Beyond tame solutions: a new paradigm for injury prevention in sports

Abstract

Injury prevention in sports remains a perpetual challenge, frequently hindered by linear approaches that fail to account for the complexity of real-world scenarios. We propose a paradigm shift in this perspective, framing injury prevention as a ‘wicked problem’ characterised by evolving, context-dependent factors and competing priorities. We suggest that while eliminating injuries entirely may not be feasible, their impact can be effectively reduced through tailored, adaptable solutions.

We illustrate the practical application of this framework through a case study of Cirque du Soleil. By adopting a revised ‘Sense-Think-Act’ paradigm, interventions were collaboratively developed with performers, medical personnel and organisational leaders. This resulted in a 15% reduction in injuries and substantial decreases in missed performances and overuse injuries over 4 years. The success of this approach can be attributed to context-sensitive strategies that effectively balance injury risk mitigation with performance objectives.

Our proposed view challenges traditional definitions of success in injury prevention, that is, developing ‘optimal solutions’ instead of ‘ultimate solutions’. By rethinking injury prevention as a wicked problem, we nudge sports professionals to adopt flexible, sustainable practices that address the dynamic realities of their environments. Such a shift enhances injury prevention outcomes and aligns these efforts with the broader priorities of athletic communities.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Traditional sports injury prevention approaches focus on single causes and linear solutions, failing to address sports contexts’ complexity and resulting in inconsistent adoption of preventive measures and high injury rates.

WHAT THIS STUDY ADDS

• We propose a context-sensitive, iterative framework emphasising stakeholder collaboration and adaptability. This means we need new outcome metrics, shifting our focus from eliminating injuries to achieving practical, optimal solutions in specific sports contexts.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• We present an alternative approach to injury prevention that provides contextually relevant interventions. We advocate for a comprehensive approach across diverse settings. While complete injury elimination is unattainable, we must prioritise developing the most effective solutions.

A persistent challenge in sports

Injuries are an inherent challenge in sports, posing significant health risks to athletes, disrupting performance and, in some cases, even shortening careers. Over the decades, research has produced robust evidence supporting interventions to mitigate injury risks.¹ Strategies like exercise, load management and tailored recovery programmes have been developed and validated.

Yet, a troubling gap remains for all this progress: an inability to consistently translate evidence into practice.^{2 3} Athletes, coaches and sports organisations often find it difficult to implement injury prevention measures sustainably. The reasons for this disconnect are multifaceted. Behavioural resistance, logistical barriers and the sheer complexity of sporting environments all play a role. As a result, the target ‘injury prevention’ remains largely unrealised, creating frustration for community partners—athletes, coaches, medical staff, financial backers and organisational leaders—who struggle to align their practice with evidence.⁴,⁶

A fundamental misconception is at the heart of this issue: the assumption that injuries are linear problems.^{7 8} Under this paradigm, injuries are seen as the result of a single or easily identifiable cause. Remove the cause, and the problem disappears. However, this oversimplification overlooks the reality that injuries are the product of dynamic, interdependent factors.⁹,¹¹ Viewing injuries through this reductive lens leads to solutions misaligned with real-world scenarios’ complexity.

To bridge this gap, we must rethink our approach to injury prevention. We must progress beyond treating injuries as tame problems—solvable with a single correct answer—and embrace their nature as wicked problems. From this viewpoint, we argue that while injuries cannot be entirely eliminated, optimal solutions can be achieved through context-sensitive, iterative approaches developed together with community partners. To illustrate this shift, we present a case study from Cirque du Soleil, where a novel framework transformed a seemingly unbeatable challenge into practical progress.

From linear assumptions to complex realities

The concept of wicked problems has been adopted in disciplines ranging from public health to environmental science.^{12 13} Wicked problems are defined by their complexity, ambiguity and resistance to definitive solutions (figure 1).¹⁴ Unlike tame problems with clear boundaries and agreed-upon solutions,¹⁵ wicked problems are characterised by evolving conditions and conflicting community partner priorities. Each attempt to address a wicked problem changes its nature, and no single solution is universally applicable.

Figure 1. Tame problems, complex problems and wicked problems. The blue dots represent known injury risk factors, the grey dots (yet) unknown injury risk factors and the red dots represent the injury outcome.

Sports injuries exemplify this complexity. They are influenced by many factors, including an athlete’s biomechanics, training loads, past injury history, psychological state, environmental conditions and even random chance.^{10 11} These factors, and many more, interact unpredictably, making it impossible to pinpoint a single cause or prescribe a one-size-fits-all intervention. Moreover, the priorities of community partners often diverge, complicating consensus on what constitutes ‘success’.

Rethinking injury prevention as a wicked problem

If injury is defined as “tissue damage or other derangement of normal physical function due to participation in sports, resulting from rapid or repetitive transfer of kinetic energy”,¹⁶ the obvious answer is to reduce or remove that energy transfer. In this paradigm, causal factors for the problem (eg, intrinsic and extrinsic risk factors, mechanisms of injury) are generally determined by researchers using scientific data,^{8 17} and interventions are proposed based on controlled studies.¹⁵ Coaches and practitioners are then expected to implement these solutions, often with little consideration of their practical constraints or the unique dynamics of their environment. While this approach has yielded valuable insights, it falls short of addressing the context of injury prevention across community partners.⁹ Evidence-based guidelines often clash with the lived experiences and immediate needs of those they aim to serve.

Conceptually, the challenges of preventing injuries in active populations may be more readily appreciated as a wicked problem.¹⁸,²¹ Wicked problems may not be completely solvable, but multiple optimal solutions exist, and there is no ‘best practice’; each problem instance is unique and requires a tailored solution.¹⁵ The challenge lies in finding such solutions in a context where they must be practical and acceptable for multiple community partners with different and sometimes competing priorities.

For example, hamstring injuries remain one of the most common issues in football despite the availability of proven preventive approaches like the Nordic Hamstring Exercise (NHE). Research shows that while NHE programmes can significantly reduce injury risk, they do not eliminate it—well-controlled trials report reductions but not 100% effectiveness, as injuries are influenced by multifactorial and context-specific elements.^{22 23} Implementing such programmes highlights the wicked nature of the problem: players may resist exercises that cause muscle soreness, coaches may prioritise short-term match readiness over long-term injury prevention and medical staff may advocate for consistent adherence to evidence-based protocols.^{5 24}

Reframing injury prevention as a wicked problem requires us to change from striving for definitive answers to seeking optimal solutions—strategies that work well enough within specific contexts, even if they do not solve the problem entirely. Success lies in finding approaches that reduce risk to an acceptable level, balancing practicality and effectiveness. This approach emphasises adaptability, collaboration with community partners, and continuously refining interventions based on real-world feedback. It also acknowledges that success is not binary but exists on a web of spectra shaped by the varying priorities of different community partners.

Case study: lessons from Cirque du Soleil

Our work for Cirque du Soleil (CdS) offers an example of how to address injury prevention as a wicked problem. As a global leader in live entertainment, CdS employs over 1500 artists who perform physically demanding acrobatics up to ten times a week, over and above their training volume. These conditions create a high injury risk, threatening individual performers and the company’s broader operational goals.²⁵

We understood that in the CdS environment, injuries were not merely the result of biomechanical failures but emerged from a complex interplay of workload, performance pressures and organisational culture. Hence, instead of eliminating injuries entirely—a near-impossible task—we aimed to find practical, optimal solutions aligned with the demands of the unique CdS environment. The resulting initiative, ‘Durability by Design’, unfolded across three phases, which we derived out of a redefined sense-think-act paradigm aligned to the context of sports²⁶ (figure 2).

Figure 2. Redefined Sense-Think-Act Paradigm for the context of sports.

Sense

The first step involved a deep dive into the unique context of CdS. Traditional metrics, such as exposure hours, were reframed to reflect the nuances of the performance environment. For example, we analysed how show intensity and schedule variations impacted artists’ risk profiles. This phase also involved extensive community partner engagement to understand the lived experiences of performers and staff.²⁷

Think

Armed with these insights, we co-developed tailored strategies that balanced injury reduction with performance excellence. Community partners, including medical staff, coaches and artists, collaborated to design practical interventions aligned with the organisation’s culture. One key innovation was the adoption of performance-based indicators to guide decision-making, ensuring that injury prevention efforts complement artistic goals (see figure 3 for examples).

Figure 3. Some examples out of the created library of preventive interventions, which were divided into three categories: ‘prepare’, ‘perform’ and ‘recover’. Prepare involved tools to aid artists in their preparation (eg, warm-up exercises, sports specific strengthening, skill training). Perform provided solutions to keep artists safe while they perform (eg, preventive devices, enforcement of safety rules and regulations, environmental conditions). Following that, recover provided advice on how to recover optimally between and after shows (eg, nutrition, resting periods, sleep).

Act

Implementation focused on empowering community partners to integrate interventions into daily routines. We achieved this through creative communication, education and branding, reinforcing the importance of injury prevention while fostering a sense of ownership among participants. Interventions were organised into three pillars—prepare, perform and recover—providing a flexible yet comprehensive framework.

Between 2015 and 2019, CdS achieved remarkable results: a 15% reduction in injuries, a 26% decrease in missed performances and a 27% decline in overuse injuries (figure 4).²⁸ As we approached this as a wicked problem, we cannot directly say which specific Durability by Design component resulted in these reductions. Nonetheless, substantial change was achieved over time after altering responsibility and culture, leading to drastic reductions in injury rates, missed performances and subsequent loss of revenue due to artists’ absence. Crucially, the initiative succeeded not by solving the injury problem but by finding optimal solutions that worked within CdS’s unique constraints.

Figure 4. Reduced injury and missed performance rates between 2015 and 2019. These numbers are derived from internal CdS injury reports.²⁸.

Such reductions in rates may be lower than what we could ideally expect from efficacy evidence stemming from controlled trials.¹ However, the real-life artistic and athletic context is not an ideal and controlled environment,^{9 29} and current implementation efforts in sports have yet to achieve such reduction rates, which are rarely sustained over extended periods.

What we have learned

The lessons from CdS have implications for the broader field of sports injury prevention. First, they underscore the need to shift from linear, one-size-fits-all approaches to strategies that embrace complexity. Injuries cannot be entirely eradicated, but their impact can be mitigated through context-sensitive and adaptable solutions.

Second, the CdS example highlights the importance of redefining success. Traditional metrics, such as injury incidence rates, often fail to capture the full scope of prevention efforts. Broader view, encompassing factors like community partners’ engagement, organisational culture and performance outcomes, is essential for evaluating progress in wicked problems.

Finally, the CdS experience demonstrates the value of iterative learning. In a dynamic environment, static solutions quickly become obsolete. By embedding continuous feedback and adaptation into the injury prevention process, practitioners can respond to emerging challenges and refine their strategies over time.

Embracing wickedness for sustainable solutions

Injury prevention in sports is complex, context-dependent and resistant to definitive solutions; in brief, it is a wicked problem. Yet, as our experiences with CdS illustrate, meaningful progress is possible. By shifting our perspective from linear problem-solving to adaptive, iterative approaches, we can identify optimal solutions that balance competing priorities and align with the realities of practice.

This paradigm shift challenges us to rethink what it means to succeed in injury prevention. Ultimately, treating injury prevention as a wicked problem is not a concession to failure. Success is not about eliminating injuries but managing their impact in practical, sustainable and contextually relevant ways. It is about embracing complexity and working collaboratively to develop solutions that evolve alongside the problem.