Superior compliance with a neuromuscular training programme is associated with fewer ACL injuries and fewer acute knee injuries in female adolescent football players: secondary analysis of an RCT

Independent data collectors decrease bias in the measurement of adherence to anterior cruciate ligament injury prevention programs

OBJECTIVES

Studies on adherence to neuromuscular training (NMT) for anterior cruciate ligament (ACL) injury prevention are frequently biased due to the use of self-reporting by coaches or the athletes themselves. Few NMT studies use data collectors (aside from the athletes or the individuals administering the NMT program) to decrease bias when assessing the adherence of coaches and sports teams. We hypothesized that the use of a data collector who is independent of the team to evaluate adherence to NMT programs would be reliable.

METHODS

In a prior a cluster-randomized controlled trial evaluating adherence to NMT training trial, twelve boys' and nine girls' high school athletic teams in a variety of sports were enrolled. Eight data collectors (unaffiliated with the NMT program) were hired specifically to record adherence of the athletes to the NMT exercises at each team's warm-ups 2-3 times a week, prior to practices and games. In addition to the data collectors, a control group of independent observers made visits throughout the season to also record adherence (solely for the purpose of this study, alongside the data collectors and in the same fashion) in order to evaluate the data collectors' performance and determine inter-observer reliability. The inter-observer reliability between data collectors and independent observers was measured using the Kappa statistic.

RESULTS

A total of 399 warm-ups for practices or games were observed by data collectors to obtain adherence data. Independent observers also measured adherence at 58 practices or games for inter-observer reliability. Exercise instruction and alignment cues for 29 different exercises were analysed. The Kappa values ranged from 0.63 to 1.0, indicating substantial to perfect agreement. The overall Kappa values of 0.89 and 0.90 for exercise instruction and alignment cues, respectively, indicated almost perfect agreement.

CONCLUSION

The use of a data collector who is independent of the team to evaluate adherence to NMT programs (rather than athlete or coach self-reporting), was shown to be a reliable method for measurement of adherence in studies of NMT for injury prevention. Avoiding self-reporting in adherence research to NMT training may decrease bias.

LEVEL OF EVIDENCE

I.

Best practices for the dissemination and implementation of neuromuscular training injury prevention warm-ups in youth team sport: a systematic review

OBJECTIVE

To evaluate best practices for neuromuscular training (NMT) injury prevention warm-up programme dissemination and implementation (D&I) in youth team sports, including characteristics, contextual predictors and D&I strategy effectiveness.

DESIGN

Systematic review.

DATA SOURCES

Seven databases were searched.

ELIGIBILITY

The literature search followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

INCLUSION CRITERIA

participation in a team sport, ≥70% youth participants (<19 years), D&I outcomes with/without NMT-related D&I strategies. The risk of bias was assessed using the Downs & Black checklist.

RESULTS

Of 8334 identified papers, 68 were included. Sport participants included boys, girls and coaches. Top sports were soccer, basketball and rugby. Study designs included randomised controlled trials (RCTs) (29.4%), cross-sectional (23.5%) and quasi-experimental studies (13.2%). The median Downs & Black score was 14/33. Injury prevention effectiveness (vs efficacy) was rarely (8.3%) prioritised across the RCTs evaluating NMT programmes. Two RCTs (2.9%) used Type 2/3 hybrid approaches to investigate D&I strategies. 19 studies (31.6%) used D&I frameworks/models. Top barriers were time restrictions, lack of buy-in/support and limited benefit awareness. Top facilitators were comprehensive workshops and resource accessibility. Common D&I strategies included Workshops with supplementary Resources (WR; n=24) and Workshops with Resources plus in-season Personnel support (WRP; n=14). WR (70%) and WRP (64%) were similar in potential D&I effect. WR and WRP had similar injury reduction (36-72%) with higher adherence showing greater effectiveness.

CONCLUSIONS

Workshops including supplementary resources supported the success of NMT programme implementation, however, few studies examined effectiveness. High-quality D&I studies are needed to optimise the translation of NMT programmes into routine practice in youth sport.

Extrinsic Risk Factors for Primary Noncontact Anterior Cruciate Ligament Injury in Adolescents Aged between 14 and 18 years: A Systematic Review

BACKGROUND

Adolescents present a high incidence of ACL injury compared with other age groups. Examining the risk factors that predispose adolescents to primary noncontact ACL injury is a key strategy to decrease the number of injuries in this population.

OBJECTIVE

The aim of this systematic review was to summarise the existing literature investigating extrinsic risk factors that have been linked with primary noncontact ACL injury risk (identified either using ACL injury occurrence or using screening tests measuring biomechanical mechanisms for noncontact ACL injury) in adolescents including research investigating: (1) the association between extrinsic risk factors and primary noncontact ACL injury risk; and (2) whether primary noncontact ACL injury risk was different in populations or groups exposed to different extrinsic risk factors in adolescents.

METHODS

The same search strategy was used in MEDLINE, SPORTDiscus, CINAHL, PubMed and Embase. Articles were included if: written in English; published in peer-reviewed journals; investigating and discussing primary noncontact ACL injury risk associated with extrinsic risk factors; they were original research articles with an observational design; and participants presented a mean age ranging between 14 and 18 years. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies (QATOCCS) was used to assess the quality and risk of bias of the articles included in this systematic review.

RESULTS

The systematic review included 16 eligible articles published up to August 2022 about extrinsic risk factors for primary noncontact ACL injury including: sport (8 studies); sport exposure amount (5); sport level (3); sport season (1); environment (2); equipment (1). Differences in biomechanical risk factors predisposing to ACL injury were reported by sport in female adolescents playing basketball and soccer; however, no good evidence of differences in primary noncontact ACL injury rate by sport was reported in both male and female adolescents. There was contrasting evidence about associations between sport exposure and biomechanical and neuromuscular risk factors predisposing to ACL injury or primary noncontact ACL injury rate in both male and female adolescent players from different sports. There was weak evidence of differences in biomechanical risk factors predisposing to ACL injury by environmental condition in both male and female adolescents playing soccer and season phase in male adolescents playing basketball. Lastly, few good-quality articles suggested that higher sport level might be associated with increased primary noncontact ACL injury rate in female adolescents playing basketball and floorball and that bracing might not prevent primary noncontact ACL injuries in both male and female adolescent players from different sports.

DISCUSSION

The findings emphasise the need for further research to clarify the evidence about extrinsic risk factors and primary noncontact ACL injury in adolescents to develop ACL injury prevention guidelines that would help practitioners and researchers identify adolescents at risk and design future interventions. Future epidemiological studies should collect data about extrinsic factors as well as data about primary noncontact injury separately from secondary injuries or contact injuries to better inform primary noncontact ACL injury prevention in adolescents.

REGISTRATION

https://doi.org/10.17605/OSF.IO/VM82F (11/08/2021).

Team Approach: Neuromuscular Training for Primary and Secondary Prevention of Anterior Cruciate Ligament Injury

Neuromuscular training is a method of performance optimization-typically combining plyometrics, balancing training, agility, and dynamic stabilization-predicated on improving the efficiency of fundamental movement patterns. Neuromuscular training has consistently been shown to reduce the risk of anterior cruciate ligament injury, particularly for athletes engaged in activities associated with noncontact knee injuries (i.e., women's soccer). Successful implementation of neuromuscular training programs requires input from coaches, physical therapists, athletic trainers, and physicians to generate efficacious programs with high rates of adherence.

Effectiveness of a specific strength program of the gluteus maximus muscle to improve dynamic postural control in female basketball players. A randomized controlled trial

BACKGROUND

Basketball is a team sport in which players perform multidirectional movements, jumps and landings, experiencing abrupt accelerations and decelerations and numerous changes of rhythm. In this sport, speed and intensity are two key factors that are associated with an increased risk of injury. The aim of this randomized controlled trial was to determine the effectiveness of a specific gluteus maximus strength programme as preventive work for young female basketball players, to improve dynamic postural stability and to observe its impact in the rate of lower limb injuries, vertical jump, dynamic knee valgus and pain.

RESEARCH QUESTION

Is effective a strength programme to improve dynamic postural stability, vertical jump and dynamic valgus in female basketball players?

METHODS

A hundred and thirteen female basketball players that play in professional clubs were recruited, reaching the final stage 92 (46 per group). One group (CG) received conventional injury prevention training while the experimental group (EG) added to the conventional team prevention program, a gluteus maximus strength programme of 5 months composed of 4 exercises/2 days per week/2 sets of 10 repetitions per leg.

RESULTS

The total injury incidence decreased from 0.33 to 0.16 cases (control group pre=0.43 to post=0.14 cases, EG pre=022 to post=0.19). The EG improved overall (p = 0.000), posterior (p = 0.001), posteromedial (p = 0.001) and posterolateral (p = 0.000) dynamic stability of the right leg; anterior (p = 0.024), medial (p = 0.07) and posteromedial (p = 0.01) of the left leg. Both groups improved vertical jump (GC: p = 0.045 and GE: p = 0.000). There was no significant improvement in pain or valgus.

SIGNIFICANCE

This strength programme is effective in improving dynamic stability especially of the dominant leg and jump height.

Implementation of the injury prevention exercise programme Knee Control+: a cross-sectional study after dissemination efforts within a football district

BACKGROUND

The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework can be used for evaluation of implementation initiatives in sports injury prevention. The aim was to evaluate the implementation of the injury prevention exercise programme Knee Control+ among amateur clubs and coaches in one regional football district using all five dimensions of the RE-AIM framework.

METHODS

Dissemination of Knee Control+ during the 2021 season with information and webinars within one regional football district. This was followed by a cross-sectional study with questionnaires to club personnel and coaches after the season.

RESULTS

The reach of Knee Control+ was fair to high, 83% of club personnel and 66% of coaches knew about the programme. 41% of club personnel and 51% of coaches had adopted it. Perceived programme effectiveness was high (6 on a 1-7 Likert scale) among coaches. Regarding implementation and maintenance, 27% of club personnel had informed coaches about Knee Control+ and 57% planned to inform coaches. The coaches had implemented the programme mainly as recommended, but half used the programme once per week or less. Intention to maintain use of the programme was high (7 on a 1-7 Likert scale) among coaches.

CONCLUSION

The reach of Knee Control+ was fair to high, and adoption was fair in clubs, but there was a lack of policies for preventive training. Active strategies probably need to accompany dissemination of programme material. Reach, perceived effectiveness, adoption, implementation and planned maintenance were positive among coaches, but further studies are needed to analyse long-term maintenance.

High Compliance with the 11+ Injury Prevention Program Results in Better Win-Loss Records

Background

The 11+ injury prevention program (IPP) has been shown to decrease injury rates. However, few studies have investigated compliance and its overall relationship to team performance.

Hypothesis/Purpose

To examine if level of compliance while implementing the 11+ would impact team performance outcomes (wins, losses and ties). The authors hypothesized that higher team compliance to the IPP would be consistent with improved overall team performance (more wins and fewer losses).

Study Design

Prospective, cluster randomized controlled trial.

Methods

This study was conducted in NCAA men's soccer teams for one season and examined the efficacy of the 11+ IPP. The outcome variables examined were levels of compliance and team performance record: wins, losses, and ties. Twenty-seven teams (n=675 players) served as the intervention group (IG) and used the 11+ program while 34 teams (n=850 players) served as the control group (CG). Compliance and team performance were recorded. There were three compliance categories that were defined prospectively, low (LC, < 1 dose/week), moderate (MC, >1 and <2 doses/week), and high (HC, >2 doses/week). Descriptive and inferential tests were used to compare the CG, the IG, and compliance to team performance. Three independent t-tests were used to analyze outcome to group (IG vs. CG). A one way-MANOVA test was used to analyze compliance to win/loss/tie record, followed up by one-way ANOVA tests to analyze how compliance impacted wins, losses and ties, independently. Partial η2 measures were calculated to determine the effect size of level of compliance on outcome. A Tukey post-hoc analysis was used to analyze specific differences between levels of compliance and specific outcome measures.

Results

There were significantly more wins (IG: 10.67±2.63 versus CG: 8.15±3.83, CI, 7.95 - 9.69, p = 0.005) and fewer losses (IG: 5.56±1.97 versus CG: 8.12±3.59, CI, 5.66 to 7.43, p = 0.002) recorded for the teams using the 11+ program. There was a statistically significant difference between levels of compliance (high, moderate or low) on the dependent variables (wins, losses, and ties), F(3, 22) = 3.780, p =0.004; Wilks' Λ = .435; partial η2 = .340.

Conclusion

The 11+ has the capacity to improve overall team performance in male collegiate soccer teams. The higher the compliance, the more favorable the team performance. This research may be a vital addition when attempting to persuade coaching staffs to adopt an IPP into their training regimen.

Level of Evidence

Level I.

Evaluating the impact of injury prevention interventions in child and adolescent sports using the RE-AIM framework and CERT: A systematic review

BACKGROUND

Participation in sport is a popular pastime for children and adolescents that improves their physical health, mental health and motor skills. Musculoskeletal injuries are a relatively common downside of sports participation and can have negative long-term consequences. Injury prevention programmes have demonstrated effectiveness in child and adolescent sports, provided compliance is adequate. However, little is known about the factors which relate to their impact on the wider community and whether the prevention programmes have been adopted and maintained in the long-term. The objective of this review was to assess the current literature on exercise-based injury prevention interventions in child and adolescent sports (aged under 19 years) against the 'Reach', 'Effectiveness', 'Adoption', 'Implementation', 'Maintenance' (RE-AIM) framework and Consensus of Exercise Reporting Template (CERT), to ascertain level of reporting for the components which relate to external validity.

METHODS

Seven electronic databases; PubMed, Medline, SPORTDiscus, PsycINFO, CINAHL, Scopus and The Cochrane Library, were searched from date of inception to July 2022 using the themes of: 'Child and Adolescent', 'Sport', 'Injury' and 'Prevention'. Eligibility criteria included: Experimental trial design, exercise-based intervention programmes, primary outcome of injury incidence and participants aged under 19 years. Two reviewers assessed each trial independently against the RE-AIM model dimension items checklist (RE-AIM MDIC) and Consensus on Exercise Reporting Template (CERT) before reaching a consensus on reporting.

RESULTS

Forty-five unique trials met the eligibility criteria. Mean reporting level for all studies across the whole RE-AIM MDIC was 31% (SD ± 16.2%, Range 7-77%). The domain of 'effectiveness' was the most comprehensively reported (60%), followed by 'implementation' (48%), 'reach' (38%), 'adoption' (26%) and 'maintenance' (7%). The mean reporting score for the CERT was 50% (SD ± 20.8, range 0-81%).

CONCLUSION

Published data on injury prevention in child and adolescent sports is highly focussed on the effectiveness of the intervention, with little consideration given to how it will be adopted and maintained in the long-term. This has led to considerable gaps in knowledge regarding optimal programme implementation, with a lack of data on adoption and maintenance contributing to the gap between research and practice. Future research needs to place greater focus on external validity and consider incorporating the study of implementation and feasibility as part of effectiveness trial design. This approach should provide the data that will help narrow the considerable gap between science and practice.

TRIAL REGISTRATION

PROSPERO Registration number CRD42021272847.

Adherence to Injury Prevention Exercise Programmes in Amateur Adolescent and Adult Football: A Detailed Description of Programme Use from a Randomised Study

BACKGROUND

Injury prevention exercise programmes (IPEPs) efficaciously reduce injuries. However, it is challenging to achieve sufficient adherence across a season. The main aim was to describe adherence to IPEPs in three groups of coaches and players partaking in a cluster randomised trial. Secondary aims were to describe perceptions of IPEPs, use of programme material, and overall preventive strategies.

METHODS

This is a sub-study analysing data from a three-armed randomised trial with teams randomised to use either a comprehensive IPEP (extended Knee Control) or an adductor strength programme, and non-randomised teams that already used a self-chosen IPEP regularly at study start (comparison group). Teams were instructed to use their respective intervention across the 2020 football season. Male and female, adolescent (≥ 14 years of age), and adult amateur players took part. Coaches and players responded to weekly and end-of-season questionnaires. Data were presented descriptively.

RESULTS

Weekly player data were reported by 502 players (weekly response rate 65%), 289 (58%) responded to end-of-season questionnaires. Teams in the extended Knee Control and comparison group used their respective IPEP in 483/529 (91%) and 585/641 (91%) of training sessions, and teams in the adductor group in in 199/315 (63%) sessions. Regarding utilisation fidelity, 42-52% of players in each group used 1-10 repetitions per exercise. Seven out of 17 teams in the adductor group had progressed as recommended in terms of number of repetitions. Two teams (10%) in the extended Knee Control group, and 7/24 of comparison teams used the same exercises across the season. Coaches accessed the IPEPs by different means (printed material, films, workshops, etc.), but half did not use the provided digital material. The players appreciated that the IPEPs could reduce injury risk and that they improved their exercise performance, but disliked that they had less time for football and that the exercises were boring. Forty-nine players had experienced pain during IPEP performance.

CONCLUSIONS

Adherence with the IPEPs was generally high. To meet different coach needs, programme material should be available via different digital and printed resources. The number of players reporting pain during IPEP performance is a noteworthy finding.

TRIAL REGISTRATION

Clinical Trials gov identifier: NCT04272047. Registered February 17, 2020. https://clinicaltrials.gov/ct2/show/NCT04272047 .

A systematic review of the evidence for effectiveness of interventions to address transport and other unintentional injuries among adolescents

INTRODUCTION

Globally, injuries are a leading cause of mortality and morbidity for adolescents, which disproportionately affect the disadvantaged. To build an investment case for adolescent injury prevention, evidence is needed as to effective interventions.

METHODS

A systematic review of peer-reviewed original research published between 2010-2022 was conducted. CINAHL, Cochrane Central, Embase, Medline and PsycINFO databases were searched for studies reporting the effectiveness of unintentional injury prevention interventions for adolescents (10-24 years), with assessment of study quality and equity (e.g., age, gender, ethnicity, socio-economic status).

RESULTS

Sixty-two studies were included; 59 (95.2%) from high-income countries (HIC). Thirty-eight studies (61.3%) reported no aspect of equity. Thirty-six studies (58.1%) reported prevention of sports injuries (commonly neuromuscular training often focused on soccer-related injuries, rule changes and protective equipment). Twenty-one studies (33.9%) reported prevention of road traffic injury, with legislative approaches, commonly graduated driver licensing schemes, found to be effective in reducing fatal and nonfatal road traffic injury. Seven studies reported interventions for other unintentional injuries (e.g., falls).

DISCUSSION

Interventions were strongly biased towards HIC, which does not reflect the global distribution of adolescent injury burden. Low consideration of equity in included studies indicates current evidence largely excludes adolescent populations at increased risk of injury. A large proportion of studies evaluated interventions to prevent sports injury, a prevalent yet low severity injury mechanism. Findings highlight the importance of education and enforcement alongside legislative approaches for preventing adolescent transport injuries. Despite drowning being a leading cause of injury-related harm among adolescents, no interventions were identified.

CONCLUSION

This review provides evidence to support investment in effective adolescent injury prevention interventions. Further evidence of effectiveness is needed, especially for low- and middle-income countries, populations at increased risk of injury who would benefit from greater consideration of equity and for high lethality injury mechanisms like drowning.

Perceptions, facilitators, and barriers regarding use of the injury prevention exercise programme Knee Control among players and coaches in youth floorball: a cross-sectional survey study

BACKGROUND

Youth participation in team ball sports is associated with a risk of both acute and gradual onset injuries but today there are several efficacious injury prevention exercise programmes (IPEPs). However, there is limited research about how to implement those programmes and the perceived barriers and facilitators among end-users.

OBJECTIVE

To investigate perceptions of the IPEP Knee Control and facilitators and barriers to programme use among coaches and youth floorball players, and explore factors associated with planned maintenance of Knee Control.

METHODS

This cross-sectional study is a sub-analysis of data from the intervention group of a cluster randomised controlled trial. Perceptions about Knee Control and facilitators and barriers to programme use were evaluated with surveys pre-intervention and post-season. 246 youth floorball players aged 12-17 years, and 35 coaches that reported no use of IPEPs during the preceding year were included. Descriptive statistics and univariate and multivariate ordinal logistic regression models were undertaken with the dependent variables: coaches' planned maintenance and players' opinions of maintenance of Knee Control. Independent variables were perceptions, facilitators and barriers regarding use of Knee Control and other potential influencing factors.

RESULTS

88% of the players believed that Knee Control can reduce injury risk. Common facilitators to Knee Control use among coaches were support, education and high player motivation, and common barriers were that injury prevention training was time-consuming, lack of space to execute the exercises and lack of player motivation. Players who planned to maintain use of Knee Control had higher outcome expectancies and belief in one's ability to use Knee Control (action self-efficacy). Coaches who planned to maintain Knee Control had higher action self-efficacy and to a lesser extent considered that Knee Control takes too much time.

CONCLUSIONS

Support, education, and high player motivation are key facilitators, while lack of time and space for injury prevention training and boring exercises are key barriers for coaches and players to use Knee Control. High action self-efficacy among coaches and players seems to be a prerequisite for maintained use of IPEPs.

Creating Prep to Play PRO for women playing elite Australian football: A how-to guide for developing injury-prevention programs

BACKGROUND

Developing context-specific, evidence-informed, and implementable injury-prevention programs is challenging. Women playing in the elite Australian Football League for Women are at high risk of serious knee injuries, and no specific injury-prevention program exists. The objective of the study was to describe the collaborative process used to create a context-specific injury-prevention program.

METHODS

A previously used intervention-development process was modified to incorporate a partnership with the sport's governing organization and focus on engaging program implementers. The Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) Sports Setting Matrix guided program development and implementation strategies.

RESULTS

The 7-step process, aligned with the RE-AIM Sports Setting Matrix, was applied to develop the injury-prevention program and was titled Prep to Play PRO. The steps were: (Step 1) gaining organizational support and establishing a project partnership; (Step 2) using research evidence and clinical experience; (Step 3) consulting content and context experts; (Step 4) engaging the organization, experts, program implementers, and end-users to concreate the intervention and develop implementation strategies; (Step 5) testing the intervention acceptability and feasibility; (Step 6) evaluating the intervention and implementation strategies against theory; and (Step 7) obtaining feedback from early implementers and end-users.

CONCLUSION

Engaging critical stakeholders at multiple ecological levels (organization, team, and athlete) throughout program development and implementation planning support real-world use. The processes and activities described can guide future sports injury-prevention program development and implementation.

Injury prevention programs including balance exercises with compliance and follow-up reduce the incidence of knee injuries in athletes: A systematic review and meta-analysis

BACKGROUND: The knee is one of the most common injuries in sports. However, the incidence of knee injuries can be decreased by enhancing balance and neuromuscular control. OBJECTIVE: The aim of this systematic review and meta-analysis was to investigate how injury prevention programs (IPPs) that include balance training influence knee injury rates in athletes. METHODS: Data were obtained from different databases (1985–2021). Only randomised controlled trials that used IPPs that include balance training, were considered. Two investigators extracted data from the qualifying documents. The critical outcome data elements derived from the included studies were the number of ACL/knee injuries, ACL/knee injury rates, exposure hours, compliance rate, and follow-up duration. RESULTS: Compared to the control groups, those who participated in the IPP had a 54% lower risk of knee injuries per 1000 hours of exposure (IRR 0.457 (95% CI 0.346–0.603), P= 0.001) and a 60% lower risk of ACL injuries per 1000 hours of exposure (IRR 0.401 (95% CI 0.215–0.750), P= 0.004). CONCLUSIONS: IPPs that include balance training may reduce the risk of knee injuries.

Higher Adherence to Anterior Cruciate Ligament Injury Prevention Programs Is Associated With Lower Injury Rates: A Meta-Analysis and Meta-Regression

Background: Athletes who participate in sports that involve cutting and pivoting movements are particularly susceptible to anterior cruciate ligament (ACL) injury. Preventing this injury is the best way to combat its health consequences and costs. There may be a dose-response relationship between adherence and injury reduction. Purpose: We sought to examine whether athletes’ adherence to injury prevention programs (IPPs) is associated with reductions in ACL and lower extremity (LE) injuries. Methods: We conducted a systematic review of the PubMed, EMBASE, and Cochrane Library databases, searching for studies published between 2011 and 2021. Studies were included if they reported on the use of an ACL IPP compared with a control group and recorded the rate of injuries to calculate a rate ratio, as well as adherence to the program as a percentage of sessions performed. For the meta-analysis, the rate ratios were pooled using the DerSimonian-Laird random-effects model. Results: For the 15 studies included (11 randomized controlled trials and 4 cohort studies), the random-effects model grouped athletes’ adherence to an IPP as high (76% or more of the sessions), moderate (51%–75% of the sessions), and low (50% or fewer of the sessions). We found that athletes with the highest level of IPP adherence had a significantly lower incidence of ACL injury. The rate ratios for moderate and low adherence did not demonstrate a reduced incidence of ACL injury. Injury prevention program participation was also associated with a decrease in LE injury rates. Conclusion: This systematic review and meta-analysis found that athletes with high adherence to IPPs had reduced rates of ACL and LE injuries. Our findings suggest that educating coaches and athletes on the dose-dependent benefits of IPPs may promote the routine incorporation of these programs into warm-up sessions to decrease the risk of ACL and LE injuries.

The perception of injury risk and prevention among football players: A systematic review

Football is associated with a certain risk of injury, leading to short- and long-term health consequences. However, the perception of football players about injury risk and prevention strategies is poorly documented. The present article reviewed the literature about perceptions, beliefs, attitudes and knowledge toward injury risk and prevention strategies in football players. An electronic search was performed in PubMed, Scopus, Web of Science, and APA PsychINFO until July 2022. Studies were eligible if they included the perceptions, beliefs, attitudes, and knowledge about injury risk and prevention in football players from any competitive level. The risk of bias was assessed in included studies using the Joanna Briggs Institute critical appraisal checklist. A total of 14 studies were included. Most football players agreed that their risk of injury is high and prevention strategies are important, however they do not intend to use some of these strategies. The most frequent perceived injury risk factors were low muscle strength, lack of physical fitness, fatigue, excessive training and type and condition of surfaces. The most frequent perceived injury prevention factors were warm-up, workload monitoring and strength and conditioning training. It is essential to acknowledge perceived injury risk factors, as well as a better understanding of how coaching and medical departments' perceptions match with players' perceptions, and a modification in the perceptions of the several stakeholders at different levels of action.

Understanding Youth Athlete Motivation, Training, and Activity Progression During and After the COVID-19 Sports Interruption

Background

COVID-19 restrictions created a period of disrupted sports participation for youth athletes. The physical conditioning, sports training habits, and patterns of sports activity resumption upon returning to normal sports activity are currently unknown.

Purpose/Hypothesis

This study aimed to determine the extent to which youth athletes maintained their training levels during the early stages of the COVID-19 pandemic and understand the strategies that enhanced motivation and adherence to a training regimen while in isolation. A secondary aim was to analyze how youth athletes returned to activity and identify injuries associated with prolonged sports interruption.

Study Design

Observational / Survey Study.

Methods

A survey designed to determine activity changes, type of organized instruction, and athlete preferences for training support were distributed by email using snowball sampling methodology to athletes 14-21 years old who were involved in competitive sports when pandemic restrictions were enacted. As sports activities resumed, a follow-up survey was distributed to the same respondents to identify feelings of preparedness, training habits, and injuries.

Results

Of the155 subjects (mean age 16.1 ± 2 years, 64.5% female) that completed the initial survey, 98% reported a stoppage of in-person sports participation and 70% decreased their exercise/training volume, with 41% (n=63) reporting > 50% reduction. Most athletes (86%) received instruction from coaches, with written workouts (70%) being most common; however, most athletes (70%) preferred instructor-led, group training sessions. Of the 43 subjects that completed the follow-up survey (34% response rate), there was an increase in athletic exposures compared to mid-pandemic levels, and 25% reported sustaining a sports-related injury shortly after resuming sports activities.

Conclusions

Pandemic-related sports restrictions resulted in a significant reduction in youth athlete training and conditioning. Coaches attempted to maintain training via the use of written workouts; however, athletes preferred instructor-led, group training sessions. There was a rapid resumption of sports activities, which may have contributed to the high rate of injuries in this study.

Level of Evidence

3.

The Effect of Shoulder and Knee Exercise Programmes on the Risk of Shoulder and Knee Injuries in Adolescent Elite Handball Players: A Three-Armed Cluster Randomised Controlled Trial

Background

The risk of injury in adolescent handball is high, and shoulder and knee injuries are among the most frequent and burdensome. The Swedish Knee Control programme reduced the risk of anterior cruciate ligament injuries in female youth football players and traumatic knee injuries in male and female youth floorball players. However, to date, Knee Control has not been evaluated in an elite youth sport setting. The literature on the prevention of shoulder injuries in sport is scarce, and there are to our knowledge no previous studies evaluating the preventative efficacy of injury prevention exercise programmes (IPEPs) on shoulder injuries in adolescent handball players.

Objectives

To study the preventive efficacy of IPEPs on shoulder and knee injuries in adolescent elite handball players.

Methods

Eighteen Swedish handball-profiled secondary schools (clusters) with players aged 15–19 years, 54% males were randomised into either the Shoulder Group or Knee Group (interventions) or a Control Group. Players in the Shoulder Group were instructed to perform the Shoulder Control programme, and  players in the Knee Group to perform the Knee Control programme, three times per week during May 2018 to May 2019. Control Group players continued their usual training. Outcomes were shoulder and knee injuries defined by the Oslo Sports Trauma Research Center Overuse Injury Questionnaire. Intention-to-treat analyses were performed using Cox regression models with hazard rate ratios (HRRs) with corresponding 95% confidence intervals (CI).

Results

Six clusters (199 players) in the Shoulder Group, six clusters (216 players) in the Knee Group and six clusters (212 players) in the Control Group were included. There were 100 shoulder injuries and 156 knee injuries. The Shoulder Group had a 56% lower shoulder injury rate, HRR 0.44 (95% CI 0.29 to 0.68), and the Knee Group had a 31% lower knee injury rate, HRR 0.69 (95% CI 0.49 to 0.97) than the Control Group. The absolute risk reduction was 11% and 8%, and the number needed to treat was 9 and 13, respectively.

Conclusions

Adolescent elite handball players who performed the Shoulder Control and the Knee Control programmes had a lower risk of shoulder and knee injuries, respectively, than players who continued their usual training. Further research on how these two programmes can be combined to reduce knee and shoulder injuries in a time effective way is warranted.

Trial registration ISRCTN15946352.

Key points

Injury prevention programs that include balance training exercises reduce ankle injury rates among soccer players: a systematic review

QUESTION

What is the effect of injury prevention programs that include balance training exercises on the incidence of ankle injuries among soccer players?

DESIGN

Systematic review of randomised trials with meta-analysis.

PARTICIPANTS

Soccer players of any age, sex or competition level.

INTERVENTIONS

The experimental intervention was an injury prevention program that included balance training exercises. The control intervention was the soccer team's usual warm-up program.

OUTCOME MEASURES

Exposure-based ankle injury rates.

RESULTS

Nine articles met the inclusion criteria. The pooled results of injury prevention programs that included balance training exercises among 4,959 soccer players showed a 36% reduction in ankle injury per 1,000 hours of exposure compared to the control group with an injury risk ratio (IRR) of 0.64 (95% CI 0.54 to 0.77). The pooled results of the Fédération Internationale de Football Association (FIFA) injury prevention programs caused a 37% reduction in ankle injury (IRR 0.63, 95% CI 0.48 to 0.84) and balance-training exercises alone cause a 42% reduction in ankle injury (IRR 0.58, 95% CI 0.41 to 0.84).

CONCLUSIONS

This meta-analysis demonstrates that balance exercises alone or as part of an injury prevention program decrease the risk of ankle injuries. PROSPERO CRD42017054450.

High compliance with the injury prevention exercise programme Knee Control is associated with a greater injury preventive effect in male, but not in female, youth floorball players

PURPOSE

Evaluate team and player compliance with the Knee Control injury prevention exercise programme, study the association between player compliance and injury rates, and compare coach demographics, baseline prevention expectancies, and programme utilisation between teams with high and low compliance.

METHODS

Prospective one-season cohort study based on a cluster randomised controlled trial on 301 (107 female) floorball players aged 12-17 years. Floorball exposure and injuries were self-reported weekly by players using the Oslo Sports Trauma Research Center questionnaire. Team and player compliance to Knee Control was reported monthly by coaches. Additionally, coaches answered pre- and post-season surveys. Teams were divided into a high (≥ 80%) or low (< 80%) compliance group based on their use of Knee Control during the season. Players were divided into three compliance groups based on their average weekly number of Knee Control sessions; high (≥ 2 sessions), intermediate (≥ 1 to < 2 sessions), and low dose (< 1 session).

RESULTS

Mean team compliance for the high and low compliance groups were 95% (range 82-100) and 50% (range 13-66), respectively. Mean ± SD weekly Knee Control dose in the three player compliance groups were 2.4 ± 0.3, 1.4 ± 0.3, and 0.7 ± 0.3 sessions, respectively. There were no differences in total injury incidence between the player compliance groups, but players in the high-dose group had a 35% lower prevalence of injuries overall [adjusted prevalence rate ratio (PRR) 0.65, 95% CI 0.48-0.89] and 60% lower prevalence of substantial injuries (adjusted PRR 0.40, 95% CI 0.26-0.61) compared with the low-dose group. Male players in the high-dose group had consistently lower injury incidence and prevalence, while no between compliance group differences were seen in female players. There were no differences in sex, years of coaching experience, or baseline prevention expectancies in general between coaches for teams in the high vs. low compliance groups, but teams in the high compliance group had a better utilisation fidelity.

CONCLUSION

There was a clear dose-response relationship between more frequent Knee Control use and lower injury rates in male floorball players, but not in female players. Teams with higher compliance also showed a better utilisation fidelity with the programme.

LEVEL OF EVIDENCE

Level II.

ACL injury prevention: Where have we come from and where are we going?

Anterior cruciate ligament (ACL) injuries are one of the most common and severe knee injuries across sports. As such, ACL injury prevention has been a focus of research and sports medicine practice for the past three-plus decades. Examining the current research and identifying both clinical strategies and research gaps, the aim of this review is to empower clinicians and researchers with knowledge of where the ACL injury prevention literature is currently and where it is going in the future. This paper examines the mechanism of ACL injury prevention, screening, implementation, compliance, adherence, coronavirus, and areas of future research. Clinical significance: The time lag between research and practical implementation in general healthcare settings can be as long as 17 years; however, athletes playing sports today are unable to wait that long. With effective programs already established, implementation and adherence to these programs is essential. Strategies such as coaching education, increasing awareness of free programs, identifying barriers, and overcoming implementation obstacles through creative collaboration are just a few ways that could help improve both ACL injury prevention implementation and adherence.

Exercise-Based Injury Prevention in High-Level and Professional Athletes: Narrative Review and Proposed Standard Operating Procedure for Future Lockdown-Like Contexts After COVID-19

In regular times, implementing exercise-based injury prevention programs into the training routine of high-level and professional athletes represents a key and challenging aspect to decrease injury risk. Barriers to implementing such prevention programs have previously been identified such as lack of resources, logistic issues or motivation. The COVID-19 pandemic associated with restrictions on daily life dramatically impacted sports participation from training to competition. It is therefore reasonable to assume that such lockdown-like context has exacerbated the challenge to implement exercise-based injury prevention programs, potentially leading to a greater musculoskeletal injury risk. In this narrative review, recommendations are proposed for building an expertise- and evidence-based Standard Operating Procedure for injury prevention in lockdown-like contexts for high-level and professional athletes. The following recommendations can be provided: (1) assess the global and sport-specific risks in the light of the ongoing cause of isolation; (2) adapt remote training materials and programs; (3) ensure regular quality communication within the staff, between athletes and the staff as well as between athletes; (4) follow the athlete's mental well-being; and (5) plan for a safe return-to-sports as well as for an ongoing monitoring of the load-recovery balance. These key domains should further be addressed to comply with local policies, which are subject to change over time in each individual country. The use of these recommendations may improve the readiness of athletes, coaches, physicians and all sports stakeholders for future lockdown-like contexts.

Hand and wrist injuries among collegiate athletes vary with athlete division

BACKGROUND

The rates, severity and consequences of hand and wrist injuries sustained by National Collegiate Athletic Association athletes are not well characterized. This study describes the epidemiology of hand and wrist injuries among collegiate athletes competing in different divisions.

METHODS

The National Collegiate Athletic Association Injury Surveillance Program (NCAA-ISP) was accessed from 2004 to 2015 for the following sports: baseball, basketball, football, ice hockey, lacrosse, soccer, wrestling, field hockey, gymnastics, softball and volleyball. The data were used to identify all hand and wrist injuries, the specific injury diagnosis, mean time loss of activity following injury, and need for surgery following injury. These were then stratified by gender. Descriptive statistics were performed to examine the association between sports, event type and division. Student's t test was used to calculate p-values for independent variables. Chi-Square test was used to calculate odds ratio. P < 0.05 was considered significant.

RESULTS

103,098 hand and wrist injuries were reported in in the studied NCAA sports from 2004 to 2015. Male athletes sustained 72,423 injuries (6.01/10,000 athlete exposure) and female athletes sustained 30,675 injuries (4.13/10,000 athlete exposure). Division I athletes sustained significantly more injuries compared to divisions II and III. Overall, 3.78% of hand and wrist injuries required surgical intervention. A significantly higher percentage of division I athletes (both male and female) underwent surgical intervention compared to divisions II and III. The mean time lost due to hand and wrist injury was 7.14 days for all athletes. Division I athletes missed the fewest days due to injury at 6.29 days though this was not significant.

CONCLUSIONS

Hand and wrist injuries are common among collegiate athletes. Division I athletes sustain higher rates of injuries and higher surgical intervention rates, while tending to miss fewer days due to injury. Improved characterization of divisional differences in hand and wrist injuries can assist injury management and prevention.

Adherence to an Injury Prevention Warm-Up Program in Children's Soccer-A Secondary Analysis of a Randomized Controlled Trial

This study examined the impact of high adherence to a neuromuscular training (NMT) warm-up on the risk of lower extremity (LE) injuries in children's soccer. Twenty U11-U14 youth clubs (n = 92 teams, 1409 players) were randomized into intervention (n = 44 teams) and control (n = 48 teams) groups. The intervention group was advised to perform an NMT warm-up 2 to 3 times a week for 20 weeks. Team adherence, injuries, and exposure were registered throughout the follow-up. Primary outcomes were the incidence of soccer-related acute LE injuries and the prevalence of overuse LE injuries. Intervention teams conducted mean 1.7 (SD 1.0) NMT warm-ups weekly through follow-up. The seasonal trend for adherence declined significantly by -1.9% (95% CI -0.8% to -3.1%) a week. There was no difference in the incidence of acute injuries nor the prevalence of overuse LE injuries in high team adherence group (n = 17 teams) compared to controls. However, the risk for acute noncontact LE injuries was 31% lower in the high team adherence group compared to controls (IRR 0.69, 95% CI 0.49 to 0.97). In an efficacy analysis (n = 7 teams), there was a significant reduction of 47% in the rate of noncontact LE injuries (IRR 0.53, 95% CI 0.29 to 0.97). In conclusion, teams conducted NMT warm-up sessions regularly, but with a declining trend. A greater protective effect was seen in teams with the highest adherence to the NMT warm-up.

A Comprehensive Summary of Systematic Reviews on Sports Injury Prevention Strategies

Background

A large volume of systematic reviews and meta-analyses has been published on the effectiveness of sports injury prevention programs.

Purpose

To provide a qualitative summary of published systematic reviews and meta-analyses that have examined the effectiveness of sports injury prevention programs on reducing musculoskeletal injuries.

Study Design

Systematic review; Level of evidence, 4.

Methods

We searched the PubMed, CINAHL, EMBASE, and the Cochrane databases for systematic reviews and meta-analyses that evaluated the effectiveness of sports injury prevention programs. We excluded published abstracts, narrative reviews, articles not published in English, commentaries, studies that described sports injury prevention strategies but did not assess their effectiveness, studies that did not assess musculoskeletal injuries, and studies that did not assess sports-related injuries. The most relevant results were extracted and summarized. Levels of evidence were determined per the Oxford Centre for Evidence-Based Medicine, and methodological quality was assessed using the AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews, revised version).

Results

A total of 507 articles were retrieved, and 129 were included. Articles pertaining to all injuries were divided into 9 topics: sports and exercise in general (n = 20), soccer (n = 13), ice hockey (n = 1), dance (n = 1), volleyball (n = 1), basketball (n = 1), tackle collision sports (n = 1), climbing (n = 1), and youth athletes (n = 4). Articles on injuries by anatomic site were divided into 11 topics: general knee (n = 8), anterior cruciate ligament (n = 34), ankle (n = 14), hamstring (n = 11), lower extremity (n = 10), foot (n = 6), groin (n = 2), shoulder (n = 1), wrist (n = 2), and elbow (n = 1). Of the 129 studies, 45.7% were ranked as evidence level 1, and 55.0% were evidence level 2. Based on the AMSTAR-2, 58.9% of the reviews reported a priori review methods, 96.1% performed a comprehensive literature search, 47.3% thoroughly described excluded articles, 79.1% assessed risk of bias for individual studies, 48.8% reported a valid method for statistical combination of data (ie, meta-analysis), 45.0% examined the effect of risk of bias on pooled study results, and 19.4% examined the risk for publication bias.

Conclusion

This comprehensive review provides sports medicine providers with a single source of the most up-to-date publications in the literature on sports injury prevention.

Biomechanical Changes During a 90º Cut in Collegiate Female Soccer Players With Participation in the 11

BACKGROUND

Valgus collapse and high knee abduction moments have been identified as biomechanical risk factors for ACL injury. It is unknown if participation in the 11+, a previously established, dynamic warm-up that emphasizes biomechanical technique and reduces ACL injury rates, reduces components of valgus collapse during a 90º cut.

HYPOTHESIS/PURPOSE

To determine whether participation in the 11+ during a single soccer season reduced peak knee abduction moment and components of valgus collapse during a 90º cut in collegiate female soccer players.

STUDY DESIGN

Prospective cohort study.

METHODS

Forty-six participants completed preseason and postseason motion analysis of a 90º cut. During the season, 31 players completed the 11+ and 15 players completed their typical warm-up (control group). Peak knee abduction moment, components of valgus collapse (hip adduction, internal rotation, and knee abduction angles), and a novel measure of knee valgus collapse were analyzed with repeated-measures ANOVAs to determine differences between preseason and postseason. Smallest detectable change (SDC) and minimal important difference (MID) values were applied to contextualize results.

RESULTS

There was a significant main effect of time for non-dominant knee valgus collapse (p=0.03), but decreases in non-dominant knee valgus collapse only exceeded the SDC in the intervention team.

CONCLUSIONS

Clinically meaningful decreases in knee valgus collapse may indicate a beneficial biomechanical effect of the 11+. Participation in the 11+ may lower ACL injury risk by reducing valgus collapse during a 90º cut.

LEVEL OF EVIDENCE

2b.

Influential Articles on Pediatric and Adolescent Anterior Cruciate Ligament Injuries: A Bibliometric Analysis

BACKGROUND

The understanding of pediatric anterior cruciate ligament (ACL) injuries and optimal treatment has evolved significantly. Influential articles have been previously evaluated using article citations to determine impact.

PURPOSE

To identify and characterize the 50 most cited and recent influential articles relating to pediatric and adolescent ACL injuries, to examine trends in publication characteristics, and to evaluate correlations of study citations with quality of evidence.

STUDY DESIGN

Cross-sectional study.

METHODS

The top 50 most cited articles on pediatric and adolescent ACL injuries were gathered using the Web of Science and Scopus online databases by averaging the number of citations from each database. Articles from recent years were also aggregated and sorted by citation density (citations/year). Publication and study characteristics were recorded. Level of evidence and methodologic quality were assessed where applicable using the modified Coleman Methodology Score (mCMS), modified Jadad scale, and Methodological Index for Non-Randomized Studies (MINORS). Spearman correlation was used to evaluate the association between citation data and level of evidence or methodologic quality scorings.

RESULTS

The top 50 cited papers had a mean of 117.5 ± 58.8 citations (range, 58.5-288.5 citations), with a mean citation density of 9.4 ± 5.4 citations per year (range, 2.9-25.8 citations/year); 80% were published in 2000 or later, and 6% were considered basic science. Articles were mainly level 4 evidence (27/42; 64.3%), and none was level 1. There were moderate, significant associations between publication year and level of evidence (r S = -0.45; P = .0030) and citation density and publication year (r S = 0.59; P < .001). Mean methodologic quality scores were as follows: mCMS, 53 ± 7.2 (range, 39-68); modified Jadad scale, 3.2 ± 1.1 (range, 2-6); and MINORS, 11.2 ± 3.2 (range, 6-20). There was a significant, strong correlation between rank of mean citations and modified Jadad scale (r S = 0.76; P < .0001), suggesting poorer score associated with more mean citations.

CONCLUSION

Influential articles on pediatric and adolescent ACL injuries were relatively recent, with a low proportion of basic science-type articles. Most of the studies had a lower evidence level and poor methodologic quality scores. Higher methodologic quality did not correlate positively with citation data.

Through the athlete lens: A novel study exploring the perspectives and experiences of injury prevention practices in women playing elite Australian Football

BACKGROUND

Efficacious injury prevention programs exist, yet translation to practice in real-world settings is poor. Little is known about how women playing elite team ball-sports perceive and experience injury prevention programs in practice. Understanding the end-user's (athlete's) perspective is essential to improve program uptake and adherence.

OBJECTIVE

To explore the perspectives and experiences of injury prevention practices in athletes from the elite Australian Football League for Women (AFLW).

METHODS

Convenience sample of 13 athletes from three AFLW clubs. Semi-structured interviews were audio-recorded and transcribed verbatim, analysed with a thematic analysis approach, and classified within the Socio-Ecological Model (SEM).

RESULTS

Women playing elite Australian Football: (1) believe injury prevention programs have multiple aims and benefits, (2) perceive varying injury prevention practices between and within AFLW clubs, (3) believe injury prevention program adoption and implementation is complex and multi-factorial, and (4) think implementing injury prevention programs in the AFLW could be enhanced through education and resources. Mapping our results onto the SEM highlighted that athletes perceive multiple ecological levels (i.e. individual, interpersonal, community, and organizational) are involved in sports injury prevention.

CONCLUSIONS

Multi-level engagement strategies are required to enhance injury prevention program adoption and implementation and to maximise athlete adherence.

Implementation of an injury prevention programme in community netball: An observational study

The Netball KNEE programme is a freely available, netball-specific injury prevention programme promoted to netball coaches. However, little is known about its implementation. This cross-sectional study aimed to evaluate the implementation of the Netball KNEE programme in community netball, and determine if implementation differed by player age. Four netball clubs participated. Training sessions (n = 67) were observed to determine if coaches used Netball KNEE programme activities as intended, modified or not at all during training, and whether feedback on technique was provided. No team performed the recommended number of activities without modification. On average, only 12%, 18% and 14% of the recommended number of activities were performed as intended in the 7-10, 11-13 and ≥14 years age groups, respectively. Warm-up/footwork activities (30%; 0-80%) were more frequently performed than strength (0%; 0-50%), balance/landing (0%; 0-50%), and agility (0%; 0-25%) activities (p < 0.001). Feedback was required in 65% of activities, but frequently not provided (56%). Netball KNEE programme implementation is low in community netball, particularly strength, balance/landing and agility activities. This finding, and lack of provision of feedback on technique, is concerning as improving movement patterns is a key aim of injury prevention programmes.

Neuromuscular Training Warm-up Prevents Acute Noncontact Lower Extremity Injuries in Children's Soccer: A Cluster Randomized Controlled Trial

Background:

Prevention of sports injuries is essential in youth, as injuries are associated with less future physical activity and thus greater all-cause morbidity.

Purpose:

To investigate whether a neuromuscular training warm-up operated by team coaches is effective in preventing acute lower extremity (LE) injuries in competitive U11-U14 soccer players.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

Twenty top-level U11 to U14 soccer clubs in Finland were randomized into intervention and control groups and assessed for 20 weeks. Participants included 1403 players (280 female, 1123 male; age range, 9-14 years): 673 players (44 teams) in the intervention group and 730 players (48 teams) in the control group. The intervention group team coaches were introduced to a neuromuscular training warm-up to replace the standard warm-up 2 to 3 times per week. The control teams were asked to perform their standard warm-up. Injury data collection was done via weekly text messages. The primary outcome measure was a soccer-related acute LE injury, and the secondary outcome measure was an acute noncontact LE injury.

Results:

A total of 656 acute LE injuries occurred: 310 in the intervention group and 346 in the control group. The overall acute LE injury incidence was 4.4 per 1000 hours of exposure in the intervention group and 5.5 per 1000 hours of exposure in the control group, with no significant difference between groups (incidence rate ratio [IRR], 0.82 [95% CI, 0.64-1.04]). There were 302 acute noncontact LE injuries: 129 in the intervention group (incidence, 1.8 per 1000 hours) and 173 in the control group (2.7 per 1000 hours). A significant reduction in acute noncontact LE injuries of 32% (IRR, 0.68 [95% CI, 0.51-0.93]) was observed in the intervention group compared with the control group. Furthermore, significant reductions in injury incidence in favor of the intervention group were seen in the subanalyses of acute noncontact LE injuries, leading to ≤7 days of time loss and fewer ankle and joint/ligament injuries.

Conclusion:

A neuromuscular training warm-up operated by team coaches was found to be effective in preventing acute noncontact LE injuries in children’s soccer, but this was not seen in all acute LE injuries.

Clinical Relevance:

We encourage children’s soccer coaches and health care professionals to implement neuromuscular training warm-up in youth sports.

Registration:

ISRCTN14046021 (ISRCTN registry).

Performance Effects with Injury Prevention Exercise Programmes in Male Youth Football Players: A Randomised Trial Comparing Two Interventions

BACKGROUND

Increased performance from injury prevention exercise programmes (IPEPs) may affect injury risks positively and support the implementation of IPEPs. The primary aim was to study the performance effects of injury prevention exercises from two different IPEPs, the Knee Control IPEP and the further developed Knee Control+ IPEP, in youth male football players, and the secondary aim was to compare potential differences in performance effects between the IPEPs.

METHODS

Four male youth football teams were tested for agility, hop and sprint performance at the start of the second half of the competitive season and after the end of the 8-week season. Per randomisation, two teams used Knee Control and two teams Knee Control+.

RESULTS

In total, 47 players executed a median of 13 IPEP sessions (range 11-21 sessions). No improvements in performance were seen in the group as a whole. The intervention groups showed small declines in sprint and agility performance. There was a significant between-group difference in change for the 505 agility test, with improved performance in the Knee Control and worse performance in the Knee Control+ group, ΔKC vs KC+ = - 0.012 (95% CI - 0.19 to -0.04), d = 0.98.

CONCLUSIONS

No clinically meaningful performance effects were seen from the Knee Control or Knee Control+ IPEP in youth male athletes and no meaningful differences were seen between Knee Control and Knee Control+ regarding effects on performance tests.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03251404 . Registered on 16 August 2017.

Perceived barriers to implementation of injury prevention programs among collegiate women's soccer coaches

OBJECTIVES

Knee injury prevention programs (IPPs) reduce knee and anterior cruciate ligament (ACL) injury rates in female athletes, however, implementation of IPPs is low. The purpose of this study was to identify barriers to implementation of IPPs among collegiate women's soccer coaches.

DESIGN

Cross-sectional survey.

METHODS

A custom survey based on the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework and existing literature was sent to 151 out of 153 women's National Collegiate Athletic Association (NCAA) soccer coaches in the NCAA's Eastern Region.

RESULTS

Ten respondents reported that they did not use an IPP (Non-users), and nineteen respondents reported that they did use an IPP (Users). "Cost" was the most highly ranked barrier (median rank: 2) to implementing an IPP among Non-users. For the statement, "Who should be responsible for completing an IPP," Users said "Coaches" (47%) and "Other" (21%), while Non-users said "Strength and conditioning" (50%) and "Athletic trainers" (30%). Respondents who marked "Other", elaborated that it was the responsibility of coaches, athletes, and additional staff members.

CONCLUSIONS

Cost was the primary barrier to implementation of an IPP. Since the majority of Non-users indicated that implementation of an IPP was the responsibility of a non-coaching staff member, cost may be a surrogate for the expense of hiring an additional staff member rather than the cost of performing the IPP itself. Additionally, using a team-based approach that encompasses athletes, coaches, and non-coaching staff members may support long-term implementation of IPPs.

Adolescent physical activity-related injuries in school physical education and leisure-time sports

Objective

The aims of this study were to investigate the prevalence of sports injuries in school physical education (PE) and leisure-time sports among 1011 15- to 16-year-old adolescents in relation to physical activity, and to examine goal orientation.

Methods

A survey was used with additional narrative descriptions.

Results

There was a higher prevalence of injuries in leisure time (645/993 = 65%) than in PE (519/998 = 52%). Two groups with high PE injury rates were identified: a) highly active (258/998 = 26%) in both school PE and leisure-time sports and b) highly inactive (180/998 = 18%) in both contexts. There were no differences between girls and boys. Task-oriented adolescents were more prone to injury.

Conclusions

The high prevalence of injuries in PE appears to have two mechanisms: renewed inadequately recovered leisure-time injuries among highly active adolescents, and injuries among fragile inactive adolescents unfamiliar with exercise. PE educators of these two groups with different injury patterns have a considerable didactic challenge. Knowledge of inadequately recovered injuries and consideration of the high volume and intensity of early sport-specific training in children and adolescents are important parameters in the design of lesson plans for PE.

Reducing Injuries in Soccer (Football): an Umbrella Review of Best Evidence Across the Epidemiological Framework for Prevention

Soccer is the most popular sport in the world. Expectedly, the incidence of soccer-related injuries is high and these injuries exert a significant burden on individuals and families, including health and financial burdens, and on the socioeconomic and healthcare systems. Using established injury prevention frameworks, we present a concise synthesis of the most recent scientific evidence regarding injury rates, characteristics, mechanisms, risk and protective factors, interventions for prevention, and implementation of interventions in soccer. In this umbrella review, we elucidate the most recent available evidence gleaned primarily from systematic reviews and meta-analyses. Further, we express the exigent need to move current soccer injury prevention research evidence into action for improved player outcomes and widespread impact through increased attention to dissemination and implementation research. Additionally, we highlight the importance of an enabling context and effective implementation strategies for the successful integration of evidence-based injury prevention programs into real-world soccer settings. This narrative umbrella review provides guidance to inform future research, practice, and policy towards reducing injuries among soccer players.

Effects of Supplementary Strength-Power Training on Neuromuscular Performance in Young Female Athletes

This study examined the effects of a short-duration supplementary strength–power training program on neuromuscular performance and sport-specific skills in adolescent athletes. Twenty-three female “Gymnastics for All” athletes, aged 13 ± 2 years, were divided into a training group (TG, n = 12) and a control group (CG, n = 11). Both groups underwent a test battery before and after 10 weeks of intervention. TG completed, in addition to gymnastics training, a supplementary 7–9 min program that included two rounds of strength and power exercises for arms, torso, and legs, executed in a circuit fashion with 1 min rest between rounds, three times per week. Initially, six exercises were performed (15 s work–15 s rest), while the number of exercises was decreased to four and the duration of each exercise was increased to 30 s (30 s rest) after the fifth week. TG improved countermovement jump performance with one leg (11.5% ± 10.4%, p = 0.002) and two legs (8.2% ± 8.8%, p = 0.004), drop jump performance (14.4% ± 12.6%, p = 0.038), single-leg jumping agility (13.6% ± 5.2%, p = 0.001), and sport-specific performance (8.8% ± 7.4%, p = 0.004), but not 10 m sprint performance (2.4% ± 6.6%, p = 0.709). No change was observed in the CG (p = 0.41 to 0.97). The results of this study indicated that this supplementary strength–power program performed for 7–9 min improves neuromuscular and sport-specific performance after 10 weeks of training.

How much, how often, how well? Adherence to a neuromuscular training warm-up injury prevention program in youth basketball

Adherence is a key implementation outcome that determines the effectiveness of an intervention. This study, an observational design involving coaches and players from 33 high school basketball teams, evaluated the dimensions of adherence to a basketball-specific neuromuscular training (NMT) warm-up program in youth basketball. Coach adherence (daily report of team adherence) was collected prospectively. Adherence measures: cumulative utilization (proportion of total sessions possible), utilization fidelity (average # of exercises completed per NMT session), utilization frequency (average # of NMT sessions completed per week) were calculated and further evaluated for optimal adherence (≥80%, ≥10.4 exercises/session and ≥2 sessions/week, respectively) per coach. Additionally, exercise fidelity (proportion of players performing individual exercises correctly) was assessed. Coach (n = 31; 27-59 years) median cumulative utilization was 80%, utilization fidelity was 12 (of a possible 13 exercises per session) and utilization frequency was 2.3 sessions per week. Optimal adherence ranged from 52% to 71% across measures of adherence. Player exercise fidelity was 48%. Time constraint (47%) was the most frequently reported adherence barrier. While coach adherence to the NMT warm-up program was reasonably high across measures of adherence, a considerable proportion of coaches did not attain optimal adherence levels and player exercise fidelity was low.

Can we improve coaches' injury prevention views and implementation practices in the community female Gaelic sport of camogie?

Objectives

To evaluate the effect of a nationwide coach education workshop on the attitudes towards, willingness and perceived ability of camogie coaches to implement a Camogie Injury Prevention Programme (CIPP) and their implementation of this programme 4 weeks after the workshop.

Methods

Coaches (n=98) from all four provinces in Ireland were recruited and completed a questionnaire prior to and immediately following a developed workshop on the CIPP. Four weeks later 40 of the 98 coaches completed a follow-up questionnaire. Descriptive statistics were completed and a mixed between-within analysis of variance was conducted to examine the differences in willingness and perceived ability to conduct the CIPP over time and between genders. Non-parametric tests examined the differences in attitude scores. The implementation rate of the programme 4 weeks following the workshop was also assessed.

Results

Just 13.4% of coaches had previously heard of the CIPP. Significant improvements in attitudes towards, willingness and perceived ability to conduct the CIPP was noted (p<0.001) post-workshop. Ninety-one per cent of coaches reported that implementing the CIPP in a phased approach with their teams would be beneficial. The camogie coaches primarily viewed the CIPP content favourably, finding the exercises important, relevant and mostly enjoyable. However, some coaches reported that the Nordic hamstring curl is too challenging for players to complete (immediately following workshop: 28.7%; 4 weeks later: 53.3%). Four weeks after the workshop, 72.5% of coaches who responded were implementing the CIPP with their teams in the community.

Conclusions

Due to the success of the education workshop, the Camogie Association should incorporate this injury prevention workshop into all mandatory camogie coaching education courses.

Forty-five per cent lower acute injury incidence but no effect on overuse injury prevalence in youth floorball players (aged 12-17 years) who used an injury prevention exercise programme: two-armed parallel-group cluster randomised controlled trial

Objective

To study whether an injury prevention exercise programme would reduce the number of injuries in youth floorball players.

Methods 

81 youth community level floorball teams (48 clusters=clubs) with female and male players (12–17 years) were cluster-randomised into an intervention or control group. Intervention group coaches were instructed to use the Swedish Knee Control programme and a standard running warm-up before every training session, and the running warm-up before every match, during the season. Control teams continued usual training. Teams were followed during the 2017/2018 competitive season (26 weeks). Player exposure to floorball and occurrence of acute and overuse injuries were reported weekly via a web-based player survey using the Oslo Sports Trauma Research Centre Questionnaire.

Results 

17 clusters (301 players) in the intervention group and 12 clusters (170 players) in the control group were included for analyses. There were 349 unique injuries in 222 players. The intervention group had a 35% lower incidence of injuries overall than the control group (adjusted incidence rate ratio (IRR) 0.65, 95% CI 0.52 to 0.81). The absolute risk reduction was 6.6% (95% CI 3.2 to 10.0), and the number needed to treat was 152 hours of floorball exposure (95% CI 100 to 316). Intervention group teams had a 45% lower incidence of acute injuries (adjusted IRR 0.55, 95% CI 0.37 to 0.83). There was no difference in the prevalence of overuse injuries (adjusted prevalence rate ratio 0.96, 95% CI 0.73 to 1.26).

Conclusion 

The Knee Control injury prevention programme reduced acute injuries in youth floorball players; there was no effect on overuse injuries.

Trial registration number

Clinical Trials NCT03309904.

Could a specific exercise programme prevent injury in elite orienteerers? A randomised controlled trial

OBJECTIVES

To determine the effect of a specific exercise programme on preventing lower extremity injury in adult elite orienteerers.

DESIGN

Randomised controlled trial.

SETTING

Elite orienteering.

PARTICIPANTS

Sixty-two orienteerers (n = 32/30, male/female) were randomized and followed over 14 weeks. The intervention group completed an exercise programme 4 times per week.

MAIN OUTCOME MEASURES

Number of substantial injuries, average substantial injury prevalence and incidence of ankle sprains over the competitive season. In per-protocol analyses, compliance rate to exercise programme was considered.

RESULTS

No significant differences between control and intervention group were found for substantial injured orienteerers (OR 0.50, 95% CI 0.19-1.34), number of substantial injuries (OR 0.46, 95% CI 0.18-1.13) and incidence of ankle sprains (p = 0.775). In per-protocol analyses, significant differences in substantial injured orienteerers (difference -7.9%, OR 0.25, 95% CI 0.06-0.97) and number of substantial injuries (difference -8.5%, OR 0.26, 95% CI 0.07-0.92) in favour for the orienteers completing the exercises at least twice a week, compared to the control group, were found.

CONCLUSIONS

An exercise programme, consisting of balance and jump exercises, is suggested to be performed at least twice per week in order to reduce the risk of lower extremity injury in elite orienteerers.

Inter-rater Reliability in Assessing Exercise Fidelity for the Injury Prevention Exercise Programme Knee Control in Youth Football Players

BACKGROUND

To receive maximum benefits from injury prevention exercise programmes (IPEP) such as Knee Control, players need to perform the exercises as prescribed. But, exercise fidelity in IPEPs is seldom evaluated. We developed a checklist to assess exercise fidelity in the Knee Control IPEP, and the primary aim was to evaluate its inter-rater reliability. The secondary aim was to study Knee Control exercise fidelity in youth football players and compare sex differences.

METHODS

This observational study included 11 teams with male and female youth players (11-18 years). On average, the players trained with the Knee Control IPEP for 7 weeks (SD 1.4, range 6-10 weeks). After the training period, two physiotherapists attended a team training session to observe players executing exercises and individually assessed their performance of these exercises as correct or incorrect based on standardised criteria set in the fidelity checklist. Agreement between observers was assessed using Cohen's kappa coefficient.

RESULTS

The observers agreed on 144 out of 160 (90%) observations (Kappa = 0.80, substantial agreement). Both observers agreed on correct exercise performance for 69 out of 144 observations (exercise fidelity 48%). Exercise fidelity was higher in females (56%) than males (40%), but the difference was not statistically significant (p = 0.18).

CONCLUSION

The Knee Control exercise fidelity checklist had high inter-rater reliability with substantial agreement. The exercise fidelity was low, which could hamper the preventive effects of an IPEP. Understanding the reasons for low exercise fidelity is important and more effort should focus on increasing exercise fidelity alongside the implementation of IPEPs.

"What's my risk of sustaining an ACL injury while playing sports?" A systematic review with meta-analysis

OBJECTIVE

To estimate the incidence proportion (IP) and incidence rate (IR) for ACL injury in athletes.

DESIGN

Systematic review with meta-analysis DATA SOURCES: The PubMed, CINAHL and SPORTDiscus electronic databases were searched from inception to 20 January 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they reported total number of participants/population by sex, total number of ACL injuries by sex and total person-time by sex.

RESULTS

Fifty-eight studies were included. The IP and IR of ACL injury in female athletes were 3.5% (1 out of every 29 athletes) and 1.5/10 000 athlete-exposures over a period of 1 season-25 years. The IP and IR of ACL injury in male athletes were 2.0% (1 out of every 50 athletes) and 0.9/10 000 athlete-exposures over a period of 1-25 years. Female athletes had a higher relative risk (RR) for ACL injury compared with males (RR=1.5; 95% CI 1.2 to 1.9; P<0.01) and a higher incidence rate ratio (IRR) of ACL injury compared with males over 1 season-25 years (IRR=1.7; 95% CI 1.4 to 2.2; P<0.010). When accounting for participation level, the disparity in the IR between female and male athletes was highest for amateur athletes compared with intermediate and elite athletes (IRR=2.1; 95% CI 1.3 to 3.4; P<0.01; I²=82%). Amateur female athletes remained at higher risk of ACL injury than did with amateur male athletes. In studies where follow-up length was <1 year, female athletes had a higher IR of ACL injury than did to males (IRR=1.7; 95% CI 1.3 to 2.2; P<0.01). Where follow-up was 1 year and beyond, there was no sex difference in the IR of ACL injury (IRR=2.1; 95% CI 0.9 to 4.8; P=0.06; I²=65%).

SUMMARY/CONCLUSIONS

One in 29 female athletes and 1 in 50 male athletes ruptured their ACL in a window that spanned from 1season to 25 years. The IR of ACL injury among female athletes in a season was 1.7 times higher than the IR of ACL injury among male athletes and the IP of ACL injury among female athletes was 1.5 times higher than the IP of ACL injury among male athletes. The reported sex disparity in ACL injury rates is independent of participation level and length of follow-up.

Evaluating the Effects of a Novel Neuromuscular Neck Training Device on Multiplanar Static and Dynamic Neck Strength: A Pilot Study

Versteegh, TH, Dickey, JP, Emery, CA, Fischer, LK, MacDermid, JC, and Walton, DM. Evaluating the effects of a novel neuromuscular neck training device on multiplanar static and dynamic neck strength: A pilot study. J Strength Cond Res 34(3): 708-716, 2020-The neck serves an important function in damping the transference of acceleration forces between the head and the trunk, such as that occurring during contact sports or motor vehicle collisions. An inability to adequately dissipate forces has been proposed as a potential mechanism for clinical conditions such as whiplash or concussion, but current approaches to neck training may not be targeting the correct mechanisms. The purpose of this study was to explore the training effect of a novel neuromuscular strengthening protocol on dynamic and static neck strength. This was a quasiexperimental pilot study design with intervention (n = 8) and control (n = 10) groups. The intervention group was trained (twice/week, ∼10 minutes, for 7 weeks) on a training device that uses self-generated centripetal force to create a dynamic rotational resistance. This protocol is intended to target the ability of the neck muscles to perform coordinated multiplanar plyometric contractions. Both groups also continued with traditional neck strengthening that included training on a straight-plane, isotonic, 4-way neck machine. Performance on the training device showed improvement after routine practice within 1 week, as evidenced by a trend toward increased peak speed in revolutions per minute (RPM). After 7 weeks, peak RPM increased from 122.8 (95% confidence interval [CI], 91.3-154.4) to 252.3 (95% CI, 241.5-263.1). There was also a large positive effect size (Hedge's d, 0.68) in isometric composite (multiplane) neck strength favoring the intervention group over the control group (difference, 20 N; 95% CI, -8 to 48). The largest magnitude strength improvement in a single plane was in axial rotation and also favored the intervention group over the control group (Hedge's d, 1.24; difference, 46 N; 95% CI, 9-83). Future studies should explore whether the dynamic training presented here could help reduce the risk of sports concussion, whiplash, or other head-neck trauma.

Current trends in sport injury prevention

Participation in sport and recreation has important positive implications for public health across the lifespan; however, the burden of sport-related musculoskeletal injury is significant, with the greatest risk being in youth and young adults. Moving upstream to primary prevention of injury is a public health priority that will have significant implications for reducing the long-term consequences of musculoskeletal injury including early post-traumatic osteoarthritis. The primary targets for the prevention of musculoskeletal injury in sport include neuromuscular training (NMT), rule modification, and equipment recommendations. Currently, there is significant high-quality evidence to support the widespread use of NMT warm up programs in team and youth sport, with an expected significant impact of reducing the risk of musculoskeletal injury by over 35%. Policy disallowing body checking in youth ice hockey has led to a >50% reduction in injuries, and rules limiting contact practice in youth American football has significant potential for injury prevention. There is evidence to support the use of bracing and taping in elite sport to reduce the risk of recurrent ankle sprain injury but not for use to prevent the primary injury, and wrist guards are protective of sprain injuries in snowboarding. Future research examining the maintenance of NMT programs across real-world sport and school settings, optimization of adherence, additional benefit of workload modification, and evaluation of rule changes in other sports is needed.

Community-level football injury epidemiology: traumatic injuries treated at Swedish emergency medical facilities

Background

Despite the popularity of the sport, few studies have investigated community-level football injury patterns. This study examines football injuries treated at emergency medical facilities using data from three Swedish counties.

Methods

An open-cohort design was used based on residents aged 0-59 years in three Swedish counties (pop. 645 520). Data were collected from emergency medical facilities in the study counties between 1 January 2007 and 31 December 2010. Injury frequencies and proportions for age groups stratified by sex were calculated with 95% confidence intervals (95% CIs) and displayed per diagnostic group and body location.

Results

Each year, more than 1/200 person aged 0-59 years sustained at least one injury during football play that required emergency medical care. The highest injury incidence was observed among adolescent boys [2009 injuries per 100 000 population years (95% CI 1914-2108)] and adolescent girls [1413 injuries per 100 000 population years (95% CI 1333-1498)]. For female adolescents and adults, knee joint/ligament injury was the outstanding injury type (20% in ages 13-17 years and 34% in ages 18-29 years). For children aged 7-12 years, more than half of the treated injuries involved the upper extremity; fractures constituted about one-third of these injuries.

Conclusions

One of every 200 residents aged 0-59 years in typical Swedish counties each year sustained a traumatic football injury that required treatment in emergency healthcare. Further research on community-level patterns of overuse syndromes sustained by participation in football play is warranted.