Elsevier

Physical Therapy in Sport

Volume 34, November 2018, Pages 208-215
Physical Therapy in Sport

Original Research
Musculoskeletal predictors of non-contact injury in cricketers – Few and far between? A longitudinal cohort study

https://doi.org/10.1016/j.ptsp.2018.10.014Get rights and content

Highlights

  • Low back and lower limb injury are common among cricketers.

  • Few musculoskeletal factors can successfully predict injury.

  • Accuracy in classification of logistic regression models are low.

  • ROC cut-off scores show high sensitivity, but low specificity.

Abstract

Objective

To determine the musculoskeletal risk factors for injury amongst professional, domestic cricket players.

Design

Longitudinal cohort study.

Setting

Medical suites associated with the respective cricket franchises.

Participants

Professional, domestic cricket players (n = 97).

Main outcome measures

A pre-participatory musculoskeletal screening battery consisting of 21 tests including flexibility, neural tension, stability, strength, balance and pain provocation tests at the start of the cricket season. Non-contact, low back and lower limb (lower quarter) injuries were monitored throughout the season. Binary logistic regression and receiver operating curves were used to determine predictive value of each test.

Results

During the course of the cricket season, 38 of the 97 (39.2%) cricketers sustained a non-contact low back and/or lower limb injury. Increased hip internal rotation ROM on the dominant side (OR = 1.065; p = 0.036), no symptoms on active slump dominant side (OR = 0.289; p = 0.014), decreased combined elevation (OR = 0.934; p = 0.029), increased shoulder internal rotation ROM on the non-dominant side (OR = 1.022; p = 0.035) and increased GIRD (glenohumeral internal rotation deficit) (OR = 1.026; p = 0.042) predicted in-season non-contact lower quarter injuries. Although statistically significant, none of these variables were strong predictors of injury as shown by the logistic regression models (accuracy in classification rate: 59.8–62.9%), the area under the curve (AUC) of the receiver operating characteristic (ROC) curves (AUC≤0.652) and the cut-off scores which revealed high sensitivity (68.4–86.8%), but low specificity (25.4–54.2%).

Conclusion

Although only a few of the many tests included in the battery showed predictive validity, the value of screening procedures should not be underestimated due to other benefits such as building patient rapport, identification of pre-existing injuries, establishing clinical and functional baselines upon which individualised management programmes can be based.

Introduction

Cricket is a sport played in many countries throughout the world. Injury prevalence ranges from 4% to 12.8%, while the incidence of injury is calculated at 23.5 to 90 injuries per 10 000 h of exposure (Frost & Chalmers, 2012; R.; Stretch & Raffan, 2011). The vast majority of non-contact injuries sustained by cricketers are to the lumbar spine (1.1–3.4 injuries per squad per season) and lower limbs (0.3–5.9 injuries per squad per season) (Orchard, James, & Portus, 2006).

Injury prevention programmes aim to modify risk factors in order to prevent injury (Bahr, 2016). Finch (2006) recommends injury prevention research to be approached systematically through the following 6 stages: 1. Injury surveillance; 2. Establish the aetiology and mechanisms of injury; 3. Development of injury prevention measures; 4. Scientific evaluation (intervention efficacy assessment under “ideal conditions”); 5 Describe the intervention context to inform implementation strategies; 6. Evaluate the effectiveness of the preventative measures in the implementation context. Pre-participatory screening forms part of stage 2 and contributes to establishing the aetiology and mechanisms of injury. Therefore; the pre-participatory screening of cricketers to ensure the early identification of intrinsic risk factors to injury forms a crucial part of the global approach to injury prevention.

Pre-participatory screening tools used by physiotherapists consist of a series of musculoskeletal tests aimed at identifying intrinsic risk factors. Many of the screening tests are based on the assessment of physical performance of movement (e.g. Star Excursion Balance Test) and movement quality (e.g. single leg squat) (Whittaker et al., 2017), while others assess flexibility (e.g. joint range of movement), muscle strength (e.g. calf heel raises) (Dennis, Finch, McIntosh, & Elliott, 2008) and pain provocation (e.g. single-legged extension test) (Crewe, Elliott, Couanis, Campbell, & Alderson, 2012). The majority of variables assessed in these screening tools are of modifiable nature (Bahr, 2016). The aim of screening is to identify injury risk factors; which will lead to early intervention through a secondary injury prevention programme. These injury prevention programmes can be individualised and adapted to remediate the impairments of the specific athlete although research on the effectiveness of injury prevention programmes are lacking (Bahr, 2016).

The investigation of factors associated with injury has been done by utilising both cross-sectional and longitudinal cohort study designs. Some cross-sectional studies establish associations with injury and these include symmetry of abdominal muscle thickness (Gray, Aginsky, Derman, Vaughan, & Hodges, 2016), reduced ability to contract the transversus abdominis muscle independently of the other abdominal muscles (Hides et al., 2008) and dominant shoulder internal rotation strength deficit (Aginsky, Lategan, & Stretch, 2004). Although it is not possible to determine cause-effect relationships using a cross-sectional design, such research is a positive step towards preventing injuries amongst cricketers and this can be further enhanced by the investigation of risk factors through prospective longitudinal cohort studies (Bahr, 2016). Longitudinal cohort studies can pose challenges due to resource demands owing to its longitudinal nature; but these study designs are powerful in identifying risk and protective factors (Finch, 2006). Risk factors identified through longitudinal cohort studies include symmetry of the cross-sectional area of quadratus lumborum muscle (Kountouris, Portus, & Cook, 2013), increased hip internal rotation (Dennis, Finch, Elliott, et al., 2008), reduced ankle dorsiflexion lunge (Dennis, Finch, Elliott, et al., 2008), shorter reach distances on the star excursion balance test in the postero-medial direction (B Olivier, Stewart, Olorunju, & McKinon, 2015), increased lumbar reposition error (B. Olivier, Stewart, & McKinon, 2014), greater hip to shoulder separation angle at back foot contact (Portus, Mason, Elliott, Pfitzner, & Done, 2004) and reduced muscle endurance of the back extensors (Bayne, Elliott, Campbell, & Alderson, 2016).

The determination of risk factors of injury in cricketers is a building block towards developing and optimising effective injury prevention strategies. From here; the factors associated with injury can be used to formulate injury prevention programmes. This is the first longitudinal cohort study to investigate risk factors for injury amongst the entire eligible population of cricketers playing at domestic level in South Africa and thus produced findings applicable to the unique local context. The aim of this study was therefore to determine the risk factors for injury amongst professional; domestic cricket players.

Section snippets

Study design and setting

A prospective, longitudinal cohort study design was employed. Data were collected at the medical suites associated with the respective cricket franchises.

Participants

The entire population of adult cricketers (≥18yrs) playing at professional, domestic level for a franchise team were invited to participate. Ethics approval was obtained from the human research ethics committee of the associated tertiary institution and all participants gave informed written consent.

Pre-participatory screening tests

Cricketers completed a standardised baseline

Participants

Of the 107 professional, domestic-level (playing for franchise teams) cricketers, 97 male cricketers completed the pre-participatory screening battery (91% of the population). The mean age was 26.8 (SD 4.3) years with a range between 19 and 38 years. Of the cricketers, 14 (14.4%) bowled with the left and 83 (85.6%) with right arm. Twenty cricketers used opposite arms to bowl and bat (e.g. bowl right and bat left). The group consisted of 31 (32%) bowlers (24 pace and 7 spin bowlers), 21 (21.6%)

Injury definition and risk factors for injury

The definition for injury used in this study included time-loss and non-time-loss injuries (Orchard et al., 2016) which increased the number of injuries captured, but also ensures that injuries with potential future time-loss consequences are not missed. In our study, all participants had uniform access to medical staff which eliminates this common source of systematic bias commonly associated with the definition of “medical attention injuries” (Clarsen & Bahr, 2014). Although all

Conclusion

Increased hip internal rotation ROM on the dominant side, no symptoms on active slump dominant side, decreased combined elevation, increased shoulder internal rotation ROM on the non-dominant side and increased GIRD were associated with in-season non-contact lower quarter injuries in domestic cricketers, although none of these variables were strong predictors of injury as shown by the logistic regression models, the ROC's AUC and the cut-off scores which revealed high sensitivity, but low

Ethical statement

Ethics approval was obtained from the human research ethics committee of the associated tertiary institution and all participants gave informed written consent.

Conflict of interest

None declared.

Funding received

Funding was provided by the University of the Witwatersrand, Johannesburg, South Africa through the Friedel Sellschop Award for Exceptional Young Researchers and the National Research Foundation.

Acknowledgements

The authors acknowledge all cricketers who participated in this study. A special thank you to Cricket South Africa for permission to use the data for research purposes and to every physiotherapist and research assistant for your contributions.

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