CANADIAN SPORT FOR LIFE

PLAY SAFE:
Physical Literacy and Injury
Prevention Guide for Leaders
Introduction This Guide

Safety is a best practice. The tools in this guide will This guide is intended to introduce the coach,
enable your organization to establish best practices parent, volunteer, administrator, leader, or official
reducing the risk of injury in your programming, to the basic concepts of injury risk reduction in
and they may also improve the overall experience sport and physical activity through the use of
of your participants. Participants who are prepared, injury prevention and risk management tools and
educated, trained, well-equipped, and follow the practices. While these practices are well established
rules will be better able to avoid injury, participate in areas such as public health and workplace safety,
with confidence, and maintain their participation they have not been fully adopted within sport,
long term. Building safe and healthy participation recreation and physical activity settings. As such,
will enrich everyone’s experience as they enjoy the organizations have the opportunity to learn from
benefits of physical activity. these evidence-based practices and apply them
to their delivery of sport, recreation and physical
activity programs in Canada.

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Part 1

Injury Prevention in Canada

Injury is the leading cause of death for children and Sport and physical activity involve some degree of
young adults. It is among the leading causes of risk. Risk is not necessarily a bad thing or something
hospitalization for children, young adults and we want to always avoid. We take risks every day
seniors, and it is a major cause of disability in walking across the street, driving to work or trying
Canada1. The annual cost of injuries to Canadians is something new. Often these risks are calculated.
estimated at $19.8 billion2. This includes the direct We weigh the pros and cons, and we prepare to
costs of health care, as well as the indirect costs face the uncertainty of risk by taking a course to
related to reduced productivity due to learn a new skill or purchasing insurance. Still, risk
hospitalization, disability and premature death3. can have serious consequences like injury or death.
More than 40% of child and youth injuries treated Building a culture of safety and injury prevention in
in emergency departments are sport and recreation sport, recreation and physical activity programming
related4. Despite this massive cost, we struggle requires a widespread agreement that injuries are
to understand the injury process and change this predictable and preventable.
outcome.

More than 40% of child and youth injuries treated in

emergency departments are sport
and recreation related4.

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Injury Prevention Tools

The following tools show how injury occurs, where interventions can reduce the number and severity of
injury, and how those interventions can be designed and evaluated for effectiveness.

• The “Haddon Matrix” describes the process of injury and identifies opportunities for intervention.
• The “Three Es” prescribe the strategies to be used at these points of intervention.

Understanding these two elements will help in different ways.

First, they will provide anyone involved in sport and physical
activity programming with a base level of understanding and
a common language for injury prevention. Second, they will
help to identify what has been successful in sport and physical
activity to date, and what has not been. These elements are not
exhaustive, but they provide a glimpse of the possibilities of injury
risk reduction.

Using the Haddon Matrix to Understand Injury

in Sport and Physical Activity

As you develop a strategy to reduce or eliminate an injury risk,

it is important to understand the process that leads to injury and
the potential opportunities to intervene. The Haddon Matrix
is a framework that provides 12 opportunities to intervene in
the injury process, the most important of which is during the
pre-injury phase. Sport and physical activity organizations
can apply the matrix to see where and/or when they can
minimize injury risk in their programs.

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The following is an example of an organization using the Haddon Matrix to understand the factors related to
ACL injuries in soccer players.
Environment
Host Agent Physical Socio-economic
Phases The person at risk of injury Is energy that is The characteristics of the The social and legal norms
transmitted to the host setting in which the injury and practices in the
event takes place culture and organization
Pre-Injury • Structured warm-up • Proper fitting shoes • Favorable weather • Where possible have
programs that and clothing conditions athletic trainer during
Stopping the injury event focus on stretching, • Use of relevant and • Well maintained and practice and game
from occurring by acting strengthening, correct size of tools safe playing fields • Optimum
on its causes improving balance and equipment e.g., absence of preparation and
and movements prior • Limit physical potholes practice
to sport participation contact during • Strict supervision
• Basic skills should practice during the game and
be mastered before practice
moving to more
complex skills
• Participants
understand playing
rules
Injury • Limit activity to • Use of personal • Hospital nearby with • Emergency response
individual ability protective specialty in trauma system ready such as
An attempt to prevent • Strict adherence equipments such as care/sport injuries phone, ambulance,
an injury or reduce the to rules and knee pads and and first aid kit
severity when an event regulations braces
actually occurs by
designing and
implementing protective
mechanisms
Post-Injury • General • Use of first aid kit • Availability of • Sport-injury
physical health of immediate trauma rehabilitation
An attempt to reduce the injured person care program
the severity of injury or • Provide prompt and • Availability of • Family and social
disability immediately appropriate first aid rehabilitation support
after an event facility
considering short and • Prompt ACL
reconstruction
long-term timeframes

Haddon Matrix in Practice: Dr. Tom Pashby, an ophthalmologist and sports safety activist, helped develop the face mask and visor and
introduce the helmet into the Canadian Hockey League. Face masks for hockey players were introduced in 1971 and soon became
mandatory in amateur leagues5. Eye injuries in hockey have steadily declined since that time. In 1980, Hockey Canada was the first league
to make face protection certified by the Canadian Standard Association (CSA), a mandatory requirement for all of its registered players6.
Prior to the introduction of the face mask in hockey, eye injuries were identified as a cause of vision loss and impairment. Dr. Pashby applied
the logic of the matrix: preventing the puck or stick (agent) from striking the face and ocular region (host) would reduce the incidence of
injuries. Mandatory rules (social environment) now support the use of protective equipment.

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The Three Es - Education, Engineering and Enforcement

The Three Es - Education, Engineering and Enforcement - were developed by Sue Barker in 19737 . Where
the Haddon Matrix helps to identify when and where interventions can be applied, the Three Es help us to
develop specific strategies for each intervention.

The following table summarizes the necessary criteria for each element:

Criteria for Effective Use of Injury Prevention Strategies8

Education Engineering Enforcement

Audience must: Modification must be: Law or regulation must (be):
• Be exposed to the • Effective and reliable • Widely known and understood
appropriate information • Compatible with the by the public
• Understand and believe the environment • Acceptable to the public
information • Result in products that • High probability (or perceived
• Have resources and skills to dominate the marketplace probability) of enforcement
take action on the information • Acceptable to the public • Punishment is (or is perceived
• Derive benefit (or perceive • Easily understood by the to be) swift and severe.
benefit) from taking action public • Evaluated for effectiveness
• Be reinforced to maintain the • Properly used by the public
change over time • Evaluated for effectiveness
• Evaluated for effective
learning

Mandatory protective equipment is a common example of an intervention in sport (Engineering). However,

equipment alone cannot fully prevent injury if players are not shown how to wear it properly (Education),
officials do not enforce its use (Enforcement), or its design is not adequate (Engineering). A breakdown in
the application of any one of the Three Es will limit the success of equipment as an intervention. Therefore,
any effective injury prevention intervention must include all three of the Three Es.

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Evaluation

Proper evaluation criteria must be included in the Education, Engineering and Enforcement interventions in
order to provide evidence of their effectiveness. This highlights an important theme in injury prevention – it
needs to be evidence-based. However, it can be difficult to gather evidence in sport and physical activity.
MacKay and Liller (2009) suggest most research in the area of sports and recreational injury “has been
descriptive, with too few studies examining prevention strategies in any rigorous manner9.” In other words,
safety practices within the sport system have not been measured in detail to determine if they provide the
safety they are intended to.

Evaluation Proves the Point

In recent years, we have seen some contention around interventions like mouthguards
and eye protection in various sports. Decision makers, with best intentions, may feel that
something must be done about a particular injury and adopt a new practice or piece of
equipment without formal evaluation. This lack of rigour (validity) raises questions about the
decision-making process. With a better understanding of the value of developing and utilizing
evidence-based practices, organizations can make decisions not only with best intentions but
also with best facts to guide them.

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Who is Ready for Change? Similarly, changing the habits of culture, policy
and process within an organization can reduce the
Injury prevention relies heavily on understanding likelihood of injury. Precisely how to change the habits
why and how people and organizations do the things of individuals and organizations is a topic too complex
they do. Often injury prevention relies on changing for this guide. However, it must be understood that the
habits because risky behaviours are perpetuated by process takes time.
habits both at the individual and organization levels.
These habits can be subconscious and continue Change is Not Linear
without anyone noticing.
With organizations and individuals, behaviour change
For example, a runner’s gait and a golfer’s swing are is a dynamic process; changes happen in steps and
behaviours driven by habit. As any coach or instructor stages over time10. As well, change does not always
knows, when an athlete or participant has learned begin at step one and move fluidly through successive
a skill with poor execution, it can be very difficult steps; people may progress from one step, regress,
to change that pattern of execution. As a result, the and then progress again until the behaviour change is
individual may be more susceptible to repetitive strain attained. People will also enter the change process at
or acute injury, or they may not be able to advance different stages, and they may not all move from one
to the next level because of their limited skills. If stage to the next at the same pace.
sport and physical activity providers can teach better
skill development at the beginning of a participant’s This is an important feature of injury prevention
experience, this should result in better skill execution planning. Change requires action to move people and
and decreased susceptibility to injury. organizations.

The following is an illustration of the stages of change according to the Transtheoretical Model (TM):

Stages of Change

Precontemplation  Contemplation  Preparation  Action  Maintenance

Action Action Action Action

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Part 2
Injury Risk Reduction in Sport and Physical Activity

“But we have insurance…”

When all other risk management steps fail,

insurance is a tool used to protect an organization
With a bit of direction, together with some
from financial loss and/or to indemnify a member for
potential injuries in a sanctioned event. In the sport evidence-based tools and common sense,
environment this usually means that a participant staff and/or volunteers can become
will pay a premium upon registration that provides proficient in identifying and reducing injury
insurance protection should a player cause injury to risk in their programming.
a Third Party or sustain serious personal injury while
participating in their sport.

Having insurance is very important, but it is not an

effective tool for reducing injury risk in the
organization’s activities, just as buying car insurance
does not automatically reduce the risk of a collision
and/or injury. Habits and practices have to change.

Time and Effort is Needed

Sport, recreation and physical activity organizations

need to commit time and effort to entrench injury
risk reduction processes in their programming. One
may ask how this can be done, when so many
organizations are already stretched to their limit for
resources. Two things to consider:

1. The process to identify and reduce injury risk is

relatively simple (outlined in this guide).
2. Sport, recreation and physical activity
organizations can also save time and energy by
learning from successful injury risk reduction
efforts in other environments.

A properly implemented risk management

guideline for organizations can help to
maintain or possibly reduce insurance costs.

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A Mandate to Prevent Injury How to Implement Injury Prevention through
Risk Management
There must be a starting place to create a culture
shift to reduce the risk of injury. It can be prompted The following pages show you how to:
by risk concerns leading to a new organization policy
or other directive from a governing body. Some 1. Use basic risk management principles to
questions to ask: identify and understand injury risk within your
organization’s activities.
• What is your organization’s injury prevention 2. Develop strategies to reduce or eliminate
policy? (See Appendix 1). identified risks.
• Is it included in your organization’s orientation 3. Monitor and evaluate your organization’s current
for all staff and volunteers? and future safety practices for effectiveness on
• Does your organization have an internal an on-going basis.
mechanism to capture injury details and share
them in a way that helps to identify trends? Note: You can position your organization for
• Does your organization have a committee that success in reducing injury risk by collecting data
oversees injury data and analysis, and provides on injuries within your activities. You can also gain
directives to management? insights by examining the safety practices of other
• Who is ultimately responsible for injury in your organizations similar to yours. Using real data and
organization? best practices, your organization will be able to
• Is there a sponsor or champion of injury respond with informed opinions based on evidence
prevention in your organization? and experience as injury risks change over time.
• Are frontline leaders in your organization
informed about injury prevention policies or
practices?
• Is there enough expertise within your
organization to lead injury prevention efforts?
• Do people within your organization believe that
injury is a problem?
• Does your organization have an injury
prevention training or education program for
participants and/or leaders?
• Is there a relationship between your
organization and the facility in which your
activities take place?

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 Step One: What If?
Physical Activity Injury Reduction (PAIR) Tool Understand Injury in Your Activities

The following is a version of the generally accepted The first step is to identify the general injury risks
risk management process adapted for a sport and within your organization. Afterwards, you will drill
physical activity audience. This process is designed down to specific details and characteristics of the
to identify, understand, counter and measure injury injury process. Begin by asking one question: Is there
and injury risk. the potential that someone can be injured in our
activities?
1. What if?
• Define the injury risks (see Appendix 2) • Define injury in your organization (risk
• Understand injury process (Haddon Matrix – assessment):
see Appendix 3) * Classify types (concussion, fracture,
• Prioritize laceration, soft-tissue, contusion, etc)
* Severity (how bad)
2. How to? * Probability (how often)
• Define points of intervention
• Develop options to reduce risk based • Understand process:
on the 3 Es * How injury occurs (improper skill, rule
• Build measurement plan infraction, contact with other participant,
• Implement best intervention equipment, play structure, conditions)
* Haddon Matrix (points of process and
3. Does it work? intervention)
• Measure intervention impact
• Analyze results
• Continue to monitor and
evaluate regularly

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Identify Potential Hazards

Prioritize injury reduction planning according to applicable legislation, standards or best practices, available
organization resources.

When you participate in an activity with great frequency, you can easily overlook some of the associated
hazards. Here are some ways you can identify the important ones:

• Look at and analyze the organization’s • Offer a way for “near misses” to be
injury records – are there common reported (by phone, email or website).
injuries? • Invite someone not intimately familiar
• Walk around your environment and look with your activity to observe the potential
at what could potentially cause harm. opportunities for injury risk.
• Ask your volunteers or participants what • Remember to think about long-term risks
they think. They may have noticed things to health, like overuse injuries.
that are not immediately obvious to you.

Assessing injury risk is as much art as it is science. Using a matrix like the one below will help your
organization to prioritize the injury risks and determine how to proceed.

Impact Injury Risk Management Actions

Considerable Must manage and Extensive management

Severe management required monitor risks essential
Risks may be worth Management effort Management effort
Moderate accepting with worthwhile required
monitoring
Accept but monitor Manage and monitor
Minor Accepted risks risks risks

Low Medium High

Likelihood

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Step Two: How To? Selecting the Best Option
Having identified the risks, you now have to decide You now have an understanding of the risks
what to do about them. Follow these steps to involved in the activities within your organization
develop options to reduce or eliminate injury risks: and a number of options to offset them. Given the
organization’s resources and capacity and the best
• Ask the question – what can we do to make sure practices of other similar organizations, what is the
injuries do not happen as often or are not as best option to reduce the injury risk? Create a small
severe? team of staff and/or volunteers to select the best
• Define points of intervention. option. Consider the following:
• Develop options to reduce risk based on
Haddon Matrix and the 3 Es - education, • Try to engage outside expertise to select options.
engineering (equipment, facilities, programming) • If you are reviewing relevant scientific literature,
and enforcement (rules, regulations and policies). be critical.
• Build a measurement plan (i.e. observation, • Make sure the decision makers in your
injury data collection, surveys, focus groups). organization have an understanding of the
• Select and implement the best intervention. evidence (facts) behind the decision.

As you go through this process, look at what your

organization is already doing. Think about what
controls you have in place and how the organization
is structured. Consider the following:

• Can we eliminate the risk altogether?

• If not, how can we control the risks so that harm
is unlikely? (Use the Haddon Matrix for this
activity.)

There are laws in place that

expect an organization to make
reasonable efforts to reduce and
eliminate a known risk.

The easiest way to know if what your

organization is doing is reasonable is to
compare what you are doing with good
practice of similar organizations,
colleagues and members.

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Step Three: Does it Work?
After choosing an intervention, you need to see • When you are a staff member or
if it works. Develop a measurement process to volunteer in charge of youth activities,
accompany the intervention option, so your
it’s easy to forget to review your risk
organization can monitor and evaluate the impacts
of the intervention. This includes any impact it has assessment until something has gone
on the known injury and related injury risks, as well wrong and it’s too late.
as injury risks that were perhaps not previously
considered.
• Whenever there is a significant change
Consider the following: in policy, programming or equipment,
don’t wait.
• How do you know for sure that the
intervention was successful in reducing the
• Check your risk assessment and change
injury risk?
• Did it have any unexpected impacts on other it where necessary.
injury risks?
• If possible, it is best to consider the
Review Regularly
injury risks when you’re planning your
Your monitoring and evaluation plan ensures your change, so you have more flexibility and
organization has a process to reconsider changes can plan for monitoring.
based on evidence gathered. Few organizations
stay the same. Sooner or later, there will be new
equipment, rules, policies and procedures that could
lead to new injury risks. It makes sense therefore to
review what the organization is doing on an ongoing
basis. At minimum, there must be an annual review.
Look at your organization’s activities and think about
whether there have been any changes.

• Are improvements still needed?

• Have stakeholders spotted a problem?
• Has the organization learned anything from
injuries or near misses?

Make sure your risk assessment stays up-to-date

using the Physical Activity Injury Reduction (PAIR)
Tool.

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Part 3

Moving Forward

This introductory guide provides basic concepts of injury risk reduction for sport, recreation and physical
activity organizations. It is intended to be a primer for a much larger experience in which organizations
and individuals begin to shift collective thinking about injury in sport and physical activity from
“accidental” to preventable.

Central to this conceptual shift is building an evidence base of injury data and evaluated injury reduction
strategies. This will require consistent, reliable injury data collection and extensive research to evaluate
current practices to understand their impact on injury risk.

As new policies, programs, equipment and laws emerge, your organization will need to monitor their
efforts to ensure safety is not compromised. Safety is a best practice and injury risk reduction is a
self-priming process. It never suggests the goal has been accomplished but rather inspires continuous
improvement. This work, when shared with the community, will help contribute to a collective
understanding that safety is a commonplace and predictable day-to-day practice at every level within
sport, recreation and physical activity programming.

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 APPENDIX 1

INJURY PREVENTION POLICY

This is the statement, general policy and arrangements for:

Overall and final responsibility for injury risk reduction is that of:

Day-to-day responsibility for ensuring this policy is put into

practice is delegated to:

Statement of General Policy Responsibility of (Name / Position) Action / Arrangements

To reduce the incidence and
severity of injuries and provide
adequate control of injury risks
arising from participation in our
sanctioned activities.
To provide adequate training and
ensure volunteers are competent to
identify and report injury risks.
To collect and analyze injury data
and produce helpful reports back to
members.
To engage and consult regularly with
member organizations, leaders and
other stakeholders on day-to-day
safety concerns.
To maintain safe and healthy playing
conditions.

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APPENDIX 2

RISK ASSESSMENT

Organization
name:

What are the injury Who might be What are you What can be Action by Action by Done
risks? harmed and how? doing already done in addition whom? when?
to minimize the to minimize the
injury risk? injury risk?
Education Education

Engineering Engineering

Enforcement Enforcement

Education Education

Engineering Engineering

Enforcement Enforcement

Education Education

Engineering Engineering

Enforcement Enforcement

Organizations with 100 or more participants must complete this assessment and provide it to their regional,
provincial or national designate. It is important to gather information for this form from various sources
such as parents, coaches, leaders, participants, officials and other volunteers and staff.

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 APPENDIX 3

HADDON MATRIX: REDUCE INJURY RISK IN SPORT AND PHYSICAL ACTIVITY

Socio-economic
Phases Human Vehicle/Equipment Physical Environment
Environment
Pre-Injury
Phase

Injury Phase

Post-Injury
Phase

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References
1
Public Health Agency of Canada. Retrieved on April 13, 2012 from:
[Link]
2
Smartrisk (2009). Economic Burden of Injury in Canada. Toronto.
3
Ibid
4
Public Health Agency of Canada. Fact Sheet: Investing in child and youth injury prevention in sports and recreation.
Retrieved on April 24, 2012 from: [Link]
5
Canadian National Institute for the Blind. Eye Safety in Hockey. Retrieved from
[Link] on April 10, 2012.
6
Ibid
7
Baker SP (1973). “Injury Control”. In Preventive medicine and public health. Rosenau MJ, Maxcy KF, & Sartwell PE.
New York: Appleton-Century-Crofts. [10th ed.]
8
Gielen AC, Sleet DA (2009). “Injury Prevention and Behavior: An Evolving Field”. In Injury and Violence Prevention:
Behavioural Science Theories, Methods, and Applications (1-16). Gielen AC, Sleet DA, DiClemente RJ (Eds.) San
Francisco: Josey-Bass.
9
MacKay M, Liller K (2009). “Behavioral Considerations for Sports and Recreational Injuries in Children and Youth. In
Injury and Violence Prevention: Behavioural Science Theories, Methods, and Applications (257-273). Gielen AC, Sleet
DA, DiClemente RJ (Eds.) San Francisco: Josey-Bass.
10
Prochaska JO, DiClemente CC, Norcross JC, (1992). “In search of how people change: Applications to the addictive
behaviors”. In Injury and Violence Prevention: Behavioural Science Theories, Methods, and Applications (257-273).
Gielen AC, Sleet DA, DiClemente RJ (Eds.) San Francisco: Josey-Bass.

Resources
For additional reading and resources, please visit the Canadian Sport for Life website:

[Link]

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 Acknowledgements

Writer Editors
Brandy Tanenbaum, BA, CRM Jim Grove
Program Coordinator, RBC First Office for Injury Kaitlyn Rosenburg
Prevention, Sunnybrook Health Sciences Centre
Design
Content Development Alethea Wilson
Brandy Tanenbaum, BA, CRM
Program Coordinator, RBC First Office for Injury Reviewers
Prevention, Sunnybrook Health Sciences Centre Drew Mitchell, Sport Technical and Performance
Services BC Sport Agency
Joanne Banfield, RN, BA, Manager
Trauma injury Prevention, RBC First Office for Injury Bill Taggart, CS4L Project Leader,
Prevention, Sunnybrook Health Science Centre Sport Newfoundland and Labrador
Dr. Susan L. Forbes, Ph.D. Benjamin Robillard, BPE, CS4L Physical Literacy
School of Kinesiology, Lakehead University Injury Prevention Project Coordinator
Steve Lacoste, AIB
Richard Way, MBA, Pacific Sport Canadian
Vice-President, National Practice Leader, BFL CANADA
Risk and Insurance Inc. Sports and Leisure Sport Centre Victoria

/CANADIANSPORTFORLIFE
/ACTIVEFORLIFE

@CS4L_ACSV
@ACTIVEFORLIFE

CANADIANSPORTFORLIFE
[Link] ACTIVEFORLIFECS4L

We acknowledge the financial support of the Government

of Canada through the Public Health Agency of Canada and
Sport Canada, a branch of the Department of Canadian Heritage.

* Funding for this project has been made possible through a contribution from the Public Health Agency of Canada.
The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada.

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