University of Groningen

Injury prevention in team sport athletesDallinga, Joan

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Citation for published version (APA):Dallinga, J. (2017). Injury prevention in team sport athletes: The role of screening tools and injuryprevention programs. [Groningen]: Rijksuniversiteit Groningen.

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Injury preventIon In team sport athletes

Joan Dallinga

General IntroductIon1

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Chapter 1

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In the Netherlands, 26% of males and 13% of females (six years and older) partic-ipate in team sports,1 of which soccer, volleyball and basketball are most popular. The number of female soccer players is increasing.2 A 4% increase was reported from the 2014-2015 season to the 2016 season,2 bringing the total number of female soccer players in the Netherlands to 151,987.2 Though this is a positive development, it needs to be considered that the risk of getting injured in team sports is consider-ably high. For instance, in 2013, 850,000 injuries occurred in soccer (4.3 per 1000 sport hours).3 Considering the large number of participants, need for research on the prevention of injuries in team sports in the Netherlands is obvious. The goal of this thesis is to increase our knowledge about the role of injury screening tools and pre-vention programs for lower extremity injuries.

Injury prevention framework In 1992, the sequence of prevention model by Van Mechelen et al.4 was introduced as a guideline for research with regards to the prevention of injuries. This model con-sists of four steps as presented in Figure 1.1. The first step is identifying the problem and describing the injury incidence and severity. The second step is identifying the mechanisms and risk factors that play a role in the occurrence of sport injuries. The third step of the sequence of prevention model is trying to reduce the risk of injury by offering an individualized prevention program to at-risk athletes. The fourth and last step is evaluating the effectiveness of the developed and implemented prevention programs.4 A limitation of the sequence of injury prevention is a lack of addressing the im-plementation of prevention programs in the field. To address this limitation, Finch5 extended the injury sequence model by adding two steps. Steps 5 and 6 were de-signed to assist in the implementation of the prevention programs and take into ac-count the context of implementation (Figure 1.1).5 In this thesis we will focus on steps two, three and four of the TRIPP frame-work: 2) establish etiology and mechanism of injury, 3 & 4) developing and evaluat-ing the effect of a new ACL injury prevention program in lab and field respectively. The first part of this thesis concentrates on screening tools for lower extremity inju-ries, whereas the second part concentrates on ACL injury prevention programs.

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figure 1.1. Injury prevention framework. The inner circle (grey) is the injury prevention sequence.4 The outer circle (blue) is the TRIPP framework.5 Adapted from Van Mechelen et al.4 and Finch.5 This thesis concentrates on steps two, three and four.

extent of the problem (step 1, TRIPP)Several studies have documented the injury incidence of lower extremity injuries in team sports (step 1, TRIPP).6-9 In team sports, injuries to the lower extremities show the highest injury rates. A large part of these injuries are classified as acute, such as anterior cruciate ligament (ACL), ankle and hamstring injuries.6-8 In the Nether-lands, 20% of all sport injuries are knee injuries, 18% are ankle injuries and 6% are upper leg injuries.3 An ACL injury is one of the most severe injuries a team sport athlete can experience, considering the long rehabilitation needed, greater chance of reoccurrence of the injury and limited sports participation.10-12 The above mentioned injuries result in short-term physical disability and pain after the injury, as well as long-term consequences such as the development of osteoarthritis after an ACL or ankle injury.13,14 These injuries can also cause psychological effects, such as fear of reinjury, that affect return to play.10,15 In addition, cognitive factors such as self-ef-ficacy and motivation may influence return to play.10 Other consequences include

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significant medical costs for the individual athlete and for society.3,16,17 All in all, it is clear that these injuries to the lower extremity in team sports are a serious problem and warrants attention.

Injury mechanisms, risk factors and screening tools (step 2, TRIPP)The etiology of lower extremity injuries has been studied in previous literature (step 2, TRIPP). The mechanisms for ACL injuries include deceleration, change of di-rection, landing and initial contact with the ground without contact with another athlete.18,19 Studies using video analyses and an in vivo study of ACL injuries showed that in most cases a fast change in knee valgus angle, combined with knee extension and knee rotation resulted in the tear of the ACL.19-21 In these studies initial contact after a landing was analyzed. The ACL tear occurred within 40ms, therefore it could also be that knee valgus is a result of or continues after the ACL tear.21 Ankle inju-ries often occur during landing, landing or stepping on the foot of another athlete, running (heel strike) or when the foot is fixed to the ground and stress is applied.22 Ankle inversion, ankle plantar flexion and internal rotation during these movements can lead to an ankle sprain.22 Additionally, potential mechanisms for hamstring inju-ries are sprinting and running, acceleration, deceleration, changing of direction and kicking.23,24

This knowledge on injury mechanisms may provide insight for the exploration of risk factors and screening tools for injuries.25,26 A risk factor is a characteristic, attribute or exposure27 that increases the risk for an athlete to sustain an injury and can be categorized as internal (e.g. physical fitness and anatomy) and external (e.g. environment and sports equipment).25 Meeuwisse developed a multifactorial model of injury etiology.26 This model showed that injuries may be caused by multiple in-ternal and external risk factors, that interact with each other. Joint kinematics and kinetics at the time of the injury (i.e. internal) as well as the behavior of the oppo-nent, the environment and the playing situation (i.e. external) need to be taken into account.28 Some internal risk factors are fixed such as sex, anatomy and previous injury, while other risk factors such as landing technique and balance could poten-tially be influenced.25 The emphasis of this thesis will be on risk factors that can be influenced. Based on the knowledge of injury risk factors, screening tools can be developed and evaluated. Screening tools are tests or a combination of tests that can be used by coaches, trainers and medical staff to determine injury risk, for example prior to the competitive season. The first part of this thesis concentrates on finding predictive screening tools for lower extremity injuries.

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Limitations current screening toolsIn recent years, there has been an increasing interest in risk factors and screening tools for lower extremity injuries in team sports.29-31 Several risk factors have been examined and screening tests have been proposed for lower extremity injuries. This is crucial as it forms the basis of the development of injury prevention programs.5 Recently, Bahr31 described that validity of current screening tools for predicting and preventing injuries is limited. Specifically, the studies so far have examined the pre-dictive value of a certain marker in a specific population, however these markers have not been validated in other populations.31 An overview of current study re-sults in regards to predictability of screening tools will provide relevant input for the validation of these tools. Moreover, insight into which tests are predictive of lower extremity injuries would be valuable to coaches, trainers and medical staff. If the screening tests are easy to use, inexpensive, sport-specific and it is clear what these tests measure, coaches may be more willing to use them in practice.29 This knowl-edge could be used in the field or in the clinic for screening athletes.

Developing and evaluating injury prevention programs (step 3 & 4, TRIPP)The second part of this thesis concentrates on the development and evaluation of prevention programs (step 3 & 4, TRIPP). The focus is primarily on ACL injury prevention programs, because of the severity of this injury, illustrated by a long re-habilitation period combined with large costs, a greater chance of reinjury, inability to reach pre-injury level of sport, psychological consequences and a greater chance for developing osteoarthritis.13,15,18,32,33 In this thesis, we focus on reducing the risk of injury and use screening tools as a method to determine injury risk. This indirect measure implies potential benefits, such as a smaller sample size, less time invest-ment and it would not require prospective studies.34

An overview of the literature regarding the effect of interventions on modifia-ble, potential risk factors for knee injuries in team ball sports will be provided (step 4, TRIPP). This overview will include prevention programs for female and male ath-letes, or a combination of both. Reducing barriers to implement and optimize current ACL injury prevention programs is also a topic of interest. This corresponds with steps three and four of the TRIPP model.4 As Finch5 explained, implementation of an injury prevention program is often problematic.5 Therefore, an injury prevention program should take into account the context of the implementation at community level (step 5 & 6, TRIPP). For instance, athletes and coaches need to accept, adopt and comply with a program.

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Limitations current ACL injury prevention programsThe effect of ACL injury prevention programs on injury rates35 and risk factors, such as landing kinematics and kinetics has been evaluated.36-39 These programs included neuromuscular, strength, balance, trunk control and plyometric exercises. However, long-term effects of current ACL injury prevention programs are limited. In fact, the overall number of ACL injuries has not decreased in the last decades.9,40,41 A wide-spread implementation of the programs in a real sports setting has not been accom-plished yet (step 6, TRIPP). This may be attributed to problems with the transfer of learned skills to the game or adherence of coaches to current programs.42-46 Issues with transfer of learned skills to the game could be explained by the focus of attention used in ACL injury prevention programs.43 Directing attention to the effect of a movement (external focus of attention (EF)) enhances performance and learning of motor skills.47,48 In contrast, directing attention to the individual’s body segments (internal focus of attention (IF)), has a negative influence on learn-ing a motor task.47,49 According to the constrained action hypothesis, consciously trying to control movements that usually are automatically regulated will disrupt automatic learning processes and will decrease the efficiency and effectiveness of that movement.47 Automatic learning processes can be enhanced by EF instructions and observational learning (imitation).49

Recent studies suggest that the use of an EF may be beneficial for prevention purposes.42,43 However, the research to date regarding ACL injury prevention pro-grams has tended to focus on instructions that focus attention internally.37,50,51 Add-ing an EF may facilitate the implementation of ACL injury prevention programs by optimizing transfer from learning movements during training to performing those movements in the field (step 6, TRIPP). An EF can be enhanced by a simple change of verbal instructions or by providing visual feedback. Based on motor learning principles,47,52-54 these are promising methods to improve motor skill execution.42 Furthermore, these methods are clinically applicable. For instance, instead of telling the athlete to “bend your knees”, an IF instruction, you can say “land softly”, an EF instruction. An example of visual instruction or feedback observing expert and self-movies, which has been shown to be a promising way to learn motor tasks.55,56

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oUTLINe of THe THeSIS

The aim of this thesis is to increase knowledge about available injury screening tools and prevention programs for lower extremity injuries. In Chapter 2 a systematic review is presented where the predictive values of anthro-pometrics and physical screening tests for injuries to the leg in general, ACL, knee, hamstring, groin and ankle in team sports are described. There is some evidence that postural stability or balance tests can predict the occurrence of ankle sprains, howev-er these tests included static balance tasks and were not sport-specific. Accordingly, Chapter 3 elaborates on the potential of dynamic postural stability measured during a landing task in discriminating between athletes with and without an ankle sprain. Preseason dynamic postural stability differences between athletes that sustained an ankle sprain in the subsequent season and non-injured athletes were evaluated as well as dynamic postural stability differences between athletes with and without a history of an ankle sprain. This is followed by the development of a new prevention program for ACL injuries. First, in Chapter 4 an overview of literature is presented regarding the effect of interventions on modifiable, potential risk factors for knee injuries in team ball sports. Verbal or video feedback is an important component in a knee injury prevention program for reducing ACL injury risk factors. Therefore, two ACL injury prevention programs were developed and evaluated for their potential to decrease ACL injury risk. In an attempt to improve current ACL injury programs, an EF was encouraged by using verbal (EF) instructions and by providing video feedback. Chapter 5 presents the feasibility and effects of an IF and an EF ACL injury pre-vention program integrated in a warmup for female soccer athletes. Subsequently, in Chapter 6 the effect of an innovative type of video feedback, including expert and self-movies, on DVJ landing strategies is evaluated in male and female soccer, bas-ketball, handball and korfball athletes. Separate analyses were performed for males and females. The video feedback was provided by means of an overlay of expert and athlete movement that allowed direct comparison. Therefore, the effect of video feedback with overlay method on overlap of athlete and expert contours in male and female team sport athletes during training sessions while performing a DVJ was determined as well. Finally, results from all chapters are discussed from a broader perspective in Chapter 7, followed by practical applications, conclusions and sug-gestions for future research.

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Injury preventIon In team sport athletes

Joan Dallinga

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