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This systematic review set out to identify randomised controlled of this review is to examine prevention strategies
in adolescent sport, focusing specifically on sports
trials and controlled intervention studies that evaluated the that are available in schools. The specific objectives
effectiveness of preventive strategies in adolescent sport and to of this systematic review are:
draw conclusions on the strength of the evidence. A literature
search in seven databases (Medline, SportDiscus, EMBASE, N (a) To identify randomised controlled trials and
controlled intervention studies that evaluate the
CINAHL, PEDro, Cochrane Review and DARE) was carried out effectiveness of preventive strategies in adoles-
using four keywords: adolescent, sport, injury and prevention cent sport.
(expanded to capture any relevant literature). Assessment of N (b) To make conclusions on the strength of the
evidence supporting methods used to prevent
154 papers found 12 studies eligible for inclusion. It can be injury.
concluded that injury prevention strategies that focus on
preseason conditioning, functional training, education, balance
and sport-specific skills, which should be continued throughout METHODS
Search strategy and selection of studies
the sporting season, are effective. The evidence for the
Relevant studies were identified using a computer-
effectiveness of protective equipment in injury prevention is based literature search in seven databases (Medline
inconclusive and requires further assessment. 1966January 2006, SportDiscus, EMBASE (1974
............................................................................. January 2006), CINAHL (1982January 2006),
PEDro and Cochrane Databases: Cochrane Review
and DARE) using four keywords: adolescent, sport,
S
port is the main cause of injury in adoles- injury and prevention. These keywords were
cents.1 2 Young people are at particular risk of expanded to capture any relevant literature:
sports injury because of high levels of
exposure at a time of major physiological N (1) Adolescent OR youth OR (high+school+stu-
dent) OR school age OR school+pupil
change.3 4 Prevention of injury is important for
several reasons not least the initial impact on N (2) Injury
health and long-term outcomethat is, early
development of osteoarthritis.5 (a) wounds AND injuries exp.
Although most sports injuries are not severe (b) sport$ injur$ OR athletic$ injur$
enough to require hospitalisation, they are frequent (c) sprain$ OR strain$ OR twist$ OR tear$
and have a major economic impact through direct OR pull OR break$ OR fracture$ OR
medical costs, treatment and rehabilitation, and
(d) soft tissue injur$ Or acute injury
indirect costs, including parents taking time off to
care for injured offspring.2 6 In addition, injury (e) chronic injur$ OR overuse injury OR
prevents future involvement in physical activity, cumulative trauma OR repetitive trauma OR
and about 8% of adolescents drop out of recreational tendonitis OR tendinopathy
sporting activities annually because of injury.7 There (f) concussion OR head injury
are long-term public health consequences associated (g) major trauma OR catastrophic injury OR
with inactivity in terms of cardiovascular disease, death
See end of article for obesity, etc, but injury may also interfere with the
authors affiliations potential benefits of greater self-esteem, relaxation, N (3) Sport
........................ socialisation, teamwork and fitness associated with
sport participation at this age.8 (a) explode sports
Correspondence to:
Dr Liz Abernethy, Injury prevention generally focuses on modifi- (b) sport$ OR exercise OR athletic$ OR
Physicians Office, W3A able risk factors: extrinsic factors, such as equip- physical education OR school games
Withers Orthopaedic Unit, ment, playing surface, rule changes and playing
Musgrave Park Hospital,
(c) hockey OR rugby OR football OR soccer
Belfast BT9 7JR, UK; time, or intrinsic factors, such as fitness, flexibility OR swim$ OR tennis OR squash OR bad-
liz.abernethy@ and balance. This is based on adult research, but is minton OR basketball OR netball OR Gaelic
btopenworld.com now supported by studies of sports injury preven- football OR GAA OR camogie OR hurley OR
tion in children and adolescents. hurling
Accepted 19 April 2007
Published Online First There are few systematic reviews of sports injury
31 May 2007 prevention in adolescents,6 and none focusing Abbreviations: ACL, anterior cruciate ligament; NNT,
........................ specifically on the adolescent age group. The aim number needed to treat
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628 Abernethy, Bleakley
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Strategies to prevent injury in adolescent sport 629
Study characteristics
Tables 35 summarise the study characteristics.
Quality
rating
Quantitative data synthesis
M
M
M
M
P
P
Table 6 gives quantitative data synthesis with results.
score
Total
8
9
9
8
6
10
11
13
10
10
active and of clinically RESULTS
appropriate duration Trial flow
Surveillance period
measures
outcome
Study characteristics
1
1
2
2
2
2
2
2
1
2
1
1 Injury-prevention studies fell into two groups: the effect of use
of protective equipment; the effect of preseason conditioning
clearly defined
Interventions
Outcome measures
comparable
and Grace et al13 used the simple definition any lower limb
defined?
blinded
Protective equipment
concealed before
that both knee and ankle braces increased lower limb injury
1
0
2
0
1
0
1
1
0
1
1
0
M, moderate; P, poor.
rates, but the use of knee pads was associated with a significant
reduction. McIntosh and McCrory17 found that headgear
Study reference
21
Wedderkopp22
Wedderkopp
Webster12
McIntosh
19
16
Olsen18
Heidt15
Hewett
Yang11
Grace
Junge
players over two seasons found that eye goggles reduced the
number of head and face injuries, particularly during competi-
tion.
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630
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Table 3 Preseason conditioning: study characteristics
Author, year, study type
(setting) Participants and recruitment Groups/intervention (compliance) Outcomes (follow-up period) Comments
Hewett 1999 Prospective 1263 high school students from (A) Preseason conditioning: 366 female athletes Injury definition: knee ligament sprain or rupture Data collection methods: injury documented by
intervention study (USA) 43 sports teams (basketball, (185 volleyball, 97 soccer, 84 basketball; 15 different causing player to seek care of athletic trainer and athletic trainers: (1) weekly reporting forms to
volleyball, soccer). teams); 6 week preseason neuromuscular training leading to at least 5 days of lost time from practice monitor numbers of injuries along with game and
programme (flexibility, plyometrics, weight training and games). practice injury risk exposures; (2) individual injury
Volunteer team allocation into and landing mechanics); 6090 min sessions; 3 times reporting forms to monitor injury type,
3 groups: 2 female and 1 male a week. Severity classification: classified by type, mechanism + treatment.
mechanism and treatment.
(B) Control groups: 463 female athletes (81 volleyball, Injury verification: athletic trainer diagnosed
193 soccer, 189 basketball). (1 sporting season) serious injury with physician referral. ACL
ruptures diagnosed with arthroscopy.
(C) Male controls: 434 male athletes (209 soccer, Authors conclusion: positive: neuromuscular
225 basketball) training reduced serious knee injuries in females.
(Compliance: self-reported).
Heidt 2000 RCT (USA) 300 female soccer players (A) Preseason conditioning: n = 42; 7 week programme Injury definition: any injury causing the athlete to Data collection methods: injury information
(aged 1418) consisting of sport-specific cardiovascular training, miss a game or practice. collected by schools athletic trainer (blinded).
plyometric work, strength training and flexibility;
20 sessions in total (2 treadmill and 1 plyometric Severity classification: (1) missed 1 game/practice; Injury verification: data recorded on injury
session a week). (2) missed 23 games/practices; (3) missed 47 incident report form (type, mechanism, severity,
games/practices; (4) missed 24 weeks; (5) missed event in which occurred, type of shoe worn).
(B) Control: n = 258; no intervention. 12 months; (6) season-ending injury.
Emery 2005 Cluster 120 subjects (aged 1419; with no (A) Balance training (n = 60 players): physiotherapist Injury definition: any injury requiring medical Data collection methods: injury report
RCT (Canada) history of musculoskeletal injury or taught each participant a home-based, proprioceptive attention or loss of 1 or more days of sporting forms; completed by subject and by any
medical condition). balance training programme; performed 20 min/day for activity or both. attending medical professional. The
6/52, then weekly for remainder of 6/12 period. physiotherapist made biweekly phone calls
Computer-generated random Severity classification: classified by area and type to all participants to ensure all eligible
recruitment of schools and students (B) No intervention (n = 60 players). (sprain, fracture, etc) of injury. (6 months). injuries reported.
(2 males and 2 females from PE
programme roster in grades 1012) (Self-reported compliance: daily record sheet with weekly Authors conclusion: positive: wobble board
phone call over 6/52 training period). reduced self-reported injury
Strategies to prevent injury in adolescent sport
Wedderkopp 1999 237 female handball players (A) Intervention protocol (11 teams; n = 111 players): Injury definition: any injury causing the player to Data collection methods: coaches
Cluster RCT (Denmark) (aged 1618; playing at elite, various functional activities followed by use of ankle disc miss the next game or practice, or to play with documented injury incidence and severity
intermediate, recreational levels). for 1015 min at all practice sessions. considerable discomfort. by questionnaire.
Randomised for intervention. (B) Control (11 teams; n = 126 players): subjects continued Severity classification: absence from Injury verification: club physiotherapist
Controlled for age, practice time, to practice as usual. (Compliance: not reported). practice/games. Minor: ,1 week. Moderate: and doctor.
playing level, floor composition and 1 week but ,1 month. Major: .1 month.
injury incidence in previous season
(self-reported, assessed with survey). (AugustMay 1996; 10 months).
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632
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Table 4 Continued
Author, year, study
type (setting) Participants and recruitment Groups/intervention (compliance) Outcomes (follow-up period) Comments
Junge, 2002 Male soccer; age 1419; 14 teams (A) Intervention group: general education and supervision Injury definition: any physical complaint caused by Data collection methods/injury
Prospective (3 high skill + 4 low skill level amateur of coaches + players. (Preventative intervention included: soccer that lasted for more than 2 weeks or verification: doctors visited participants
intervention study youth teams in each group). warm-up, cool-down, taping, rehabilitation, fair play and resulted in absence from a subsequent match or weekly to perform an interview and
(Switzerland) flexibility/stability exercises). training session. physical examination of injury. Type,
Group allocation by geographic severity and location of injury also
location (2 regions). (B) Control: subjects trained and played soccer as usual. Severity classification. Mild: absence up to 1 week documented.
(Physiotherapists delivered the primary intervention. or complaints for .2 weeks. Moderate: absence
Amount of training and matches was recorded for each for .1 week but ,4 weeks. Severe: absence for at
player by coaches.) least 4 weeks or severe tissue damage, eg,
fracture/dislocation (1 year).
Yang 2005 Cluster cohort Random selection; 100 schools; stratified (A) Protective equipment: any self-reported Injury definition: any new injury sustained between hip Data collection methods: 4
study (USA) according to size and region; 19 728 use of discretionary protective equipment and toe that required medical attention or restricted questionnaires, administered during the
athlete seasons (1 104 354 athlete not required by sports rules. participation on the day after the injury. season by trained member of school
exposures); grades 912; from 6 male staff.
sports and 6 female sports in each school (B) Control: self-reported non-use of Severity classification: (1) no time lost to participation;
(sport selected using systematic sampling). discretionary protective equipment. (Self- (2) mild injury, ,1 week lost; (3) moderate injury, Injury verification: not described.
reported compliance: questionnaire). ,3 weeks lost; (4) serious injury, lost more than
3 weeks. (3 year period).
Strategies to prevent injury in adolescent sport
Authors conclusion: positive: the use of protective eyewear Injury verification: not described
is beneficial in preventing injury in womens lacrosse.
Grace 1988 Prospective cohort 580 (694) male high school varsity + (A) Knee brace: 330 athletes in knee Injury definition: mild, less than 1 day of participation lost; Data collection methods: injuries of
study (matched pair) (USA) junior varsity footballers. braces (247 single hinged brace, minor (grade 1), loss of ,7 days; moderate (grade II), 7 lower extremity + treatment documented
83 single-upright double hinged brace). 20 days lost; major (grade III), >21 days lost. during the season by schools full time
athletic trainer.
(B) Control: 250 non-braced players (2 year study period).
matched for height, weight and Injury verification: injuries diagnosed
playing position. Authors conclusion: negative: braces did not reduce and managed by school doctors
incidence of knee injuries, and were associated with (voluntary).
increased injuries of ankle and foot on same side as
knee injury.
633
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634 Abernethy, Bleakley
ACL, anterior cruciate ligament; NNT, number needed to treat; RR, relative risk.
*+ indicates increased risk in intervention group.
In summary, there is limited evidence that eye goggles and (11/18), using a smaller group of female soccer players. The
knee pads can reduce the incidence of head and face study randomised subjects to either a 7-week conditioning
(RR = 0.52)12 and knee (RR = 0.44)11 injuries, respectively, programme designed to improve sports-specific cardiovascular
and there is currently no evidence to suggest that headgear fitness, lower limb strength, flexibility and power or to a control
(RR = 1.05)17 and knee braces (RR = 2.24)13 have a positive group receiving no preseason intervention. A 1-year (two
effect on injury prevention. seasons) follow-up showed that the injury rate of the
conditioning group was significantly lower than that of the
Preseason conditioning control group.
Hewett et al19 used a preseason conditioning strategy to develop In summary, there is poor evidence from one cohort study
flexibility, strength, power and landing mechanics. Using a and moderate evidence from one randomised controlled study
sample of female soccer, volleyball and basketball players, he that 6 weeks of preseason conditioning can significantly reduce
found that 6 weeks of this preventive intervention (three injury rate in female athletes (RR = 0.2519, RR = 0.4215).
sessions a week) decreased the number of serious knee injuries
over the next sporting season. Although this study used a large Injury prevention strategies throughout the playing
sample size (n = 1263), it scored poorly on the quality scale season
(,50%), and subjects entered into either the intervention or Proprioceptive training
control group on a voluntary basis. Moreover, the effect of this Three studies14 21 22 using cluster randomisation and scoring
strategy on other lower limb injuries is not clear. moderately (10/18) on the quality scoring scale examined the
Heidt et al15 carried out a similar study, but used a effectiveness of various balance-training protocols. Emery et al14
randomised controlled study design with moderate quality found that a home-based proprioceptive balance-training
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Strategies to prevent injury in adolescent sport 635
programme (daily for 6 weeks, then weekly for a further soccer-specific agility was significantly more effective than a
5 months) using a wobble board improved static and dynamic traditional warm-up at reducing ACL injuries in female soccer
balance in healthy adolescents and reduced the incidence of players. A more generic preventive programme (including
self-reported injury over a 6-month period. Similarly, education, warm-up, cool-down, taping, rehabilitation, flex-
Wedderkopp et al21 found that female handball players using ibility and stability) delivered in the 1-year cohort study of
an ankle disc in conjunction with functional strengthening at Junge et al16 was also effective in reducing male soccer injuries.
each practice session were less likely to be injured than a In summary, there is moderate evidence that all the reviewed
control group (training as normal). A follow-up study by the injury-prevention strategies carried out throughout the playing
same group22 using similar methods and population provided season prevented injury (RR 0.20.73, table 6).
evidence that the combination of ankle disc training and
functional strengthening is more effective at reducing injury Quantitative data synthesis
incidence than functional strengthening alone. Tables 1 and 2 describe the quality scoring key and study
quality scores respectively. These tables illustrate that there was
Structured warm-up no good quality study scoring 16 or more, but seven moderate
Three trials16 18 20 of moderate quality studied the cumulative studies scoring between 9 and 15, and five poor quality studies
effect of using a range of injury-preventive strategies during the scoring less than 9. There were several criteria that consistently
playing season. Olsen et al18 block-randomised handball clubs in limited the quality of studies: none of the included studies
Norway to either a control intervention (training as normal) or carried out allocation concealment, and only one was con-
an intervention group that used a structured 20-min warm-up sidered to have performed sufficient randomisation; however,
before each training session. The warm-up consisted of lower six additional studies demonstrated acceptable cluster rando-
limb proprioception, strengthening exercises and technical misation.
training, with all athletes encouraged to maintain optimal We assessed the treatment effect by (1) considering
lower limb alignment and control. This study, which scored preventive strategy in relation to the risk, type and severity of
highest on methodological quality rating (13/18), found that injuries, (2) considering the feasibility of replicating the
fewer knee and ankle injuries occurred in the intervention intervention used, and (3) calculating the number needed to
group during the one-season follow-up period. Furthermore, a treat (NNT) to prevent one injury. Treatment effect in terms of
prospective cohort study20 found that a structured warm-up NNT was calculated where there were sufficient data and is
emphasising strengthening, stretching, plyometrics and given in table 6.
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636 Abernethy, Bleakley
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Strategies to prevent injury in adolescent sport 637
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638 Abernethy, Bleakley
45 Thacker SB, Gilchrist J, Stroup DF, et al. The impact of stretching on sports injury 48 Bixler B, Jones RL. High-school football injuries: effects of a post-halftime warm-
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46 Pope RP, Herbert RD. Effects of flexibility and stretching on injury risk in army 49 van Mechelen W, Hiobil H, Kemper HC, et al. Prevention of running injuries by
recruits. Aust J Physiother 1998;44:16572. warm up, cool down, and stretching exercises. Am J Sports Med
47 Pope RP, Herbert RD, Kirwan JD, et al. A randomized trial of preexercise 1993;21:71119.
stretching for prevention of lower-limb injury. Med Sci Sports Exerc 50 Yeung EW, Yeung SS. A systematic review of interventions to prevent lower limb
2000;32:2717. soft tissue running injuries. Br J Sports Med 2001;35:3839.
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