Context Matters: Revisiting the First Step of the “Sequence of Prevention” of Sports Injuries

Caroline Bolling, Willem van Michelen, H. Roeline Pasman, Evert Verhagen

The Big Idea

This research literature review paper was published in the journal Sports Medicine in 2018.  The problem these researchers are concerned with is sports injury prevention.  A little more than 25 years ago a seminal paper was published proposing a sequential, stepped approach to injury prevention.  Over the years this linear approach has been used, abused, tinkered with, and celebrated.  The significance of focusing on prevention of injuries is a given.  The explosion of recreational, youth, and elite sports participation world-wide produces exponential increases in injuries.  Anything that can be done to reduce the likelihood of injuries is of paramount importance to players, parents, coaches, and spectators alike.


  • It is possible to reduce sports injuries.
  • Controlled research studies do show ways to reduce injury incidence.
  • Research also shows ways to reduce injury severity and costs tied to sports injuries.
  • But implementing these findings into practical usefulness is a problem if qualitative approaches to injury reduction are under employed.
  • The sequence of prevention is a commonly used framework for injury reduction.
  • This sequence has four analytical linear steps: description, risk factors, preventive measures, evaluation.
  • The first step in this process—injury description—is a misstep these authors claim, because all injuries are complex, relational, and non-lineal.
  • In other words, all injuries must be taken within their context, and taken contextually throughout all four steps.
  • No matter how inconvenient, to take the first step without considering the context of the injury is to over-simplify the entire injury reduction process.
  • We all must wear sombreros in our efforts to energize the sequence of prevention in sports injuries. (Note to our dear readers: You will have to read the entire review if you want to know why we need to wear sombreros).

The Research


Ongoing empirical studies largely confirm the efficacy of what has been called the sequence of injury prevention in modern sports.  Empirical research of this sort is designed to control the phenomena under study, usually by using clinical trials or other experimental designs. 

But the rub comes in when the results of controlled studies are translated into practice.  In other words, the results of a study may show ideal efficacy; but actual everyday application may not show pragmatic effectiveness at all.  So, the question the above researchers are asking is:  What in the heck is wrong when we try to implement the results of the sciences into useful applications?

Complexity and context

The original sequence of prevention of sports injuries model had these four process steps: 1) Describe the sports injury magnitude and the severity; 2) Find the risk factors (etiology); 3) Introduce preventive measures (environmental or behavioral interventions); and 4) Evaluate the effectiveness of the intervention(s).

Over the years there have been suggested modifications of this guide to injury prevention.  Most of the suggested improvements to the original framework involved are, what else, but more steps?  But the researchers in this review paper will argue that no number of additional steps will successfully hot wire the sequence of prevention.  Instead, their strategy is to simply propose a novel way to insulate the entire framework from shorting itself out.

The authors want to improve the effectiveness of the sequence of prevention model of sports injuries.  They argue that the traditional model is strictly linear in its application.  It presupposes the factual non-linear context of injuries themselves.  That’s why there is recent enthusiasm for taking a dynamical systems approach to injury prevention using the complexity of injuries as the go-juice for their studies. 

If injuries are intrinsically complex, then what is only sequential (steps 1 through 4) cannot provide an accurate interpretation of the process of injury reduction.  This is because injuries are relational.  The same injury—let’s say the popular ACL tear—occurs in countless different circumstances.  Different sports.  Different injury presentations.  Different genders.  Different emotions.  Different individual constitutions.  Different environmental effects.  Different ages. Different continents.  Different cultures.  Different socioeconomic classes.  Consequently, designing injury prevention solutions requires a re-evaluation of the very first step in the original model where context is taken for granted.

A socioecological model

The authors of this review paper are stumping for a radical change in how sports injury prevention is conceived.  Although they do not use the actual word “radical,” their call for context before decisions is indeed radical if we mean by radical, square root radical, a going to the root.

We discover then the power of non-linearity injury prevention. They admonish those dealing with sports injuries: “Instead of asking whether an intervention works for a specific problem, new questions should ask how context impacts a problem.” More mystery than straightforwardness, where looking laterally finds the unexpected

Qualitatively speaking

To get to the context of sports injury prevention these researchers are not advocating so much using qualitative methods over the quantitative methods of research.   They are simply asking qualitative questions that arise from injury contexts overlooked by the empirical sciences.

For comparison, look at a different way of describing the four steps between the linear context-free evidence and the non-linear context-driven sequence of prevention of sports injuries.


Step 1 Injury

Step 2   Isolated risk factors

Step 3   Context-free intervention

Step 4   Efficacy evaluation


Step 1   Injury and its context

Step 2   Contextual determinants

Step 3   Context-driven interventions

Step 4   Evaluation of multiple measures

Finally, these authors are arguing for a subtle shift in the relationship between ourselves and the science of injury prevention in sports.  Building evidence in a qualitative direction automatically means diversifying sources of injury prevention.  When our thinking evolves laterally, our discoveries satisfy truthfully.  Just ask the poet Wallace Stevens about non-linearity, from a qualitative point of view, as fluid rather than fixed:

Rationalists, wearing square hats,

Think, in square rooms,

Looking at the floor,

Looking at the ceiling.

They confine themselves

To right-angled triangles.

If they tried rhomboids,

Cones, waving lines, ellipses—

As, for example, the ellipse of the half-moon—

Rationalists would wear sombreros.                         

Wallace Stevens

(last stanza from Six Significant Landscapes)

Image Source: Pexels 

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