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1.  Neuromuscular training and the risk of leg injuries in female floorball players: cluster randomised controlled study 
BMJ : British Medical Journal  2008;337(7661):96-99.
Objective To investigate whether a neuromuscular training programme is effective in preventing non-contact leg injuries in female floorball players.
Design Cluster randomised controlled study.
Setting 28 top level female floorball teams in Finland.
Participants 457 players (mean age 24 years)—256 (14 teams) in the intervention group and 201 (14 teams) in the control group—followedup for one league season (six months).
Intervention A neuromuscular training programme to enhance players’ motor skills and body control, as well as to activate and prepare their neuromuscular system for sports specific manoeuvres.
Main outcome measure Acute non-contact injuries of the legs.
Results During the season, 72 acute non-contact leg injuries occurred, 20 in the intervention group and 52 in the control group. The injury incidence per 1000 hours playing and practise in the intervention group was 0.65 (95% confidence interval 0.37 to 1.13) and in the control group was 2.08 (1.58 to 2.72). The risk of non-contact leg injury was 66% lower (adjusted incidence rate ratio 0.34, 95% confidence interval 0.20 to 0.57) in the intervention group.
Conclusion A neuromuscular training programme was effective in preventing acute non-contact injuries of the legs in female floorball players. Neuromuscular training can be recommended in the weekly training of these athletes.
Trial registration Current Controlled Trials ISRCTN26550281.
doi:10.1136/bmj.a295
PMCID: PMC2453298  PMID: 18595903
2.  Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial 
BMJ : British Medical Journal  2005;330(7489):449.
Objective To investigate the effect of a structured warm-up programme designed to reduce the incidence of knee and ankle injuries in young people participating in sports.
Design Cluster randomised controlled trial with clubs as the unit of randomisation.
Setting 120 team handball clubs from central and eastern Norway (61 clubs in the intervention group, 59 in the control group) followed for one league season (eight months).
Participants 1837 players aged 15-17 years; 958 players (808 female and 150 male) in the intervention group; 879 players (778 female and 101 male) in the control group.
Intervention A structured warm-up programme to improve running, cutting, and landing technique as well as neuromuscular control, balance, and strength.
Main outcome measure The rate of acute injuries to the knee or ankle.
Results During the season, 129 acute knee or ankle injuries occurred, 81 injuries in the control group (0.9 (SE 0.09) injuries per 1000 player hours; 0.3 (SE 0.17) in training v 5.3 (SE 0.06) during matches) and 48 injuries in the intervention group (0.5 (SE 0.11) injuries per 1000 player hours; 0.2 (SE 0.18) in training v 2.5 (SE 0.06) during matches). Fewer injured players were in the intervention group than in the control group (46 (4.8%) v (76 (8.6%); relative risk intervention group v control group 0.53, 95% confidence interval 0.35 to 0.81).
Conclusion A structured programme of warm-up exercises can prevent knee and ankle injuries in young people playing sports. Preventive training should therefore be introduced as an integral part of youth sports programmes.
doi:10.1136/bmj.38330.632801.8F
PMCID: PMC549653  PMID: 15699058
3.  Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial 
Objective To examine the effect of a comprehensive warm-up programme designed to reduce the risk of injuries in female youth football.
Design Cluster randomised controlled trial with clubs as the unit of randomisation.
Setting 125 football clubs from the south, east, and middle of Norway (65 clusters in the intervention group; 60 in the control group) followed for one league season (eight months).
Participants 1892 female players aged 13-17 (1055 players in the intervention group; 837 players in the control group).
Intervention A comprehensive warm-up programme to improve strength, awareness, and neuromuscular control during static and dynamic movements.
Main outcome measure Injuries to the lower extremity (foot, ankle, lower leg, knee, thigh, groin, and hip).
Results During one season, 264 players had relevant injuries: 121 players in the intervention group and 143 in the control group (rate ratio 0.71, 95% confidence interval 0.49 to 1.03). In the intervention group there was a significantly lower risk of injuries overall (0.68, 0.48 to 0.98), overuse injuries (0.47, 0.26 to 0.85), and severe injuries (0.55, 0.36 to 0.83).
Conclusion Though the primary outcome of reduction in lower extremity injury did not reach significance, the risk of severe injuries, overuse injuries, and injuries overall was reduced. This indicates that a structured warm-up programme can prevent injuries in young female football players.
Trial registration ISRCTN10306290.
doi:10.1136/bmj.a2469
PMCID: PMC2600961  PMID: 19066253
4.  Prevention of acute knee injuries in adolescent female football players: cluster randomised controlled trial 
Objective To evaluate the effectiveness of neuromuscular training in reducing the rate of acute knee injury in adolescent female football players.
Design Stratified cluster randomised controlled trial with clubs as the unit of randomisation.
Setting 230 Swedish football clubs (121 in the intervention group, 109 in the control group) were followed for one season (2009, seven months).
Participants 4564 players aged 12-17 years (2479 in the intervention group, 2085 in the control group) completed the study.
Intervention 15 minute neuromuscular warm-up programme (targeting core stability, balance, and proper knee alignment) to be carried out twice a week throughout the season.
Main outcome measures The primary outcome was rate of anterior cruciate ligament injury; secondary outcomes were rates of severe knee injury (>4 weeks’ absence) and any acute knee injury.
Results Seven players (0.28%) in the intervention group, and 14 (0.67%) in the control group had an anterior cruciate ligament injury. By Cox regression analysis according to intention to treat, a 64% reduction in the rate of anterior cruciate ligament injury was seen in the intervention group (rate ratio 0.36, 95% confidence interval 0.15 to 0.85). The absolute rate difference was −0.07 (95% confidence interval −0.13 to 0.001) per 1000 playing hours in favour of the intervention group. No significant rate reductions were seen for secondary outcomes.
Conclusions A neuromuscular warm-up programme significantly reduced the rate of anterior cruciate ligament injury in adolescent female football players. However, the absolute rate difference did not reach statistical significance, possibly owing to the small number of events.
Trial registration Clinical trials NCT00894595.
doi:10.1136/bmj.e3042
PMCID: PMC3342926  PMID: 22556050
5.  Efficacy of the FIFA 11+ Warm-Up Programme in Male Youth Football: A Cluster Randomised Controlled Trial 
The FIFA 11+ is a structured warm-up programme specially designed to prevent injuries among football players from age 14 years and above. However, studies to prove its efficacy are generally few and it is yet to be tested in male youth footballers and among African players. The purpose of the study was to examine the efficacy of the FIFA 11+ programme in reducing the risk of injuries among male youth football players of the Lagos Junior League. A cluster randomised controlled trial was conducted. All the 20 teams (414 players aged 14 -19 years) in the Premier League division were block-randomised into either an intervention (INT) or a control (CON) group. The INT group performed the FIFA 11+ exercises as warm-up during training sessions and the CON group performed usual warm-up. Participating teams were prospectively followed through an entire league season of 6 months in which they were visited every week to assess injured players for time-loss injuries in both groups. The primary outcomes were any injury to the players, injuries by type of exposure and injuries specific to the lower extremities. The secondary outcomes were injuries reported by body location, aetiology, mechanism and severity. In total, 130 injuries were recorded affecting 104 (25%) of the 416 players. Team and player compliance with the INT was 60% and 74% respectively. Based on the primary outcome measures of the study, the FIFA 11+ programme significantly reduced the overall rate of injury in the INT group by 41% [RR = 0.59 (95% CI: 0.40 – 0.86; p = 0.006)] and all lower extremity injuries by 48% [RR = 0.52 (95% CI: 0.34 – 0.82; p = 0.004)]. However, the rate of injury reduction based on secondary outcomes mostly did not reach the level of statistical significance. The FIFA 11+ programme is effective in reducing the rates of injuries in male youth football players.
Key pointsThe FIFA 11+ has only been tested in randomised controlled trials conducted on female youth football players; this study reports its efficacy in male youth football for the first timeThe FIFA 11+ programme significantly reduced the overall rate of injuries and lower extremity injuries in male youth football playersYouth football administrators in Africa and other parts of the world should pursue the implementation of the FIFA 11+ in order to minimize the incidence of injuries among players
PMCID: PMC3990886  PMID: 24790486
Injury prevention; neuromuscular training; FIFA; sports
6.  Effectiveness of an injury prevention programme for adult male amateur soccer players: a cluster-randomised controlled trial 
British Journal of Sports Medicine  2012;46(16):1114-1118.
Background
The incidence rate of soccer injuries is among the highest in sports, particularly for adult male soccer players.
Purpose
To investigate the effect of the ‘The11’ injury prevention programme on injury incidence and injury severity in adult male amateur soccer players.
Study design
Cluster-randomised controlled trial.
Methods
Teams from two high-level amateur soccer competitions were randomly assigned to an intervention (n=11 teams, 223 players) or control group (n=12 teams, 233 players). The intervention group was instructed to perform The11 in each practice session during one soccer season. The11 focuses on core stability, eccentric training of thigh muscles, proprioceptive training, dynamic stabilisation and plyometrics with straight leg alignment. All participants of the control group continued their practice sessions as usual.
Results
In total, 427 injuries were recorded, affecting 274 of 456 players (60.1%). Compliance with the intervention programme was good (team compliance=73%, player compliance=71%). Contrary to the hypothesis, injury incidences were almost equal between the two study groups: 9.6 per 1000 sports hours (8.4–11.0) for the intervention group and 9.7 (8.5–11.1) for the control group. No significant differences were found in injury severity, but a significant difference was observed in the location of the injuries: players in the intervention group sustained significantly less knee injuries.
Conclusions
This study did not find significant differences in the overall injury incidence or injury severity between the intervention and control group of adult male soccer players. More research is recommended, focusing on injury aetiology and risk factors in adult male amateur soccer players.
doi:10.1136/bjsports-2012-091277
PMCID: PMC3596860  PMID: 22878257
7.  Science of floorball: a systematic review 
Background
The purpose of this study was to comprehensively review the scientific research on floorball at the competitive and recreational levels according to field of study.
Methods
Full articles containing original data on floorball that had been published in English in peer-reviewed journals were considered for inclusion.
Results
Of 75 articles screened, 19 were included in this systematic review. One article each was identified in the fields of sports management and sports psychology, and the remaining 17 articles were in the field of sports medicine. Injury epidemiology in floorball players was the most thoroughly examined topic of research. To date, no research has been performed on the incidence of floorball-related injury, or any aspect of the sport, in children and adolescents.
Conclusion
Collaborative research among sports science disciplines is needed to identify strategies to reduce the incidence of injury and enhance the performance of licensed floorball players. Despite the increasing popularity of floorball in recent years, surprisingly little research has examined this sport.
doi:10.2147/OAJSM.S60490
PMCID: PMC4208738  PMID: 25349484
floorball; unihockey; review
8.  What do community football players think about different exercise-training programmes? Implications for the delivery of lower limb injury prevention programmes 
Background
Players are the targeted end-users and beneficiaries of exercise-training programmes implemented during coach-led training sessions, and the success of programmes depends upon their active participation. Two variants of an exercise-training programme were incorporated into the regular training schedules of 40 community Australian Football teams, over two seasons. One variant replicated common training practices, while the second was an evidence-based programme to alter biomechanical and neuromuscular factors related to risk of knee injuries. This paper describes the structure of the implemented programmes and compares players’ end-of-season views about the programme variants.
Methods
This study was nested within a larger group-clustered randomised controlled trial of the effectiveness of two exercise-training programmes (control and neuromuscular control (NMC)) for preventing knee injuries. A post-season self-report survey, derived from Health Belief Model constructs, included questions to obtain players’ views about the benefits and physical challenges of the programme in which they participated.
Results
Compared with control players, those who participated in the NMC programme found it to be less physically challenging but more enjoyable and potentially of more benefit. Suggestions from players about potential improvements to the training programme and its future implementation included reducing duration, increasing range of drills/exercises and promoting its injury prevention and other benefits to players.
Conclusions
Players provide valuable feedback about the content and focus of implemented exercise-training programmes, that will directly inform the delivery of similar, or more successful, programmes in the future.
doi:10.1136/bjsports-2013-092816
PMCID: PMC3995235  PMID: 24047571
Implementation; Injury Prevention; Training
9.  Ball Possession Effectiveness in Men’s Elite Floorball According to Quality of Opposition and Game Period 
Journal of Human Kinetics  2013;38:227-237.
The aim of the present study was to identify the importance of floorball tactical variables to predict ball possession effectiveness, when controlling quality of opposition and game periods. The sample was composed by 1500 ball possessions, corresponding to 14 games randomly selected from the International Championships played during 2008 and 2010 (World Championship, Four nations tournament and classificatory phases for World Championship) by teams from different competition levels (HIGH, INTERMEDIATE and LOW). The effects of the predictor variables on successful ball possessions according to the three game contexts (HIGH vs. HIGH; HIGH vs. LOW; LOW vs. LOW games) were analyzed using Binomial Logistic Regressions. The results showed no interaction with the game period. In HIGH vs. HIGH games, quality of opposition showed an association with ball possession effectiveness with ending zone, offensive system, possession duration, height of shooting and defensive pressures previous to the shot. In HIGH vs. LOW games the important factors were the starting zone, possession duration, defensive pressure previous to the last pass and to the shot, technique of shooting and the number players involved in each ball possession. Finally, in LOW vs. LOW games, the results emphasized the importance of starting and ending zones, the number of passes used and the technique of shooting. In conclusion, elite floorball performance is mainly affected by quality of opposition showing different game patterns in each context that should be considered by coaches when preparing practices and competitions.
doi:10.2478/hukin-2013-0062
PMCID: PMC3827758  PMID: 24235997
notational analysis; situational variables; team sports; performance analysis
10.  The Preventing Australian Football Injuries with Exercise (PAFIX) Study: a group randomised controlled trial 
Injury Prevention  2009;15(3):e1.
Background:
Knee injuries are a major injury concern for Australian Football players and participants of many other sports worldwide. There is increasing evidence from laboratory and biomechanically focused studies about the likely benefit of targeted exercise programmes to prevent knee injuries. However, there have been few international studies that have evaluated the effectiveness of such programmes in the real-world context of community sport that have combined epidemiological, behavioural and biomechanical approaches.
Objective:
To implement a fully piloted and tested exercise training intervention to reduce the number of football-related knee injuries. In so doing, to evaluate the intervention’s effectiveness in the real-world context of community football and to determine if the underlying neural and biomechanical training adaptations are associated with decreased risk of injury.
Setting:
Adult players from community-level Australian Football clubs in two Australian states over the 2007–08 playing seasons.
Methods:
A group-clustered randomised controlled trial with teams of players randomly allocated to either a coach-delivered targeted exercise programme or usual behaviour (control). Epidemiological component: field-based injury surveillance and monitoring of training/game exposures. Behavioural component: evaluation of player and coach attitudes, knowledge, behaviours and compliance, both before and after the intervention is implemented. Biomechanical component: biomechanical, game mobility and neuromuscular parameters assessed to determine the fundamental effect of training on these factors and injury risk.
Outcome measures:
The rate and severity of injury in the intervention group compared with the control group. Changes, if any, in behavioural components. Process evaluation: coach delivery factors and likely sustainability.
doi:10.1136/ip.2008.021279
PMCID: PMC2684655  PMID: 19494090
11.  Compliance With Neuromuscular Training and Anterior Cruciate Ligament Injury Risk Reduction in Female Athletes: A Meta-Analysis 
Journal of Athletic Training  2012;47(6):714-723.
Context
No consensus exists about the influence of compliance with neuromuscular training programs on reduction of the risk of anterior cruciate ligament (ACL) injury.
Objective
To systematically review and synthesize the published literature to determine if compliance with neuromuscular training is associated with reduced incidence of ACL injury in young female athletes.
Data Sources
We searched PubMed, SPORTDiscus, CINAHL, and MEDLINE for articles published from 1995 to 2010 using the key words anterior cruciate ligament prevention, ACL prevention, knee prevention, prospective knee prevention, neuromuscular training, and neuromuscular intervention.
Study Selection
Criteria for inclusion required that (1) the number of ACL injuries was reported, (2) a neuromuscular training program was used, (3) females were included as participants, (4) the study design was prospective and controlled, and (5) compliance data for the neuromuscular training program were provided.
Data Extraction
Extracted data included the number of ACL injuries, total number of participants per group, observation time period, number of participants who completed each session, number of sessions completed by an entire team, and number of total sessions. Attendance was calculated as the number of participants who completed each session converted into a percentage of the total number of participants. Intervention completion was calculated as the number of sessions completed by an entire team converted into a percentage of the total number of training sessions. These data were used to calculate an overall rate of compliance.
Data Synthesis
Six of 205 identified studies were included. Incidence rates of ACL injury were lower in studies with high rates of compliance with neuromuscular training than in studies with low compliance rates (incidence rate ratio = 0.27 [95% confidence interval = 0.07, 0.80]). Tertile analysis indicated rates of ACL injury incidence were lower in studies with high compliance rates than in studies with moderate and low compliance rates (incidence rate ratio = 0.18 [95% confidence interval = 0.02, 0.77]).
Conclusions
A potential inverse dose-response relationship exists between compliance with neuromuscular training and incidence of ACL injury. Attending and completing recommended neuromuscular sessions appears to be an important factor for preventing ACL injuries.
PMCID: PMC3499896  PMID: 23182020
knee; injury prevention; exercises
12.  Preventing knee injuries in adolescent female football players – design of a cluster randomized controlled trial [NCT00894595] 
Background
Knee injuries in football are common regardless of age, gender or playing level, but adolescent females seem to have the highest risk. The consequences after severe knee injury, for example anterior cruciate ligament (ACL) injury, are well-known, but less is known about knee injury prevention. We have designed a cluster randomized controlled trial (RCT) to evaluate the effect of a warm-up program aimed at preventing acute knee injury in adolescent female football.
Methods
In this cluster randomized trial 516 teams (309 clusters) in eight regional football districts in Sweden with female players aged 13–17 years were randomized into an intervention group (260 teams) or a control group (256 teams). The teams in the intervention group were instructed to do a structured warm-up program at two training sessions per week throughout the 2009 competitive season (April to October) and those in the control group were informed to train and play as usual. Sixty-eight sports physical therapists are assigned to the clubs to assist both groups in data collection and to examine the players' acute knee injuries during the study period. Three different forms are used in the trial: (1) baseline player data form collected at the start of the trial, (2) computer-based registration form collected every month, on which one of the coaches/team leaders documents individual player exposure, and (3) injury report form on which the study therapists report acute knee injuries resulting in time loss from training or match play. The primary outcome is the incidence of ACL injury and the secondary outcomes are the incidence of any acute knee injury (except contusion) and incidence of severe knee injury (defined as injury resulting in absence of more than 4 weeks). Outcome measures are assessed after the end of the 2009 season.
Discussion
Prevention of knee injury is beneficial for players, clubs, insurance companies, and society. If the warm-up program is proven to be effective in reducing the incidence of knee injury, it can have a major impact by reducing the future knee injury burden in female football as well as the negative long-term disabilities associated with knee injury.
Trial registration
NCT00894595
doi:10.1186/1471-2474-10-75
PMCID: PMC2711921  PMID: 19545453
13.  Soccer-Specific Warm-Up and Lower Extremity Injury Rates in Collegiate Male Soccer Players 
Journal of Athletic Training  2013;48(6):782-789.
Context:
A number of comprehensive injury-prevention programs have demonstrated injury risk-reduction effects but have had limited adoption across athletic settings. This may be due to program noncompliance, minimal exercise supervision, lack of exercise progression, and sport specificity. A soccer-specific program described as the F-MARC 11+ was developed by an expert group in association with the Federation Internationale de Football Association (FIFA) Medical Assessment and Research Centre (F-MARC) to require minimal equipment and implementation as part of regular soccer training. The F-MARC 11+ has been shown to reduce injury risk in youth female soccer players but has not been evaluated in an American male collegiate population.
Objective:
To investigate the effects of a soccer-specific warm-up program (F-MARC 11+) on lower extremity injury incidence in male collegiate soccer players.
Design:
Cohort study.
Setting:
One American collegiate soccer team followed for 2 seasons.
Patients or Other Participants:
Forty-one male collegiate athletes aged 18–25 years.
Intervention(s):
The F-MARC 11+ program is a comprehensive warm-up program targeting muscular strength, body kinesthetic awareness, and neuromuscular control during static and dynamic movements. Training sessions and program progression were monitored by a certified athletic trainer.
Main Outcome Measure(s):
Lower extremity injury risk and time lost to lower extremity injury.
Results:
The injury rate in the referent season was 8.1 injuries per 1000 exposures with 291 days lost and 2.2 injuries per 1000 exposures and 52 days lost in the intervention season. The intervention season had reductions in the relative risk (RR) of lower extremity injury of 72% (RR = 0.28, 95% confidence interval = 0.09, 0.85) and time lost to lower extremity injury (P < .01).
Conclusions:
This F-MARC 11+ program reduced overall risk and severity of lower extremity injury compared with controls in collegiate-aged male soccer athletes.
doi:10.4085/1062-6050-48.4.08
PMCID: PMC3867089  PMID: 23848519
injury prevention; sport injuries; athletic trainers
14.  Neuromuscular training with injury prevention counselling to decrease the risk of acute musculoskeletal injury in young men during military service: a population-based, randomised study 
BMC Medicine  2011;9:35.
Background
The rapidly increasing number of activity-induced musculoskeletal injuries among adolescents and young adults is currently a true public health burden. The objective of this study was to investigate whether a neuromuscular training programme with injury prevention counselling is effective in preventing acute musculoskeletal injuries in young men during military service.
Methods
The trial design was a population-based, randomised study. Two successive cohorts of male conscripts in four companies of one brigade in the Finnish Defence Forces were first followed prospectively for one 6-month term to determine the baseline incidence of injury. After this period, two new successive cohorts in the same four companies were randomised into two groups and followed prospectively for 6 months. Military service is compulsory for about 90% of 19-year-old Finnish men annually, who comprised the cohort in this study. This randomised, controlled trial included 968 conscripts comprising 501 conscripts in the intervention group and 467 conscripts in the control group. A neuromuscular training programme was used to enhance conscripts' motor skills and body control, and an educational injury prevention programme was used to increase knowledge and awareness of acute musculoskeletal injuries. The main outcome measures were acute injuries of the lower and upper limbs.
Results
In the intervention groups, the risk for acute ankle injury decreased significantly compared to control groups (adjusted hazards ratio (HR) = 0.34, 95% confidence interval (95% CI) = 0.15 to 0.78, P = 0.011). This risk decline was observed in conscripts with low as well as moderate to high baseline fitness levels. In the latter group of conscripts, the risk of upper-extremity injuries also decreased significantly (adjusted HR = 0.37, 95% CI 0.14 to 0.99, P = 0.047). In addition, the intervention groups tended to have less time loss due to injuries (adjusted HR = 0.55, 95% CI 0.29 to 1.04).
Conclusions
A neuromuscular training and injury prevention counselling programme was effective in preventing acute ankle and upper-extremity injuries in young male army conscripts. A similar programme could be useful for all young individuals by initiating a regular exercise routine.
Trial registration
ClinicalTrials.gov identifier number NCT00595816.
doi:10.1186/1741-7015-9-35
PMCID: PMC3084158  PMID: 21481230
15.  Teaching landing skills in elite junior Australian football: evaluation of an injury prevention strategy 
British Journal of Sports Medicine  2006;40(10):834-838.
Objective
To evaluate the effectiveness of a preseason physical training programme that taught landing and falling skills in improving landing skills technique and preventing injury in junior elite Australian football players.
Methods
723 male players who participated in an under 18 elite competition were studied prospectively in a non‐randomised controlled trial over two consecutive football seasons. There were 114 players in the intervention group and 609 control players. The eight session intervention programme taught players six landing, falling, and recovery skills, which were considered fundamental for safe landing in Australian football. Landing skills taught in these sessions were rated for competence by independent and blinded assessors at baseline and mid‐season.
Results
Evaluation of landing skills found no significant differences between the groups at baseline. Evaluation after the intervention revealed overall improvement in landing skills, but significantly greater improvement in the intervention group (z  =  −7.92, p  =  0.001). Players in the intervention group were significantly less likely (relative rate 0.72, 95% confidence interval 0.52 to 0.98) to sustain an injury during the season than the control group. In particular, the time to sustaining a landing injury was significantly less for the intervention group (relative rate 0.40, 95% confidence interval 0.17 to 0.92) compared with the control group.
Conclusions
Landing and falling ability can be taught to junior elite Australian football players. Players in the intervention group were protected against injury, particularly injuries related to landing and falls.
doi:10.1136/bjsm.2006.025692
PMCID: PMC2465083  PMID: 16920776
injury; Australian football; prevention; intervention; landing
16.  Comparison of the incidence, nature and cause of injuries sustained on grass and new generation artificial turf by male and female football players. Part 2: training injuries 
British Journal of Sports Medicine  2007;41(Suppl 1):i27-i32.
Objective
To compare the incidence, nature, severity and cause of training injuries sustained on new generation artificial turf and grass by male and female footballers.
Methods
The National Collegiate Athletic Association Injury Surveillance System was used for a two‐season (August to December) prospective study involving American college and university football teams (2005 season: men 52 teams, women 64 teams; 2006 season: men 54 teams, women 72 teams). Injury definitions and recording procedures were compliant with the international consensus statement for epidemiological studies of injuries in football. Athletic trainers recorded details of the playing surface and the location, diagnosis, severity and cause of all training injuries. The number of days lost from training and match play was used to define the severity of an injury. Training exposures (player hours) were recorded on a team basis.
Results
The overall incidence of training injuries for men was 3.34 injuries/1000 player hours on artificial turf and 3.01 on grass (incidence ratio 1.11; p = 0.21) and for women it was 2.60 injuries/1000 player hours on artificial turf and 2.79 on grass (incidence ratio 0.93; p = 0.46). For men, the mean severity of injuries that were not season ending injuries was 9.4 days (median 5) on artificial turf and 7.8 days (median 4) on grass and, for women, 10.5 days (median 4) on artificial turf and 10.0 days (median 5) on grass. Joint (non‐bone)/ligament/cartilage and muscle/tendon injuries to the lower limbs were the most common general categories of injury on artificial turf and grass for both male and female players. Most training injuries were acute (men: artificial turf 2.92, grass 2.63, p = 0.24; women: artificial turf 1.94, grass 2.23, p = 0.21) and resulted from player‐to‐player contact (men: artificial turf 1.08, grass 0.85, p = 0.10; women: artificial turf 0.47, grass 0.56; p = 0.45).
Conclusions
There were no major differences between the incidence, severity, nature or cause of training injuries sustained on new generation artificial turf and on grass by either men or women.
doi:10.1136/bjsm.2007.037275
PMCID: PMC2465252  PMID: 17646247
acute; gradual onset; contact; non‐contact; risk
17.  The effectiveness of neuromuscular warm-up strategies, that require no additional equipment, for preventing lower limb injuries during sports participation: a systematic review 
BMC Medicine  2012;10:75.
Background
Lower limb injuries in sport are increasingly prevalent and responsible for large economic as well as personal burdens. In this review we seek to determine which easily implemented functional neuromuscular warm-up strategies are effective in preventing lower limb injuries during sports participation and in which sporting groups they are effective.
Methods
Seven electronic databases were searched from inception to January 2012 for studies investigating neuromuscular warm-up strategies and injury prevention. The quality of each included study was evaluated using a modified version of the van Tulder scale. Data were extracted from each study and used to calculate the risk of injury following application of each evaluated strategy.
Results
Nine studies were identified including six randomized controlled trials (RCT) and three controlled clinical trials (CCT). Heterogeneity in study design and warm-up strategies prevented pooling of results. Two studies investigated male and female participants, while the remaining seven investigated women only. Risk Ratio (RR) statistics indicated 'The 11+' prevention strategy significantly reduces overall (RR 0.67, confidence interval (CI) 0.54 to 0.84) and overuse (RR 0.45, CI 0.28 to 0.71) lower limb injuries as well as knee (RR 0.48, CI 0.32 to 0.72) injuries among young amateur female footballers. The 'Knee Injury Prevention Program' (KIPP) significantly reduced the risk of noncontact lower limb (RR 0.5, CI 0.33 to 0.76) and overuse (RR 0.44, CI 0.22 to 0.86) injuries in young amateur female football and basketball players. The 'Prevent Injury and Enhance Performance' (PEP) strategy reduces the incidence of anterior cruciate ligament (ACL) injuries (RR 0.18, CI 0.08 to 0.42). The 'HarmoKnee' programme reduces the risk of knee injuries (RR 0.22, CI 0.06 to 0.76) in teenage female footballers. The 'Anterior Knee Pain Prevention Training Programme' (AKP PTP) significantly reduces the incidence of anterior knee pain (RR 0.27, CI 0.14 to 0.54) in military recruits.
Conclusions
Effective implementation of practical neuromuscular warm-up strategies can reduce lower extremity injury incidence in young, amateur, female athletes and male and female military recruits. This is typically a warm-up strategy that includes stretching, strengthening, balance exercises, sports-specific agility drills and landing techniques applied consistently for longer than three consecutive months. In order to optimize these strategies, the mechanisms for their effectiveness require further evaluation.
doi:10.1186/1741-7015-10-75
PMCID: PMC3408383  PMID: 22812375
neuromuscular training; lower limb; injuries; prevention
18.  Risk factors for injuries in elite female soccer players 
Objective
To describe risk factors for injuries in elite female soccer.
Methods
A total of 143 female soccer players from the German national league participated in the study. Baseline information on player characteristics—for example, anthropometric measurements and playing position—and medical history were recorded at the start of the study. During one outdoor season, injuries and training and match exposure times were prospectively documented for each player.
Results
The risk of a new anterior cruciate ligament (ACL) rupture was significantly increased in players with a previous rupture (odds ratio (OR)  =  5.24, p  =  0.01). This was not the case for ankle sprain (OR  =  1.39) or knee sprain (OR  =  1.50). In addition, no significantly increased risk of new sprains or ACL ruptures was found when the injured leg was the unit of analysis. Injury incidence was considerably higher in defenders (9.4 injuries per 1000 hours exposure) and strikers (8.4/1000 hours) than goalkeepers (4.8/1000 hours) and midfielders (4.6/1000 hours). Ten per cent of all players (n  =  14) sustained more than three injuries. Most of these were defenders (n  =  8) or strikers (n  =  4). Significantly more injuries occurred to the dominant leg (105 v 71, p  =  0.01); this was particularly true for contact injuries (52 v 29, p  =  0.01).
Conclusions
Injury risk should be assessed on an individual basis. Therefore it seems appropriate to individualise preventive training programmes, as is recommended for other training content. Evaluating the existing rules of soccer and their appropriate application may also help to decrease injury risk, particularly in contact situations.
doi:10.1136/bjsm.2006.027540
PMCID: PMC2564395  PMID: 16825269
epidemiology; prospective cohort study; women; football; injury risk factors
19.  Neuromuscular Control Training Programs and Noncontact Anterior Cruciate Ligament Injury Rates in Female Athletes: A Numbers-Needed-to-Treat Analysis 
Journal of Athletic Training  2006;41(4):450-456.
Objective: To determine the numbers needed to treat (NNT) and relative risk reduction (RRR) associated with neuromuscular training programs aimed at preventing noncontact anterior cruciate ligament (ACL) injuries in female athletes.
Data Sources: We searched PubMed, MEDLINE, SPORT Discus, CINAHL, and Web of Science from 1966 through 2005 using the terms knee, injury, anterior cruciate ligament, ACL, prevention, plyometric, and neuromuscular training.
Study Selection: Selected articles were from peer-reviewed journals written in English that described original research studies comparing neuromuscular training programs with control programs to determine the number of noncontact ACL injuries per event exposure or hours of playing time. Five studies met the inclusion criteria and were independently rated by 3 reviewers using the Physiotherapy Evidence Database (PEDro) scale. Consensus PEDro scores ranged from 4 to 7 out of 10.
Data Extraction: We used numbers of subjects, ACL injuries, and injury exposure rates to calculate NNT and RRR for each study. The NNT calculations from all studies were based on the number of players across 1 competitive season and were described as NNT benefit or NNT harm.
Data Synthesis: All 5 studies demonstrated a prophylactic effect due to the neuromuscular training programs. The pooled NNT estimates showed that 89 individuals (95% confidence interval: 66 to 136) would need to participate in the prophylactic training program to prevent 1 ACL injury over the course of 1 competitive season. Pooled RRR was 70% (95% confidence interval: 54% to 80%) among individuals who participated in the intervention program. One high-quality randomized control trial and 4 medium-quality prospective cohort studies showed mostly consistent findings. Thus, a Strength of Recommendation Taxonomy level of evidence of 1 with a grade B recommendation supports the use of neuromuscular training programs in the prevention of noncontact ACL injuries in female athletes.
PMCID: PMC1748422  PMID: 17273472
knee injury; balance; plyometrics; injury prevention
20.  The reach and adoption of a coach-led exercise training programme in community football 
Objective
To determine the reach and adoption of a coach-led exercise training programme for lower limb injury prevention.
Design
Secondary analysis of data from a group-clustered randomised controlled trial.
Setting
A periodised exercise training warm-up programme was delivered to players during training sessions over an 8-week preseason (weeks 1–8) and 18-week playing season.
Participants
1564 community Australian football players.
Main outcome measurements
Reach, measured weekly, was the number of players who attended training sessions. Adoption was the number of attending players who completed the programme in full, partially or not at all. Reasons for partial or non-participation were recorded.
Results
In week 1, 599 players entered the programme; 55% attended 1 training session and 45% attended > 1 session. By week 12, 1540 players were recruited but training attendance (reach) decreased to <50%. When players attended training, the majority adopted the full programme—ranging from 96% (week 1) to above 80% until week 20. The most common reasons for low adoption were players being injured, too sore, being late for training or choosing their own warm-up.
Conclusions
The training programme's reach was highest preseason and halved at the playing season's end. However, when players attended training sessions, their adoption was high and remained close to 70% by season end. For sports injury prevention programmes to be fully effective across a season, attention also needs to be given to (1) encouraging players to attend formal training sessions and (2) considering the possibility of some form of programme delivery outside of formal training.
doi:10.1136/bjsports-2012-091797
PMCID: PMC3995237  PMID: 23482922
Implementation; Injury Prevention
21.  Comparison of the incidence, nature and cause of injuries sustained on grass and new generation artificial turf by male and female football players. Part 1: match injuries 
British Journal of Sports Medicine  2007;41(Suppl 1):i20-i26.
Objective
To compare the incidence, nature, severity and cause of match injuries sustained on grass and new generation artificial turf by male and female footballers.
Methods
The National Collegiate Athletic Association Injury Surveillance System was used for a two‐season (August to December) prospective study of American college and university football teams (2005 season: men 52 teams, women 64 teams; 2006 season: men 54 teams, women 72 teams). Injury definitions and recording procedures were compliant with the international consensus statement for epidemiological studies of injuries in football. Athletic trainers recorded details of the playing surface and the location, diagnosis, severity and cause of all match injuries. The number of days lost from training and match play was used to define the severity of an injury. Match exposures (player hours) were recorded on a team basis.
Results
The overall incidence of match injuries for men was 25.43 injuries/1000 player hours on artificial turf and 23.92 on grass (incidence ratio 1.06; p = 0.46) and for women was 19.15 injuries/1000 player hours on artificial turf and 21.79 on grass (incidence ratio = 0.88; p = 0.16). For men, the mean severity of non‐season ending injuries was 7.1 days (median 5) on artificial turf and 8.4 days (median 5) on grass and, for women, 11.2 days (median 5) on artificial turf and 8.9 days (median 5) on grass. Joint (non‐bone)/ligament/cartilage and contusion injuries to the lower limbs were the most common general categories of match injury on artificial turf and grass for both male and female players. Most injuries were acute (men: artificial turf 24.60, grass 22.91; p = 0.40; women: artificial turf 18.29, grass 20.64; p = 0.21) and resulted from player‐to‐player contact (men: artificial turf 14.73, grass 13.34; p = 0.37; women: artificial turf 10.72; grass 11.68; p = 0.50).
Conclusions
There were no major differences in the incidence, severity, nature or cause of match injuries sustained on new generation artificial turf and grass by either male or female players.
doi:10.1136/bjsm.2007.037267
PMCID: PMC2465254  PMID: 17646246
acute; gradual onset; contact; non‐contact; risk
22.  A prospective epidemiological study of injuries in four English professional football clubs 
OBJECTIVE: To define the causes of injuries to players in English professional football during competition and training. METHOD: Lost time injuries to professional and youth players were prospectively recorded by physiotherapists at four English League clubs over the period 1994 to 1997. Data recorded included information related to the injury, date and place of occurrence, type of activity, and extrinsic Playing factors. RESULTS: In all, 67% of all injuries occurred during competition. The overall injury frequency rate (IFR) was 8.5 injuries/1000 hours, with the IFR during competitions (27.7) being significantly (p < 0.01) higher than that during training (3.5). The IFRs for youth players were found to increase over the second half of the season, whereas they decreased for professional players. There were no significant differences in IFRs for professional and youth players during training. There were significantly (p < 0.01) injuries in competition in the 15 minute periods at the end of each half. Strains (41%), sprains (20%), and contusions (20%) represented the major types of injury. The thigh (23%), the ankle (17%), knee (14%), and lower leg (13%) represented the major locations of injury, with significantly (p < 0.01) more injuries to the dominant body side. Reinjury counted for 22% of all injuries. Only 12% of all injuries were caused by a breach of the rules of football, although player to player contact was involved in 41% of all injuries. CONCLUSIONS: The overall level of injury to professional footballers has been showed to be around 1000 times higher times higher than for industrial occupations generally regarded as high risk. The high level of muscle strains, in particular, indicates possible weakness in fitness training programmes and use of warming up and cooling down procedures by clubs and the need for benchmarking players' levels of fitness and performance. Increasing levels of injury to youth players as a season progresses emphasizes the importance of controlling the exposure of young players to high levels of competition. 



PMCID: PMC1756169  PMID: 10378073
23.  Balance Training Exercises Decrease Lower-Limb Strength Asymmetry in Young Tennis Players 
The issue of functional asymmetries in the lower-limbs has been the subject of numerous recent investigations concerning many different contact, limited-contact and non-contact sports. The presence of strength asymmetries in the lower-limbs of young athletes practicing various sporting disciplines is considered an intrinsic risk factor for injury; in such cases, compensation strategies should thus be implemented aimed at eliminating, or at least limiting, the degree of asymmetry in order to avoid the negative consequences asymmetries can have upon the health of young sportsmen and women on the long-term. The aim of the present study was to examine the presence of functional asymmetries in the lower-limbs of young tennis players in strength and speed drill performance and to test a specific balance-training programme in its capacity to effectively reduce such asymmetries. Twenty-three young tennis players were randomly assigned to the Experimental Group (EG) (n = 11: 4 females, 7 males; 13.2 ± 0.9 years; 50.8 ± 8.9 Kg; 1.63 ± 0.08 m) or Comparison Group (CG) (n = 12: 4 females, 8 males; 13.0 ± 0.9 years; 51.1 ± 9.2 Kg; 1.61 ± 0.09 m). To quantify percent asymmetries in lower-limb strength before (T0) and following (T1) training, performances were assessed in the one-leg hop test (OLH), side-hop test (SH) and side steps and forward 4.115-m test (4m-SSF). Performances in the 10 and 20m sprint tests and the Foran test were also assessed. The EG completed a total of 12 training sessions directed at balance training: two 30-minute sessions/week over a 6-week period. The CG followed an identical training schedule, but training sessions consisted of tennis-specific drills only. The results reveal significant differences between pre- and post-training tests in the EG only: the degree of lower-limb asymmetry was decreased in the EG following completion of the training programme, as assessed using the OLH test (p < 0.001), SH test (p < 0.001) and 4m-SSF test (p < 0.05). A significant interaction and main effect of training was also observed in the EG: balance training led to a significant reduction in the percent of asymmetry in lower-limb strength, as measured using the SH (p < 0.01), 4m-SSF (p < 0.01) and OLH (p < 0.05) tests. These results confirm that balance training exercises are able to counteract/reduce the degree of asymmetry in lower-limb strength in young tennis players.
Key pointsThe determination of functional asymmetries in the lower-limbs has been the subject of numerous recent investigations aimed at the prevention of injuries in many different contact, limited-contact and non-contact sports.Sport-specific movements in tennis impose different loads upon the two lower-limbs and can cause the development of lower-limb strength asymmetries in young tennis players.The planning of athletic conditioning in young tennis players requires that strength in the lower-limbs is evaluated such that appropriate injury prevention strategies may be inserted into training programmes.Balance training exercises, and indeed all tasks performed on unstable surfaces, lead to benefits in sport-specific performance.
PMCID: PMC3990896  PMID: 24790496
Strength asymmetry; risk of injury; speed; lateral/side movements
24.  Differential neuromuscular training effects onACL injury risk factors in"high-risk" versus "low-risk" athletes 
Background
Neuromuscular training may reduce risk factors that contribute to ACL injury incidence in female athletes. Multi-component, ACL injury prevention training programs can be time and labor intensive, which may ultimately limit training program utilization or compliance. The purpose of this study was to determine the effect of neuromuscular training on those classified as "high-risk" compared to those classified as "low-risk." The hypothesis was that high-risk athletes would decrease knee abduction moments while low-risk and control athletes would not show measurable changes.
Methods
Eighteen high school female athletes participated in neuromuscular training 3×/week over a 7-week period. Knee kinematics and kinetics were measured during a drop vertical jump (DVJ) test at pre/post training. External knee abduction moments were calculated using inverse dynamics. Logistic regression indicated maximal sensitivity and specificity for prediction of ACL injury risk using external knee abduction (25.25 Nm cutoff) during a DVJ. Based on these data, 12 study subjects (and 4 controls) were grouped into the high-risk (knee abduction moment >25.25 Nm) and 6 subjects (and 7 controls) were grouped into the low-risk (knee abduction <25.25 Nm) categories using mean right and left leg knee abduction moments. A mixed design repeated measures ANOVA was used to determine differences between athletes categorized as high or low-risk.
Results
Athletes classified as high-risk decreased their knee abduction moments by 13% following training (Dominant pre: 39.9 ± 15.8 Nm to 34.6 ± 9.6 Nm; Non-dominant pre: 37.1 ± 9.2 to 32.4 ± 10.7 Nm; p = 0.033 training X risk factor interaction). Athletes grouped into the low-risk category did not change their abduction moments following training (p > 0.05). Control subjects classified as either high or low-risk also did not significantly change from pre to post-testing.
Conclusion
These results indicate that "high-risk" female athletes decreased the magnitude of the previously identified risk factor to ACL injury following neuromuscular training. However, the mean values for the high-risk subjects were not reduced to levels similar to low-risk group following training. Targeting female athletes who demonstrate high-risk knee abduction loads during dynamic tasks may improve efficacy of neuromuscular training. Yet, increased training volume or more specific techniques may be necessary for high-risk athletes to substantially decrease ACL injury risk.
doi:10.1186/1471-2474-8-39
PMCID: PMC1871588  PMID: 17488502
25.  The Football Association Medical Research Programme: an audit of injuries in professional football—analysis of preseason injuries 
Objectives: To conduct a detailed analysis of preseason football injuries sustained in English professional football over two competitive seasons.
Methods: Club medical staff at 91 professional football clubs annotated player injuries. A specific injury audit questionnaire was used together with a weekly form that documented each club's current injury status.
Results: 17% (1025) of the total number of injuries over the two seasons were sustained during the preseason, the mean number of days absent per injury was 22.3 days. Younger age groups (17–25 yrs) were more likely to sustain a preseason injury than more experienced players (26–35+) (p<0.01). There were relatively more "slight" and "minor" injuries (as defined in the methodology), overuse, and tendon related injuries sustained during preseason compared to the in season (p<0.01). The thigh (23%), knee (17%), and ankle (17%) were the most common locations for injuries during the preseason, there was a relatively greater number of lower leg injuries (15%) during the preseason (p<0.05). Achilles tendonitis was most prevalent in the preseason, with 33% of all Achilles related injuries sustained during this period (p<0.01). Muscle strains were the most common injury during preseason (37%). Rectus femoris muscle strains were observed twice as frequently during the preseason relative to the in season (p<0.01). Ligament sprains were the second most common injury during preseason (19%). Non-contact mechanisms were the cause of significantly more injuries during the preseason (p<0.01), with relatively more preseason injuries sustained while running or shooting (p<0.01). For 70% of the injuries reported during the preseason, the ground condition was described as dry.
Conclusions: Players are at a greater risk of slight and minor injuries, overuse injuries, lower leg injuries (especially the Achilles tendon) and rectus femoris strains during the preseason period. Prevention of preseason injury is important to ensure availability of players for the commencement of the season and to decrease the risk of injury later in the season, we recommend the implementation of a risk management policy for this purpose. Areas requiring further investigation include methods of prevention for the common preseason injuries that have been identified, a detailed analysis of preseason and closed season training programmes, and a smaller study involving exposure data.
doi:10.1136/bjsm.36.6.436
PMCID: PMC1724575  PMID: 12453838

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