Influencing Risk: From Military to Sports Injuries
I recently read the book Risk: A User’s Guide*, by General Stanley McChrystal and Anna Butrico. It made for a very interesting read, highlighting that we cannot eliminate risk but must focus our energies on boosting our “Risk Immune System”.
Risk was discussed across various themes, many focusing on military operational risk given McChrystal’s background, but also lessons from business, politics, and health, including of course the COVID-19 Pandemic. McChrystal and Butrico described dealing with risk as "the active process of controlling every single factor within your reach".
I could not read this book without thinking about injury risk. We cannot eliminate injury risk altogether, but can focus on boosting our Injury Risk Immune System. This immune system describes one for each individual athlete, as well as the team or organisation as a whole. As with applying the Swiss Cheese model, implementing a combination of interventions can develop our defences against injury risk.
McChrystal and Butrico present ten dimensions of control within our Risk Immune System. Here, I will discuss each within the context of injury risk.
“We cannot control the emergence of threats [injury] – but we can make our organizations [athletes] less vunerable.” General Stanley McChrystal & Anna Butrico, Risk*
Communication is described as the “essential enabler” and the most critical factor. In their Risk Immune System illustrations, it is presented as the link between each of the other factors. Many in the professional sport ecosystem would agree. From my experiences, communication is always identified in end of season reviews as something that people have both done well in but also something people can do better in! This speaks to its importance.
In athletic settings, communication has been identified as a preventative strategy. Communication quality amongst professional football staff has been associated with injury burden and player availability (Ekstrand et al., 2018).
We are dealing with human beings and complex outcomes in injury and performance. The uncertain, non-linear, and recursive nature of such systems require continual observation of emergent patterns that should then be communicated. With many key stakeholders positioned around the athlete – as well as the athlete themselves – communication is the essential enabler to all other dimensions of the Injury Risk Immune System.
The narrative is the story we tell ourselves; one that drives who we are, what we do, and why we do it, both as individuals and collectively. Given the influence of belief on athletic outcomes, the narrative an athlete builds in their heads, as well as that reinforced by their environment, can have a profound impact. Building a positive pre-workout narrative through motivational video and positive coach feedback can improve hormonal concentrations and consequent performance, without inducing metabolic stress in athletes for example (Cook and Crewther, 2012).
When however, our narrative does not align with our actions, this invites further risk. If an athlete says they are professional but their habits do not mirror this, they may invite greater injury risk through sub-optimal preparation. Similarly, if a performance staff claims to be evidence-based but do not implement such approaches, the misaligned system may foster greater injury risk within the organisation.
Structure is described by McChrystal and Butrico as a double-edged sword. With greater structure comes greater clarity, but it can also limit the ability for individuals or an organisation to adapt.
In the athletic environment, for example, we need a training plan but also the ability to adapt the plan. That is the crux of load monitoring – to objectively determine times when the training plan may benefit from adjustment. Both under- and over-management of athlete load can theoretically contribute to increased injury risk.
Structure is also important from a personnel perspective, helping to define roles and responsibilities and informing the power dynamics within an organisation. Yet, when clarity around such responsibilities is lacking, we can witness duplicative efforts or gaps in services. An organisational chart is not enough: roles need to be determined and communicated to ensure the athletes receive the services they require from the most appropriate individual at the optimal time.
It comes as no surprise to read technology as a factor within the Risk Immune System. Sports technology carries both opportunity and risk itself. As technology evolves, so must we, but we also need to “employ human judgement to navigate technology’s effects” as urged by McChrystal and Butrico.
Technological advances in sports science have provided tools that can help to reduce injury risk. However, simply investing in technology is not necessarily causal in reducing injury risk. It is dependent on how it is implemented and the decisions and actions that are made as a consequence. Maximising its value, while seeking to minimise athlete burden, is crucial to leveraging technology in support of the Injury Risk Immune System.
According to Risk, settings that lack diversity invite greater risk through the stale preservation of Status Quo, being outpaced by innovation and groupthink mindsets. Indeed, we’ve previously discussed the dangers of the “we’ve always done it this way” mindset. Conversely, diversity offers an antidote to groupthink, by bringing different perspectives into the decision making process.
In both performance and injury, we are dealing with complex entities. This means so-called best practice is often not actually best, we must be dynamic and open-minded to respond to problems with good or emerging practice (Greenberg and Clubb, 2021).
By leveraging different perspectives and experiences, we reduce the likelihood of groupthink and search for the best approach to a particular situation. For those looking to support diversity in their setting, check out my post that offers practical steps to promoting gender diversity.
McChrystal and Butrico present bias as the lens through which we view the world, influenced by our own experiences and self-interests. Biases are unavoidable but awareness of them can help us to manage their effects. Interestingly, the authors were able to link many common biases to the Risk Immune System factors. For example, confirmation bias links to narrative, status quo bias to action, hindsight bias to timing, and in-group bias to diversity, among others.
As practitioners, we have developed biases towards approaches, strategies, technologies, metrics, and analysis techniques. We are also biases by our own experiences, so it is tempting to want to bring in injury risk mitigation strategies we’ve used previously.
I’ve previously shared how I was biased towards bringing in approaches from football into new sports, but learning about the new sport highlighted the prior assumptions I’d brought with me. This reinforces the need to translate, rather than transplant systems, with part of such an approach recognising your own biases and assumptions.
Action sits on a continuum with inaction at the opposite end. Where we end up on this continuum is influenced by the coefficient of friction; how much work is required to overcome the inertia to action.
Often, people have a bias towards inaction (i.e. the status quo bias). A commonly discussed example of inaction, also included in Risk, is Blockbuster and their failure to take action in response to their competitor Netflix and the future of film and TV consumption. We all know how that worked out…
Determining when to take action and when not to is a challenge for sports practitioners. Athlete screening is commonplace to try to understand injury risk (though this of course is a complex and debated topic). However, taking action on such screening results I fear is less common. How are we actioning this data? If not, is it actually boosting our Injury Risk Immune System? Conversely, if we are taking action in an inappropriate or ill-informed manner we may be damaging it.
Timing is essential to sports performance; taking the shot at the right time, timing your header, releasing the ball at the optimal moment, there are endless examples. In “Risk”, timing is discussed within the context of the Decision, the Execution, and the Impact, as well as the time lags between each phase. For instance, a decision may be correct but if too long is taken to reach that conclusion, it may be too late to execute efficiently or successfully. The authors illustrate this with discussions of response timing to Hurricane Katrina and COVID-19.
Seeking to master timing in our injury risk minimisation programmes is important to enhance the Injury Risk Immune System. When to load, when to unload/recover, when to travel, when to train etc. Optimising the schedule can help teams win “unbeatable games”. To enhance our timing, we must employ dynamic perspectives, to be able to judge big-picture decisions, such as when to start pre-season training, down to finite detailed decisions, such as where to place a specific exercise or set within a programme.
The authors state that constantly changing threats demand continuous adaptation. This is clear throughout human evolution, both biologically and socially. Had we not adapted our societal norms throughout 2019-21, we would have succumbed ever more to the risks of the COVID-19 Pandemic. The importance of adaptability was also illustrated by the Fosbury Flop technique in high jump, which propelled its creator, Dick Fosbury, to Olympic Gold in 1968 and had later been adopted by all but one athlete in the 1988 Olympics.
A key point is made in acknowledging that adaptability requires both the willingness and the ability to change. There are a number of ways we can view such need through the lens of sports injury and performance.
Does a performance staff have the willingness to adapt their support services, but then also the knowledge, man-power, management support, and financial and time constraints to be able to implement the change?
It also applies to the individual athlete: do they have the willingness to carry out their injury risk minimisation programme with good intent, but also the (physical/mental/time) ability to do so within their own demands or constraints.
In the complex realm of injury and performance, being both willing and able to adapt to emerging contexts is important to keep each athlete’s Injury Risk Immune System effective.
General McChrystal is a retired four-star general and the co-founder of a leadership consulting firm, the McChrystal Group.
As such, it is not a surprise that he would describe leadership as the “indispensable factor” within the Risk Immune System. It is presented as the ability to effectively oversee multidimensional risk.
Leadership influences each of the other dimensions of the system. For instance, a leader is tasked with managing information sharing (communication), constantly monitoring and tweaking organisation structure (structure), consciously committing to incorporating a spectrum of perspectives (diversity), and controlling the trigger (timing). The authors contend that leadership is necessary to make the entire system work.
Many may have experienced potentially positive or negative effects of leadership, through decisions and communication, and injury outcomes. Indeed, research has demonstrated an association between leadership style and injury rates and availability (Ekstrand et al., 2017). Much like communication, leadership styles can influence injury risk and outcomes.
In the book Risk*, a ten-factor Immune System is presented to highlight influential risk factors, whether that is military, business, financial, political, or health risks. Each of these factors are pertinent to sports injury risk too.
Injury risk is inherent and unavoidable. As such, there can be a cost associated with becoming overly focussed upon risk, particularly given the tug of war between performance and injury. Yet, seeking to leverage each of these factors within our own practice, as well as the wider organisation, can contribute to developing resilience to injury risk.
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