Musculoskeletal injuries associated with “underuse” mechanism.

I recently received an e-mail from a supplement company telling me to ‘start my summer prep’, which lead me to think about the stereotypical summer holiday preparation. You have just booked yourself a beach holiday, or a hotel getaway to lounge by the pool, and you begin making preparations: someone to watch the house, someone to look after the cat or dog, you purchase new clothes, and you feel the need to hit the gym to feel more comfortable. Whilst making healthier nutrition choices or becoming more physically active would be sufficient, the subconscious bombardment of the ‘ideal beach bod’ on TV commercials and e- mails such as the one I received, lead people to take up more intense exercise to achieve their goal. This article is going to focus on the injuries associated with the uptake in physical activity (PA) due to an underuse mechanism.

PA has been defined by the National Institute for Health and Care Excellence (NICE) as the full range of human movement, including hobbies such as walking or cycling, and any activities of daily living such as walking up stairs, gardening, or housework.3 PA has been associated with numerous health benefits, such as a reduction in the incidence and mortality associated with: cardiovascular disease, diabetes, obesity, hypertension, and cancer.4,6 As such, there are guidelines published across the world regarding the minimal amount of physical activity that should be achieved by various age groups to attain these associated health benefits.

High levels of physical inactivity are of global concern,7 with many countries

facing an epidemic of physical inactivity8 for example, out of 85 countries, 50%

or less of adolescents achieved the minimum recommendations.9 Physical

inactivity has prompted a rise in diseases (obesity, diabetes etc) and the number

of musculoskeletal injuries (MSKI’s) amongst children and adults.9,10

The World Health Organization (WHO) classifies physical inactivity as the 4th

leading risk factor of global mortality.1 Evidence has shown that those with lower

levels of PA had the strongest association with overall MSKI risk,11,12  with Body

Mass Index (BMI) being significantly associated with injuries of the lower

extremity and the odds of injury increased 6-10% for each unit increase in BMI.5,10,13

Numerous authors have proposed possible mechanisms by which physical inactivity contributes to an increased MSKI risk, some theorized that this was due to low levels of strength and decreased cardiovascular fitness.4,14 Whilst others postulated that increased weight during childhood combined with physical inactivity, affected bone development in load-bearing bones contributing to

skeletal malalignment and/or changes in muscular function.10,13 Essentially, those who were more physically inactive tended to underuse their body.

The idea of the bodies’ susceptibility to injury from underuse is not completely new. As part of a new model for tendinopathies, it was proposed that the underloaded tendon does not receive appropriate physiological stresses; leading to degradation.15 Therefore once the tendon is subjected to activity that is higher in level than that which is normally placed upon it, this will subject the tissues to overload; starting the degenerative cascade of tendinopathies.15 This idea seemed to be a further contribution to the small body of evidence,8 where the authors detail how research typically classifies MSKI’s as ‘acute’ or ‘overuse’ due to reports interpreting that the preceding movement caused a persons MSKI. However the underlying cause for many MSKI’s in a physically inactive population is in fact ‘underuse’; whereby the body is required to move in an unfamiliar method.8

The literature has shown trends that those who are more physically inactive tend to underuse their body, and once they start a period of activity above that which their body is used to, their body cannot adapt and tissues are overloaded causing an injury. Is it then possible to prevent or reduce the likelihood of acquiring an MSKI? In short yes, but how can one go about this?

First lets address previous injuries, so as to start fresh. Previous injuries have been shown to be a significant risk factor for sustaining an injury16,20 due to the incomplete recovery of the earlier injury.18 Research has shown17,19 that those who have had a previous ankle sprain have a 30-50% higher chance of sustaining another ankle sprain, these authors further state that these repetitive injuries are location specific, i.e. a previous ankle injury has the potential to cause another injury to the same ankle.17 So in the lead up to the summer holiday and before beginning any new exercise program, especially if it has been a sufficient time period since the last formalized training period, any previous injuries should be fully rehabilitated. Proper injury rehabilitation can be achieved through a qualified Physiotherapist, Physical Therapist, or an Athletic Trainer

Next up is periodized training; to periodize ones training means to deliberately adjust or manipulate the training volume and intensity over time.21 It is one method of reducing the sudden and abrupt load exerted on the body,22 optimizing performance whilst mitigating injury risk.23 The body has the ability to adapt to any new form of training, however this process takes time,22 as such periodized training is normally formed around macro-, meso- and micro-cycles; ≈ 1-year, ≈ 6-12 weeks, ≈ 1-day respectively.21,23 These cycles allow for greater variety in ones training, changing up the stimuli (types of exercises, reps, sets, rest etc)23,24 received by the body allowing it to adapt, and therefore progress21,23 e.g. to lift a heavier weight, run a longer distance, or run a quicker time. A qualified Sports Physiotherapist, Sports Physical Therapist, Athletic

Trainer or a qualified Strength and Conditioning Coach will be able to assist with training periodization.

The final tip is centred on the warm-up; the multiple benefits of a well-designed warm-up are well known, such as: Injury reduction, faster muscle contraction, increased blood flow and therefore improved oxygen delivery, etc.25-30 Warm- ups will vary dependent on the physical activity about to be undertaken but will generally last 10-30 mins,25 and typically consist of a pulse raiser, stretching and sport specific movements.25-26,31 Warm-ups will typically follow a protocol such as the Raise, Activate and Mobilize, and Potentiate system – aptly named the ‘RAMP’ system.25 Sports governing bodies have listened to the research and recognize the benefits of a well-designed warm-up; as such organizations like Fédération Internationale de Football Association (FIFA), have produced an easy to follow / administer, standardized warm-up: the FIFA 11+.27,30 The research has shown the FIFA 11+ to reduce injuries in young female football players by approximately one third and all severe injuries by half,27 with significantly fewer training and match injuries in amateur players.28

In summary, the MSKI risk is higher in those who are physically inactive, when undertaking PA; due to an underuse mechanism. The evidence has shown that those who are classified as ‘obese’ have a higher MSKI risk than those who are ‘overweight’ or ‘normal weight’, as the risk increased 6-10% for every unit increase in BMI. The greatest risk is for the lower extremities/load bearing bones, which is of particular importance for children and adolescents due to the increased stresses placed on their developing body.

For these more physically inactive populations, while PA may cause the injury, it is due to the underuse of the body. The underuse has led to weakening of the body in general, whereby it cannot cope once the body begins to move in intensities above that which it can handle; especially if in an abnormal pattern. This article provides three simple building blocks to help reduce the likelihood of suffering from an underuse injury in the lead up to the summer. These three building blocks should form questions you should ask yourself prior to starting a new workout or fitness regime, especially after a prolonged period of inactivity or reduced activity:

  • Do I have any injuries I need to sort out first?
  • How am I going to structure my training?
  • What will my warm-up consist of?


  1. World Health Organization, 2010.Global recommendations on physical activity for health. WHO Library Cataloguing-in-Publication Data, pp. 7
  2. National Institute on Aging 2016. Exercise and Physical Activity:Your Everyday Guide. Department of Health and Human Services: National
    Institute on Aging Publication No. 17-AG-4258, pp 18
  3. National Institute for Health and Clinical Excellence,2015. Preventing excessive weight gain. NICE guideline (NG7)
  4. Hootman,J.M., Macera,C.A., Ainsworth,B.E., Addy,C.L., Martin,M. and
    Blair, S.N., 2002. Epidemiology of musculoskeletal injuries among sedentary and physically active adults. Medicine and Science in Sports and Exercise, 34(5), pp. 838-844.
  5. Janney,C.A. and Jakicic,J.M., 2010. The influence of exercise and BMI on injuries and illnesses in overweight and obese individuals: a randomized control trial. International Journal of Behavioral Nutrition and Physical Activity, 7(1), pp. 1-11.
  6. Mendes,R., Sousa,N., Reis,V.M. and Themundo-Barata,J.L., 2016. Prevention of exercise-related injuries and adverse events in patients with type 2 diabetes. Postgraduate Medical Journal, 89(1058), pp. 715-721.
  7. Gray,C., Gibbons,R., Larouche,R., Sandseter,E.B.H., Bienenstock,A., Brussoni, M., Chabot, G., Herrington, S., Janssen, I., Pickett, W., Power, M., Stanger, N., Sampson, M. and Tremblay, M.S., 2015. What Is the Relationship between Outdoor Time and Physical Activity, Sedentary Behaviour, and Physical Fitness in Children? A Systematic Review. International Journal of Environmental Research and Public Health, 12(6), pp. 6455-6474.
  8. Stovitz,S.D. and Johnson,R.J., 2006.“Underuse” as a cause for musculoskeletal injuries: is it time that we started reframing our message? British Journal of Sports Medicine, 40(9), pp.738-739
  9. Draper,C.E., Grobler,L., Micklesfield,L.K. and Norris,S.A., 2015. Impact of social norms and social support on diet, physical activity and sedentary behaviour of adolescents: a scoping review. Child: Care, Health and Development, 41(5), pp. 654-667.
  10. Shultz, S.P., Anner, J. and Hills, A.P., 2009. Paediatric obesity, physical activity and the musculoskeletal system. Obesity Reviews, 10(5), pp. 576- 582.
  11. Nauta, J., Martin-Diener, E., Martin, B.W., van Mechelen, W. and Verhagen, E., 2015. Injury risk during different physical activity behaviours in children: a systematic review with bias assessment. Sports Medicine, 45(3), pp. 327-336.
  12. Bloemers, F., Collard, D., A Paw, M.C., van Mechelen, W., Twisk, J. and Verhagen, E., 2012. Physical inactivity is a risk factor for physical activity-

related injuries in children. British Journal of Sports Medicine, 46(9), pp.

13.Adams, A.L., Kessler, J.I., Deramerian, K., Smith, N., Black, H.B., Porter,

A.H., Jacobsen, S.J. and Koebnick, C., 2013. Associations between childhood obesity and upper and lower extremity injuries. Injury Prevention, 19(3), pp. 191-197.

  1. Trudelle-Jackson, E., Jackson, A.W. and Morrow, J.R., 2011. Relations of meeting national public health recommendations for muscular strengthening activities with strength, body composition, and obesity: the women’s injury study. American Journal of Public Health, 101(10), pp. 1930-1935.
  2. Lewis, J.S., 2010. Rotator cuff tendinopathy: a model for the continuum of pathology and related management. British Journal of Sports Medicine, 44(13), pp. 918-923.
  3. Opar, D.A., Williams, M.D. and Shield, A.J., 2012. Hamstring strain injuries: Factors that lead to injury and re-injury. Sports Medicine, 42(3), pp. 209-226.
  4. Zambraski, E.J. and Yancosek, K.E., 2012. Prevention and rehabilitation of musculoskeletal injuries during military operations and training. Journal of Strength and Conditioning Research, 26(7), pp. S101-S106.
  5. Jacobsson, J., Timpka, T., Kowalski, J., Nilsson, S., Ekberg, J., Dahlström, Ö. And Renström, P.A., 2013. Injury patterns in Swedish elite athletics: annual incidence, injury types and risk factors. British Journal of Sports Medicine, 47(15), pp.1-13.
  6. Fulton, J., Wright, K., Kelly, M., Zebrosky, B., Zanis, M., Drvol, C. and Butler, R., 2014. Injury risk is altered by previous injury: A systematic review of literature and presentation of causative neuromuscular factors. The International Journal of Sports Physical Therapy, 9(5), pp. 583-595.
  7. Saragiotto, B.T., Yamato, T.P., Hespanhol Junior, L.C., Rainbow, M.J., Davis, I.S. and Lopes, A.D., 2014. What are the main risk factors for running-related injuries? Sports Medicine, 44(8), pp.1153-1163.
  8. Nindl, B.C., 2015. Physical training strategies for military women’s performance optimization in combat-centric occupations. Journal of Strength and Conditioning Research, 29(11S), pp. S101-S106.
  9. Sharma, J., Greeves, J.P., Byers, M., Bennett, A.N. and Spears, I.R., 2015. Musculoskeletal injuries in British Army recruits: a prospective study of diagnosis-specific incidence and rehabilitation times. BMC Musculoskeletal Disorders, 16(106), pp. 1-7.
  10. Kraemer, W.J. and Szivak, T.K., 2012. Strength training for the warfighter. Journal of Strength and Conditioning Research, 26(7), pp. S107-S118.
  11. Lauersen, J.B., Bertelsen, D.M. Andersen, L.B., 2014. The effectiveness of exercise interventions to prevent sports injuries: A systematic review and meta-analysis of randomised controlled trials. British Journal of Sports Medicine, 48, pp.871-877.
  12. Jeffreys, I., 2007. Warm up revisited – the “ramp” method of optimising performance preparation. Professional Strength and Conditioning, 6, pp.15-19.
  13. Woods, K., Bishop, P. and Jones, E., 2007. Warm-Up and Stretching in the Prevention of Muscular Injury. Sports Medicine, 37(12), pp. 1089- 1087.
  14. Soligard, T., Mykleburst, G., Steffen, K., Holme, I., Silvers, H., Bizzini, M., Junge, A., Dvorak, J., Bahr, R. and Anderson, T.E., 2008. Comprehensive warm-up programme to prevent injuries in young female footballers: clustered randomised controlled trial. British Medical Journal, 9(337), pp. 1-9.
  15. Junge, a., Lamprecht, M., Stamm, H., Hasler, H., Bizzini, M., Tschopp, M., Reuter, H., Pshch, D., Wyss, H., Chilvers, C. and Dvorak, J., 2010. Coutnrywide campaign to prevent soccer injuries in Swiss amateur players. The American Journal of Sports Medicine, 39(1), pp. 1-7.
  16. Soligard, T., Nilstad, A., Steffen, K., Mykleburst, G., Holme, I., Dvorak, J., Bahr, R. and Andersen, T.E., 2010. Complience with a comprehensive warm-up programme to prevent injuries in youth football.
  17. Herman, K., Barton, C., Malliaras, P. and Morrissey, D., 2012. The effectiveness of neuromuscular warm-up strategies, that require no additional equipment, for preventing lower limb injuries during sports participation: a systematic review. BMC Medicine, 10(75), pp. 1-12.
  18. Fletcher, I.M. and Jones, B., 2004. The effect of different warm-up stretch protocols on 20 meter sprint performance in trained rugby union players. Journal of Strength and Conditioning Research, 18(4), pp. 885-888.

Opinions expressed by physiogramworld contributors are their own.


Leave a Reply

Your email address will not be published. Required fields are marked *