time of the session.
When we put these 2 measures together we get total load. For example, todays training session went for 60 minutes and the athlete gave an RPE of 8, therefore 60 x 8 = 480 units. This is to occur for all training sessions, whether it be gym sessions, conditioning, skill based or individual workouts, team training, and games. At the end of the week the total units are calculated, which is the acute load, and this is divided by the average of the last 4 weeks acute loads, which is the chronic load, to determine the acute:chronic workload ratio.
As you can see the acute load spike in week 4 has placed the athlete in the ‘Danger Zone’ and has increased their injury risk. Multiple studies have shown that if your ratio is below .8 and above 1.3, then your injury risk increases, as shown below (Blanch & Gabbett, 2015).
During this year’s World University Games in Taiwan, I was working with the Australian Emerging Boomers. Our squad was made up of players from different NBL teams and US college teams, therefore accessing their training loads was quite difficult. Therefore, the players were expected to enter all their training data for 6 weeks prior to the tournament, so that I could collate the individual athlete’s loads. This was done via a phone app that both myself and the athletes could easily access. I could then advise them if they needed to increase/decrease their training load if I calculated that they were at risk of injury during this pre-tournament period, or if their loads were not going to be high enough that when they arrived for the World University Games, they would be at risk of injury during the tournament due to a spike in load. I estimated that the athletes would require a chronic workload of at least 3000 units, therefore reaching this pre-tournament would help minimise injury risk and increase the teams chance of success.
PICTURED: Jamie behind the bench at World Uni Games with from left to right Craig Moller (NBL), Tyrell Harrison (NBL), Kyle Adman (NBL), Jack McVeigh (Uni of Nebraska), Tanner Krebs (St Marys) . He loves the game and cares about his athletes health AND their success.
These days many professional sporting teams are monitoring load data, therefore being able to determine if a player is at a higher risk of injury, which enables sports science/medicine staff to be able to make informed decisions on whether to reduce an athletes training load, game minutes, or even be rested from a game. There are times however when these risks are identified, and it is excepted that the athlete will train and play with greater risk, such as playing in an important game like a final. It is up to the sports science/medicine team to advise the coaching staff of the risk and then it is up to the coaching staff to determine whether that risk is worth taking.
The pathological principals behind injury risk with increased load is that basically our body’s tissues (e.g. Bone, tendon, muscle etc.) become stronger via loading them, however they cannot cope with rapid increases in load, which does not give the tissues time to recover, adapt and increase strength to be able to cope with the next, and the next and the next bout of training load. Small increases in load allow the tissues to progressively adapt and therefore become stronger and have capacity to tolerate loads. Hence, why there is evidence that high training loads is protective against injury. Therefore, we can reduce our athletes risk of injury through training hard, but we must get there in a smart and progressive fashion, which is why monitoring training load is so important. In recent years the NBA has been under scrutiny with teams resting key players before playoffs. Now if these players have high training loads, then this is a good idea. However, we need to be careful that their training load do not drop too much as this is also associated with risk, as maladaptive processes can occur, potentially reducing readiness to perform.
Load monitoring has been a major part of injury prevention in AFL, soccer and rugby, however basketball is lacking in this area, with many professional teams not utilising the large quantity of evidence that supports its use in injury prevention. Load monitoring should be crucial for any sports pre-season training plans, and then monitored in-season. This is because athletes have had a rest period in the off-season, and their chronic workload has reduced, therefore returning to higher levels of training has an increased risk associated with it. A study performed in AFL showed that the greater number of pre-season training sessions completed correlated with a greater likelihood of being fit to complete in-season training and games, and if you completed less than half the pre-season sessions you were at a greater risk of injury in-season (Murray et al. 2017). Therefore, pre-season needs to be a period where informed decisions around injury prevention need to be put in place, as this will set the athletes and team up to be health in-season and therefore increase the chance of success. AFL, rugby and soccer are sports known to have long pre-seasons, trying to get their athletes fit over a longer period, therefore reducing risk of injury, however many NBA teams have a pre-season of only around 4-6 weeks. Maybe it’s not a coincidence that there is a high incidence of injuries in the NBA early in the season? Maybe it is?
Not only is overall training/work-load associated with injuries, but rapid increases in certain training measures. Rapid increases in high speed running has been shown to be predictive of hamstring strain injuries, however slowly increasing high speed running rates, then maintaining a healthy acute:chronic ratio of high-speed running, has shown to be protective of hamstring strain injuries in football (Duhig et al. 2016). Therefore, other activities that are associated with certain injuries need to be monitored and managed. Increased jumping loads may increase risk of patellar tendinopathy, increased change of direction loads may increase risk of groin injuries. That does not mean we don’t eliminate these, we must expose our athletes to these activities to build tissue tolerance, however we need to take care of rapid increases, especially our athletes with a previous history of a specific injury. Therefore, an athlete with a history of patellar tendinopathy needs to have their jumping loads monitored and modified more than an athlete without a history of patellar tendinopathy. This suggests that training strategies need to represent the demands of the game. There’s no point doing pre-season training running on sand if you play on a court. If your sport involves lots of jumping, change of direction, deceleration/acceleration (e.g. Basketball), these activities need to be performed progressively in the pre-season to build tissue tolerance to the activities, therefore reducing the risk of injury to that area when games and the season begin.
The last piece of the puzzle is to monitor your athlete’s well-being. Many studies have shown that athlete reported poor health and well-being is related to injury and illness. Poor sleep, muscle soreness, fatigue/tiredness have been shown to be related to injury risk. Therefore, recording these daily can give the sports science/medicine staff a lot of information, and may be the decisive factor when determining whether to reduce an athletes training, when their acute:chronic workload ratio is on the edge. This can be easily done vis mobile phone apps, and does require your athletes to be honest, however if your athletes know the value, importance and risks associated with these well-being measures, then they will realise that these measures are in place for the short and long-term health of the athlete. Untruthful reporting therefore puts the athlete’s health at risk and the success of the team at risk.
In summary, injury prevention has become a large part of professional sport, and rightly so with all the evidence and research backing it up, however these practices are still developing in basketball. Since reducing injuries has been shown to increase team success, these injury prevention strategies should also be seen as performance enhancing. To summarise these strategies and a few ending thoughts;
Screen your athletes for previous injuries and injuries associated with your sport, to help implement individual and team based injury prevention programs.
Prevention strategies should include training/game warm-up, individually targeted prevention programs, and load and wellness monitoring.
Continue to monitor athletes for injury risk, and modify their training accordingly.
Load monitoring is a necessity for making informed decisions around training and game availability to reduce injury risk.
Train your athletes hard, but smart!! Therefore, develop high chronic workloads to safe guard your athletes, however it is important to get to these high chronic workloads safely.
Teams need to implement injury prevention programs through a collaborative approach of high performance, strength and conditioning, sports science and sports medicine staff, in collaboration with coaching staff, to not only reduce injury rates, but to increase performance and success rates!
Injuries are always going to happen. I am definitely not saying that we can eradicate injuries from sports, but we do know that many non-contact injuries can be reduced via these injury prevention strategies. With millions of dollars being lost to professional athletes getting injured, maybe more money needs to be put into injury prevention strategies to improve athlete health and ultimately team success?
PICTURED: Jamie and Delly..... and, typically, a bag of ice. Taken whilst Jamie was working with the Bucks.
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Timmins, R., Bourne, M., Shield, A., Williams, M., Lorenzen, C., & Opar, D. (2015). Short biceps femoris fascicles and eccentric knee ﬂexor weakness increase the risk of hamstring injury in elite football (soccer): a prospective cohort study. British Journal of Sports Medicine, doi:10.1136/bjsports-2015-095362