In this third phase, a set of postcompetition exercises with low-load physical activity were also included. A range of 5-8 min of PNF stretching exercises of the hamstring muscles, piriformis, gluteus (maximus, minimus, and medius), iliopsoas, femoral quadriceps, latissimus dorsi, teres minor muscle, trapezius muscle, rhomboid muscles, and flexors and extensors of the elbow was applied. Furthermore, sailors wore compressive clothing on the trunk and upper limb (short-sleeved shirt) and lower limb (long trousers) 12 h·d−1 (13,16). The objective of this phase 3 prevention program during competition was based on appropriate warm-up, which would improve control, strength, and functionality of movements, and equilibrium inside the boat. Prevention was also based on new functional techniques involving neuromuscular work on movement control, equilibrium, and strength development.
The position of the athlete in the boat and their different physical-work intensity was also considered to establish the incidence of injuries and the benefits of the program of preventive physiotherapy and rehabilitation in each position. The different positions were classified into three categories depending on the physical-work intensity involved: high physical work intensity (mastmen, grinders, and bowmen; n = 16), moderate physical work intensity (pitmen, trimmers, and runners; n = 7), and low physical work intensity (navigator, skipper, tactician, and strategist; n = 7).
The entire prevention program and different strategies were developed and supervised by a sports physiotherapist and medical doctor working with the team. All data related to injuries, training sessions, and sailing periods were registered by the medical team and team manager.
The incidence and number of injuries in the different prevention periods were calculated with the ratio of injury per athlete per day and per 1000 h of competition. Z tests were used to compare ratios (number of injuries per hours of exposure) between the three groups of sailors according to physical activity. Fisher's exact test was used to compare the severity of injuries, as well as the proportion of recurrent injuries between the groups. P values of <0.05 were regarded as significant.
In the preintervention stage (2004 season), the ratio of injured sailors per competition day was 1.66, progressively decreasing along the different phases of application of the different prevention programs until reaching 0.60 in 2007 (phase 3; Table 3). The number of athletes with more than one injury was significantly reduced from 53% (8 of 15) to 16.6% (2 of 12). This reduction of athletes with just one injury took place despite that the intensity and the number of competition days increased from 9 d of competition in 2004 and 2005 to 18 d in 2006 and 20 d in 2007 (Table 3).
In the preintervention phase, 57.5% of injuries were acute. This percentage was reduced to 35% after the three prevention phases (Fig. 3). The risk of suffering acute injuries in 2004 was 2.1 (injury per competition day), decreasing to 0.05 after the third prevention phase in 2007. The risk of suffering chronic injuries was 1.5 (injury per competition day) in 2004, being reduced to 0.45 after the third prevention stage in 2007.
Specifically, muscle injuries and tendinopathies (epicondylitis, golfer's elbow, and brachial biceps) decreased during the prevention study (Fig. 4). In 2004, muscle injuries reached 61% (22 of 36). In 2007, after phase 3 of the preventive program, muscle injuries decreased to 14% (5 of 36). In 2004, tendinopathies accounted for 30% (10 of 33) of all injuries, decreasing to 10% (1 of 10) in 2007 after the last phase of the prevention program. Regarding articular injuries (sprains) and contusions, the risk slightly increased throughout the time of the study. The mechanism of these injuries consisted of acute injuries due to trauma.
The risk of suffering injuries in the shoulder girdle and the cervical spine was approximately 0.73 (injury per athlete) before intervention. This risk decreased to 0.21 after the first phase of the physiotherapy program, to 0.1 (P < 0.01) after phase 2, and to 0.03 (P < 0.01) after phase 3 (Fig. 5). Injuries of the lumbar spine, elbow, and wrist decreased slightly after phase 3 but without statistical significance. Knee injuries increased slightly from 0.03 injuries per athlete in 2004 to 0.06 injuries per athlete in 2006 due to sports accidents (contusions and ligament sprains).
In the preintervention period, those athletes in positions of mastman, grinder, and bowman showed an injury ratio of 2.88 injuries per competition day. At the end of the third prevention phase, this group showed a ratio of 0.35 injuries per competition day (Fig. 6). In sailors with moderate physical work intensity (pitman, trimmer, and runner), the frequency of injuries was low and did not vary significantly along the study (injury ratio in 2004: 0.55 injuries per competition day; injury ratio in 2007: 0.10 injuries per competition day). In the case of sailors with low physical work intensity (navigator, skipper, tactician, and strategist), the number of injuries did not change with the application of the first two intervention phases (ratio in 2004-2005: 0.22 injuries per competition day); however, injuries in this group decreased after phase 3 of preventive physiotherapy to 0.05 injuries per competition day.
At the beginning of the study, 63% (17 of 27) of the injuries of those sailors performing higher physical demands (mastman, grinder, and bowman) were in the cervical spine and shoulder girdle. After the prevention program, these injuries decreased to 14% (1 of 7; Fig. 7). Excluding the shoulder, injury risk in the upper limb reached 0.60 (injuries per competition day) in 2004. After prevention, such risk decreased to 0.05 (injuries per competition day) in 2007. Acute injuries induced by sports accidents (impacts and sprains) were observed in the lower limb. The incidence was independent of the application of prevention programs. Injuries in the lumbar spine also remained constant and turned out to be recurrences of chronic injuries.
Grinders were the athletes with the highest risk of injury (33 (36%) of 90 lesions). In 2004, overuse injuries in grinders accounted for 78% (15 of 19). In 2007, at the end of the preventive program phase 3, the incidence decreased to 20% (1 of 5) and was statistically significant (P < 0.01) (Fig. 8).
Most injuries in the position of grinder were muscle lesions accounted for 57% in 2004 (sprain muscles and contractures). After the application of the prevention program, muscle injuries decreased to 20% (1 of 5). At the beginning of the study, 100% (n = 7) of all tendinopathies (epicondylitis, golfer's elbow, and brachial biceps) occurred in grinders. After the prevention program, these injuries did not appear in this group of athletes in any competition along 2005-2007. Articular injuries suffered by grinders appeared with different frequencies through the course of the study, mainly due to sports accidents (direct impacts and ligament sprains) during competition (Fig. 9).
This is first prospective study to focus on the evaluation of different strategies of physiotherapy and rehabilitation for prevention of sports injuries affecting America's Cup sailors during competition. Only a few studies addressing the epidemiology of injuries in this sailing sport have been published, but none of them have covered any aspect of injury prevention (3,4,20). These studies reported global injury rates varying from 5.6 injuries per 1000 during competition and training hour (20) to 10 injuries per 1000 competition hour (14). These previous findings point out the necessity of conducting more research specifically focused on the field of prevention, physical conditioning, and recovery. In other more popular sports, such as volleyball, soccer, and handball, several studies exclusively centered on prevention aspects have already been executed (5,11,15,18,19,21-23,25,26,28). To our knowledge, there are no works in the literature describing prevention, physical conditioning, or training programs even in other modalities of the sailing sports.
The incorporation of different strategies and new prevention techniques along successive competition seasons was mainly motivated by the nature and special requirements of the America's Cup. Each year, this competition becomes longer, harder, and involves higher physical demands (from 9 d of competition in 2004 to 20 d of competition in 2007). Most of the precompetition and off-season time consists of boat maintenance and sailing other competitions. All these activities take approximately from 9 to 13 working hours per day. These long sessions of physical work have important repercussions in the physical state of every sportsman (1-4).
Our prevention strategies were mainly based on techniques of neuromuscular and proprioceptive physiotherapy applied during the competition. The use of compressive clothing was also added during passive rest (6-12 h) after competition in phase 3 as an attempt to reduce muscular fatigue. Kraemer et al. (16) reported a decreased perception of soreness after eccentric exercise, with less swelling and improved recovery of force production compared with a control group after wearing a compressive sleeve 24 h·d−1 for 5 d after muscle injury.
Our study clearly demonstrated that sailors with a first episode of acute injury experience a higher risk of injury recurrence, especially during the months following competition after recovery. In other sports, the risk of ankle sprain has been found to be four to five times higher if there is a history of previous injury to the same ankle (internal risk factor), mainly because of reduced neuromuscular function (5,15,19,25). This is another reason that supports the development of the different strategies in prevention programs.
The outcome of our preventive physiotherapy strategies was found to be satisfactory, although they were implemented mainly during competition periods. In 2004, the period in which prevention actions were not carried out, the ratio of injury per day was 1.66, the highest ratio during the period of study (2004-2007). After applying the subsequent prevention programs, this ratio progressively decreased to 0.60 injuries per day at the end of the study (phase 3 ). Similarly, the number of athletes suffering more than one injury was also significantly reduced from 53% (without prevention ) to 6.5% (phase 3 ). A significant decrease in the frequency of athletes suffering acute injuries, which was another objective of the study, was also accomplished. Specifically, the program was highly effective in the prevention of the most frequent injuries in this sports modality, that is, muscle injuries (2004: 61%; 2007: 14%) and tendinopathies due to overuse (2004: 52%; 2007: 5%). However, the prevention program failed in decreasing articular injuries of a traumatic nature (ligament sprains) and contusions, both related to sports accidents.
Another aspect that reflects the satisfactory results of the prevention program is the reduction of the number of injuries in those anatomic areas, which are more prone to be affected in this sailing sport. Such was the case regarding injuries located around the shoulder girdle and the cervical spine, in which the study showed high effectiveness.
Preventive physiotherapy programs have turned out to be very successful in other sports, especially in those characterized by contact. In a study carried out by Wedderkopp et al. (28) in handball players, the incidence of ankle injuries after the implementation of a preventive program was described. In the control group without preventive intervention global, the incidence of injuries was 6.9 per 1000 competition hour, whereas the incidence was significantly lower in the group who underwent the prevention program (2.4 per 1000 competition hour).
In another study carried out by Petersen et al. (22), also involving the prevention of injuries in the lower limb in handball players, it was observed that the ratio of ankle injuries in the control group was 0.55, being reduced to 0.22 after the implementation of a prevention program. In the same study, the incidence of knee injuries (especially injuries involving the anterior cruciate ligament) in the control group was 0.21 per 1000 playing hour, whereas the prevention group had a significant reduction of injuries to 0.04 per 1000 playing hour. In soccer, injuries in the test teams were 75% fewer than those in the controls. The most common types of soccer injuries, sprains and strains to ankles and knees, were all significantly reduced. It was concluded that the proposed prophylactic program, including close supervision and correction by physicians and physiotherapists, significantly reduces soccer injuries (5,11,15,18). Furthermore, there is preliminary evidence that use of prophylactic knee extensor eccentric training protocols can effectively prevent sports-related anterior knee pain from patellar tendinopathy (12). All these studies demonstrate the effectiveness and necessity of injury prevention in sports. All these prevention programs were developed on the basis of functional strengthening which incorporates neuromuscular and proprioceptive techniques (5,11,12,15,18,19,21-23,25-28).
Even from an economic point of view, the effectiveness of a program on the prevention of ankle sprains in volleyball players has been described (6,12,23,26). In a group of 628 players who took part in the prevention program (1,information on injury mechanism; 2, equilibrium training; and 3, training of two-feet jumping), the global injury incidence was 0.5 per 1000 playing hour, 93.87 Euro [147$] being the total cost of the treatment per player. In the 494 players of the control group, the global incidence was 0.9 per 1000 playing hour and the final cost per player was 147 Euro [230$].
Another important finding of our study reflecting the effectiveness of the preventive physiotherapy program was the diminution of the risk of injury in sailors performing in positions with higher physical work intensity (mastman, grinder, and bowman). In this group, the ratio of 2.88 injuries per competition day in the period of nonprevention was significantly reduced to 0.35 injuries per competition day after the prevention phase (phase 3). Of note, in grinders, the intervention was very effective, especially in the case of muscle injuries, which were reduced from 68.5% (2004) to 6% (2007). In 2004, 100% of grinders (n = 7) suffered tendinopathies due to overuse in the upper limbs. From the first phase of preventive intervention in 2005, these injuries did not recur.
The present study demonstrated the effectiveness and necessity of applying preventive physiotherapy programs during competition periods of the America's Cup. Our results suggest that this kind of intervention might also be very useful in other modalities of sailing sports. In the America's Cup and other sailing competitions, the risk of injury can be significantly reduced in those anatomic areas that are most commonly affected, as it is the case of the cervical spine and shoulder girdle. In the case of injuries in the lower limb, this study demonstrates the necessity of developing more specific prevention programs at this level. Further research should be performed to know if these new prevention programs may be as effective as they are in other sports, such as handball, volleyball, or soccer (5,11,15,18,19,21-23,25,26,28).
New studies are also needed to determine the key component(s) of the whole program causing the decrease of injury risk. The physiologic effects of each applied strategy, as well as the effect on the risk of injury, should also be investigated (6). In this way, it may be possible to develop even more specific programs that require less time and effort and may be suitable for recreational athletes.
Although sports medicine has made tremendous advances in the treatment and rehabilitation of serious injuries, both through research as well as through trial and error, the ultimate goal should be to prevent injuries so that athletes can remain competitive (22,26,28). The socioeconomic and financial consequences of injury are of such a proportion that a prevention program to reduce the incidence of injuries is urgently required.
In summary, implementation of a preventive physiotherapy program significantly diminished the risk of injuries suffered during competition by a yachting race crew of the America's Cup. The program was highly effective in the reduction of the most frequent injuries, especially in positions of high physical work intensity. The results point out the necessity of more thorough research in this field, especially in those aspects of physical conditioning, prevention, and recovery.
No funding received for this project. Authors disclose professional relationships with companies or manufacturers who will benefit from the results of the present study. The results of the present study do not constitute endorsement of the product by the authors or ACSM.
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Keywords:© 2009 American College of Sports Medicine
SAILING; EPIDEMIOLOGY; INCIDENCE; REHABILITATION; EXERCISE; PERFORMANCE