Review

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The training—injury prevention paradox: should
athletes be training smarter and harder?
Tim J Gabbett1,2

1
School of Exercise Science, ABSTRACT injury, fitness and performance is critical to sports
Australian Catholic University, Background There is dogma that higher training load medicine/physiotherapy and sport science practi-
Brisbane, Queensland,
Australia causes higher injury rates. However, there is also tioners. In this paper I use the term ‘practitioners’
2
School of Human Movement evidence that training has a protective effect against to refer to the wide gamut of health professionals
Studies, University of injury. For example, team sport athletes who performed and also sport scientists who work with athletes/
Queensland, Brisbane, more than 18 weeks of training before sustaining their teams (ie, strength and conditioning coaches, certi-
Queensland, Australia
initial injuries were at reduced risk of sustaining a fied personal trainers, etc). Our field—sports per-
Correspondence to subsequent injury, while high chronic workloads have formance and sports injury prevention is a
Dr Tim J Gabbett, School of been shown to decrease the risk of injury. Second, multidisciplinary one and this paper is relevant to
Exercise Science, Australian across a wide range of sports, well-developed physical the field broadly.
Catholic University, 1100 qualities are associated with a reduced risk of injury. Injuries impair team performance, but any injur-
Nudgee Road, Brisbane,
QLD 4014, Australia; Clearly, for athletes to develop the physical capacities ies that could potentially be considered ‘training
[email protected] required to provide a protective effect against injury, they load-related’ are commonly viewed as ‘preventable’,
must be prepared to train hard. Finally, there is also and therefore the domain of the sport science and
Accepted 16 November 2015 evidence that under-training may increase injury risk. medicine team. Sport science (including strength
Published Online First
12 January 2016
Collectively, these results emphasise that reductions in and conditioning) and sports medicine (including
workloads may not always be the best approach to doctors and physiotherapists) practitioners share a
protect against injury. common goal of keeping players injury free. Sport
Main thesis This paper describes the ‘Training-Injury science and strength and conditioning staff aim to
Prevention Paradox’ model; a phenomenon whereby develop resilience through exposing players to
athletes accustomed to high training loads have fewer physically intense training to prepare players for
injuries than athletes training at lower workloads. The the physical demands of competition, including the
Model is based on evidence that non-contact injuries are most demanding passages of play.
not caused by training per se, but more likely by an On the other hand, doctors and physiotherapists
inappropriate training programme. Excessive and rapid are often viewed as the staff responsible for ‘man-
increases in training loads are likely responsible for a aging players away from injury’. A stereotype is the
large proportion of non-contact, soft-tissue injuries. If physiotherapist or doctor advocating to reduce
training load is an important determinant of injury, it training loads so that fewer players will succumb to
must be accurately measured up to twice daily and over ‘load-related’ (eg, overuse) injuries. However, how
periods of weeks and months (a season). This paper many of the decisions governing players and their
outlines ways of monitoring training load (‘internal’ and individual training loads are based on empirical evi-
‘external’ loads) and suggests capturing both recent dence or the practitioners’ ‘expert’ intuition (ie,
(‘acute’) training loads and more medium-term ‘gut feel’)?
(‘chronic’) training loads to best capture the player’s Banister et al2 proposed that the performance of
training burden. I describe the critical variable—acute: an athlete in response to training can be estimated
chronic workload ratio—as a best practice predictor of from the difference between a negative function
training-related injuries. This provides the foundation for (‘fatigue’) and a positive function (‘fitness’). The
interventions to reduce players risk, and thus, time-loss ideal training stimulus ‘sweet spot’ is the one that
injuries. maximises net performance potential by having an
Summary The appropriately graded prescription of appropriate training load while limiting the nega-
high training loads should improve players’ fitness, tive consequences of training (ie, injury, illness,
which in turn may protect against injury, ultimately fatigue and overtraining).3
leading to (1) greater physical outputs and resilience in Several studies have investigated the influence of
Open Access competition, and (2) a greater proportion of the squad training volume, intensity and frequency on athletic
Scan to access more
free content available for selection each week. performance, with performance generally improved
with increases in training load.4–10 In individual
sports (eg, swimming and running) greater training
TRAINING–PERFORMANCE RELATIONSHIP volume,4 8 and higher training intensity5 6 8
In a British Journal of Sports Medicine blog, Dr improved performance. In a study of 56 runners,
John Orchard1 proposed hypothetical relationships cyclists and speed skaters undertaking 12 weeks of
between training (both under-training and over- training, a 10-fold increase in training load was
training), injury, fitness and performance. He associated with an approximately 10% improve-
speculated that both inadequate and excessive train- ment in performance.10 In competitive swimmers,
To cite: Gabbett TJ. Br J ing loads would result in increased injuries, significant associations were found between greater
Sports Med 2016;50: reduced fitness and poor team performance (see training volume (r=0.50–0.80) and higher training
273–280. figure 1). The relationship between training load, intensity (r=0.60–0.70) and improved
Gabbett TJ. Br J Sports Med 2016;50:273–280. doi:10.1136/bjsports-2015-095788 1 of 9
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male will have very different physiological and perceptual
responses to an 800 m effort than a trained runner. Although
the external training load is identical, the internal training load
will be much higher in the older, unfit individual! As the dose–
response to training varies between individuals, training should
be prescribed on an individual basis.

EXTERNAL TRAINING LOAD—‘TRACKING’ EVERY METRE!

Global positioning systems (GPS) have been a ‘game-changer’ in
the monitoring of external loads.17 These devices, which are
typically no larger than a mobile phone, are worn by athletes
during training and match-play activities. GPS provides informa-
tion on speed and distances covered, while inertial sensors (ie,
accelerometers, gyroscopes) embedded in the devices also
provide information on non-locomotor sport-specific activities
(eg, jumps in volleyball, collisions in rugby and strokes in swim-
ming).18 Importantly, most of this data can be obtained in ‘real-
Figure 1 Hypothetical relationship between training loads, fitness, time’ to ensure athletes are meeting planned performance
injuries and performance. Redrawn from Orchard.1 targets.

performance.9 However, adverse events of exercise training are INTERNAL TRAINING LOAD—THE ATHLETE’S PERCEPTION
also dose related, with the highest incidence of illness and injury OF EFFORT
occurring when training loads were highest.10–15 The session-rating of perceived exertion (RPE) has been used to
quantify the internal training loads of athletes. At the comple-
tion of each training session, athletes provide a 1–10 ‘rating’ on
TRAINING LOADS CAN BE MEASURED IN DIFFERENT WAYS
the intensity of the session. The intensity of the session is multi-
Sport scientists typically obtain measurements of a prescribed
plied by the session duration to provide training load. The units
external training load (ie, physical ‘work’), accompanied by an
are ‘RPE units×minutes’ and in football codes generally range
internal training load (ie, physiological or perceptual
between 300 and 500 units for lower-intensity sessions and
‘response’). External training loads may include total distance
700–1000 units for higher-intensity sessions. For ease, we have
run, the weight lifted or the number and intensity of sprints,
referred to them as ‘arbitrary units’ in previous work. A more
jumps or collisions (to name a few).16 Internal training loads
accurate term might be ‘exertional minutes’. The value of
include ratings of perceived exertion and heart rate. The indi-
session-RPE will depend on the goal of those measuring it and
vidual characteristics of the athlete (eg, chronological age, train-
that topic is beyond the scope of this paper.
ing age, injury history and physical capacity) combined with the
applied external and internal training loads determine the train-
ing outcome.16 MONITORING INDIVIDUAL ATHLETE WELL-BEING
For example, identical external training loads could elicit con- Monitoring athlete well-being is common practice in high per-
siderably different internal training loads in two athletes with formance sport.19–21 A wide range of subjective questionnaires
vastly different individual characteristics; the training stimulus are used with many of them employing a simple 5, 7 or
may be appropriate for one athlete, but inappropriate (either 10-point Likert scale.19–23 Longer, more time consuming
too high or too low) for another. An overweight, middle-aged surveys are also employed.24 25

Table 1 Relationship between external workloads and risk of injury in elite rugby league players
Relative risk (95% CI)
Risk factors Transient Time lost Missed matches

Injury history in the previous season (no vs yes) 1.4 (0.6 to 2.8) 0.7 (0.4 to 1.4) 0.9 (0.2 to 4.1)
Total distance (≤3910 vs >3910 m) 0.6 (0.3 to 1.4) 0.5 (0.2 to 1.1) 1.1 (0.2 to 6.0)
Very low intensity (≤542 vs >542 m) 0.6 (0.2 to 1.3) 0.4 (0.2 to 0.9)* 0.4 (0.1 to 2.8)
Low intensity (≤2342 vs >2342 m) 0.5 (0.2 to 1.1) 0.5 (0.2 to 0.9)* 1.2 (0.2 to 5.5)
Moderate intensity (≤782 vs >782 m) 0.4 (0.2 to 1.1) 0.5 (0.2 to 1.0) 0.5 (0.1 to 2.3)
High intensity (≤175 vs >175 m) 0.8 (0.2 to 3.1) 0.9 (0.3 to 3.4) 2.9 (0.1 to 16.5)
Very high intensity (≤9 vs >9 m) 2.7 (1.2 to 6.5)* 0.7 (0.3 to 1.6) 0.6 (0.1 to 3.1)
Total high intensity (≤190 vs >190 m) 0.5 (0.1 to 2.1) 1.8 (0.4 to 7.4) 0.7 (0.1 to 30.6)
Mild acceleration (≤186 vs >186 m) 0.2 (0.1 to 0.4)† 0.5 (0.2 to 1.1) 1.5 (0.3 to 8.6)
Moderate acceleration (≤217 vs >217 m) 0.3 (0.1 to 0.6)† 0.4 (0.2 to 0.9)* 1.4 (0.3 to 7.5)
Maximum acceleration (≤143 vs >143 m) 0.4 (0.2 to 0.8)* 0.5 (0.2 to 0.9)* 1.8 (0.4 to 8.8)
Repeated high-intensity effort bouts (≤3 vs >3 bouts) 0.9 (0.4 to 2.0) 1.6 (0.8 to 3.3) 1.0 (0.2 to 4.4)
All injuries were classified as a transient (no training missed), time loss (any injury resulting in missed training) or a missed match (any injury resulting in a subsequent missed match)
injury. *p<0.05; †p<0.01.
Reproduced from Gabbett and Ullah.26

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associated with greater injury rates. Youth pitchers who threw
over 100 innings in a season, had 3.5 times greater injury risk
than players who pitched fewer than 100 pitches.30
Similar findings have been observed in cricket players; fast
bowlers who bowled more than 50 overs in a match were at
increased risk of injury for up to 28 days (OR=1.62).31
Furthermore, bowlers who bowled more deliveries in a week
(>188 deliveries, relative risk=1.4) and had less recovery
between sessions (<2 days, relative risk=2.4) were at greater
injury risk than those who bowled between 123 and 188 deliv-
eries per week and had 3–3.99 days recovery between sessions.
Complicating this issue is that bowlers who bowled fewer deliv-
Figure 2 Relationship between training load and injury rate in team eries each week (<123 deliveries, relative risk=1.4) and had
sport athletes. Training loads were measured using the session-rating greater recovery (>5 days, relative risk=1.8) were also at
of perceived exertion method. Redrawn from Gabbett.11 increased risk of injury.32

These questionnaires are used to determine the readiness of INTERNAL WORKLOADS AND INJURY
team sport athletes to train. Typically players report their mood, These findings on external loads are consistent with results from
stress level, energy, sleep and diet, along with their feelings of studies on internal loads; higher training loads were associated
soreness in the upper-body, quadriceps, hamstring, groin and with greater injury rates.11 15 33–36 In early work11 a strong rela-
calf. The sum of the questions indicates the athlete’s well-being. tionship (r=0.86) was reported between training loads (derived
Practitioners can then adapt the training prescription for players from the session-RPE) and training injury rates across a playing
on an individual basis (eg, continue regular training, investigate season in semiprofessional rugby league players (figure 2).
training loads or modify training programme). Furthermore, over a 3-year period, reduced training loads mark-
edly reduced injury rates in the same cohort of players (figure
RELATIONSHIP BETWEEN TRAINING LOADS AND INJURY 3).37 It is likely that excessive training loads performed early in
Training load monitoring is increasingly popular in high per- the study, led to overtraining, resulting in a spike in injury rates.
formance sport to ensure athletes achieve an adequate training However, it should be noted that this study was published over
stimulus and to minimise the negative consequences of training 10 years ago, and no subsequent study has replicated these
(injury risk, overtraining). In the following section, I discuss the results.
relationship between training loads (both internal and external In professional rugby union players, higher 1-week (>1245
loads) and injury in team sport athletes. arbitrary units) and 4-week cumulative loads (>8651 arbitrary
units) were associated with a higher risk of injury.14 In profes-
EXTERNAL WORKLOADS AND INJURY sional rugby league players, training load was associated with
In elite rugby league, players who performed greater amounts overall injury (r=0.82), non-contact field injury (r=0.82), and
(>9 m) of very high-speed (>7 m/s) running per session were contact field injury (r=0.80) rates.35 Significant relationships
2.7 times more likely to sustain a non-contact, soft-tissue injury were also observed between the field training load and overall
than players who performed less very high-speed running per field injury (r=0.68), non-contact field injury (r=0.65), and
session (table 1).26 This ‘threshold’ of 9 m of very high-speed contact field injury (r=0.63) rates. Strength and power training
running is lower than what would typically be performed in loads were significantly related to the incidence of strength and
other team sport training sessions (eg, soccer and Australian power injuries (r=0.63). There was no significant relationship
football),27 and likely reflects the greater contact and between field training loads and the incidence of strength and
repeated-effort demands, and lower running demands of rugby power injuries. However, strength and power training loads
league.27 For example, in studies of Australian football players, were significantly associated with the incidence of contact
higher 3-weekly total distance (73 721–86 662 m, OR=5.5) and (r=0.75) and non-contact (r=0.87) field training injuries.
3-weekly sprint distance (>1453 m, OR=3.7) were associated Collectively, these findings suggest that (1) the harder rugby
with a greater risk of injury.13 league players train, the more injuries they will sustain and (2)
Although external loads are commonly measured using GPS high strength and power training loads may contribute indirectly
devices, some team sports expose athletes to physically demand- to field injuries. Monitoring of training loads and careful sched-
ing external loads that require very little high-speed running uling of field and gymnasium sessions to avoid residual fatigue is
(eg, baseball pitching, cricket fast bowling). Of the studies that warranted to minimise the effect of training-related injuries on
have been performed in baseball,28–30 greater pitch counts were professional rugby league players.

Figure 3 Influence of reductions in

preseason training loads on injury
rates and changes in aerobic fitness in
team sport athletes. Training loads
were measured using the
session-rating of perceived exertion
method. Redrawn from Gabbett.37

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differently to a given training stimulus, suggesting that training
programmes should be modified to accommodate differences in
training age.
Rogalski et al39 also showed that at a given training load,
older and more experienced (7+ years’ experience in the
Australian Football League competition) players were at greater
risk of injury than less experienced, younger (1–3 years’ experi-
ence in the Australian Football League competition) players. It is
likely that the higher training injury risk in the more experi-
enced players is confounded by previous injury which is a major
risk factor for a new injury.40 Older players likely had experi-
enced a greater number of injuries across the course of their
careers than the less experienced first to third year players.
Clearly, further research investigating the dose–response rela-
tionship between training and injury in athletes of different ages
Figure 4 Relationships between training load, training phase, and and genders is warranted.41
likelihood of injury in elite team sport athletes. Training loads were
measured using the session-rating of perceived exertion method.
MODELLING THE TRAINING LOAD–INJURY RELATIONSHIP
Players were 50–80% likely to sustain a preseason injury within the
training load range of 3000–5000 arbitrary units. These training load AND USING IT TO PREDICT INJURY
‘thresholds’ were considerably reduced (1700–3000 arbitrary units) in This section focuses on the use of training monitoring to model
the competitive phase of the season (indicated by the arrow and shift the relationship between load and injury risk.
of the curve to the left). On the steep portion of the preseason training Over a 2-year period, Gabbett42 used the session-RPE to
load-injury curve (indicated by the grey-shaded area), very small model the relationship between training loads and the likelihood
changes in training load result in very large changes in injury risk. of injury in elite rugby league players. Training load and injury
Pre-Season Model: Likelihood of Injury=0.909327/(1+exp(−(Training data were modelled using a logistic regression model with a
Load−2814.85)/609.951)). Early Competition Model: Likelihood of binomial distribution (injury vs no injury) and logit link func-
Injury=0.713272×(1−exp(−0.00038318×Training Load)). Late tion, with data divided into preseason, early competition and
Competition Model: Likelihood of Injury=0.943609/(1+exp(−(Training
late competition phases.
Load−1647.36)/485.813)). Redrawn from Gabbett.42
Players were 50–80% likely to sustain a preseason injury
within the weekly training load range of 3000 to 5000 arbitrary
minutes (RPE×minutes, as above). These training load ‘thresh-
DIFFERENCES IN TRAINING ADAPTATIONS BETWEEN olds’ for injury were considerably lower (1700–3000
YOUNGER AND OLDER ATHLETES session-RPE units/week) in the competitive phase of the season.
The age of the athlete influences adaptations to training.38 39 Importantly, on the steep portion of the sigmoidal training
Gabbett38 investigated training loads, injury rates and physical load-injury curve, very small changes in training load resulted in
performance changes associated with a 14-week field condition- very large changes in injury risk (figure 4).
ing programme in junior (approximately 17 years) and senior Training load and injury data were prospectively recorded
(approximately 25 years) rugby league players. Training over a further two competitive seasons in those elite rugby
improved muscular power and maximal aerobic power in the league players. An injury prediction model based on planned
junior and senior players, however the improvement in muscular and actual training loads was developed and implemented to
power and maximal aerobic power were greatest in the junior determine if non-contact, soft-tissue injuries could be predicted.
players. Training loads and injury rates were higher in the senior One-hundred and fifty-nine non-contact, soft-tissue injuries
players. Thus, junior and senior rugby league players may adapt were sustained over those two seasons. The percentage of true-

Table 2 Accuracy of model for predicting non-contact, soft-tissue injuries

Actual status
Injured Not injured
Predicted injury True positive False positive Positive predictive value
N=121 N=20 85.8%
Predicted status
Predicted no injury False negative True negative Negative predictive value
N=18 N=1589 98.9%
Sensitivity Specificity
87.1 (80.5 to 91.7)% 98.8 (98.1 to 99.2)%
Likelihood ratio positive
70.0 (45.1 to 108.8)
Likelihood ratio negative
0.1 (0.1 to 0.2)
‘True Positive’—predicted injury and player sustained injury; ‘False Positive’—predicted injury but player did not sustain injury; ‘False Negative’—no injury predicted but player sustained
injury; ‘True Negative’—no injury predicted and player did not sustain injury. ‘Sensitivity’—proportion of injured players who were predicted to be injured; Specificity—proportion of
uninjured players who were predicted to remain injury-free. ‘Likelihood ratio positive’—sensitivity/(1−specificity); ‘Likelihood ratio negative’—(1−sensitivity)/specificity.
While there were 91 players in the sample, injury predictions based on the training loads performed by individual players were made on a weekly basis, so that within the total cohort,
there was a total number of true positive and negative predictions, and a total number of false positive and negative predictions. Sensitivity and specificity data, and positive and
negative likelihood ratios are expressed as rates (and 95% CIs).
Reproduced from Gabbett.42

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positive predictions was 62% (N=121) and the false-positive THE CRITICAL ELEMENT OF WEEK-TO-WEEK CHANGE
and false-negative predictions were 13% (N=20) and 11% (USUALLY INCREASES!) IN TRAINING LOAD
(N=18), respectively. Players who exceeded the weekly training Accepting that high absolute training loads are associated with
load threshold were 70 times more likely to test positive for greater injury risk,42 strength and conditioning practitioners must
non-contact, soft-tissue injury, while players who did not exceed also consider how week-to-week changes in training load inde-
the training load threshold were injured 1/10 as often (table 2). pendently influence injury risk (aside from total training load). In
Furthermore, following the introduction of this model, the inci- a study of Australian football players, Piggott et al34 showed that
dence of non-contact, soft-tissue injuries was halved.42 40% of injuries were associated with a rapid change (>10%) in
We also analysed the prevalence of injury and the predictive weekly training load in the preceding week. Rogalski et al39 also
ratios obtained from the model. The prevalence of injury in this showed that larger 1-weekly (>1750 arbitrary units, OR=2.44–
sample of professional rugby league players was 8.6%. If the 3.38), 2-weekly (>4000 arbitrary units, OR=4.74) and previous
predictive equation was positive for a given player, the likeli- to current week changes in internal load (>1250 arbitrary units,
hood of injury increased from 8.6% to 86%, and if the results OR=2.58) were related to a greater risk of injury. Large
of the test were negative, the likelihood of injury decreased week-to-week changes in training load (1069 arbitrary units) also
from 8.6% to 0.1%. Furthermore, 87% (121 from 139 injuries) increased the risk of injury in professional rugby union players.14
of the 8.6% of players who sustained an injury were correctly We have also modelled the relationship between changes in weekly
identified by the injury prediction model. training load (reported as a percentage of the previous weeks’
Although several commercially available software programs training load) and the likelihood of injury (unpublished observa-
claim to predict training load-related injuries, to date, this is tions). When training load was fairly constant (ranging from 5%
the only study to predict injury based on training load data, less to 10% more than the previous week) players had <10% risk
apply that model in a high performance sporting environ- of injury (figure 5). However, when training load was increased by
ment, and then report the results in a peer-reviewed journal. ≥15% above the previous week’s load, injury risk escalated to
We acknowledge that any regression model that predicts between 21% and 49%. To minimise the risk of injury, practi-
injury is best suited to the population from which it is tioners should limit weekly training load increases to <10%.
derived. Caution should be applied when extrapolating these
results to other sports and populations. Despite this potential
limitation, these findings provide information on the training CONSIDERING BOTH ACUTE AND CHRONIC TRAINING
dose–response relationship in elite rugby league players, and a LOAD: A BETTER WAY TO MODEL THE TRAINING–INJURY
scientific method of monitoring and regulating training RELATIONSHIP?
load in these athletes. Importantly, in a team environment, Is there a benefit in modelling the training–injury relationship
this approach allows players to be managed on an individual using a combination of both acute and chronic training loads?
basis. Acute training loads can be as short as one session, but in team
sports, 1 week of training appears to be a logical and convenient
unit. Chronic training loads represent the rolling average of the
most recent 3–6 weeks of training. In this respect, chronic train-
ing loads are analogous to a state of ‘fitness’ and acute training
loads are analogous to a state of ‘fatigue’.2
Comparing the acute training load to the chronic training load
as a ratio provides an index of athlete preparedness. If the acute
training load is low (ie, the athlete is experiencing minimal
‘fatigue’) and the rolling average chronic training load is high (ie,
the athlete has developed ‘fitness’), then the athlete will be in a
well-prepared state. The ratio of acute:chronic workload will be
around 1 or less. Conversely, if the acute load is high (ie, training
loads have been rapidly increased resulting in ‘fatigue’) and the
rolling average chronic training load is low (ie, the athlete has
performed inadequate training to develop ‘fitness’), then the
athlete will be in a fatigued state. In this case the ratio of the
acute:chronic workload will exceed 1. The use of the acute:
chronic workload ratio emphasises both the positive and negative
consequences of training. More importantly, this ratio considers
the training load that the athlete has performed relative to the
Figure 5 Likelihood of injury with different changes in training load. training load that he or she has been prepared for.43
Unpublished data collected from professional rugby league players over The first study to investigate the relationship between the
three preseason preparation periods. Training loads were measured acute:chronic workload ratio and injury risk was performed on
using the session-rating of perceived exertion method. Training loads elite cricket fast bowlers.43 Training loads were estimated from
were progressively increased in the general preparatory phase of the
both session-RPE and balls bowled. When acute workload was
preseason (ie, November through January) and then reduced during the
specific preparatory phase of the preseason (ie, February). The training similar to, or lower than the chronic workload (ie, acute:
programme progressed from higher volume-lower intensity activities in chronic workload ratio ≤0.99) the likelihood of injury for fast
the general preparatory phase to lower volume-higher intensity bowlers in the next 7 days was approximately 4%. However,
activities in the specific preparatory phase. Each player participated in when the acute:chronic workload ratio was ≥1.5 (ie, the work-
up to five organised field training sessions and four gymnasium-based load in the current week was 1.5 times greater than what the
strength and power sessions per week. Over the three preseasons, 148 bowler was prepared for), the risk of injury was 2–4 times
injuries were sustained. Data are reported as likelihoods ±95% CIs. greater in the subsequent 7 days.43
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Figure 6 Guide to interpreting and applying acute:chronic workload ratio data. The green-shaded area (‘sweet spot’) represents acute:chronic
workload ratios where injury risk is low. The red-shaded area (‘danger zone’) represents acute:chronic workload ratios where injury risk is high. To
minimise injury risk, practitioners should aim to maintain the acute:chronic workload ratio within a range of approximately 0.8–1.3. Redrawn from
Blanch and Gabbett.46

Using total weekly distance as a predictor variable, almost that training has a protective effect against injury. The results of
identical results have been found in elite rugby league44 and these studies should be considered when evaluating the influ-
soccer45 players; ‘spikes’ in acute load relative to chronic load ence of high training workloads on injury risk:
(ie, when the acute:chronic workload ratio exceeded 1.5) were 1. Team sport athletes who performed greater than 18 weeks of
associated with an increased risk of injury. training before sustaining their initial injuries were at
Taken from three different sports (cricket, Australian football reduced risk of sustaining a subsequent injury.50 These find-
and rugby league), a guide to interpreting and applying acute: ings are consistent with others43 44 who have shown that
chronic workload ratio data is shown in figure 6.46 In terms of high chronic workloads may decrease the risk of injury.
injury risk, acute:chronic workload ratios within the range of Furthermore, greater training prior to entering an elite
0.8–1.3 could be considered the training ‘sweet spot’, while junior soccer programme was associated with a decreased
acute:chronic workload ratios ≥1.5 represent the ‘danger zone’. risk of developing groin pain.51
To minimise injury risk, practitioners should aim to maintain 2. Second, across a wide range of sports, well-developed phys-
the acute:chronic workload ratio within a range of ical qualities are associated with a reduced risk of
approximately 0.8–1.3. It is possible that different sports will injury.50 52–54 Clearly, for athletes to develop the physical
have different training load–injury relationships; until more data capacities required to provide a protective effect against
is available, applying these recommendations to individual sport injury, they must be prepared to train hard.
athletes should be performed with caution. 3. Importantly, there is evidence that over-training and under-
training may increase injury risk.14 28 32 For example, cricket
THE BALANCE BETWEEN INJURY PREVENTION AND HIGH fast bowlers who bowled fewer deliveries per week with
PERFORMANCE: TRAINING TOO MUCH OR NOT TRAINING greater recovery between sessions were at an increased risk
ENOUGH of injury, while bowlers who bowled more deliveries per
Successful sporting teams report lower injury rates and greater week with less recovery between sessions were also at an
player availability than unsuccessful teams.47–49 Although the increased risk of injury. Similar findings have been reported
evidence linking greater training loads with high injury rates is in baseball and rugby union.14 28 The ‘U’-shaped relation-
compelling, focusing on the negative aspects of training detracts ship between workload and injury from these data demon-
from the many positive adaptations that arise from the training strate that both inadequate and excessive workloads are
process. In addition, there are several reasons why the results associated with injury.
linking high training loads to injury should be taken in context Collectively, these results emphasise that reductions in work-
with the wide range of performance issues relevant to sport. loads may not always be the best approach to protect against
Wrapping players in cotton wool will not bring on-field success. injury. How do practitioners find the ‘sweet spot’ of training load?
How can practitioners help coaches train players at the ideal
level (maximising performance while also maintaining a low risk
of non-contact soft-tissue injuries)? TRAINING SMARTER AND HARDER—THE MECHANISMS
THAT MAY UNDERPIN THESE FINDINGS
DOES THIS MEAN ATHLETES SHOULD STOP TRAINING?! Although high training loads have been associated with higher
Although studies have shown a positive relationship between injury rates, results are equivocal with recent evidence also dem-
training load and injury, there is also evidence demonstrating onstrating a protective effect of high chronic training loads.43 44
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In this section I elaborate on the data shown in tables 1 and Equally, note that in figure 4, on the steep portion of the
2. Table 1 above shows that players who performed greater training load–injury curve small changes in training load (either
amounts of very high-speed running were 2.7 times more likely increases or decreases) result in large changes in injury risk (in
to sustain a non-contact soft-tissue injury than players with the respective direction). Under-emphasised in this study, was
lower running loads.26 Given the high risk of injury with that due to the sigmoidal nature of the curve, at large training
greater running loads, it is tempting to suggest that athletes loads the training load–injury relationship is almost completely
should avoid very high-speed running in training to minimise ‘flat’. On this portion of the curve, large changes in training
the risk of injury. However, by restricting running loads in an load result in very small changes in injury risk. Thus, if athletes
attempt to reduce injury risk, it is possible that during critical can safely train through the ‘high risk’ portions of the curve
passages of play when players are required to exert maximally (using the acute:chronic workload ratio model), then they may
they are inadvertently put at greater risk of injury due to being develop greater resilience and training tolerance.
under prepared. Although injury prediction models may have sufficient pre-
Greater amounts of very high-speed running may be asso- dictive accuracy to warrant systematic use in an elite team sport
ciated with increased injury risk, however there is evidence programme, a fine balance exists between training, detraining
(from the same data set) of lower injury risk when players per- and overtraining. Training programmes must be physiologically
formed greater amounts of low-intensity activity and short accel- and psychologically appropriate58 to allow players to cope with
eration efforts.26 High-intensity team sports such as soccer, the demands of competition. With this in mind, it may be
basketball and the rugby codes require players to perform short argued that it is worthwhile using preseason training and train-
(2–3 s) acceleration efforts,55 followed by longer durations of ing camps to prescribe high training loads (note, not excessive)
lower intensity activity.56 In competition, longer high-speed to determine which players are most susceptible to injury under
efforts are uncommon.57 physically stressful situations (these players most likely will not
Given that high training loads can be achieved in different tolerate the intensity and fatigue of competition), and which
ways (ie, volume, intensity and frequency of training, as well as players are not susceptible to injury under physically stressful
the balance of training activities performed) it is inappropriate situations (these players are more likely to tolerate the intensity
to consider all ‘high training loads’ as carrying identical injury and fatigue of competition).
risk. To be explicit, ‘high training loads’ per se may not be the
largest contributing factor to increased injury risk, but rather A NEW VIEW OF TRAINING—A ‘VACCINE’ AGAINST
the type of ‘high training load’ that is prescribed may be an INJURIES!
important predictor of injury. Greater amounts of short, high- This paper proposes the training-injury prevention paradox.
intensity acceleration effort training and game-specific aerobic Physically hard (and appropriate) training may protect against
activity may provide team sport athletes with the appropriate injuries. There is no disputing that high training loads are gener-
physical qualities to not only perform at a high level, but also ally associated with better developed fitness and thus, good per-
protect against injury. formance. One cost of high training load is often considered to
Table 2 illustrates the accuracy of an injury prediction model. be soft tissue injury risk. To address this risk, training loads
It demonstrates that the training load model was both sensitive could be reduced to decrease the incidence of injury, however
and specific for predicting non-contact, soft tissue injuries. low training loads (in the form of reduced training volumes)
However, the injury prediction model was far better at identify- have also been associated with increased injury risk; exposing
ing when injuries were unlikely to occur (ie, true negatives) than players to low training loads may place them at risk of further
it was at predicting injuries. These findings are intuitive; if per- injury. Once players enter the rehabilitation process, it is a chal-
formance staff focus on injury prevention, and prevent injuries lenge for practitioners to expose them to appropriate loads to
through ‘managing athletes away from training’, then the low enhance physical qualities which provide a protective effect
numbers of training-load related injuries may be expected, as against injury, and prevent the ‘spike’ in loads when players
athletes are unlikely to ever train with adequate volumes or return to full training. As a result, it is not uncommon for teams
intensities to sustain an injury. to have a constant ‘rehab-er’ in their squad—a player who

Figure 7 Relationship between

physical qualities, training load, and
injury risk in team sport athletes.

Gabbett TJ. Br J Sports Med 2016;50:273–280. doi:10.1136/bjsports-2015-095788 7 of 9

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breaks down repeatedly ( potentially with different injuries) Open Access This is an Open Access article distributed in accordance with the
because his or her training load is not high enough to adapt to Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
match demands. The data presented suggest that prescribing and license their derivative works on different terms, provided the original work is
high training loads can lead to improved levels of fitness, which properly cited and the use is non-commercial. See: http://creativecommons.org/
in turn offers a protective effect against injury, ultimately licenses/by-nc/4.0/
leading to (1) greater physical outputs and resilience in competi-
tion, and (2) a greater proportion of the squad available for
selection each week (figure 7). REFERENCES
1 Orchard J. Who is to blame for all the football injuries? Br J Sports Med 2012; June 20,
guest blog. http://blogs.bmj.com/bjsm/2012/06/20/who-is-to-blame-for-all-the-
football-injuries/
CONCLUSIONS
2 Banister EW, Calvert TW, Savage MV, et al. A systems model of training for athletic
In conclusion, while there is a relationship between high train- performance. Aust J Sports Med 1975;7:57–61.
ing loads and injury, this paper demonstrates that the problem is 3 Morton RH. Modeling training and overtraining. J Sports Sci 1997;15:335–40.
not with training per se, but more likely the inappropriate train- 4 Foster C, Daniels JT, Yarbrough RA. Physiological and training correlates of
ing that is being prescribed. Excessive and rapid increases in marathon running performance. Aust J Sports Med 1977;9:58–61.
5 Krebs PS, Zinkgraf S, Virgilio SJ. Predicting competitive bicycling performance with
training loads are likely responsible for a large proportion of training and physiological variables. J Sports Med Phys Fit 1986;26:323–30.
non-contact, soft-tissue injuries. However, physically hard (and 6 Mujika I, Chatard JC, Busso T, et al. Effects of training on performance in
appropriate) training develops physical qualities, which in turn competitive swimming. Can J Appl Physiol 1995;20:395–406.
protects against injuries. This paper highlights the importance of 7 Mujika I, Busso T, LaCoste L, et al. Modeled responses to training and taper in
competitive swimmers. Med Sci Sports Exerc 1996;28:251–8.
monitoring training load, including the load that athletes are
8 Scrimgeour AG, Noakes TD, Adams B, et al. The influence of weekly training
prepared for (by calculating the acute:chronic workload ratio), distance on fractional utilization of maximum aerobic capacity in marathon and
as a best practice approach to the long-term reduction of ultramarathon runners. Eur J Appl Physiol 1986;55:202–9.
training-related injuries. 9 Stewart AM, Hopkins WG. Seasonal training and performance of competitive
swimmers. J Sports Sci 2000;18:873–84.
10 Foster C. Monitoring training in athletes with reference to overtraining syndrome.
Med Sci Sports Exerc 1998;30:1164–8.
What are the findings? 11 Gabbett TJ. Influence of training and match intensity on injuries in rugby league.
J Sports Sci 2004;22:409–17.
12 Huxley DJ, O’Connor D, Healey PA. An examination of the training profiles
▸ Dogma exists around the effects of high (and low) training and injuries in elite youth track and field athletes. Eur J Sport Sci 2014;14:
loads on injury. 185–92.
13 Colby MJ, Dawson B, Heasman J, et al. Accelerometer and GPS-derived running
▸ This review highlights the positive and negative effects of loads and injury risk in elite Australian footballers. J Strength Cond Res
high training loads on injury risk, fitness and thus, 2014;28:2244–52.
performance. 14 Cross MJ, Williams S, Trewartha G, et al. The influence of in-season training loads
▸ There is a relationship between high training loads and on injury risk in professional rugby union. Int J Sports Physiol Perform 2015 (in
press).
injuries but well-developed physical qualities protect against 15 Anderson L, Triplett-McBride T, Foster C, et al. Impact of training patterns on
injury. incidence of illness and injury during a women’s collegiate basketball season.
▸ The ratio of acute to chronic training load is a better J Strength Cond Res 2003;17:734–8.
predictor of injury than acute or chronic loads in isolation. 16 Impellizzeri FM, Rampinini E, Marcora SM. Physiological assessment of aerobic
training in soccer. J Sports Sci 2005;23:583–92.
17 Cummins C, Orr R, O’Connor H, et al. Global positioning systems (GPS) and
microtechnology sensors in team sports: a systematic review. Sports Med
2013;43:1025–42.
18 Chambers R, Gabbett TJ, Cole MH, et al. The use of wearable microsensors to
How might it impact on clinical practice in the future? quantify sport-specific movements. Sports Med 2015;45:1065–81.
19 Gastin PB, Meyer D, Robinson D. Perceptions of wellness to monitor adaptive
responses to training and competition in elite Australian football. J Strength Cond
▸ In many high performance settings, training loads are Res 2013;27:2518–26.
reported on a week-to-week basis. Recording acute and 20 Wehbe GM, Gabbett TJ, Hartwig TB, et al. Reliability of a cycle ergometer peak
chronic training loads, and modelling the acute:chronic power test in running-based team sport athletes: a technical report. J Strength Cond
workload ratio allows practitioners to determine if athletes Res 2015;29:2050–5.
are in a state of ‘fitness’ (ie, net training recovery, lower 21 McNamara DJ, Gabbett TJ, Naughton G, et al. Physical preparation and competition
workloads and fatigue responses of elite junior cricket players. Int J Sports Physiol
than average risk of injury) or ‘fatigue’ (ie, net training Perform 2013;8:517–26.
stress, higher than average risk of injury). 22 Gallo T, Cormack S, Gabbett T, et al. Characteristics impacting on session rating of
▸ The Training-Injury Prevention Paradox Model allows perceived exertion training load in Australian footballers. J Sports Sci
practitioners to monitor and prescribe training to team sport 2015;33:467–75.
23 Johnston RD, Gabbett TJ, Jenkins DG. Influence of an intensified competition on
athletes on an individual basis. fatigue and match performance in junior rugby league players. J Sci Med Sport
▸ Providing evidence around the effects of acute and chronic 2013;16:460–5.
training load on injury risk, physical fitness and performance 24 Kellmann M, Kallus KW. The recovery-stress questionnaire for athletes: user manual.
will allow practitioners to systematically prescribe high Champaign, IL: Human Kinetics, 2001.
training loads while minimising the risk of athletes 25 Main L, Grove JR. A multi-component assessment model for monitoring training
distress among athletes. Eur J Sport Sci 2009;9:195–202.
sustaining a ‘load-related’ injury. 26 Gabbett TJ, Ullah S. Relationship between running loads and soft-tissue injury in
elite team sport athletes. J Strength Cond Res 2012;26:953–60.
Correction notice The paper has been amended since it was published Online 27 Varley MC, Gabbett T, Aughey RJ. Activity profiles of professional soccer,
First. The title of the paper has been changed slightly. rugby league and Australian football match play. J Sports Sci 2014;32:
1858–66.
Competing interests None declared. 28 Lyman S, Fleisig GS, Waterbor J, et al. Longitudinal study of elbow and shoulder
Provenance and peer review Not commissioned; internally peer reviewed. pain in youth baseball pitchers. Med Sci Sports Exerc 2001;33:1803–10.

8 of 9 Gabbett TJ. Br J Sports Med 2016;50:273–280. doi:10.1136/bjsports-2015-095788

 Review

Br J Sports Med: first published as 10.1136/bjsports-2015-095788 on 12 January 2016. Downloaded from http://bjsm.bmj.com/ on January 16, 2023 by guest. Protected by copyright.
29 Lyman S, Fleisig GS, Andrews JR, et al. Effect of pitch type, pitch count, and 44 Hulin BT, Gabbett TJ, Lawson DW, et al. The acute:chronic workload ratio predicts
pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. injury: high chronic workload may decrease injury risk in elite rugby league players.
Am J Sports Med 2002;30:463–8. Br J Sports Med 2016;50:231–6.
30 Fleisig GS, Andrews JR, Cutter GR, et al. Risk of serious injury for young 45 Ehrmann FE, Duncan CS, Sindhusake D, et al. GPS and injury prevention in
baseball pitchers: a 10-year prospective study. Am J Sports Med 2011;39: professional soccer. J Strength Cond Res 2015 (in press).
253–7. 46 Blanch P, Gabbett TJ. Has the athlete trained enough to return to play safely? The
31 Orchard JW, James T, Portus M, et al. Fast bowlers in cricket demonstrate up to acute:chronic workload ratio permits clinicians to quantify a player’s risk of
3- to 4-week delay between high workloads and increased risk of injury. Am J subsequent injury. Br J Sports Med Published Online First: 23 Dec 2015.
Sports Med 2009;37:1186–92. doi:10.1136/bjsports-2015-095445
32 Dennis R, Farhart P, Goumas C, et al. Bowling workload and the risk of injury in 47 Arnason A, Sigurdsson SB, Gudmundsson A, et al. Physical fitness, injuries,
elite cricket fast bowlers. J Sci Med Sport 2003;6:359–67. and team performance in soccer. Med Sci Sports Exerc 2004;36:278–85.
33 Gabbett TJ, Domrow N. Relationships between training load, injury, and fitness in 48 Hagglund M, Walden M, Magnusson H, et al. Injuries affect team performance
sub-elite collision sport athletes. J Sports Sci 2007;25:1507–19. negatively in professional football: an 11-year follow-up of the UEFA Champions
34 Piggott B, Newton MJ, McGuigan MR. The relationship between training load and League injury study. Br J Sports Med 2013;47:738–42.
incidence of injury and illness over a pre-season at an Australian Football League 49 Eirale C, Tol JL, Farooq A, et al. Low injury rate strongly correlates with team
club. J Aust Strength Cond 2009;17:4–17. success in Qatari professional football. Br J Sports Med 2013;47:807–8.
35 Gabbett TJ, Jenkins DG. Relationship between training load and injury in 50 Gabbett TJ, Domrow N. Risk factors for injury in sub-elite rugby league players. Am
professional rugby league players. J Sci Med Sport 2011;14:204–9. J Sports Med 2005;33:428–34.
36 Killen NM, Gabbett TJ, Jenkins DG. Training loads and incidence of injury during 51 Lovell G, Galloway H, Hopkins W, et al. Osteitis pubis and assessment of bone
the preseason in professional rugby league players. J Strength Cond Res marrow edema at the pubic symphysis with MRI in an elite junior male soccer
2010;24:2079–84. squad. Clin J Sports Med 2006;16:117–22.
37 Gabbett TJ. Reductions in pre-season training loads reduce training injury rates in 52 Gastin PB, Meyer D, Huntsman E, et al. Increase in injury risk with low body mass
rugby league players. Br J Sports Med 2004;38:743–9. and aerobic-running fitness in elite Australian football. Int J Sports Physiol Perform
38 Gabbett TJ. Performance changes following a field conditioning program 2015;10:458–63.
in junior and senior rugby league players. J Strength Cond Res 2006;20: 53 Gabbett TJ, Ullah S, Finch CF. Identifying risk factors for contact injury in
215–21. professional rugby league players—application of a Frailty model for recurrent
39 Rogalski B, Dawson B, Heasman J, et al. Training and game loads and injury risk in injury. J Sci Med Sport 2012;15:496–504.
elite Australian footballers. J Sci Med Sport 2013;16:499–503. 54 Quarrie KL, Alsop JC, Waller AE, et al. The New Zealand rugby injury and
40 Fulton J, Wright K, Zebrosky B, et al. Injury risk is altered by previous injury: performance project. VI. A prospective cohort study of risk factors for injury in rugby
a systematic review of the literature and presentation of causative neuromuscular union football. Br J Sports Med 2001;35:157–66.
factors. Int J Sports Phys Ther 2014;9:583–95. 55 Spencer M, Bishop D, Dawson B, et al. Physiological and metabolic responses of
41 Gabbett TJ, Whyte DG, Hartwig TB, et al. The relationship between workloads, repeated-sprint activities: specific to field based team sports. Sports Med
physical performance, injury and illness in adolescent male football players. Sports 2005;35:1025–44.
Med 2014;44:989–1003. 56 Reilly T, Thomas V. A motion analysis of work-rate in different positional roles in
42 Gabbett TJ. The development and application of an injury prediction model for professional football match-play. J Hum Mov Stud 1976;2:887–97.
non-contact, soft-tissue injuries in elite collision sport athletes. J Strength Con Res 57 Gabbett TJ. Sprinting patterns of National Rugby League competition. J Strength
2010;24:2593–603. Cond Res 2012;26:121–30.
43 Hulin BT, Gabbett TJ, Blanch P, et al. Spikes in acute workload are associated 58 Baron B, Moullan F, Deruelle F, et al. The role of emotions on pacing strategies and
with increased injury risk in elite cricket fast bowlers. Br J Sports Med performance in middle and long duration sport events. Br J Sports Med
2014;48:708–12. 2011;45:511–17.

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