Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                
Skip to main content
Springer Nature Link
Log in

Training Load and Injury: Causal Pathways and Future Directions

  • Review Article
  • Published:
Sports Medicine Aims and scope Submit manuscript

A Letter to the Editor to this article was published on 22 July 2021

A Letter to the Editor to this article was published on 22 July 2021

Abstract

Causal pathways between training loads and the mechanisms of tissue damage and athletic injury are poorly understood. Here, the relation between specific training load measures and metrics, and causal pathways of gradual onset and traumatic injury are examined. Currently, a wide variety of internal and external training load measures and metrics exist, with many of these being commonly utilized to evaluate injury risk. These measures and metrics can conceptually be related to athletic injury through the mechanical load-response pathway, the psycho-physiological load-response pathway, or both. However, the contributions of these pathways to injury vary. Importantly, tissue fatigue damage and trauma through the mechanical load-response pathway is poorly understood. Furthermore, considerable challenges in quantifying this pathway exist within applied settings, evidenced by a notable absence of validation between current training load measures and tissue-level mechanical loads. Within this context, the accurate quantification of mechanical loads holds considerable importance for the estimation of tissue damage and the development of more thorough understandings of injury risk. Despite internal load measures of psycho-physiological load speculatively being conceptually linked to athletic injury through training intensity and the effects of psycho-physiological fatigue, these measures are likely too far removed from injury causation to provide meaningful, reliable relationships with injury. Finally, we used a common training load metric as a case study to show how the absence of a sound conceptual rationale and spurious links to causal mechanisms can disclose the weaknesses of candidate measures as tools for altering the likelihood of injuries, aiding the future development of more refined injury risk assessment methods.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Reproduced from Edwards with permission [5]

Similar content being viewed by others

References

  1. Impellizzeri FM, Marcora SM, Coutts AJ. Internal and external training load: 15 years on. Int J Sports Physiol Perform. 2019;14(2):270–3.

    Article  PubMed  Google Scholar 

  2. Bahr R, Krosshaug T. Understanding injury mechanisms: a key component of preventing injuries in sport. Br J Sports Med. 2005;39(6):324–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. McIntosh AS. Risk compensation, motivation, injuries, and biomechanics in competitive sport. Br J Sports Med. 2005;39(1):2–3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Bertelsen ML, Hulme A, Petersen J, Brund RK, Sorensen H, Finch CF, et al. A framework for the etiology of running-related injuries. Scand J Med Sci Sports. 2017;27(11):1170–80.

    Article  CAS  PubMed  Google Scholar 

  5. Edwards WB. Modeling overuse injuries in sport as a mechanical fatigue phenomenon. Exerc Sport Sci Rev. 2018;46(4):224–31.

    Article  PubMed  Google Scholar 

  6. Kalkhoven JT, Watsford ML, Impellizzeri FM. A conceptual model and detailed framework for stress-related, strain-related, and overuse athletic injury. J Sci Med Sport. 2020;23(8):726–34.

    Article  PubMed  Google Scholar 

  7. Peterson R. Discussion of a century ago concerning the nature of fatigue, and review of some of the subsequent researches concerning the mechanism of fatigue. ASTM Bull. 1950;164:50–6.

    Google Scholar 

  8. Gabbett TJ. The training-injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med. 2016;50(5):273–80.

    Article  PubMed  Google Scholar 

  9. Gallagher S, Heberger JR. Examining the interaction of force and repetition on musculoskeletal disorder risk: a systematic literature review. Hum Factors. 2013;55(1):108–24.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Gallagher S, Schall MC Jr. Musculoskeletal disorders as a fatigue failure process: evidence, implications and research needs. Ergonomics. 2017;60(2):255–69.

    Article  PubMed  Google Scholar 

  11. Fung YC. Biomechanics: mechanical properties of living tissues. New York: Springer-Verlag; 1981.

    Book  Google Scholar 

  12. Fung YC. Biomechanics: mechanical properties of living tissues. 2nd ed. New York: Springer-Verlag; 1993.

    Book  Google Scholar 

  13. Carter DR, Caler WE. A cumulative damage model for bone fracture. J Orthop Res. 1985;3(1):84–90.

    Article  CAS  PubMed  Google Scholar 

  14. Hart NH, Nimphius S, Rantalainen T, Ireland A, Siafarikas A, Newton RU. Mechanical basis of bone strength: influence of bone material, bone structure and muscle action. J Musculoskelet Neuronal Interact. 2017;17(3):114–39.

    CAS  PubMed  PubMed Central  Google Scholar 

  15. Lieber RL, Friden J. Muscle damage is not a function of muscle force but active muscle strain. J Appl Physiol (1985). 1993;74(2):520–6.

    Article  CAS  Google Scholar 

  16. Garrett WE Jr. Muscle strain injuries. Am J Sports Med. 1996;24(6 Suppl):S2-8.

    Article  PubMed  Google Scholar 

  17. Crossley K, Bennell KL, Wrigley T, Oakes BW. Ground reaction forces, bone characteristics, and tibial stress fracture in male runners. Med Sci Sports Exerc. 1999;31(8):1088–93.

    Article  CAS  PubMed  Google Scholar 

  18. Schechtman H, Bader DL. In vitro fatigue of human tendons. J Biomech. 1997;30(8):829–35.

    Article  CAS  PubMed  Google Scholar 

  19. Wang XT, Ker RF, Alexander RM. Fatigue rupture of wallaby tail tendons. J Exp Biol. 1995;198(Pt 3):847–52.

    Article  CAS  PubMed  Google Scholar 

  20. Lipps DB, Oh YK, Ashton-Miller JA, Wojtys EM. Morphologic characteristics help explain the gender difference in peak anterior cruciate ligament strain during a simulated pivot landing. Am J Sports Med. 2012;40(1):32–40.

    Article  PubMed  Google Scholar 

  21. Lipps DB, Wojtys EM, Ashton-Miller JA. Anterior cruciate ligament fatigue failures in knees subjected to repeated simulated pivot landings. Am J Sports Med. 2013;41(5):1058–66.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Thornton GM, Schwab TD, Oxland TR. Cyclic loading causes faster rupture and strain rate than static loading in medial collateral ligament at high stress. Clin Biomech (Bristol, Avon). 2007;22(8):932–40.

    Article  Google Scholar 

  23. Bellucci G, Seedhom BB. Mechanical behaviour of articular cartilage under tensile cyclic load. Rheumatology (Oxford). 2001;40(12):1337–45.

    Article  CAS  Google Scholar 

  24. Brinckmann P, Biggemann M, Hilweg D. Fatigue fracture of human lumbar vertebrae. Clin Biomech (Bristol, Avon). 1988;3(Suppl 1):1-S23.

    Google Scholar 

  25. Cyron BM, Hutton WC. The fatigue strength of the lumbar neural arch in spondylolysis. J Bone Joint Surg Br. 1978;60-B(2):234–8.

    Article  CAS  PubMed  Google Scholar 

  26. Gallagher S, Marras WS, Litsky AS, Burr D. Torso flexion loads and the fatigue failure of human lumbosacral motion segments. Spine (Phila Pa 1976). 2005;30(20):2265–73.

    Article  Google Scholar 

  27. Gallagher S, Marras WS, Litsky AS, Burr D, Landoll J, Matkovic V. A comparison of fatigue failure responses of old versus middle-aged lumbar motion segments in simulated flexed lifting. Spine (Phila Pa 1976). 2007;32(17):1832–9.

    Article  Google Scholar 

  28. Barbe MF, Gallagher S, Massicotte VS, Tytell M, Popoff SN, Barr-Gillespie AE. The interaction of force and repetition on musculoskeletal and neural tissue responses and sensorimotor behavior in a rat model of work-related musculoskeletal disorders. BMC Musculoskelet Disord. 2013;25(14):303.

    Article  Google Scholar 

  29. Andarawis-Puri N, Flatow EL. Tendon fatigue in response to mechanical loading. J Musculoskelet Neuronal Interact. 2011;11(2):106–14.

    CAS  PubMed  Google Scholar 

  30. Harris-Adamson C, Eisen EA, Kapellusch J, Garg A, Hegmann KT, Thiese MS, et al. Biomechanical risk factors for carpal tunnel syndrome: a pooled study of 2474 workers. Occup Environ Med. 2015;72(1):33–41.

    Article  PubMed  Google Scholar 

  31. Kuipers H, Drukker J, Frederik PM, Geurten P, van Kranenburg G. Muscle degeneration after exercise in rats. Int J Sports Med. 1983;4(1):45–51.

    Article  CAS  PubMed  Google Scholar 

  32. Lieber RL, Woodburn TM, Friden J. Muscle damage induced by eccentric contractions of 25% strain. J Appl Physiol (1985). 1991;70(6):2498–507.

    Article  CAS  Google Scholar 

  33. Fung DT, Wang VM, Laudier DM, Shine JH, Basta-Pljakic J, Jepsen KJ, et al. Subrupture tendon fatigue damage. J Orthop Res. 2009;27(2):264–73.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Herman BC, Cardoso L, Majeska RJ, Jepsen KJ, Schaffler MB. Activation of bone remodeling after fatigue: differential response to linear microcracks and diffuse damage. Bone. 2010;47(4):766–72.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Brockett CL, Morgan DL, Proske U. Human hamstring muscles adapt to eccentric exercise by changing optimum length. Med Sci Sports Exerc. 2001;33(5):783–90.

    Article  CAS  PubMed  Google Scholar 

  36. Timmins RG, Shield AJ, Williams MD, Opar DA. Is there evidence to support the use of the angle of peak torque as a marker of hamstring injury and re-injury risk? Sports Med. 2016;46(1):7–13.

    Article  PubMed  Google Scholar 

  37. Yasui Y, Tonogai I, Rosenbaum AJ, Shimozono Y, Kawano H, Kennedy JG. The risk of Achilles tendon rupture in the patients with Achilles tendinopathy: healthcare database analysis in the United States. BioMed Res Int. 2017;2017.

  38. Tallon C, Maffulli N, Ewen SW. Ruptured Achilles tendons are significantly more degenerated than tendinopathic tendons. Med Sci Sports Exerc. 2001;33(12):1983–90.

    Article  CAS  PubMed  Google Scholar 

  39. Zitnay JL, Jung GS, Lin AH, Qin Z, Li Y, Yu SM, et al. Accumulation of collagen molecular unfolding is the mechanism of cyclic fatigue damage and failure in collagenous tissues. Sci Adv. 2020;6(35):eaba2795.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Martin B. A theory of fatigue damage accumulation and repair in cortical bone. J Orthop Res. 1992;10(6):818–25.

    Article  CAS  PubMed  Google Scholar 

  41. Desmouliere A, Redard M, Darby I, Gabbiani G. Apoptosis mediates the decrease in cellularity during the transition between granulation tissue and scar. Am J Pathol. 1995;146(1):56–66.

    CAS  PubMed  PubMed Central  Google Scholar 

  42. Tomasek JJ, Gabbiani G, Hinz B, Chaponnier C, Brown RA. Myofibroblasts and mechano-regulation of connective tissue remodelling. Nat Rev Mol Cell Biol. 2002;3(5):349–63.

    Article  CAS  PubMed  Google Scholar 

  43. Komi PV, Belli A, Huttunen V, Bonnefoy R, Geyssant A, Lacour JR. Optic fibre as a transducer of tendomuscular forces. Eur J Appl Physiol Occup Physiol. 1996;72(3):278–80.

    Article  CAS  PubMed  Google Scholar 

  44. Finni T, Komi PV, Lukkariniemi J. Achilles tendon loading during walking: application of a novel optic fiber technique. Eur J Appl Physiol Occup Physiol. 1998;77(3):289–91.

    Article  CAS  PubMed  Google Scholar 

  45. Burr DB, Milgrom C, Fyhrie D, Forwood M, Nyska M, Finestone A, et al. In vivo measurement of human tibial strains during vigorous activity. Bone. 1996;18(5):405–10.

    Article  CAS  PubMed  Google Scholar 

  46. Smith DW, Rubenson J, Lloyd D, Zheng M, Fernandez J, Besier T, et al. A conceptual framework for computational models of Achilles tendon homeostasis. Wiley Interdiscip Rev Syst Biol Med. 2013;5(5):523–38.

    Article  PubMed  Google Scholar 

  47. Loundagin LL, Schmidt TA, Edwards WB. Mechanical fatigue of bovine cortical bone using ground reaction force waveforms in running. J Biomech Eng. 2018;140(3).

  48. Amirouche F, Bobko A. Bone remodeling and biomechanical processes—a multiphysics approach. Austin J Biotechnol Bioeng. 2015;2(2):1–11.

    Google Scholar 

  49. Verheul J, Nedergaard NJ, Vanrenterghem J, Robinson MA. Measuring biomechanical loads in team sports–from lab to field. Sci Med Football. 2020;1–7. https://doi.org/10.1080/24733938.2019.1709654.

  50. Seth A, Hicks JL, Uchida TK, Habib A, Dembia CL, Dunne JJ, et al. OpenSim: simulating musculoskeletal dynamics and neuromuscular control to study human and animal movement. PLoS Comput Biol. 2018;14(7):e1006223.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  51. Petersen C, Pyne D, Portus M, Dawson B. Validity and reliability of GPS units to monitor cricket-specific movement patterns. Int J Sports Physiol Perform. 2009;4(3):381–93.

    Article  PubMed  Google Scholar 

  52. Buchheit M, Al Haddad H, Simpson BM, Palazzi D, Bourdon PC, Di Salvo V, et al. Monitoring accelerations with GPS in football: time to slow down? Int J Sports Physiol Perform. 2014;9(3):442–5.

    Article  PubMed  Google Scholar 

  53. Johnston RJ, Watsford ML, Kelly SJ, Pine MJ, Spurrs RW. Validity and interunit reliability of 10 Hz and 15 Hz GPS units for assessing athlete movement demands. J Strength Cond Res. 2014;28(6):1649–55.

    Article  PubMed  Google Scholar 

  54. Gabbett TJ. Quantifying the physical demands of collision sports: does microsensor technology measure what it claims to measure? J Strength Cond Res. 2013;27(8):2319–22.

    Article  PubMed  Google Scholar 

  55. Ehrmann FE, Duncan CS, Sindhusake D, Franzsen WN, Greene DA. GPS and injury prevention in professional soccer. J Strength Condition Res. 2016;30(2):360–7.

    Article  Google Scholar 

  56. Colby MJ, Dawson B, Heasman J, Rogalski B, Gabbett TJ. Accelerometer and GPS-derived running loads and injury risk in elite Australian footballers. J Strength Cond Res. 2014;28(8):2244–52.

    Article  PubMed  Google Scholar 

  57. Kupperman N, Hertel J. Global positioning system-derived workload metrics and injury risk in team-based field sports: a systematic review. J Athletic train. 2020;55(9):931–43.

    Article  Google Scholar 

  58. Meyer DL. Misinterpretation of interaction effects: a reply to Rosnow and Rosenthal. Psychol Bull. 1991;110(3):571–3 (discussion 4–6).

    Article  CAS  PubMed  Google Scholar 

  59. Boyd LJ, Ball K, Aughey RJ. The reliability of MinimaxX accelerometers for measuring physical activity in Australian football. Int J Sports Physiol Perform. 2011;6(3):311–21.

    Article  PubMed  Google Scholar 

  60. Raper DP, Witchalls J, Philips EJ, Knight E, Drew MK, Waddington G. Use of a tibial accelerometer to measure ground reaction force in running: a reliability and validity comparison with force plates. J Sci Med Sport. 2018;21(1):84–8.

    Article  PubMed  Google Scholar 

  61. Gurchiek RD, McGinnis RS, Needle AR, McBride JM, van Werkhoven H. The use of a single inertial sensor to estimate 3-dimensional ground reaction force during accelerative running tasks. J Biomech. 2017;61:263–8.

    Article  PubMed  Google Scholar 

  62. Ancillao A, Tedesco S, Barton J, O’Flynn B. Indirect measurement of ground reaction forces and moments by means of wearable inertial sensors: a systematic review. Sensors. 2018;18(8):2564. https://doi.org/10.3390/s18082564.

    Article  PubMed Central  Google Scholar 

  63. Hennig EM, Milani TL, Lafortune MA. Use of ground reaction force parameters in predicting peak tibial accelerations in running. J Appl Biomech. 1993;9(4):306–14.

    Article  PubMed  Google Scholar 

  64. Crowell HP, Milner CE, Hamill J, Davis IS. Reducing impact loading during running with the use of real-time visual feedback. J Orthop Sports Phys Ther. 2010;40(4):206–13.

    Article  PubMed  Google Scholar 

  65. Hamill J, Derrick TR, Holt KG. Shock attenuation and stride frequency during running. Hum Mov Sci. 1995;14(1):45–60.

    Article  Google Scholar 

  66. Matijevich ES, Branscombe LM, Scott LR, Zelik KE. Ground reaction force metrics are not strongly correlated with tibial bone load when running across speeds and slopes: Implications for science, sport and wearable tech. PLoS ONE. 2019;14(1):e0210000.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  67. Johnson CD, Tenforde AS, Outerleys J, Reilly J, Davis IS. Impact-related ground reaction forces are more strongly associated with some running injuries than others. Am J Sports Med. 2020;48(12):3072–80.

    Article  PubMed  Google Scholar 

  68. Sasimontonkul S, Bay BK, Pavol MJ. Bone contact forces on the distal tibia during the stance phase of running. J Biomech. 2007;40(15):3503–9.

    Article  PubMed  Google Scholar 

  69. Matijevich ES, Scott LR, Volgyesi P, Derry KH, Zelik KE. Combining wearable sensor signals, machine learning and biomechanics to estimate tibial bone force and damage during running. Hum Mov Sci. 2020;22(74):102690.

    Article  Google Scholar 

  70. Martin JA, Brandon SCE, Keuler EM, Hermus JR, Ehlers AC, Segalman DJ, et al. Gauging force by tapping tendons. Nat Commun. 2018;9(1):1592.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  71. Miner MA. Cumulative damage in fatigue. J Appl Mech. 1945;67:A159–64.

    Article  Google Scholar 

  72. Palmgren AJN. Die Lebensdauer von Kugellagern. VDI-Zeitschrift. 1924;58:339–41.

    Google Scholar 

  73. Weightman B, Chappell DJ, Jenkins EA. A second study of tensile fatigue properties of human articular cartilage. Ann Rheum Dis. 1978;37(1):58–63.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  74. Wren TA, Lindsey DP, Beaupre GS, Carter DR. Effects of creep and cyclic loading on the mechanical properties and failure of human Achilles tendons. Ann Biomed Eng. 2003;31(6):710–7.

    Article  PubMed  Google Scholar 

  75. Stephens RI, Fatemi A, Stephens RR, Fuchs HO. Metal fatigue in engineering. New York: Wiley; 2000.

    Google Scholar 

  76. Roylance DJ. Fatigue. Department of Materials Science and Engineering. Massachusetts Institute of Technology Cambridge, MA, 2139. 2001.

  77. Drew MK, Finch CF. The relationship between training load and injury, illness and soreness: a systematic and literature review. Sports Med. 2016;46(6):861–83.

    Article  PubMed  Google Scholar 

  78. Huygaerts S, Cos F, Cohen DD, Calleja-Gonzalez J, Guitart M, Blazevich AJ, et al. Mechanisms of hamstring strain injury: interactions between fatigue, muscle activation and function. Sports (Basel). 2020;8(5): 65.

  79. Morin JB, Samozino P, Edouard P, Tomazin K. Effect of fatigue on force production and force application technique during repeated sprints. J Biomech. 2011;44(15):2719–23.

    Article  PubMed  Google Scholar 

  80. Butterfield TA, Herzog W. Effect of altering starting length and activation timing of muscle on fiber strain and muscle damage. J Appl Physiol (1985). 2006;100(5):1489–98.

    Article  Google Scholar 

  81. Liederbach M, Compagno JM. Psychological aspects of fatigue-related injuries in dancers. J Dance Med Sci. 2001;5(4):116–20.

    Google Scholar 

  82. Bourne MN, Webster KE, Hewett TE. Is fatigue a risk factor for anterior cruciate ligament rupture? Sports Med. 2019;49(11):1629–35.

    Article  PubMed  Google Scholar 

  83. Doyle TLA, Schilaty ND, Webster KE, Hewett TE. Time of season and game segment is not related to likelihood of lower-limb injuries: a meta-analysis. Clin J Sport Med. 2019. https://doi.org/10.1097/JSM.0000000000000752.

    Article  Google Scholar 

  84. Zhou J, Schilaty ND, Hewett TE, Bates NA. Analysis of timing of secondary ACL injury in professional athletes does not support game timing or season timing as a contributor to injury risk. Int J Sports Phys Ther. 2020;15(2):254–62.

    Article  PubMed  PubMed Central  Google Scholar 

  85. Della Villa F, Buckthorpe M, Grassi A, Nabiuzzi A, Tosarelli F, Zaffagnini S, et al. Systematic video analysis of ACL injuries in professional male football (soccer): injury mechanisms, situational patterns and biomechanics study on 134 consecutive cases. Br J Sports Med. 2020. https://doi.org/10.1136/bjsports-2019-101247.

    Article  PubMed  Google Scholar 

  86. Halson SL. Monitoring training load to understand fatigue in athletes. Sports Med. 2014;44(Suppl 2):S139–47.

    Article  PubMed  Google Scholar 

  87. Raya-Gonzalez J, Nakamura FY, Castillo D, Yanci J, Fanchini M. Determining the relationship between internal load markers and noncontact injuries in young elite soccer players. Int J Sports Physiol Perform. 2019;14(4):421–5.

    Article  PubMed  Google Scholar 

  88. Esmaeili A, Hopkins WG, Stewart AM, Elias GP, Lazarus BH, Aughey RJ. The individual and combined effects of multiple factors on the risk of soft tissue non-contact injuries in elite team sport athletes. Front Physiol. 2018;9:1280.

    Article  PubMed  PubMed Central  Google Scholar 

  89. Jaspers A, Kuyvenhoven JP, Staes F, Frencken WGP, Helsen WF, Brink MS. Examination of the external and internal load indicators’ association with overuse injuries in professional soccer players. J Sci Med Sport. 2018;21(6):579–85.

    Article  PubMed  Google Scholar 

  90. Fanchini M, Rampinini E, Riggio M, Coutts AJ, Pecci C, McCall A. Despite association, the acute: chronic work load ratio does not predict non-contact injury in elite footballers. Sci Med Football. 2018;2(2):108–14.

    Article  Google Scholar 

  91. Lolli L, Bahr R, Weston M, Whiteley R, Tabben M, Bonanno D, et al. No association between perceived exertion and session duration with hamstring injury occurrence in professional football. Scand J Med Sci Sports. 2019;30(3):523–530.

  92. Altman N, Krzywinski M. Association, correlation and causation. Nat Methods. 2015;12(10):899–900.

    Article  CAS  PubMed  Google Scholar 

  93. Okasha S. Philosophy of science: very short introduction. Oxford: Oxford University Press; 2016.

    Book  Google Scholar 

  94. Myer GD, Faigenbaum AD, Cherny CE, Heidt RS Jr, Hewett TE. Did the NFL Lockout expose the Achilles heel of competitive sports? J Orthop Sports Phys Ther. 2011;41(10):702–5.

    Article  PubMed  Google Scholar 

  95. Rogalski B, Dawson B, Heasman J, Gabbett TJ. Training and game loads and injury risk in elite Australian footballers. J Sci Med Sport. 2013;16(6):499–503.

    Article  PubMed  Google Scholar 

  96. Hagglund M, Walden M, Ekstrand J. Exposure and injury risk in Swedish elite football: a comparison between seasons 1982 and 2001. Scand J Med Sci Sports. 2003;13(6):364–70.

    Article  PubMed  Google Scholar 

  97. Stovitz SD, Shrier I. Injury rates in team sport events: tackling challenges in assessing exposure time. Br J Sports Med. 2012;46(14):960–3.

    Article  PubMed  Google Scholar 

  98. van Mechelen W, Hlobil H, Kemper HC. Incidence, severity, aetiology and prevention of sports injuries. A review of concepts. Sports Med. 1992;14(2):82–99.

    Article  PubMed  Google Scholar 

  99. Impellizzeri F, Woodcock S, Coutts AJ, Fanchini M, McCall A, Vigotsky A. What role do chronic workloads play in the acute to chronic workload ratio? Time to dismiss ACWR and its underlying theory. Sports Med. 2020. https://doi.org/10.1007/s40279-020-01378-6.

  100. Lolli L, Batterham AM, Hawkins R, Kelly DM, Strudwick AJ, Thorpe RT, et al. The acute-to-chronic workload ratio: an inaccurate scaling index for an unnecessary normalisation process? Br J Sports Med. 2019;53(24):1510–2.

    Article  PubMed  Google Scholar 

  101. Wang C, Vargas JT, Stokes T, Steele R, Shrier I. Analyzing activity and injury: lessons learned from the Acute:Chronic workload ratio. Sports Med. 2020;50(7):1243–54.

    Article  PubMed  Google Scholar 

  102. Lolli L, Batterham AM, Hawkins R, Kelly DM, Strudwick AJ, Thorpe R, et al. Mathematical coupling causes spurious correlation within the conventional acute-to-chronic workload ratio calculations. Br J Sports Med. 2019;53(15):921–2.

    Article  PubMed  Google Scholar 

  103. Hulin BT, Gabbett TJ, Lawson DW, Caputi P, Sampson JA. The acute:chronic workload ratio predicts injury: high chronic workload may decrease injury risk in elite rugby league players. Br J Sports Med. 2016;50(4):231–6.

    Article  PubMed  Google Scholar 

  104. Blanch P, Gabbett TJ. Has the athlete trained enough to return to play safely? The acute:chronic workload ratio permits clinicians to quantify a player’s risk of subsequent injury. Br J Sports Med. 2016;50(8):471–5.

    Article  PubMed  Google Scholar 

  105. Bowen L, Gross AS, Gimpel M, Li FX. Accumulated workloads and the acute:chronic workload ratio relate to injury risk in elite youth football players. Br J Sports Med. 2017;51(5):452–9.

    Article  PubMed  Google Scholar 

  106. Banister E, Calvert T, Savage M, Bach T. A systems model of training for athletic performance. Aust J Sports Med. 1975;7(3):57–61.

    Google Scholar 

  107. Impellizzeri FM, Ward P, Coutts AJ, Bornn L, McCall A. Training load and injury part 2: questionable research practices hijack the truth and mislead well-intentioned clinicians. J Orthop Sports Phys Ther. 2020;50(10):577–84.

    Article  PubMed  Google Scholar 

  108. Impellizzeri FM, McCall A, Ward P, Bornn L, Coutts AJ. Training load and its role in injury prevention, part 2: conceptual and methodologic pitfalls. J Athl Train. 2020;55(9):893–901.

    Article  PubMed  PubMed Central  Google Scholar 

  109. Hulin BT, Gabbett TJ, Blanch P, Chapman P, Bailey D, Orchard JW. Spikes in acute workload are associated with increased injury risk in elite cricket fast bowlers. Br J Sports Med. 2014;48(8):708–12.

    Article  PubMed  Google Scholar 

  110. Windt J, Gabbett TJ, Ferris D, Khan KM. Training load–injury paradox: is greater preseason participation associated with lower in-season injury risk in elite rugby league players? Br J Sports Med. 2017;51(8):645–50.

    Article  PubMed  Google Scholar 

  111. Ekstrand J, Spreco A, Windt J, Khan KM. Are elite soccer teams’ preseason training sessions associated with fewer in-season injuries? A 15-year analysis from the Union of European Football Associations (UEFA) elite club injury study. Am J Sports Med. 2020;48(3):723–9.

    Article  PubMed  Google Scholar 

  112. Hulin BT, Gabbett TJ, Caputi P, Lawson DW, Sampson JA. Low chronic workload and the acute:chronic workload ratio are more predictive of injury than between-match recovery time: a two-season prospective cohort study in elite rugby league players. Br J Sports Med. 2016;50(16):1008–12.

    Article  PubMed  Google Scholar 

  113. Bailey DA, McKay HA, Mirwald RL, Crocker PR, Faulkner RA. A six-year longitudinal study of the relationship of physical activity to bone mineral accrual in growing children: the university of Saskatchewan bone mineral accrual study. J Bone Miner Res. 1999;14(10):1672–9.

    Article  CAS  PubMed  Google Scholar 

  114. Kemper HC, Twisk JW, van Mechelen W, Post GB, Roos JC, Lips P. A 15-year longitudinal study in young adults on the relation of physical activity and fitness with the development of the bone mass: the Amsterdam Growth And Health Longitudinal Study. Bone. 2000;27(6):847–53.

    Article  CAS  PubMed  Google Scholar 

  115. Kalkhoven JT, Watsford M. Mechanical contributions to muscle injury: implications for athletic injury risk mitigation. SportRxiv. 2020;15. https://doi.org/10.31236/osf.io/a5um4.

  116. Docking SI, Cook J. How do tendons adapt? Going beyond tissue responses to understand positive adaptation and pathology development: a narrative review. J Musculoskelet Neuronal Interact. 2019;19(3):300–10.

    CAS  PubMed  PubMed Central  Google Scholar 

  117. Carey DL, Blanch P, Ong KL, Crossley KM, Crow J, Morris ME. Training loads and injury risk in Australian football-differing acute: chronic workload ratios influence match injury risk. Br J Sports Med. 2017;51(16):1215–20.

    Article  PubMed  Google Scholar 

  118. Griffin A, Kenny IC, Comyns TM, Lyons M. The association between the acute:chronic workload ratio and injury and its application in team sports: a systematic review. Sports Med. 2020;50(3):561–80.

    Article  PubMed  Google Scholar 

  119. Suarez-Arrones L, De Alba B, Roell M, Torreno I, Strütt S, Freyler K, et al. Player monitoring in professional soccer: spikes in acute:chronic workload are dissociated from injury occurrence. Front Sports Active Living. 2020;2:75.

    Article  Google Scholar 

  120. Kerr NL. HARKing: hypothesizing after the results are known. Pers Soc Psychol Rev. 1998;2(3):196–217.

    Article  CAS  PubMed  Google Scholar 

  121. Impellizzeri FM, Menaspa P, Coutts AJ, Kalkhoven J, Menaspa MJ. Training load and its role in injury prevention, part I: back to the future. J Athl Train. 2020;55(9):885–92.

    Article  PubMed  PubMed Central  Google Scholar 

  122. Dalen-Lorentsen T, Bjørneboe J, Clarsen B, Vagle M, Fagerland MW, Andersen TE. Does load management using the acute: chronic workload ratio prevent health problems? A cluster randomised trial of 482 elite youth footballers of both sexes. Br J Sports Med. 2020;. https://doi.org/10.1136/bjsports-2020-103003.

    Article  PubMed  Google Scholar 

  123. West SW, Williams S, Cazzola D, Kemp S, Cross MJ, Stokes KA. Training load and injury risk in elite rugby union: the largest investigation to date. Int J Sports Med. 2020;. https://doi.org/10.1055/a-1300-2703.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

The authors would like to thank Blake McLean, Michael Rennie, Emily Matijevich, and Brook Kalkhoven for their contributions to the manuscript.

Author information

Authors and Affiliations

  1. School of Sport, Exercise and Rehabilitation, Human Performance Research Centre, Faculty of Health, University of Technology Sydney, Moore Park Precinct, Broadway, Ultimo, PO Box 123, Sydney, NSW, 2007, Australia

    Judd T. Kalkhoven, Mark L. Watsford, Aaron J. Coutts & Franco M. Impellizzeri

  2. Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada

    W. Brent Edwards

Authors
  1. Judd T. Kalkhoven
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mark L. Watsford
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Aaron J. Coutts
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. W. Brent Edwards
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Franco M. Impellizzeri
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Judd T. Kalkhoven.

Ethics declarations

Conflict of Interest

Judd Kalkhoven, Mark Watsford, Aaron Coutts, W. Brent Edwards and Franco Impellizzeri declare that they have no conflicts of interest.

Author contributions

JTK conceived the idea for the article, wrote the first draft of the manuscript and all versions thereafter. MLW contributed substantially to the editing and conceptual direction of the manuscript. AJC contextualised the information provided in the manuscript within the current climate of training load research. WBE contributed to the tissue engineering and mechanical load components of the manuscript. FMI contributed to the conceptual formation and editing of the manuscript as a whole with a special emphasis to Sect. 3. All authors read and approved the final manuscript.

Funding

No sources of funding were used to assist in the preparation of this article.

Data availability

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kalkhoven, J.T., Watsford, M.L., Coutts, A.J. et al. Training Load and Injury: Causal Pathways and Future Directions. Sports Med 51, 1137–1150 (2021). https://doi.org/10.1007/s40279-020-01413-6

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40279-020-01413-6

Search

Navigation