University of Groningen. Injury prevention in team sport athletes Dallinga, Joan

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1 University of Groningen Injury prevention in team sport athletes Dallinga, Joan IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record Publication date: 2017 Link to publication in University of Groningen/UMCG research database Citation for published version (APA): Dallinga, J. (2017). Injury prevention in team sport athletes: The role of screening tools and injury prevention programs [Groningen]: Rijksuniversiteit Groningen Copyright Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons). Take-down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Downloaded from the University of Groningen/UMCG research database (Pure): For technical reasons the number of authors shown on this cover page is limited to 10 maximum. Download date:

2 1 General IntroductIon

3 Chapter 1 8

4 General introduction In the Netherlands, 26% of males and 13% of females (six years and older) participate 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 season to the 2016 season, 2 bringing the total number of female soccer players in the Netherlands to 151, Though this is a positive development, it needs to be considered that the risk of getting injured in team sports is considerably 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 prevention programs for lower extremity injuries. Chapter 1 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 consists 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 implementation of prevention programs in the field. To address this limitation, Finch 5 extended the injury sequence model by adding two steps. Steps 5 and 6 were designed to assist in the implementation of the prevention programs and take into account the context of implementation (Figure 1.1). 5 In this thesis we will focus on steps two, three and four of the TRIPP framework: 2) establish etiology and mechanism of injury, 3 & 4) developing and evaluating 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 injuries, whereas the second part concentrates on ACL injury prevention programs. 9

5 Chapter 1 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 Netherlands, 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 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-efficacy and motivation may influence return to play. 10 Other consequences include 10

6 General introduction 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 direction, 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 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 injuries 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 injuries 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 exposure 27 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 internal 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 opponent, 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 potentially 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. Chapter 1 11

7 Chapter 1 Limitations current screening tools In recent years, there has been an increasing interest in risk factors and screening tools for lower extremity injuries in team sports 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, Bahr 31 described that validity of current screening tools for predicting and preventing injuries is limited. Specifically, the studies so far have examined the predictive 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 results 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 knowledge 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 rehabilitation 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 investment and it would not require prospective studies. 34 An overview of the literature regarding the effect of interventions on modifiable, 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 athletes, 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 Finch 5 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. 12

8 General introduction Limitations current ACL injury prevention programs The effect of ACL injury prevention programs on injury rates 35 and risk factors, such as landing kinematics and kinetics has been evaluated 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 widespread implementation of the programs in a real sports setting has not been accomplished 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 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 learning 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 programs has tended to focus on instructions that focus attention internally. 37,50,51 Adding 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 Chapter 1 13

9 Chapter 1 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 anthropometrics 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, however 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 prevention 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, basketball, 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 suggestions for future research. 14

10 General introduction RefeReNCeS 1. CBS: Actieve en passieve sportparticipatie; personen van 6 jaar en ouder. Updated KNVB. Meiden- en vrouwenvoetbal. Accessed 9/25, VeiligheidNL. Sport blessures. blessurecijfers. VeiligheidNL Web site. Updated Accessed October/15, Van Mechelen W, Hlobil H, Kemper H. Incidence, severity, aetiology and prevention of sports injuries. A review of concepts. Sports Med. 1992;14(2): Finch C. A new framework for research leading to sports injury prevention. J Sci Med Sport. 2006;9(1): Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: Summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42(2): Agel J, Olson DE, Dick R, Arendt EA, Marshall SW, Sikka RS. Descriptive epidemiology of collegiate women s basketball injuries: National collegiate athletic association injury surveillance system, through J Athl Train. 2007;42(2): Dick R, Hertel J, Agel J, Grossman J, Marshall SW. Descriptive epidemiology of collegiate men s basketball injuries: National collegiate athletic association injury surveillance system, through J Athl Train. 2007;42(2): Agel J, Rockwood T, Klossner D. Collegiate ACL injury rates across 15 sports: National collegiate athletic association injury surveillance system data update ( through ). Clin J Sport Med Ardern CL, Glasgow P, Schneiders A, et al consensus statement on return to sport from the first world congress in sports physical therapy, bern. Br J Sports Med Shelbourne KD, Gray T, Haro M. Incidence of subsequent injury to either knee within 5 years after anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med. 2009;37(2): Paterno MV, Schmitt LC, Ford KR, et al. Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport. Am J Sports Med. 2010;38(10): Øiestad BE, Engebretsen L, Storheim K, Risberg MA. Knee osteoarthritis after anterior cruciate ligament injury. Am J Sports Med. 2009;37(7): Gross P, Marti B. Risk of degenerative ankle joint disease in volleyball players: Study of former elite athletes. Int J Sports Med. 1999;20(01): Ardern CL, Taylor NF, Feller JA, Whitehead TS, Webster KE. Psychological responses matter in returning to preinjury level of sport after anterior cruciate ligament reconstruction surgery. Am J Sports Med. 2013;41(7): Hewett TE, Ford KR, Myer GD. Anterior cruciate ligament injuries in female athletes: Part 2, a meta-analysis of neuromuscular interventions aimed at injury prevention. Am J Sports Med. 2006;34(3): Hupperets MDW, Verhagen EALM, Heymans MW, Bosmans JE, Van Tulder MW, Van Mechelen W. Potential savings of a program to prevent ankle sprain recurrence. Am J Sports Med. 2010;38(11): Alentorn-Geli E, Myer GD, Silvers HJ, et al. Prevention of non-contact anterior cruciate ligament injuries in soccer players. part 1: Mechanisms of injury and underlying risk factors. Knee Surg Sports Traumatol Arthrosc. 2009;17(7): Krosshaug T, Nakamae A, Boden BP, et al. Mechanisms of anterior cruciate ligament injury in basketball video analysis of 39 cases. Am J Sports Med. 2007;35(3): Shin CS, Chaudhari AM, Andriacchi TP. Valgus plus internal rotation moments increase anterior cruciate ligament strain more than either alone. Med Sci Sports Exerc. 2011;43(8): Koga H, Nakamae A, Shima Y, et al. Mechanisms for noncontact anterior cruciate ligament injuries knee joint kinematics in 10 injury situations from female team handball and basketball. Am J Sports Med. 2010;38(11): Chapter 1 15

11 Chapter Ferran NA, Maffulli N. Epidemiology of sprains of the lateral ankle ligament complex. Foot Ankle Clin. 2006;11(3): Brooks JH, Fuller CW, Kemp SP, Reddin DB. Incidence, risk, and prevention of hamstring muscle injuries in professional rugby union. Am J Sports Med. 2006;34(8): Elliott MC, Zarins B, Powell JW, Kenyon CD. Hamstring muscle strains in professional football players: A 10-year review. Am J Sports Med. 2011;39(4): Bahr R, Holme I. Risk factors for sports injuries a methodological approach. Br J Sports Med. 2003;37(5): Meeuwisse WH. Assessing causation in sport injury: A multifactorial model. Clin J Sport Med. 1994;4(3): World Health Organization. Risk factors. Accessed January, Bahr R, Krosshaug T. Understanding injury mechanisms: A key component of preventing injuries in sport. Br J Sports Med. 2005;39(6): Fox AS, Bonacci J, McLean SG, Spittle M, Saunders N. A systematic evaluation of field-based screening methods for the assessment of anterior cruciate ligament (ACL) injury risk. Sports Med. 2015;46(5): Rafeeuddin R, Sharir R, Staes F, et al. Mapping current research trends on neuromuscular risk factors of non-contact ACL injury. Phys Ther Sport. 2016;22: Bahr R. Why screening tests to predict injury do not work-and probably never will...: A critical review. Br J Sports Med. 2016;50(13): Langford JL, Webster KE, Feller JA. A prospective longitudinal study to assess psychological changes following anterior cruciate ligament reconstruction surgery. Br J Sports Med. 2009;43(5): Mather RC,3rd, Koenig L, Kocher MS, et al. Societal and economic impact of anterior cruciate ligament tears. J Bone Joint Surg Am. 2013;95(19): Monajati A, Larumbe-Zabala E, Goss-Sampson M, Naclerio F. The effectiveness of injury prevention programs to modify risk factors for non-contact anterior cruciate ligament and hamstring injuries in uninjured team sports athletes: A systematic review. PloS one. 2016;11(5):e Alentorn-Geli E, Myer GD, Silvers HJ, et al. Prevention of non-contact anterior cruciate ligament injuries in soccer players. part 2: A review of prevention programs aimed to modify risk factors and to reduce injury rates. Knee Surg Sports Traumatol Arthrosc. 2009;17(8): Lim BO, Lee YS, Kim JG, An KO, Yoo J, Kwon YH. Effects of sports injury prevention training on the biomechanical risk factors of anterior cruciate ligament injury in high school female basketball players. Am J Sports Med. 2009;37(9): Chappell JD, Limpisvasti O. Effect of a neuromuscular training program on the kinetics and kinematics of jumping tasks. Am J Sports Med. 2008;36(6): Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes. Am J Sports Med. 2005;33(7): Soligard T, Myklebust G, Steffen K, et al. Comprehensive warm-up programme to prevent injuries in young female footballers: Cluster randomised controlled trial. BMJ. 2008;337:a2469-a Agel J, Arendt EA, Bershadsky B. Anterior cruciate ligament injury in national collegiate athletic association basketball and soccer a 13-year review. Am J Sports Med. 2005;33(4): Waldén M, Hägglund M, Magnusson H, Ekstrand J. Anterior cruciate ligament injury in elite football: A prospective three-cohort study. Knee Surg Sports Traumatol Arthrosc. 2011;19(1): Benjaminse A, Gokeler A, Dowling A, et al. Optimization of the ACL injury prevention paradigm: Novel feedback techniques to enhance motor learning and reduce injury risk. J Orthop Sports Phys Ther. 2015;45(3): Benjaminse A, Otten E. ACL injury prevention, more effective with a different way of motor learning? Knee Surg Sports Traumatol Arthrosc. 2011;19(4):

12 General introduction 44. Sugimoto D, Myer GD, Bush HM, Klugman MF, Medina McKeon JM, Hewett TE. Compliance with neuromuscular training and anterior cruciate ligament injury risk reduction in female athletes: A meta-analysis. J Athl Train. 2012;47(6): Hagglund M, Atroshi I, Wagner P, Walden M. 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. Br J Sports Med. 2013;47(15): Joy EA, Taylor JR, Novak MA, Chen M, Fink BP, Porucznik CA. Factors influencing the implementation of anterior cruciate ligament injury prevention strategies by girls soccer coaches. J Strength Cond Res. 2013;27(8): Wulf G. Attentional focus and motor learning: A review of 10 years of research. E-journal Bewegung und Training. 2007;1(2-3): Benjaminse A, Welling W, Otten B, Gokeler A. Novel methods of instruction in ACL injury prevention programs, a systematic review. Phys Ther Sport. 2014;Jun 19. doi: /j.ptsp Wulf G, Shea C, Lewthwaite R. Motor skill learning and performance: A review of influential factors. Med Educ. 2009;44(1): Myer GD, Ford KR, Brent JL, Hewett TE. The effects of plyometric vs. dynamic stabilization and balance training on power, balance, and landing force in female athletes. J Strength Cond Res. 2006;20(2): Myklebust G, Engebretsen L, Brækken IH, Skjølberg A, Olsen OE, Bahr R. Prevention of anterior cruciate ligament injuries in female team handball players: A prospective intervention study over three seasons. Clin J Sport Med. 2003;13(2): Prinz W. Experimental approaches to imitation. In: Meltzoff AN, Prinz W, eds. The imitative mind. Cambridge (UK): Cambridge University Press; 2002: Calvo-Merino B, Glaser DE, Grezes J, Passingham RE, Haggard P. Action observation and acquired motor skills: An FMRI study with expert dancers. Cereb Cortex. 2005;15(8): Rizzolatti G, Fogassi L, Gallese V. Neurophysiological mechanisms underlying the understanding and imitation of action. Nat Rev Neurosci. 2001;2(9): Etnoyer J, Cortes N, Ringleb SI, Van Lunen BL, Onate JA. Instruction and jump-landing kinematics in college-aged female athletes over time. J Athl Train. 2013;48(2): Munro A, Herrington L. The effect of videotape augmented feedback on drop jump landing strategy: Implications for anterior cruciate ligament and patellofemoral joint injury prevention. Knee. 2014;21(5): Chapter 1 17

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