Tempering is a process used to impart strength and toughness, and essentially serves to bring out the intrinsic properties of the material under stress. Athletes forged in the crucible of severely testing conditions may be similarly rendered highly resilient to future challenges and stressors. Those who successfully come through such trial by fire paradoxically often prove stronger from the experience. The notion that stressors can not only make systems more resilient, but in fact stronger and better as a consequence, speaks to the concept of antifragility, a phenomenon observed in nature and highlighted by Nassim Taleb who famously coined the term. In this post, we will bring this antifragility lens, and a general reticence to accept that sports injuries ‘just happen’, to reframe how we think about preparing athletes to ‘future proof’ them to risks and scenarios that we cannot fully anticipate. In place of safeguarding measures and interventions that seek to protect, we will make the argument for tempering athletes to harness and develop their intrinsic reserves and coping abilities. Adopting this perspective and general strategy for managing injury risk, we will outline some tactics to help guide practitioners in their approach.
I began my career in sport working in the contact sport of professional rugby union. Sports injury is not entirely avoidable in the chaos of game play when violent bodily contact is a feature of the sport. When I subsequently moved onto working with other (non contact) sports, I was not willing to accept that injury was a fact of life in the same way. Whilst contact injuries are not entirely avoidable, I viewed the respective non-contact and overuse injuries in these other sports as a different matter.
Whilst this might seem naive, happily I was not swayed by such opinions, and this lack of acceptance of the inevitability of sports injury has stayed with me. My reasoning was (and remains) that if we have a thorough understanding of what the sport demands, and we can anticipate the types and magnitude of stresses involved, it follows that it is our task to prepare the athlete accordingly. In essence, @@we should deploy any and all tools at our disposal in our quest to make the athlete unbreakable@@.
I share this personal viewpoint to set the tone for the discussion to follow, as it differs in fundamental and important ways from the norm, and the more typical perspectives of authors of much of the literature on sports injury prevention. My contention is that despite the best intentions we have become too conservative and protective in our approach, with unanticipated and paradoxical consequences. As I hope to make the case, we can better serve our athletes and ultimately shift the odds of injury in their favour by being more aggressive in our approach.
A REVELATION: WE ARE NOT MACHINES…
There is a temptation in sports science and medicine to model the human body as a machine. Such a machine approach assumes failure limits and structural capacities are predetermined and unchanging (aside from the assumption that they will degrade over time). Here is an example of how we apply this machine model to relate workload and injury: the story goes that when cumulative load exceeds said predetermined failure limits, the result is injury to the structures affected.
Of course biological systems have not evolved this way. Unlike machines, our capacities, stress tolerance, capabilities, and coping resources are fluid and adaptable. Failure limits are flexible and dynamic, and the boundaries are constantly shifting as our system continuously responds to whatever conditions and stressors (or lack thereof) it is exposed to.
Aside from the notion of a fixed ceiling, another part of the machine framework is the assumption that there is an unchanging equilibrium that our system will default to (like a thermostat with a fixed setting). Based on this assumption it is advocated that training loads remain within a narrow bandwidth around a predetermined fixed point, in order to operate effectively and avoid pushing into our failure limits. The acute-to-chronic workload concept as currently applied is an exemplar of this approach, whereby arbitrary restrictions are imposed to minimise deviations between successive training days.
In fact, the notion of a predetermined equilibrium is in itself flawed in relation to biological systems. As John Kiely notably pointed out, we are dealing with allostasis rather than simply homeostasis. Once again, any default ‘set point’ and associated parameters are not fixed, but are dynamic and responsive to conditions. Rather than operating within a narrow and predictable range, our systems require and respond well to perturbation, such as random fluctuations or mini shocks. Acute (short term) exposure to a variety of stressors of varying magnitudes ultimately serves to stretch our bandwidth of what we are able to readily tolerate.
Tolerance to workload at any time varies widely between individuals, based on their individual make up, previous exposure, and present status. Ultimately our individual threshold, in terms of what we can tolerate, is not fully knowable. After all, the limits of human endeavour are constantly being redrawn. Whatever our individual limits may be, they will further fluctuate over time in a manner that is also not entirely predictable.
To further confuse matters, as complex adaptive systems, biological organisms such as ourselves also have inbuilt redundancy and reserve capacity. Moreover, as we will explore, the situation is more complex than a linear input = output scenario, or a direct relationship between cause (workload) and effect (injury risk).
Clearly the models we use to think about training stress and injury are in need of revision. The assumptions common to present approaches are not only flawed, but have made us ultra conservative in our practices. Ultimately, our urge to protect may paradoxically serve to compromise athletes’ ability to cope with the stress of training and competition.
Stress testing strengthens biological systems (within tolerable bounds). Fundamentally, we must be exposed to stressors in order to confer protection. This is quite opposite to ‘protecting’ from exposure to stressors. When viewed in the this way, the common approach of protecting, constraining the degree of stressors we are exposed to, and eliminating unpredictability is likely to create fragility and render athletes more vulnerable.
STRESS IS NECESSARY…
By our nature, we are complex adaptive systems. Fundamentally, to elicit adaptation that will increase stress tolerance, and improve our reserves to allow us some buffering capacity, we must be exposed to stressors. In essence, @@the only route to altering our tolerance to stress is via exposure to stressors@@.
The term ‘eustress’ is used to differentiate beneficial stress from ‘harmful’ (distress). But the situation is not binary when it comes to stress. An illustration of how even potentially harmful stress drives adaptation is hormesis.
Hormesis describes the adaptive response of biological organisms to exposure to an agent that is toxic and even lethal in larger doses. Biological systems not only tolerate but paradoxically benefit from acute exposure to potentially toxic or harmful agents. This is the case as long as the dose or exposure does not overwhelm our present coping resources, otherwise it can prove fatal. It turns out there is some truth to the old adage; what doesn’t kill us makes us stronger.
As demonstrated with hormesis, it is not a simple case of good/bad or beneficial/harmful, but rather depends on dose and context. Duration of exposure is also crucial. In general we cope well and can even benefit from acute (short term) exposure to ‘negative’ stress, whereas chronic or persisting exposure is typically harmful and causes maladaptation.
Conversely, when we eliminate or excessively restrict our exposure to stressors we deem to be ‘harmful’, this paradoxically makes us more fragile. @@In the absence of the necessary stimulus, our coping resources diminish@@.
Stress inoculation equally applies to psychological and emotional coping resources. Interventions such as cognitive behavioural therapy adopt this approach. Rather than avoiding or eliminating the stressor or trigger, the strategy is to systematically expose the individual to a controlled dose of the stressor, whilst providing the support and assistance to guide their coping strategy and ultimately bolster their coping resources.
Clearly this approach is counter-intuitive: we naturally have the urge to protect those in our care, and our instinct is to keep them out of harm’s way. The default strategy is thus to avoid, and protect the individual from any and all exposure to potential harm. With this urge to protect and the best of intentions we unwittingly render those in our care more fragile and susceptible when they inevitably encounter stressful events.
WE ARE COMPLEX ADAPTIVE SYSTEMS - WITH A MIND ATTACHED…
Supercompensation that follows exposure to a tolerable stressor is essentially an extension of biological systems’ drive adaptability favouring redundancy and reserve capacity. The other defining characteristic of supercompensation is that it readies us for stressors which exceed those encountered to date. Essentially, our natural adaptive response prepares us for the unprecedented.
Epigenetics is the process by which we express our potential and ‘switch on genes’ to mobilise coping resources following exposure to stressors, shocks, and survival pressures. @@It bears repeating that we have no concept of what an individual athlete’s limits might be@@. What is clear is that we will never allow them to express their full tolerance and coping resources unless we permit the necessary exposure to stressors. A key tenet of antifragility is that the harm from errors is more than compensated by the benefits derived, in terms of information and discovery. The only caveat is that mistakes need to be of a magnitude that the system can survive them.
Requiring things to be highly predictable with little deviation is the hallmark of a fragile system. The flip side to this is that by artificially controlling fluctuations and striving to eliminate unpredictability we can unwittingly cause the system to acquire fragility. When we adopt this approach with athletes, it follows that they become less able to cope with future deviations and to handle uncertainty.
Variability and volatility in conditions are not negative as long as the system is sufficiently adaptable. And once again, @@depriving the system of variability and volatility renders it less adaptable, and less able to cope with future unforeseen events@@. Clearly this is the opposite of what we are aiming for in our quest to future-proof our athletes.
Returning to the first part of complex adaptive systems, complex systems comprise a host of constituent parts and subsystems that are interconnected, and have redundancies (or back up subsystems) inbuilt. As a complex system, when dealing with humans there is not a simple or linear cause and effect relationship. Input does not equal output. Any stimulus has ripple effects and adaptations throughout the constituent parts of the system, which cannot be fully anticipated. Conversely, depriving the athlete of a stimulus has similar unforeseen ripple effects.
Moreover as a complex adaptive biological system with a mind attached there are a host of other factors relating to how the athlete anticipates, perceives, experiences, and reflects on the event that can alter the system response. It follows we need to be mindful in our approach and account for these critical factors.
On this theme, a fundamental truth we need to recognise is that a major source of athletes’ anxiety stems from doubts and concerns about their ability to cope. Exposing the athlete to stressors, and allowing them to come through these trials conversely promotes self-efficacy, and ultimately reduces anxiety as a result. @@The knowledge that you have survived stressful situations makes you less daunted by the prospect of facing such trials in the future@@.
AN ALTERNATIVE APPROACH TO MANAGING SPORTS INJURY RISK…
We can take more of an aggressive approach and seek to prepare and equip, rather than getting locked in a defensive or protective mode. Such an approach to managing injury risk differs to injury prevention initiatives in important ways, which may not be immediately obvious.
Firstly, it acknowledges the reality that it is not feasible to devise preventive countermeasures for something that we cannot entirely predict. Returning to ‘future-proofing’, we have a forecasting problem, whereby we cannot anticipate future events with any degree of accuracy. Rather than giving us an out, and accepting that injuries will happen and there’s nothing we can hope to do about it, our approach should be to better prepare and equip athletes for the uncertain and unpredictable.
Going on the offensive is also an important departure in strategy, given that the major failing of injury prevention initiatives is that they are typically too conservative and narrow in scope. Aside from offering only limited solutions, the more glaring issue is that injury prevention initiatives do not provide sufficient challenge. The exercises employed for injury prevention initiatives are most often repurposed rehabilitation exercises, which by definition are designed for use with injured athletes. It is little wonder that healthy athletes find them tedious. The lack of challenge and the manner of delivery (deemed to be the domain of medical support staff) goes some way to explaining the poor compliance that plagues these interventions.
In order to be effective risk management strategies need to create reserve capacity, improve capability, or develop strategies and athletic skill execution that the athletes can apply in the context of the sport.
One of the most readily apparent avenues to extend failure limits to future proof the athlete is by building reserve capacity, with respect to force-generating capacity, the capacity to store and return elastic energy and dissipate energy, load tolerance of respective structure and tissues, and work capacity. Rather than simply preparing athletes for the expected demands of practice and competition, we should take a lead from nature and aim to ‘over prepare’ the athlete. @@Essentially we want to equip the athlete to handle the aberrant and the unprecedented@@.
When embarking on the task of developing these respective capacities, we need to meet the athlete where they are. Determining an individual athlete’s presence tolerance, in terms of what volume and density of work they can handle, is often a trial and error process. Whilst frequency is important from a dose-response viewpoint, the density of exposure with respect to time also has a bearing on the regeneration that occurs between. The upper limits in terms of intensity or magnitude of loading are similarly dynamic, so once again it will be an ongoing process of experimentation to push the envelope with respect to present capacity, as this will be a moving target.
From a capability viewpoint, we can leverage mechanical effectiveness and find efficiencies to mitigate risk. Physics does apply universally, so we can employ these principles to guide our intervention. Specifically, enhancing mechanical effectiveness of athletic movements directs and distributes forces to greater effect, and so benefits both performance and load tolerance. Improving mechanical efficiency similarly allows us to effectively reduce and redirect stress placed on respective parts of the kinetic chain.
Capability hereby relates to the ability to express qualities more effectively during athletic movement. One aspect is removing restrictions and improving function (or addressing dysfunction) to facilitate movement efficiency. Another critical element, which relates back to capacity, is targeted strength development to open up different options with respect to movement strategy to facilitate the sought after changes. This is exemplified with female athletes: if you wish to shift them from a knee extensor dominant strategy it is first necessary to develop the requisite hip extensor strength to make alternative options viable.
Capability also pertains to developing the host of aptitudes we describe as athleticism. Rather than providing a single solution, the objective is to acquire the deepest and widest playbook of solutions that the athlete can bring to whatever scenario or movement problem they encounter. Rather than good/bad, whatever variation and permutation the athlete trials merely needs to respect the physics of the task. We should also allow that some exposure to trials when they get it wrong is a necessary part of the process, and may in fact prove beneficial (hormesis again).
Adaptability and ability to improvise will similarly help the athlete get out of trouble. Returning to the theme of future proofing, we are aiming hone the athlete’s ability to deal with the unanticipated, via progressive and systematic exposure to unpredictability and uncertainty. Continually developing somatosensory awareness during this exposure similarly permits online adjustment in real-time.
Finally, from a context viewpoint, our efforts in the physical and athletic preparation realm should seek to support technical refinement in the sport. Rather than restricting and attempting to make the movement ‘safe’, our efforts should facilitate performance and enhance the athlete’s ability to express skilled movement. We can direct our approach to specifically develop somatosensory awareness and feel for the movement, develop integrity in relevant postures and shapes, and target specific links in the chain which are likely to be failure points or the ‘rate limiting step’ for the movement.
The majority of athletes at higher levels of competition bring with them some history of injury (in many cases recent injury), and even ‘healthy’ athletes are generally managing some sort of niggle or complaint. The presence of pre-existing or current injury clearly affects athletes’ present tolerance. On the other hand, given that previous injury is the number one risk factor for future injury, this scenario makes it more important to develop reserve capacity and mobilise additional coping resources, not less.
If anything prior injury should prompt us to take a more progressive approach, given the need to mitigate the higher risk that the athlete will otherwise be exposed to. This notion contrasts sharply with how injuries are managed and most return to competition protocols in present use. Once again, most often we adopt a defensive approach and aim to protect the athlete by restricting and constraining their exposure, which, as the reader might have guessed by now, ultimately makes athletes more vulnerable.
It bears repeating that we need to meet the athlete where they are and cater to their present tolerance. Exercising caution in our initial approach, some trial and error will allow us to determine what magnitude of stress they can presently handle, and what density and volume of work they can presently tolerate. Equally, from this starting point it should be our intention to progressively push the envelope, and periodically provide perturbations to extend their limits and expand the manifold of what they can tolerate, in terms of fluctuations and variability in stressors.
@@We have abundant resources, reserves, and redundancies at our disposal@@. When handled in the right manner athletes can leverage these intrinsic qualities and continue to perform at the highest level, even in the presence of pathology.
There are also strong psychological and emotional elements at play with injury. Injury and ongoing symptoms take an emotional toll on the athlete. Likewise, there is a lot of fear and anxiety involved with the prospect of injury (or reinjury).
With their permission, exposing the athlete to stressors, both physical and mental, is an integral part of mastering these emotional and psychological demons. This approach of systematic exposure, or ‘stress inoculation’, is akin to the premise of cognitive behavioural therapy, and such methods should be an integral part of dealing with injury.
Following a significant injury, such as ACL, aside from underlying neuroplastic changes, the athlete’s motor control strategy is also often altered, as they attempt to reinvest conscious control. Another common behavioural aspect of the debilitating effects of chronic injuries is kinesiophobia - i.e. the athlete comes to fear and avoid movements and scenarios that might elicit pain. Both of these responses are maladaptive, rendering the athlete more fragile and reducing their odds of successfully returning to performance and avoiding further injury. Encouraging the athlete to confront fearful movements and situations, and to get out of their head and let go when performing skilled movement, demands considerable faith and courage on the part of the athlete.
Sadly, kinesiophobia is contagious - and too often we as practitioners are the unwitting source of this contagion. The need to rehabilitate the athlete from a mental and emotional standpoint in itself should make us reconsider how we typically manage injuries and the return to performance process that follows injury. As practitioners we also need to learn courage, as our anxiety will inevitably communicate itself to the athlete. This is not only unhelpful but may be actively detrimental to their successful return.
The treating practitioner needs to recognise when working with athletes in the acute phase following significant injury that the athlete is in a vulnerable place and can easily form emotional bonds. Retaining excessive involvement in the athlete’s ongoing rehabilitation comes at great risk of fostering this dependency through the rehabilitation process, and even the return to competition process that follows. Practitioners must be conscious of this important point and remain keenly aware of what unintended consequences their continued involvement might have.
Practically, it is important to take steps to allow the athlete a longer leash and foster autonomy as early in the process as possible. A crucial part of this will be creating vital distance and separation by allowing the ongoing rehabilitation and preparation to transition to a suitably qualified and informed coach, in order to best serve the physical, emotional, and psychological needs of the athlete. Recognising this need for a different face and voice in the transition when progressing rehabilitation and the subsequent return to competition process, at my former workplace we created the role of ‘Performance Rehabilitation Coach’ for precisely this purpose.
In part this post is a call to overcome our natural aversion to risk and reconsider the default response of protecting from exposure to potential harm when dealing with sports injury risk. Our overzealous attempts to make participation in practices and competition more safe paradoxically may be rendering athletes more vulnerable to injury. We need to consider these potential adverse effects of our well-intentioned interventions.
To that end, we need to rethink ‘preventive’ approaches in current use, such as artificially imposing arbitrary restrictions on workload imposed and excessively controlling exposure to stressors. For some practitioners this may mean challenging the underlying and unspoken assumption that the particular activity or participation in the sport is inherently injurious.
Conversely, it is easy to dismiss the ‘just make them strong’ camp as myopic. The more progressive approach of tempering athletes via systematic exposure to relevant stress conditions should not be confused for the suggestion that we should just lock athletes in the weights room. We need to be clear what capacities we are seeking to build, and under what conditions they need to be expressed. For instance, structural integrity and force generating capacity must be expressed in extreme ranges and positions in many sports. Clearly developing these specific qualities necessitates more than just conventional heavy resistance training.
Equally, advanced training modes that include heavy resistance training, speed-strength training modes, eccentric training modalities, and plyometrics can prove highly potent tools for developing reserve capacity, improving tolerance, extending failure limits. A range of modalities employed in the realm of athletic preparation in different sports similarly have application for developing the capabilities that athletes require to adapt and improvise. Finally, a deep knowledge and thorough understanding of the technical model for the sport and athlete is critical in helping to support athletes in refining specific tools. Whatever tools we employ we need to test our imagination when it comes to preparing for worst case scenarios, and rather aim to equip athletes for the unprecedented.
Ultimately our task is to embrace the challenge and continually explore the boundaries of the athlete’s present tolerance and capabilities to ensure that they are equipped to not only survive but excel in the uncertainty and unpredictable context of the sport. Returning to the familiar themes of ego and humility, rather than wrestling over spheres of influence, or which part falls within our domain or respective areas of expertise, the only consideration in terms of delivery should be what best serves the physical, emotional, and psychological needs of the athlete.
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