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.

Core stability and its relationship to lower extremity function and injury

Core stability may provide several benefits to the musculoskeletal system, from maintaining low back health to preventing knee ligament injury. As a result, the acquisition and maintenance of core stability is of great interest to physical therapists, athletic trainers, and musculoskeletal researchers. Core stability is the ability of the lumbopelvic hip complex to prevent buckling and to return to equilibrium after perturbation. Although static elements (bone and soft tissue) contribute to some degree, core stability is predominantly maintained by the dynamic function of muscular elements. There is a clear relationship between trunk muscle activity and lower extremity movement. Current evidence suggests that decreased core stability may predispose to injury and that appropriate training may reduce injury. Core stability can be tested using isometric, isokinetic, and isoinertial methods. Appropriate intervention may result in decreased rates of back and lower extremity injury.

Prevention of hamstring strains in elite soccer: an intervention study

The purpose was to test the effect of eccentric strength training and flexibility training on the incidence of hamstring strains in soccer. Hamstring strains and player exposure were registered prospectively during four consecutive soccer seasons (1999-2002) for 17-30 elite soccer teams from Iceland and Norway. The first two seasons were used as baseline, while intervention programs consisting of warm-up stretching, flexibility and/or eccentric strength training were introduced during the 2001 and 2002 seasons. During the intervention seasons, 48% of the teams selected to use the intervention programs. There was no difference in the incidence of hamstring strains between teams that used the flexibility training program and those who did not [relative risk (RR)=1.53, P=0.22], nor was there a difference compared with the baseline data (RR=0.89, P=0.75). The incidence of hamstring strains was lower in teams who used the eccentric training program compared with teams that did not use the program (RR=0.43, P=0.01), as well as compared with baseline data for the same intervention teams (RR=0.42, P=0.009). Eccentric strength training with Nordic hamstring lowers combined with warm-up stretching appears to reduce the risk of hamstring strains, while no effect was detected from flexibility training alone. These results should be verified in randomized clinical trials.

A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains

STUDY DESIGN

Prospective randomized comparison of 2 rehabilitation programs.

OBJECTIVES

The objectives of this study were to compare the effectiveness of 2 rehabilitation programs for acute hamstring strain by evaluating time needed to return to sports and reinjury rate during the first 2 weeks and the first year after return to sport. A third objective was to investigate the relationship between functional testing performance and time to return to sports and reinjury rates after return to sport.

BACKGROUND

Hamstring muscle strains are common in sports and often result in chronic pain, recurrent hamstring strains, and reduced sports performance. Current rehabilitation programs are primarily developed anecdotally and lack support from prospective, randomized research.

METHODS AND MEASURES

Twenty-four athletes with an acute hamstring strain were randomly assigned to 1 of 2 rehabilitation groups. Eleven athletes were assigned to a protocol consisting of static stretching, isolated progressive hamstring resistance exercise, and icing (STST group). Thirteen athletes were assigned to a program consisting of progressive agility and trunk stabilization exercises and icing (PATS group). The number of days for full return to sports, injury recurrence within the first 2 weeks, injury recurrence within the first year of returning to sports, and lower-extremity functional evaluations were collected for all subjects and compared between groups.

RESULTS

The average (+/- SD) time required to return to sports for athletes in the STST group was 37.4 +/- 27.6 days, while the average time for athletes in the PATS group was 22.2 +/- 8.3 days. This difference was not statistically significant (P = .2455). In the first 2 weeks after return to sports, reinjury rate was significantly greater (P = .00343, Fisher's exact test) in the STST group, where 6 of 11 athletes (54.5%) suffered a recurrent hamstring strain after completing the stretching and strengthening program, as compared to none of the 13 athletes (0%) in the PATS group. After 1 year of return to sports, reinjury rate was significantly greater (P = .0059, Fisher's exact test) in the STST group. Seven of 10 athletes (70%) who completed the hamstring stretching and strengthening program, as compared to only 1 of the 13 athletes (7.7%) who completed the progressive agility and trunk stabilization program, suffered a recurrent hamstring strain during that 1-year period.

CONCLUSIONS

A rehabilitation program consisting of progressive agility and trunk stabilization exercises is more effective than a program emphasizing isolated hamstring stretching and strengthening in promoting return to sports and preventing injury recurrence in athletes suffering an acute hamstring strain. Future randomized clinical trials should investigate the potential for progressive agility and trunk stabilization programs in the prevention of hamstring strain injury during sports.

Balance board training: prevention of traumatic injuries of the lower extremities in female soccer players? A prospective randomized intervention study

This prospective randomized intervention investigated whether training on a balance board could reduce the amount of traumatic injuries of the lower extremities in female soccer players. A total of 221 female soccer players from 13 different teams playing in the second and third Swedish divisions volunteered to participate in the study. Seven teams (n = 121) were randomized to an intervention group and six teams (n = 100) to a control group and were followed during one outdoor season (April-October). Before and after the season muscle flexibility and balance/postural sway of the lower extremities were measured in the players. There were no significant differences in age, height, weight, muscle flexibility and balance/postural sway of the lower extremities between the intervention and the control group. During the season the players in the intervention group performed a special training program consisting of 10-15 min of balance board training in addition to their standard soccer practice and games. After a 37% drop-out the intervention group consisted of 62 players and the control group of 78 players. The results showed no significant differences between the groups with respect either to the number, incidence, or type of traumatic injuries of the lower extremities. The incidence rate of "major" injuries was higher in the intervention group than in the control group. Four of five anterior cruciate ligament injuries occurred in the intervention group, which means that we could not prevent severe knee injuries in female soccer players with balance board training. However, among the players who had been injured during the 3-month period prior to this investigation there were significantly more players from the control group than from the intervention group who sustained new injuries during the study period.

Risk factors for leg injuries in female soccer players: a prospective investigation during one out-door season

The following possible risk factors for leg injuries in female soccer players were studied: age, anatomical alignment, generalized joint laxity, thigh muscle torque, muscle flexibility, ligamentous laxity of the knee and ankle joints, recent injuries, and duration of soccer exposure. A total of 146 players from 13 teams in the second and third Swedish divisions underwent clinical examination, isokinetic measurements of quadriceps and hamstring torques, and testing of postural sway of the legs. All soccer-related leg injuries resulting in absence from at least one scheduled practice session or game were recorded during one outdoor season (April-October). In 50 players there were 61 traumatic injuries, and 17 players sustained 19 overuse injuries. The overall injury incidence rate (traumatic and overuse) was 5.49/1000 h of soccer. Variables significantly increasing the risk of traumatic leg injuries included generalized joint laxity, low postural sway of the legs, hyperextension of the knee joint, and a low hamstring-to-quadriceps ratio during concentric action. Multivariate logistic regression showed hyperextension of the knee joint, a low postural sway, reduced H/Q ratio during concentric action, and a higher exposure to soccer to significantly increase the risk of traumatic leg injury. All five players who suffered an anterior cruciate ligament injury during the study period had a lower hamstring-to-quadriceps ratio during concentric action on the injured side than on their noninjured side.

A randomized trial of preexercise stretching for prevention of lower-limb injury

PURPOSE

This study investigated the effect of muscle stretching during warm-up on the risk of exercise-related injury.

METHODS

1538 male army recruits were randomly allocated to stretch or control groups. During the ensuing 12 wk of training, both groups performed active warm-up exercises before physical training sessions. In addition, the stretch group performed one 20-s static stretch under supervision for each of six major leg muscle groups during every warm-up. The control group did not stretch.

RESULTS

333 lower-limb injuries were recorded during the training period, including 214 soft-tissue injuries. There were 158 injuries in the stretch group and 175 in the control group. There was no significant effect of preexercise stretching on all-injuries risk (hazard ratio [HR] = 0.95, 95% CI 0.77-1.18), soft-tissue injury risk (HR = 0.83, 95% CI 0.63-1.09), or bone injury risk (HR = 1.22, 95% CI 0.86-1.76). Fitness (20-m progressive shuttle run test score), age, and enlistment date all significantly predicted injury risk (P < 0.01 for each), but height, weight, and body mass index did not.

CONCLUSION

A typical muscle stretching protocol performed during preexercise warm-ups does not produce clinically meaningful reductions in risk of exercise-related injury in army recruits. Fitness may be an important, modifiable risk factor.

Prevention of lower extremity stress fractures: a controlled trial of a shock absorbent insole

A prospective controlled trial was carried out to determine the usefulness of a viscoelastic polymer insole in prevention of stress fractures and stress reactions of the lower extremities. The subjects were 3,025 US Marine recruits who were followed for 12 weeks of training at Parris Island, South Carolina. Polymer and standard mesh insoles were systematically distributed in boots that were issued to members of odd and even numbered platoons. The most important finding was that an elastic polymer insole with good shock absorbency properties did not prevent stress reactions of bone during a 12-week period of vigorous physical training. To control for the confounding effects of running in running shoes, which occurred for about one and one-half hours per week for the first five weeks, we also examined the association of age of shoes and cost of shoes with injury incidence. A slight trend of increasing stress injuries by increasing age of shoes was observed. However, this trend did not account for the similarity of rates in the two insole groups. In addition, we observed a strong trend of decreasing stress injury rate by history of increasing physical activity, as well as a higher stress injury rate in White compared to Black recruits. The results of the trial were not altered after controlling for these factors. This prospective study confirms previous clinical reports of the association of stress fractures with physical activity history. The clinical application of a shock absorbing insole as a preventive for lower extremity stress reactions is not supported in these uniformly trained recruits. The findings are relevant to civilian populations.

A controlled prospective case control study of a prevention training program in female team handball players: the German experience

BACKGROUND

Few authors have investigated the effectiveness of preventive intervention in European team handball.

PURPOSE

The aim of the present study was to evaluate the effects of a prevention program on the incidence of injuries in female European team handball players.

STUDY DESIGN

Prospective controlled study.

METHODS

Ten female handball teams (134 players) took part in the prevention program (1. Information about injury mechanism, 2. Balance-board exercises, 3. Jump training) while 10 other teams (142 players) were instructed to train as usual. Over one season all injuries were documented weekly.

RESULTS

Ankle sprain was the most frequent diagnosis in both groups with 11 ankle sprains in the control group and 7 ankle sprains in the intervention group (Odds ratio: 0.55, 95% confidence interval: 0.22-1.43). The knee was the second frequent injury site. In the control group 5 of all knee injuries were anterior cruciate ligament (ACL) ruptures (incidence: 0.21 per 1000 h) in comparison with one in the intervention group (incidence: 0.04 per 1000 h). Odds ratio was 0.17 with 95% confidence interval of 0.02-1.5.

CONCLUSIONS

This study confirms that proprioceptive and neuromuscular training is appropriate for the prevention of knee and ankle injuries among female European team handball players.

Predictors of hamstring injury at the elite level of Australian football

BACKGROUND

Hamstring injuries are the most common injury sustained by elite Australian football players and result in substantial costs because of missed training time, unavailability for matches and lost player payments. Evidence to support proposed risk factors for hamstring injury is generally lacking, limiting the development of appropriate prevention strategies.

AIM

To identify intrinsic risk factors for hamstring injury at the elite level of Australian football.

METHODS

A prospective cohort of 222 players underwent baseline measurement in the form of a self-report questionnaire and a musculo-skeletal screen during the pre-season period of the 2002 Australian football season. Injury surveillance and exposure data were collected for the full season. Logistic regression analyses were used to identify independent predictors of hamstring injury in this group of players.

RESULTS

Thirty-one players sustained a hamstring injury. A past history (previous 12 months) of hamstring injury and increasing age were found to be independent predictors of hamstring injury.

CONCLUSIONS

Older players and those with a previous history of hamstring injury are target groups for further research and implementation of injury prevention strategies. Restricted ankle dorsiflexion range of movement warrants consideration in the development of prevention programs for hamstring injury.

Increasing hamstring flexibility decreases lower extremity overuse injuries in military basic trainees

The purpose of this intervention study was to prove that increasing flexibility of the hamstring musculotendinous unit would decrease the number of lower extremity overuse injuries that occur in military infantry basic trainees. Two different companies going through basic training at the same time were used. Hamstring flexibility was checked at the beginning and at the end of the 13-week infantry basic training course. The control company (N = 148) proceeded through normal basic training. The intervention company (N = 150) followed the same program but added three hamstring stretching sessions to their already scheduled fitness program. All subsequent lower extremity overuse injuries were recorded through the troop medical clinic. Hamstring flexibility increased significantly in the intervention group compared with the control group. The number of injuries was also significantly lower in the intervention group. Forty-three injuries occurred in the control group for an incidence rate of 29.1%, compared with 25 injuries in the intervention group for an incidence rate of 16.7%. Thus, in this study, the number of lower extremity overuse injuries was significantly lower infantry basic trainees with increased hamstring flexibility.

Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review

OBJECTIVE

To determine the effects of stretching before and after exercising on muscle soreness after exercise, risk of injury, and athletic performance.

METHOD

Systematic review.

DATA SOURCES

Randomised or quasi-randomised studies identified by searching Medline, Embase, CINAHL, SPORTDiscus, and PEDro, and by recursive checking of bibliographies.

MAIN OUTCOME MEASURES

Muscle soreness, incidence of injury, athletic performance.

RESULTS

Five studies, all of moderate quality, reported sufficient data on the effects of stretching on muscle soreness to be included in the analysis. Outcomes seemed homogeneous. Stretching produced small and statistically non-significant reductions in muscle soreness. The pooled estimate of reduction in muscle soreness 24 hours after exercising was only 0.9 mm on a 100 mm scale (95% confidence interval -2.6 mm to 4.4 mm). Data from two studies on army recruits in military training show that muscle stretching before exercising does not produce useful reductions in injury risk (pooled hazard ratio 0.95, 0.78 to 1.16).

CONCLUSIONS

Stretching before or after exercising does not confer protection from muscle soreness. Stretching before exercising does not seem to confer a practically useful reduction in the risk of injury, but the generality of this finding needs testing. Insufficient research has been done with which to determine the effects of stretching on sporting performance.

Retrospective comparison of taping and ankle stabilizers in preventing ankle injuries

The effectiveness of taping and the effectiveness of wearing a laced stabilizer in preventing ankle injuries and reinjuries over six seasons of collegiate football practices and games were assessed retrospectively. For 1 1/2 years the players all had taped ankles, and for the remaining 4 1/2 years the players chose their type of ankle support. Over the entire period, the players chose high-top or low-top shoes as preferred. During 51,931 exposures to injury (46,789 practice-exposures and 5,142 game-exposures), the 297 players sustained 224 ankle injuries and 24 reinjuries. Tape was worn during 38,658 exposures to injury (233 players), stabilizers during 13,273 exposures (127 players). Tape had been worn when 159 of the injuries and 23 of the reinjuries occurred; a stabilizer had been worn when 37 of the injuries (P = 0.003) and one of the reinjuries occurred. The combination allowing the fewest injuries overall was low-top shoes and laced ankle stabilizers.

Hamstring muscle injuries among water skiers. Functional outcome and prevention

Water skiing is associated with severe injuries to the proximal hamstring muscles. We wanted to define the mechanism of injury, describe the associated pathologic changes, determine the functional limitations of patients, and suggest measures to prevent injury. Twelve patients with water skiing-related hamstring injuries were included. Six patients were experienced skiers and six were novices. The mechanism of injury was identical in five of six novice skiers. Each sustained the injury while attempting to get up on one or two skis from a submerged position. In contrast, the expert skiers all sustained injury secondary to a fall while skiing. Physical examination documented evidence of complete or partial avulsion of the proximal hamstring muscle origins in all patients. In addition, six patients had magnetic resonance imaging or computed tomography scans that confirmed the location and extent of the tear. Convalescence ranged from 3 months to 1.5 years before the patient could return to vigorous activities. Seven patients (58%) returned to most of their preinjury sports, albeit at a lower level. Five patients (42%), all with complete disruptions, were unable to run or participate in sports requiring agility. Two of these patients required delayed surgical repairs because of persistent functional limitations.

Evidence based prevention of hamstring injuries in sport

A common soft tissue injury in sports involving sprinting and jumping is the hamstring strain. A major problem with hamstring strains is the high incidence of reinjury. Muscle injuries can be classified as direct or indirect and are typically grouped into three categories according to severity. A number of potential risk factors have been proposed for hamstring strains. Only a few are evidence based and some are mainly based on theoretical assumptions. There is a lack of clinical research on the effectiveness of rehabilitation programmes for hamstring strains. Although the initial treatment of rest, ice, compression, and elevation is accepted for muscle strains, no consensus exists for their rehabilitation. Not much evidence based research has been carried out on prevention of hamstring strain. To our knowledge only two prospective studies have so far been published. As the injuries are common in football and other sports involving sprinting and jumping, there is a need for further research preferably in the form of randomised controlled trials.

Prevention of running injuries by warm-up, cool-down, and stretching exercises

The purpose of this study was to evaluate the effect of a health education intervention on running injuries. The intervention consisted of information on, and the subsequent performance of, standardized warm-up, cool-down, and stretching exercises. Four hundred twenty-one male recreational runners were matched for age, weekly running distance, and general knowledge of preventing sports injuries. They were randomly split into an intervention and a control group: 167 control and 159 intervention subjects participated throughout the study. During the 16-week study, both groups kept a daily diary on their running distance and time, and reported all injuries. In addition, the intervention group was asked to note compliance with the standardized program. At the end of the study period, knowledge and attitude were again measured. There were 23 injuries in the control group and 26 in the intervention group. Injury incidence for control and intervention subjects was 4.9 and 5.5 running injuries per 1000 hours, respectively. The intervention was not effective in reducing the number of running injuries; it proved significantly effective (P < 0.05) in improving specific knowledge of warm-up and cool-down techniques in the intervention group. This positive change can perhaps be regarded as a first step on the way to a change of behavior, which may eventually lead to a reduction of running injuries.

Lower extremity injuries in drivers of airbag-equipped automobiles: clinical and crash reconstruction correlations

OBJECTIVE AND DESIGN

To determine the relationship between airbags and lower extremity injuries, 10 drivers admitted to a level-I trauma center with substantial lower extremity trauma incurred in crashes involving airbag-equipped vehicles were studied in depth with regard to their injuries, the circumstances of the crashes, and the medical charges for the acute management of those injuries.

MATERIALS AND METHODS

During the clinical investigation portion of this study, we photographed lower extremity injuries, both soft tissue and radiographs, and performed a detailed surgical exploration during the debridement of open wounds or fracture fixation to treat them appropriately and to define the mechanism of injury, the fracture pattern, the pattern of soft-tissue insult, and the extent of periosteal stripping. We recorded the hospital and professional charges associated with the acute management not only of these injuries, but of the other injuries as well. The analysis performed for each case included a detailed crash reconstruction, including force, contact point, and vehicle intrusion data. Particular attention was paid to the dashboard and toe pan areas to determine deformation and intrusion and their association with thigh, leg, and foot injuries. Pertinent deformation and trajectory information was entered into the Calspan Reconstruction of Accident Speeds on the Highway (CRASH) computer program to generate a delta V or change in velocity measurement used as a measure of collision severity. When field data were incompatible with the limitations of the CRASH program, manual calculations such as "slide to stop" and conservation of momentum formulas were used.

RESULTS

The seven male and three female drivers had a mean age of 39.4 years. Only four used seatbelt restraints. The mean delta V was 28.3 mph and the mean maximum crush was 32.4 inches. The mean Injury Severity Score of 13.2. Musculoskeletal injuries included 11 foot/ankle fractures, 6 tibial fractures, 2 patellar fractures, 6 femoral fractures, and two acetabular/pelvic fractures. Other trauma included abdominal, thoracic, head and upper torso injuries, it seems that these safety devices do not prevent injuries to the lower extremity.

Reductions in pre-season training loads reduce training injury rates in rugby league players

OBJECTIVES

To investigate if reductions in pre-season training loads reduced the incidence of training injuries in rugby league players, and to determine if the reductions in training loads compromised the improvements in physical fitness obtained during the pre-season preparation period.

METHODS

A total of 220 sub-elite rugby league players participated in this 3 year prospective study. Players underwent measurements of speed, muscular power, and maximal aerobic power before and after three 4 month (December to March) pre-season preparation periods (2001-2003). A periodised skills and conditioning program was implemented, with training loads progressively increased in the general preparatory phase of the season (December to February) and reduced slightly in March in preparation for the competitive phase of the season. Training loads were calculated by multiplying the training session intensity by the duration of the training session. Following the initial season (2001), training loads were reduced through reductions in training duration (2002) and training intensity (2003). The incidence of injury was prospectively recorded over the three pre-season periods.

RESULTS

The training loads for the 2002 and 2003 pre-season periods were significantly lower (p<0.001) than those in 2001. The incidence of injury was significantly higher in the 2001 pre-season than the 2002 and 2003 pre-season periods. The increases in maximal aerobic power progressively improved across the three seasons with a 62-88% probability that the 2002 and 2003 pre-season improvements in maximal aerobic power were of greater physiological significance than the 2001 pre-season improvements in maximal aerobic power.

CONCLUSIONS

These findings demonstrate that reductions in pre-season training loads reduce training injury rates in rugby league players and result in greater improvements in maximal aerobic power.

Stress fractures and bone health in track and field athletes

The effect of exercise on bone health has received much attention in recent years. The problems of the female athlete triad: disordered eating, amenorrhea and osteoporosis have helped us to better understand and appreciate the important interaction of mechanical, hormonal, nutritional as well as genetic factors on bone health in the young female athlete. The relatively high stress fracture incidence of young track and field athletes can be quite disabling for the athlete's present and future running career. A number of risk factors including low bone mineral density (BMD), menstrual irregularities, dietary factors and prior history of stress fractures have been associated with an increased risk for stress fractures in the female athlete. Few studies have found risk factors for stress fractures in the male athlete. Female gender has been found to be a risk factor for stress fractures in the military population, but this finding is less apparent in athlete studies. Caucasians have been found to have a higher risk for stress fractures than African-American military recruits, but there is very limited data assessing stress fracture risk in athletes of varying ethnicity. Prevention of stress injury to bone involves maximizing peak bone mass in the pediatric and young adult age groups. Maintaining adequate calcium nutrition, caloric intake as well as hormonal and energy balance are important preventive measures, as are ensuring appropriate amounts of weight bearing exercise for optimizing bone health and preventing fractures. More research is needed to determine factors leading to improvements in bone density and fracture reduction in athletes at risk.

Alpine ski bindings and injuries. Current findings

In spite of the fact that the overall incidence of alpine ski injuries has decreased during the last 25 years, the incidence of serious knee sprains usually involving the anterior cruciate ligament (ACL) has risen dramatically since the late 1970s. This trend runs counter to a dramatic reduction in lower leg injuries that began in the early 1970s and to date has lowered the risk of injury below the knee by almost 90%. One of the primary design objectives of modern ski boots and bindings has been to protect the skier from tibia and ankle fractures. So, in that sense, they have done an excellent job. However, despite advances in equipment design, modern ski bindings have not protected the knee from serious ligament trauma. At the present time, we are unaware of any binding design, settings or function that can protect both the knee and lower extremities from serious ligament sprains. No innovative change in binding design appears to be on the horizon that has the potential to reduce the risk of these severe knee injuries. Indeed, only 1 study has demonstrated a means to help reduce this risk of serious knee sprains, and this study involved education of skiers, not ski equipment. Despite the inability of bindings to reduce the risk of severe knee injuries there can be no doubt that improvement in ski bindings has been the most important factor in the marked reduction in incidence of lower leg and ankle injuries during the last 25 years. The authors strongly endorse the application of present International Standards Organisation (ISO) and American Society for Testing and Materials (ASTM) standards concerning mounting, setting and maintaining modern 'state of the art' bindings.

Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults

BACKGROUND

Stress reaction in bone, which may proceed to a fracture, is a significant problem in military recruits and in athletes, particularly long distance runners.

OBJECTIVES

To evaluate the evidence from randomised controlled trials of interventions for prevention or management of lower-limb stress fractures and stress reactions of bone in active young adults.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group Specialised Register (April 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to September week 1, 2004), EMBASE, CINAHL, Index to UK Theses, reference lists of relevant articles and contacted trialists.

SELECTION CRITERIA

Any randomised or quasi-randomised trials evaluating interventions for preventing or treating lower limb stress reactions of bone or stress fractures in active young adults.

DATA COLLECTION AND ANALYSIS

We independently selected trials for inclusion, assessed trial quality and extracted data. Only limited data pooling was undertaken.

MAIN RESULTS

We included 16 trials. All 13 prevention trials involved military recruits undergoing training. Participants of two of the three treatment trials were military personnel. Ten prevention trials tested the effects of various foot inserts and other footwear modifications. While pooling of data was not possible, the four trials evaluating the use of "shock-absorbing" boot inserts versus control found fewer stress injuries of the bone in their intervention groups. However, the only trial showing a significant benefit lacked important information about trial design. A key issue in several trials was the acceptability, in terms of practicality and comfort, of the boot inserts. Two cluster-randomised prevention trials found no significant effect of leg muscle stretching during warm up before exercise. Pooled data from three small but very different trials testing the use of pneumatic braces in the rehabilitation of tibial stress fractures showed a significant reduction in the time to recommencing full activity (weighted mean difference -33.39 days, 95% confidence interval -44.18 to -22.59 days). These results were highly heterogeneous (I squared = 90%), which is likely to reflect the underlying differences of the trials, including differences in the control group interventions and definitions of outcomes.

AUTHORS' CONCLUSIONS

The use of shock absorbing inserts in footwear probably reduces the incidence of stress fractures in military personnel. There is insufficient evidence to determine the best design of such inserts but comfort and tolerability should be considered. Rehabilitation after tibial stress fracture may be aided by the use of pneumatic bracing but more evidence is required to confirm this.

The prevention of shin splints in sports: a systematic review of literature

PURPOSE

To review the published and unpublished evidence regarding risk factors associated with shin splints, assess the effectiveness of prevention strategies, and offer evidence-based recommendations to coaches, athletes, and researchers.

METHODS

We searched electronic data bases without language restriction, identified citations from reference sections of research papers retrieved, contacted experts in the field, and searched the Cochrane Collaboration. Of the 199 citations identified, we emphasized results of the four reports that compared methods to prevent shin splints. We assessed the methodologic quality of these reports by using a standardized instrument.

RESULTS

The use of shock-absorbent insoles, foam heel pads, heel cord stretching, alternative footwear, as well as graduated running programs among military recruits have undergone assessment in controlled trials. There is no strong support for any of these interventions, and each of the four controlled trials is limited methodologically. Median quality scores in these four studies ranged from 29 to 47, and serious flaws in study design, control of bias, and statistical methods were identified.

CONCLUSION

Our review yielded little objective evidence to support widespread use of any existing interventions to prevent shin splints. The most encouraging evidence for effective prevention of shin splints involves the use of shock-absorbing insoles. However, serious flaws in study design and implementation constrain the work in this field thus far. A rigorously implemented research program is critically needed to address this common sports medicine problem.