EUROPEAN MASTER IN HEALTH AND PHYSICAL ACTIVITY

MASTER THESIS

CAUSES AND PREVENTION OF INJURIES IN FOOTBALL

(SOCCER), HANDBALL AND BASKETBALL AT ADOLESCENTS

Supervisor: Prof. Karsten Froberg

2015

Student: Mladen Prani

KEY WORDS:
Adolescents, youth, injury, injury risk factor, causes of injury, mechanisms
of injury, injury prevention, football, handball, basketball
ABSTRACT:
Based on available literature, the occurrence and prevention of injuries in
adolescents is analyzed in intensive and semi-intensive sport activities
related to football, handball and basketball. Injury risk factors and their
causes /mechanisms of injury in adolescents, who participate in these sports,
are described in the thesis. Methods of prevention that may leave an impact
on reducing the number of injuries, along with their intensity and duration
of injury, are also presented.
In all three mentioned sports most often injuries are injuries of lower limbs,
respectively ankles, thighs and knees. One of the most serious injuries in
adolescents (especially of female adolescents) that occur, in above
mentioned sports, is rupture of anterior cruciate ligament (ACL) in the knee,
which can cause long-term and demanding recovery periods. Another
reason for concern, over the last two decades, is the drastic increase of
incidence of concussion injuries in basketball.
Most common reasons and risk factors of injuries for adolescents involved
in mentioned sporting activities are: aging and maturation (the number of
injuries increases with age), female sex, improper training, matches, sudden
cutting movements, landing, falls, irregular biomechanical relationships,
contacts between players, preseason, and so forth.

Most effective way to reduce the number of injuries is to maintain

prevention measures/activities, especially concerning the knee and ankle
through a neuromuscular training, strength training and usage of unstable
exercise platforms.

CONTENT:
1.
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3.
4.

5.

6.

7.
8.

Acknowledgment
Preface and main objectives
Methods
The physiological background of adolescence
4.1. Terms relevant to adolescence
4.2. Adolescence
4.3. Growing in adolescent age
4.4. Sexual maturation in adolescent age
4.5. Changing of aerobic capacity in adolescent age
4.6. Changing of anaerobic capacity in adolescent age
4.7. Heart rate in adolescent age
4.8. Strength, endurance, speed and agility during
adolescent age
Basics of football, handball and basketball
5.1. Football
5.2. Handball
5.3. Basketball
Injuries in sports (sports injuries)
6.1. Types of injury
6.1.2.
Divide of injuries according to duration
Acute injuries
Chronic injuries
6.1.3.
Divide of injuries according to the place of
origin
Soft tissue injuries
Injuries of hard structures
Injuries of the skin and mucosae
Eye and dental injuries
6.2. Specific definitions of injuries
6.2.1.
Time loss injury
6.2.2.
Medicine attention injury
6.2.3.
Repetitive injury
Incidence of injuries, Table (1,2,3)
Risk injury factors, causes and mechanisms of injury
occurence
8.1. Internal injury risk factors
8.1.1.
Aging
8.1.2.
Sex
8.1.3.
Factors associated with growth
8.1.4.
Body composition
8.1.5.
Poor biomechanical relationships and
anatomical variation
8.1.6.
Individual motor abilities
8.1.7.
Physiological risk factors
8.1.8.
Psychological risk factors
8.1.9.
Previous injuries

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8.2. External risk factors

8.2.1.
Length of sports participation
8.2.2.
Matches as risk factor
8.2.3.
Preseason as risk factor
8.2.4.
Players position
8.2.5.
Training and improper technique of training
8.2.6.
Poor condition
8.2.7.
Neglecting of stretching and non-use bandages
8.2.8.
Poor postural control of the body
8.2.9.
Dominant side of the player
8.2.10. Jump and landing (drop jump)
8.2.11. Pivoting and cutting maneuvers
8.2.12. Contact and non contact
8.2.13. Tackling
8.2.14. Fatigue
8.2.15. Running
8.2.16. Shooting in the target
8.2.17. The surface quality
8.2.18. Size of the playing court
8.2.19. Inadequate sports equipment
8.2.20. Phase of the playing
8.2.21. The level of competition
8.2.22. The visiting team
8.2.23. Athletic shoes
8.2.24
Education of parents
8.3. Causes of injuries by looking at the body part and
diagnosis
8.3.1.
Causes of concussion
8.3.2.
Causes of shoulder injuries
8.3.3.
Causes of the upper limbs injuries
8.3.4.
Causes of finger injuries
8.3.5.
Causes of groin and hip injuries
8.3.6.
Causes of thigh injuries
8.3.7.
Causes of knee (ACL and meniscus) injuries
Patellar tendinopathy and epiphyseal injuries of
8.3.8.
the knee
8.3.9.
Causes of the overuse injuries at lower leg
8.3.10. Causes of Achilles tendon injuries
8.3.11. Causes of ankle injuries
8.3.12. Causes of chronic injuries
8.3.13. Causes of stress fractures
General information about injuries prevention
9.1. Diagnostic measures
9.1.1.
Preventive medical examinations
9.1.2.
Functional diagnostic methods
9.1.3.
Psychological diagnostics
9.2. Primary injury prevention
9.2.1.
Orthoses

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9.2.2.
Shin pads
9.2.3.
Mouth guard
9.2.4.
Eye protection wearing of safety glasses
9.3. Secondary injury prevention
9.4. Training measures
a)
General training measures aimed to reduce of all
injuries
9.4.1.
Improving of physical skills
9.4.2.
Conditioning of players
9.4.3.
Proper stretching and warm-up at the beginning
of each training / match
9.4.4.
Calming (cooling) down of the body at the end
of each training / match
9.5. Ergonomic measures
b)
Training measures specifically directed at preventing
of specific injuries in certain sports
9.5.1.
Training measures for the prevention of the
player contact injuries
9.5.2.
The training measures for preventing noncontact injuries of muscles and tendons
9.5.3.
The training measures for preventing of noncontact injuries to the lower limbs
9.5.4.
Proprioceptive and neuromuscular training
9.5.5.
Table 4. Prevention programs in football
(soccer)
9.5.6.
Table 5. Prevention programs in handball
9.5.7.
The impact of the equipment on the occurrence
of injuries in sport
9.5.8.
Choosing of footwear
9.5.9.
Quality of the surface
9.6. Educational and control measures
9.6.1.
Rule changes
9.6.2.
Frequency controls of trainings and matches
9.7. Measures of recovery and additional measures for the
prevention of injuries
9.7.1.
Physiotherapy measures
9.7.2.
Supplementary training measures
9.7.3.
Rehabilitation measures
9.7.4.
Prehabilitation and proper periodization of
training
9.8. Specific forms of prevention, looking at the body
localization and diagnosis
9.8.1.
Prevention of ankle injuries
9.8.2.
Prevention of Achilles tendon injuries
9.8.3.
Prevention of ACL injuries
9.8.4.
Preventing of stress fracture
9.8.5.
Prevention of tibial syndrome
10. Discussion

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Conclusion
Literature
List of figures
Appendix - presentation of two preventive programs

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1.

ACKNOWLEDGMENT

I would like to thank Prof. Karsten Froberg for helping me to develop this
master's thesis.
I would also like to express my gratitude to Prof. Daniela Caporossi who
was helping me during my study in Rome.
Biggest thanks to my family and friends for supporting and helping me
during study and writing of this thesis.

Mladen Prani

2.

PREFACE AND MAIN OBJECTIVES

This study is focused on adolescent athletes, who are dealing intensively or

semi-intensively with football, handball and basketball.
Football, handball and basketball are the most widespread common team,
contact ball sports that adolescents are dealing with.
All these sports have changed recently. In adolescent age, matches between
athletes become faster and more aggressive. As adolescents mature, their
trainings and matches are becoming longer and more difficult. Frequency of
trainings and matches with aging are increasing too.
These factors from adolescent players require the best possible conditioning
and excellent motor skills. Good coordination of the body, good control of
the ball, good motor communication between ball and players, and an
adequate space control are very necessary. For the recreational athlete, all
these facts are probably less significant.
Adolescence is the time of growing up, the transition from a phase of the
immaturity in childhood, to the maturity in adulthood from the age of 12 to
19 years old. It can be divided in: early, middle and late adolescence
(Malina et al, 2004). This transition involves biological, anatomical,
cognitive, psychological and social changes. Onset of puberty marks a
significant acceleration in the growth of body size, with the average
annual growth of children in the height of 8-12 cm (Markovi et al, 2009).
In adolescent period, bones are still not merged (Malina et al, 2004).

According to this, it can be assumed that injuries often occur during sport
activities in adolescence, which can significantly influence on the mental
and physical development of athlete as whole person.

The objective of this master thesis is that by review of the available

scientific literature, which analyses injuries in adolescents, occurred during
football, handball and basketball present following:

To present injury risk factors and most common causes and

mechanisms of injury during football, handball and basketball in relation to

the adolescent age and gender;

To present ways of preventing the occurrence of injuries and

reducing their frequency and severity, in relation to age, gender and type of
the sport.

Sports injury is most often defined as an incident during a match or

training, causing a lack of players at least one next game or training (Brooks
& Fuller, 2006; Kofotolis et al., 2007; Frisch et al., 2011)

Most of the articles have shown that the most frequent injuries in all three
analyzed sports are injuries of the leg - ankle, knee and upper leg. Looking
on diagnosis, ankle strain is the most frequent. One of the most serious
injuries that cause long absence from the pitch is injury of anterior cruciate
ligament of the knee.

Adolescent female athletes are being injured more often (especially knees)
in comparison with male athletes. In basketball, increasing incidence of
concussion and brain injuries is very worrisome.
Bahr et al, 2005 concludes that occurrence of injury is consequence from
the complex interaction between the external and internal risk factors.
The internal injury risk factors are specific to each athlete individually
and it is very difficult to influence on them. Contrary on that, external
injury risk factors reflect on the environment in which an athlete exercises
and it is much easier to influence on them. Some important internal risk
factors are: age, female sex, previous injuries, poor biomechanics, and
external risk factors are: matches, preseason period, muscle imbalance,
jump, landing etc.
Randall et al, states that the cause of the increased incidence for the
development of concussion in females is because of their smaller size,
more fragile structure and less strength of neck.
Cause of knee injury can be of contact and noncontact nature. Serious
injuries often occur due to noncontact injuries.
Ankle injuries arise in most cases due to collision between players or
during landing. Specifically for basketball is landing on someone else foot,
which can lead to the ankle injury (Agel et al, 2007).
In these three sports overusing injuries and stress fractures occur, due to
growing or maladjusted training.

Prevention (from the Latin. Praevenire = prevention) means a set of

measures to prevent any adverse effects (Wikipedia).
Structured plan of preventive measures can be applied through four main
steps: Gathering information, identification and description of preventive
measures, their implementation and review of achieved (Gall et al, 2006;
Mechelen et al, 1992; Backx et al, 1991; Olsen et al, 2006; Myklebust et al,
2013). The timely implementation of preventive measures is important.
(Olsen et al, 2005; Myklebust et al, 2003; Steffen et al, 2010). Before the
beginning of the new game season it is recommended to make diagnostic
measures (medical control, functional tests etc.) in order to detect potential
health problems. The most productive of all preventive measures is proven
to be neuromuscular training on unstable surfaces.
Also, each sport has its own characteristics and rules, and it is certainly
necessary to achieve good technique in order to avoid possible injury.
The use of protective equipment such as protective glasses, mouthguards
or wearing of ankle braces has also shown some preventive effect in
preventing of sports injuries.

3.

METHODS

In this thesis descriptive methods and methods of compilation are being

used. (not original work, but composed from material collected by another
author).
In the purpose of this thesis, 230 scientific articles and few abstracts have
been analised,while much more abstracts, articles and books were
overviewed. A scientific literature search was performed during March 2015
in Pubmed, Google Scholar and from the Croatian and Slovenian national
library base. Notes from lectures during the study in Odense are also used.
Looking on the topic of thesis, search is performed based on the following
key words: adolescence, injuries, causes of injury, mechanism of injury,
injury prevention, football, basketball and handball.
The data from the literature was analised according to the following criteria:
originality of the data, the amount of data, the size of the sample, the period
of observation, and the method of data processing.
Characteristics of analysed articles and data from those articles:
Number of articles:
I included all relevant available articles related to the topic, regardless to the
adolescent age. This thesis presents the most recent data, but in the case of
lack of such data I used some older sources. Most found scientific articles
were about football. Articles on injuries in basketball and handball were in a
significantly less number and because of that, for the purpose of this thesis,
articles with a similar topic or similar keywords were searched (high school,
university, youth, young, children, etc.).

Finally, I analised 60 articles dealing with causes and prevention of injuries

in football, 46 in basketball and 40 in handball.Other analyzed articles are
describing adolescents, injury causes and their prevention, regard to the type
of the sport. The exclusion of articles was mainly due to the lack of data
and an inappropriate age (not adolescence) or due to analysis of different
sports without detailed processing information, separately for each sport or
for each age. In some cases I used data from other sports or with other
certain age group due to their importance or to their mutual comparing.
Localization
With analysis of scientific articles, their large territorial localization is being
established. Almost all studies dealing with the topic of injuries in
basketball are from the USA, and those dealing with handball are from the
Scandinavian countries, respectively Norway and Denmark. Articles about
injuries in football cover some more widespread area, though most of these
articles come from richer countries (Western Europe or USA).
Data from the reviewed articles
Reviewed articles are characterized by lack of data and unevenness (no
consistency), in terms of data collection and analysis.
Unevenness is manifested through:

Selection of the sample; e.g .:

By sexes (only males, only females, males and females

mixed)

By observed age (e.g. U13; U14;U15;U16;U17;U19; U1315; U15-U17;from 15 to 25 year; from 5 to 19 year etc.)

By the size of the sample

Selection of sports (football, handball, basketball, mixedfootball and rugby, football American football, sports in
general ...).

The way of performing activities (competitive, recreational,

school activities).

Selection of the observation period (e.g. pre-season, season,

postseason, certain number of competitive games, certain
number of months or years and the like.).

Way of getting an injury (e.g.: every incident event, injuries

that prevent players to participate in the certain numbers of
matches and / or trainings; or in certain period (24h, 48h,
72h) etc.)

Way of analysing of injury localization (e.g., hip, groin,

mixed hip and groin, hip and thigh, etc.).

Way of injury diagnose analyzing (conscious, head injury,

face injury, conscious and head injury)

Way of obtaining information (coach, physiotherapist,

doctor, clinic, athlete, parents )

Types and organization of data (nominal, ordinal, interval or

ratio)

Types of study (retrospective or prospective)

The way of statistical tests selectioning

The way of interpretation of the obtained results

4. THE PHYSIOLOGICAL BACKGROUND OF ADOLESCENCE

4.1.

Terms relevant to adolescence:

Growth refers to measurable changes in size, physique and body

composition, and various systems of the body (Malina et al, 2004).
There are three underlying cellular processes during growing:
1.

Hyperplasia increasing in number of cells

2.

Hypertrophy increasing in cell size

3.

Accretion - increasing in the substances that hold the cells together;

found between cells (ex. bone mineral, collagen), (Dudoniene V, 2012).

Growth in stature is rapid in infancy and early childhood, rather steady
during middle childhood, rapid during the adolescent spurt, and then slow as
adult stature is attained. Final adult height is usually reached at 20 year of
age (Malina et al, 2004).

Figure 1: Stages of growing during childhood and adolescent period

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Maturation refers to progress toward the mature state. Maturation is

variable among bodily systems and also in timing and tempo of progress.
The processes of growth and maturation are related, and both influence on
physical performance (Malina et al, 2004).
Development is more general process, including aspects of:

growth,

maturation

Learning/training/evolution from novice to expert

Experiences in micro & macro environment

Development can be on biological, behavioral, cognitive, emotional, social,

moral and motor way (Dudoniene V, 2012).
4.2.

Adolescence

Adolescence begins with an onset of the puberty and ends with the
formation of identity. It can be divided in: early, middle and late
adolescence. Early adolescence covers the period from 12 to 14 years,
middle from 15 to 16, and late from 17 to 19 years of life. After that age
starts perod of early adulthood (Malina et al, 2004).

Figure 2: Stages in growth and development up to adulthood

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Division of adolescence fits the way that our society groups young people in
educational institutions: the first group comprises of pupils of higher class in
the elementary school, second are high school pupils, and third students on
the universities. Cognitive development does not always follow physical
changes in adolescent age. Adolescence is a period of rapid changes of
mood, internal conflicts and quarrels with the environment, rebelliousness,
and researching of environment (oljaga, 2010).
4.3.

Growing in adolescent age

Onset of puberty marks a significant acceleration in the growth of body size,

with the average annual growth of children , approximately they grow 8-12
cm . Generally speaking, a phase of rapid growth (peak height velocity),
first affects girls (12 1year), and then the boys (14 1 year). This period
lasts for a year or two. Peak height velocity is maximal growth in stature
and also maturity indicator. After puberty, children continue to grow but
with much slower pace (Malina et al, 2004).

Figure 3: Peak height velocity and peak bone mass growth

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Growing of body in girls is lower than in the boys and ends approximately
with 16.5 years. Boys grow up until they turn 19 years. Girls are usually
maturing two years faster than boys (Markovi et al., 2009). Besides the
differences between the genders, there also exist considerable variations in
maturation inside the gender (Malina et al, 2004).
Although, growth is largely characterized by genetic factors. Height of the
child can not be determined based on the height of the parents (Markovi et
al., 2009).

Figure 4: Changes in the size and shape of the body during growing
As chronological age is not supported by the actual age of every child,
there is also term biological age (Markovi et al., 2009).
Skeletal age is determined by the ossification of the bones, reflects more of
the physiological age (Dudoniene V, 2012). Skeletal maturation means a
fully ossified skeleton and determine age of the skeleton (Malina et al,
2004).

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In order of reaching the height of adult, children and adolescents go through

periods of linear growth which is taking place in the region of the
epiphyseal growth plates of long bones (Higins et al., 2009). Growth
occurs at the each end of the bone around the growth plate. When a child
becomes full-grown, the growth plates harden into solid bone (Malina et al,
2004).
Result of the higher volumes of cartilage tissue in the bones is their greater
flexibility, but on the other hand, children's bones have significantly lower
bone strength than adults. By injuring of growth plate, standstill in growth
and development of the bone may occur. (Markovi et al., 2009). The most
prevalence of epiphyseal growth plate injuries is between 10 and 16 years
and high vigorous activities should be avoided (Dudoniene V, 2012).
Bone is growing first and precedes to elongation of muscles, tendons and
nerves. Possible delay in growth and development can lead to a reduction in
flexibility, muscle imbalance and poor coordination (Higins et al., 2009). In
that way, inappropriate load during exercises may cause injury of epiphyseal
regions on the bone, and complete cessation or slowing down of bone
growth in length.

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Figure 5. Description of bone growth in length

Figure 6: Difference in bone ossification between boys and girls at different

adolescent age

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As regards to soft tissue flexibility, girls deliver more performance than

boys in the overall growth and development. Flexibility in girls is constantly
increasing until 16 years, while in boys reaches its minimum during the
maximum phase of growth, at the age about13-14 years. After that, in boys
flexibility slowly increases until 18 years (Markovi et al., 2009).

Figures 7 and 8: Slides show measuring of hamstrings flexibility

4.4. Sexual maturation in adolescent age
In adolescent age, sexual maturation is developing, which means fully
functional reproductive capability and changing of main gender features.
Girls: Breast development, pubic hair development, age at menarche
(axillary hair). Menarcha also depends about sports activities.
Boys: Genital development (testes, scrotum, penis), pubic hair development,
axillary hair, voice changes, facial hair (Dudoniene V, 2012).

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Onset of puberty indicates a significant increase of the testosterone in boys

and estrogen in girls.
Testosterone stimulates the development of muscle mass, while estrogen
development of body fat cells. Hormonal changes make the difference in the
shape of the skeleton and bone morphology (Markovi et al., 2009).
4.5.

Changing of aerobic capacity in adolescent age

Pubertal changes in functional abilities are apparent in boys especially in

terms of aerobic capacity according to body mass (ml/kg/min) while in
girls changes are less visible because a significant increase in body weight
occurred after puberty (Higins et al., 2009). Maximal uptake of oxygen
keeps increasing until the age about 17 to 18, but increases hardly at all
beyond age 14 in girls. It depends on respiratory and hemodynamic factors
and is also related to the oxidative enzymatic activity in the exercising
muscles and to the size of these muscles.
When maximal oxygen uptake of adolescents of different ages, but the same
body weight or body height is compared, it is positively related to the age.
Maximal aerobic power depends on maturity and not only on body
dimensions. Adolescent whose body mass is smaller may not need as much
absolute maximal oxygen uptake as the heavier adolescent or adult.
Majority of studies express maximal oxygen uptake per kg of body mass
(Bar-Or & Rowland, 2004).

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4.6.

Changing of anaerobic capacity in adolescent age

An activity that depends predominantly on non oxidative energy turnover

is considered anaerobic. Such activity can be sustained for 1 min or less and
is of a very high intensity (for example, short and long sprints and jumps).
Energy source for this is high energy phosphate (creatin phosphate) that
is stored in the muscle, or ATP that is produced through anaerobic
glycolysis. The use of available ATP and CP is not accompanied by lactate
productions and is called alactic. Adolescent anaerobic activities are
higher than in children, but lower than in adults (Bar-Or & Rowland, 2004).
With increasing of age, absolute and relative anaerobic power also
increase. In boys during puberty anaerobic power develops and reaches its
maximum at the age of 18 years. In girls, anaerobic power is significantly
lower, and reaches its maximum between 15 and 16 years, and after that
absolute power is stagnant, and the relative decline (Bar-Or & Rowland,
2004) .
Children have lower anaerobic glycolytic capacity than adults. Full
development of the glycolytic energy system can be expected after 18 years,
or at the end stage of adolescence (Markovi et al., 2009).
Possibile reasons for lower anaerobic performace in childhood and
adolescence are: smaller muscle mass per body mass, lower glycolytic
capability and deficient neuromuscular coordination. Anaerobic
characteristics depend on a certain extent of the persons genotype.

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Compared with adult athletes, prepubertal and early pubertal child athletes
are less specialized as anaerobic or aerobic performers. The nature is unclear
(Bar-Or & Rowland, 2004).
4.7.

Heart rate in adolescent age

Maximal heart rate in adolescents and children ranges between 195 -210
beats per minute. It starts declining in age during the late teens. Such decline
is independent of gender, level of training, climate or other environmental
conditions. It is equivalent to 0,7- 0,8 beat per minute-1 a year. Females have
heigher rate than males at any given exercise level (Bar-Or & Rowland,
2004).
4.8.

Strength, endurance, speed and agility during adolescent age

Years of the largest development of most fitness levels coincides with the
years of greatest growth in height (Markovi et al., 2009). The growth spurt
in height happens first and it is followed by the growth spurt in weight and
then the growth spurt in strength (Malina et al, 2004)
Strength is the ability to acting through muscular activity and external
forces to overcome or not. It comes from the contraction of muscles and is
effective through the external skeletal system (Garopoulou et al, 2011).
Strength training is important for children and adolescents, for those
participating in sports, and also for those participating in physical
recreational activities. For boys, the development of strength increases
linearly up to 13 to 14 years, after which performs of this ability rapid
growth, while in girls, strength is increasing linearly (Markovi 2009).

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Muscular endurance is the ability of a muscle or group of muscles to

sustain repeated contractions against resistance for an extended period of
time (http://sportsmedicine.about.com/od/glossary/g/MuscleEndur_
def.htm).
Muscular endurance develops linearly in both sexes until puberty, after
which in the boys it accelerates while in the girls it is slowing down. The
result is an increase of the difference in muscle strength between the sexes.
After 13 years in boys is slightly increasing explosive strength, while in
girls this trend is slowing down (Markovi et al., 2009).
Speed and agility - the largest increase in development of speed and agility
in children is between 5th and 9th year, after which linear growth is present
until 13 to14 years.
Second acceleration of agility and speed in boys occurs at the same time,
while in girls slows down from the age of 16 to 17 years. During this period
significant differences are happening in the speed and agility in favor of
boys. This is associated with the rapid development of explosive and
maximum intensity during the phase of rapid adolescent growth (Markovi
et al., 2009).
Due to these changes it is necessary to adapt training and the level of its
intensity to adolescents engaged in sports activities. This is particularly
important in the phase of intensive growth when it can happen that superbly
trained child suddenly becomes clumsy and awkward.

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Therefore, it is certainly necessary to allow adolescents to adapt to new

conditions in terms of understanding his body and knowing itself and his/her
new features.
This fact represents a challenge for coaches because of the fact that in these
situations it is necessary to reduce the load with special attention on
flexibility exercises and re-adoption of sport movements and technique.

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5. BASICS OF FOOTBALL, HANDBALL AND BASKETBALL

5.1. Football (Soccer)
Football is a team sport in which compete two teams with 11 members. The
aim of the game is to score more goals than the opponent with any part of
the body except the hand. Goalkeeper is the only player to whom is allowed
to play with hands. Football players are trying to achieve goals by the
individual control of the ball ("dribbling") that passes along the ground or in
the air by hitting the ball into the net. Team that scores more goals wins.
Venue can be natural or artificial grass. International matches are played on
the courts of the length of 100-110 m and a width of 64-75 m. A goal is set
on the each side of goal line, with dimensions 7.32 x 2.44 m (FIFA, 2015).

Figure 9.Football field with standard measurements

The ball's circumference is 68-70 cm and weights 410- 450 g. It is bloated
with air and covered with leather or suitable synthetic material. The game
lasts 90 minutes, and the players go to the fifteen-minute break after first 45
minutes (FIFA, 2015).

22

Football is a complex sport which consists of cyclic and acyclic movements.

The cyclical movements include various forms of running and ball leading.
Acyclic forms of movement are hitting the ball, receiving and passing the
ball, cheating, jumps, shots, falling, etc.
Some movements have characteristics of both cyclic and acyclic
movements. Depending on the position in the game, players have certain
tasks and activities (defensive players seizure of the ball, playing with
head; midfield players - dribbling and passing the ball, attackers - cheating,
shot on goal) (Elsner, 1997).
Aerobic and anaerobic capacities of the players are very important for the
football performance. Aerobic capacity enables player to overcome every
effort, and anaerobic during maximal or submaximal speeds and loads.
Although aerobic condition is necessary, as a base, while anaerobic
condition is becoming more and more important (Ekstrand, 2003).
Football is a sport in which very high loads on the joints of the lower limbs
are expressed, with frequent fouls and contacts, which can lead to the
occurrence of injuries.

Figure 10.Show of body position during change of direction in football

23

5.2. Handball
Handball is a team sport with a ball, where two teams with 7 players (6
court players + 1 goalkeeper) are competing on each side. The aim of the
game is to achieve the goal and to have a better result than the opponent
team. The game consists of two halves of 30 or 20 minutes (depending on
the age of the players). Players can touch the ball with hands, and bandy ball
between each other, but the aim is to get the score. Dimensions of handball
courts are: length 40 m, a width of 20 m. The terrain consists of the playing
field and two goal areas. All players are free to move around the field,
except 6 meters in front of both goals. In this space may only stand one
member of the defense team goalkeeper (IHF, 2010).

Figure 11. Show of different movements of the body related to handball

game
Two basic phases of the game are phase of the attack and the defense phase.
In the attack phase, players most commonly use a formation with two side
players (left and right winger), three external players (left, center and right
back player) and pivot or centerforward (Medveek, 2011).

24

In the defense phase, it is being used formation of several different players

in front of area of 6 m (formation 6-0, 5-1 etc.), (Medveek, 2011). For
handball game significant are numerous changes of direction, accelerations
and decelerations and physical contact between the players. All mentioned
activities are intertwined in short time intervals, depending on the situation
in the game. Highly intensive workloads such as changing of direction,
jumping, landing, shots, defense activity, etc., require good condition and
fine motor skills of the players (Luzar K, 2011). Handball is agile game
associated with a number of unexpected situations, different loads and
disturbances that can easily lead to the injury during the movement in the
game. It can be concluded that a well-developed motor skills affect on the
performance of handball players and reduce the possibility of injury.

Figure 12. Show of danger position in handball due to landing on one leg
(potential ankle or knee injury) and valgus position of the right players knee
during jumping that can lead to ACL injury, especially in case of stronger
contact between players or fall.

25

5.3. Basketball
Basketball is a sport in which two teams of five players are trying to score
more points by inserting the ball through the hoop of the basket in
accordance with prescribed rules. The team that wins is one that at the end
of the game has more points in comparison with the opponent. A successful
shot is valid with two points if the shot was released inside the arc radius of
6.75 meters in Europe or 7.24 meters in the NBA league. The shot out of
that arc is valid like three points. A free throw is 1 point, and it is performed
from the distance line of 4.5 meters.
The ball may be leaded to the basket as a shot, passing between players, as
throwing, rolling or dribbling (bouncing the ball from the ground during
running).
Regular basketball court in international basketball has measures 28 x15
meters, and in the NBA 29x15 meters. Most courts are made from the wood,
parquet. One basket is at the each end of the court. The top of the rim is
exactly 3.04 meters above the court and 1.21 meters inside the baseline at
almost all levels of the competition. (FIBA, 2014).

Figure 13. Basketball court

26

Five players from each team may be on the court at the same time ( Point
guard, often called the "1" ; Shooting guard, the "2" ; Small forward the
"3"; Power forward, the "4" ; Center, the "5").

Figure 14. Position of basketball players

Games are played in four quarters of 10 (FIBA) or 12 minutes (NBA).

College games use two 20 minute halves, while United States high school
varsity games use 8 minute quarters. Fifteen minutes breaks are allowed for
a half-time under FIBA, NBA, and NCAA rules and 10 minutes in United
States high schools (FIBA, 2014).
On the professional level of basketball, most players are higher than 1.90 m,
and most females are higher than 1.75 m
(http://wiki.royalfamily.ba/wiki/Ko%C5%A1arka#.VaPJufkpr6k).
Basketball is a sport which asks from the players a good spatial overview of
the game and between players. In the same time, excellent movement
coordination of legs and hands and control of the ball are also necessary.

27

During the game, especially during adding the ball, players should consider
the size of the field.
At stage of adolescence, basketball players who are still in the stage of
development can be injured by different or repeated movements, like sudden
cutting movement changes, jumping and landing with high postural sway
etc. (Mc Gee et al, 2007; Bruce et al, 2010; Wang et al, 2006).

Figure 15. Typical basketball situation for centers during shooting in the
basket

28

6.

INJURIES IN SPORTS (SPORTS INJURIES)

Great variety of defining an injury was established during the examination

of scientific articles that cover the topic of injuries in sport.
Fuller et al., 2006, reported about achieved compromise in the term of
sports injury among scientists that deal with injuries in football:
Sports injury is defined as an incident during a match or training,
causing a lack of players at least one next game or training (Kofotolis et
al., 2007; Frisch et al., 2011)
This definition of sports injuries is most common. It is also partially
accepted by scientists that deal with themes of injuries in other sports, but
there are plenty of modifications of this definition. Fifteen ways of defining
sports injuries are recorded during examination of scientific articles.

6.1. Types of injury

Injuries can be divided:

according to duration

according to place of origin

6.1.2. According to duration

Acute injuries
Acute injury is type of injury which occurs suddenly, unexpectedly, and
which causes disorder in the structure of the injured tissue. This type of
injury causes tissue damage and currently leads to the inability to participate
at sports activities. Luigi and Henke, 2010 defined acute injury as a result of
specific incidental event that can be documented.

29

A similar definitions of acute injury are presented in some other articles,

too. Football: (Brito et al., 2012 ; Soligard et al., 2008 ; Froholdt et al.,
2009 ; Steffen et al., 2007) Handball: (Moller et al., 2012 ; Olsen et al.,
2005; 2006).
o Acute contact injuries are caused by external loads and by
contact with other player, Football: (Frisch et al., 2011).
o Acute non contact injuries are sudden injuries without external
influence, Football: (Frisch et al., 2011).
Chronic injuries
Chronic injuries is defined as evolving gradually as a result of overuse, and
are caused by mikrotrauma without any exact event responsible for the
occurrence of injuries, Football: (Brito et al., 2012; Junge et al., 2003;
Soligard et al., 2008; Froholdt et al., 2009; Steffen et al., 2007), Handball:
(Moller et al., 2012; Olsen et al., 2005; 2006; Luig i Henke, 2010).
Overuse syndrome occurs as a result of repetitive mikrotrauma
accumulated beyond reparative ability of tissue.
In contrast to the acute injuries, where in a split of second very high
mechanical load leads to the destruction of the tissue, in the case of overuse
injuries, occurs much repetitive mikrotrauma. Tissue damage caused by
the impact of repeated microtrauma, are not enough to damage tissue, but
repetitive actions overwhelm the body's ability for regenerating tissue
(api et al., 2001). Untreated overuse injuries over the time induce
degenerative processes in soft tissues.

30

By neglecting the pain and movement restrictions, and by extensions of the

compensatory movements, it is possible to spread the impact of
microtrauma to other parts of the body. Common point for the injuries and
damages (overuse syndromes) is that they are at the end manifest in the
form of inability for athletes further sports activities (Vukeli, 2011).
Some of the most common overuse injuries are: Osgood Schlater disease,
Severs disease, tennis elbow, bursitis, stress fracture etc. (Vukeli, 2011).
6.1.3. Divide of injuries according to the place of origin
Soft tissue injuries Injuries of muscles, tendons and ligaments (strain or
rupture of fibers).

Strain (Distension)

First degree rupture - Laceration - break in continuity of a small

number of muscle fibers with generally held muscle function for
normal activities of life that do not involve sports.

Second degree rupture partial rupture

Third degree rupture complete rupture

Muscle contusion contusion of muscle without rupture of muscle

fibers, but with damage of blood vessels, which result with
hematoma.

Inflammation of tendons tendinitis

31

Injuries of hard structures

Injuries of bones

Fracture Severe injury that describe bone fracture

Contusion

Injuries of joints

Contusions

Luxation / Dislocation - dislocation means shift a bone in relation to

the other bone in the joint without the possibility of spontaneous
return to the starting position.

Subluxation / Distortion (sprain) is actually a short-term dislocation,

with spontaneous return of two bones connected by joint to the more
or less its original position. After sprain, due to strain of joint soft
tissue (muscles, tendons, ligaments) in the joint may lapse
instability.

Injury of the cartilage and meniscus

Avulsion

Rupture

Injuries of the skin and mucosae

Contusions

Lacerations

Abrasions

Cuts

Blisters

32

Eye and dental injuries

The most common eye injuries are corneal abrasions. Teeth injuries can be
of serious nature (Ivkovi, 2009; Brzi, 2012).
6.2.

Specific definitions of injuries

Authors have also created some specific subgroups of injuries: Time-loss

injury, medicine attention injury, repetitive injury and others.
6.2.1. Bahr 2009, argued that the time loss injury definition is probably the
most used because it covers most of the relevant injury, and the use of this
definition is understandable especially when it conducts retrospective
studies, Handball: (Luig and Henke, 2010).
6.2.2. Medicine attention injury are those injuries which require medical
treatment Football: (Fuller et al 2006, 2007; Ergun et al., 2013), Handball:
(Luigi and Henke, 2010).
6.2.3. Repetitive injury is defined as an injury of the same type and on the
same part of the body, that occurs after the players return to the full
participation after the initial injury Football: (Brito et al., 2012; Soligard et
al., 2008 ; Frisch et al., 2011; Steffen et al., 2007 ), Handball: (Moller et
al., 2012).
Football: Le Gall et al., 2006 reported that the repetitive injury is one that
appears on the same location within two months after the rehabilitation of
an earlier injury. Ergn et al., 2013 repetitive injuries still divide on early
repetitive injuries that occur within 2 months after initial injury and late
repetitive injuries that occur within 2 months to 12 months after the initial
injury.

33

7.

INCIDENCE OF INJURIES

By examining scientific papers, during football and handball matches was

recorded slightly higher incidence of injuries, compared with basketball.
The incidence of injuries in trainings is quite similar in all these sports, but
in handball are some fewer incidences of injuries.
The incidence of injuries in football match on 1000 hours amounts from 1.2
to 30.4 injuries while in training it is much lower, from 1.7 to 7.4 injuries at
1000 training hours. Highest incidence of injuries was reported in the
Turkish national team members (Ergun et al., 2013).
Studies in handball have shown that incidence of injury in matches range
from 8.3 to 17.1 injuries on 1000 match hours, and during trainings from 0.6
to 4.6 injuries per 1000 training hours. Wedderkopp has reported the
significantly higher incidence of injuries in female handball player (41
injury/1000h during matches) in comparison with other authors.
In basketball incidence of injury in matches amounts 3.2 to 14.9 injuries
per 1000 match hours. At training incidence is much lower and ranges from
1.6 to 6.45 injuries at 1000h of training.
In football the most common injury in the adolescent male players was
muscle strain with a 33% incidence of injuries, while adolescent female
players had 10.7% of the same type of injury. Ligament sprains were most
common in female football players with a mean incidence of 39%, while in
male players that incidence was 25%. Female football players had more
often appearance of contusion 29.7%, opposed to males with 22.3% of
injuries.

34

Ankle injuries were most common localization of injury (m 27%: f 24.5%).

In football it can be seen a big difference between the sexes, looking on
thigh injury (m 22%: f 9.6%). The higher incidence of knee injuries is also
in the female population (f 17%: m 13%).
Table 1: Location of Injuries Sustained According to Age Group During
the 10-Season Period- males (Le Gall, 2006)

U14, younger than 14 years; U15, younger than 15 years; U16, younger than 16 years.

Table 2: Nature of Injuries Sustained According to Age Group During the

10-Season Period - males (Le Gall, 2006)
U14
Nature
Contusion/hematoma
Sprain
Muscle strain
Tendinopathy
Vertebral lesions
Osteochondroses
Fracture
Meniscal lesion
Dislocation
Other overuse
Others

n
109
76
53
55
22
50
25
9
2
5
14

%
26
18,1
12,6
13,1
5,2
11,9
6
2,1
0,5
1,2
3,3

Injuries
U15
n
132
58
61
24
26
16
19
8
4
5
8

U16
%
36,6
16,1
16,9
6,6
7,2
4,4
5,3
2,2
1,1
1,4
2,2

n
111
58
62
29
30
6
24
8
4
9
30

%
29,9
15,6
16,7
7,8
8,1
1,6
6,5
2,2
1,1
2,4
8,1

All age groups

Total
%
352
30,6
192
16,7
176
15,3
108
9,4
78
6,8
72
6,3
68
5,9
25
2,2
10
0,9
19
1,6
52
4,5

U14, younger than 14 years; U15, younger than 15 years; U16, younger than 16 years.

35

Ankle in basketball is being more often injured in adolescent males than in

adolescent females (f 43%: m 46%). Knee injuries are more serious in
female basketball players than in males (f 28%: m 10%). Unlike football, in
basketball incidence of concussion is significantly higher, (m 6.5%: f 7.5%).
Looking on both sexes, sprains and strains have occupied 48% of injuries
and fractures 11%. A large part has also occupied contusions with incidence
of 9.8%, looking on both genders.
In handball , incidence of injuries is similar to the previous two sports with
most often injuries on the lower limbs, ankle 28% and knee 21%. Handball
is different from other sports with higher percentage of finger (17%) and
shoulder injuries (6%). Looking at the type of injury, the most present are
sprained ligaments with a 46% incidence of injuries (Moller et al, 2012).
Table 3: Number of injuries and injury incidence in 346 elite handball
players by age group, injury type and body region (Moller et al, 2012).
Injury localization
Shoulder / upper arm
Elbow / under arm
Hand / wrist
Finger
Hip / Groin
Thigh
Knee
Lower leg
Achilles
Ankle / foot
Head / cervical spine
Thoracal spine
Lumbal spine
Pelvis
Total

u-18 (n=152, Exp h=20447)

Overuse injuries
Traumatic injuries
No
IR
No
IR
8
0.4 (0.2 to 0.8)
5
0.2 (0.08 to 0.6)
3
0.1 (0.03 to 0.4
3
0.1 (0.03 to 0.4)
1
0.05 (0.0 to 0.3)
3
0.1 (0.03 to 0.4)
1
0.05 (0.0 to 0.3)
8
0.4 (0.2 to 0.8)
3
0.1 (0.03 to 0.4)
2
0.01 (0.01 to 0.4)
1
0.05 (0.0 to 0.3)
5
0.2 (0.08 to 0.6)
8
0.4 (0.2 to 0.8)
11
0.5 (0.3 to 0.1)
8
0.4 (0.2 to 0.8)
3
0.1 (0.03 to 0.4)
0
0.00
0
0
3
0.1 (0.03 to 0.4)
27
1.3 (0.9 to 1.9)
1
0.05 (0.0 to 0.3)
4
0.2 (0.05 to 0.5)
2
0.1 (0.01 to 0.4)
1
0.05 (0.0 to 0.3)
3
0.1 (0.03 to 0.4)
3
0.1 (0.03 to 0.4)
0
0.1 (0.01 to 0.4)
0
0.00
42
2.1 (1.5 to 2.8)
75
3.7 (2.9 to 4.6)

u-16 (n=194, Exp h= 24668)

Overuse injuries
Traumatic injuries
No
IR
No
IR
6
0.2 (0.09 to 0.5)
7
0.3 (0.1 to 0.6)
3
0.1 (0.03 to 0.4)
1
0.04 (0 to 0.2)
0
0
4
0.2 (0.04 to 0.4)
0
0
6
0.2 (0.09 to 0.5)
7
0.3 (0.1 to 0.6)
4
0.2 (0.09 to 0.5)
0
0
2
0.08 (0.0 to 0.03)
14
0.6 (0.3 to 1.0)
23
0.9 (0.6 to 1.4)
26
1.1 (0.7 to 1.5)
1
0.04 (0 to 0.2)
1
0.04 (0 to 0.2)
0
0
4
0.2 (0.04 to 0.4)
26
1.1 (0.7 to 1.5)
0
0
2
0.08 (0.0 to 0.03)
0
0
0
0
4
0.2 (0.04 to 0.4)
4
0.2 (0.04 to 0.4)
2
0.08 (0.0 to 0.03)
1
0.04 (0 to 0.2)
67
2.7 (2.1 to 3.4)
81
3.3 (2.6 to 4.1)

Incidence is per 1000 athlete participation hours - 95% CI; Exp H,

exposure hours;

Better comparison are impossible due to the lack of necessary data for
statistical analysis.

36

8.

RISK INJURY FACTORS, CAUSES AND MECHANISMS OF

INJURY OCCURENCE
Sport, apart from its positive effects on the physical body, also brings risks
of injuries. In order to reduce the existing risk, it is necessary to determine
the exact causes of injury and its components caused by sports activities. It
is necessary to recognize the risks of injuries and try to manage with them.
Fuller et al., 2011 quotes that it is important to set an objective target that
does not include the reduction of risk of injury to zero, but this risk should
be reduced to the acceptable levels. Fuller also made the scheme of
management injuries risks:

Scheme 1. Management of injury risks (Fuller, 2006).

This scheme shows that on the occurrence of injury may influence two types
of risk factors - external and internal risk factors. Bahr et al, 2005 has
asserted that injury can be caused by a single incident event that is the
consequence of the complex interaction between the external and
internal risk factors.

37

Internal risk injury factors, such as age, sex and body composition can
affect on the increased injury risk and predispose an athlete to occurrence of
injury. The internal risk factors are specific for each athlete individually and
it is very difficult to influence on them.
External injury risk factors reflect the environment in which athlete
exercise and by omission or change of negative external factors, it is much
easier to influence on them. For example, risk factors such as friction
between surface and sport shoes can modify and change the risk factors that
can further increase the risk of injury in athletes. The existence of these risk
factors is not by itself sufficient for the occurrence of injuries. The sum of
these risks and the interaction between them lead athletes to the injury
that may occur in certain incidental situation (Bahr et al, 2005).

Scheme 2. Complex interaction between internal and external risk factors

that leading to injury (Bahr et al., 2005).

There are three models that describe the risk injury factors in sports:

Meeuwiss multifactorial model

Biomechanical model

Comprehensive injury causation model (Bahr et al., 2005).

38

Meeuwisses model explains incidental event as a final content of chain that

causes injury, and this event is usually a trigger for the occurrence of that
injury.
Biomechanical model of injury mechanism takes into account the
characteristics of the tissue and characteristics of the forces. Mechanical
characteristics of the human body such as stiffness (relationship of stress
and strains) and the ultimate power, tell us about the way in which body
responds to physical loads. Features vary for each type of tissue and depend
on the nature and type of force, frequency and repetition of force, magnitude
of transferred energy and internal factors such as age, sex and physical
condition. The relationship between force and force tolerance determine
how will injury look after incidental events. The key issue is to explain how
mechanical forces are tolerated under normal circumstances or at the
reduced degree of tolerance, to the point where normal mechanical forces
can not be tolerated.
Tolerance of force is largely determined by internal risk factors, for
example, the properties of ligaments and their sizes are determined by age,
sex, body size and previous training. The same factors may also affect on
force for example large male football player can submit more force than
smaller female gymnast when performing the same task.

External risk factors also affect on the force; protective equipment such as
helmets reduces force, while training on hard surface increases the force.

39

McIntosh described the complex biomechanical model that describes the

interaction of force and force tolerance (positive or negative) with other
factors such as attitude / behavior of players, training, skill level,
quality and types of equipment, kind of training, influence of other
competitors and the environment.
The importance of this model is a description of how forces and tolerance of
forces can be changed through intervention. For example, exercising some
new skills can influence on different situations and allow that athlete
maintain a balance what can reduce the load on the knee in the frontal and
transverse plane.
Improved condition can protect tissue from injury and through the effects of
training change its properties, but also result in more loads that can be
applied on the tissue. For example, improved strength at handball player
also develops a stronger throwing of the ball. This can affect on the larger
forces in the shoulder, but also on the larger forces at the goalkeeper during
defense action.
Comprehensive injury causation model is based on Meeuwisse model that
besides the biomechanical factors also account for the factors of sport. In
this model the internal and external risk factors can affect on the force and
on the force tolerance (Bahr et al., 2005). The model is shown below in the
slide:

40

Scheme 3.Comprehensive model for injury causation. BMD, Body mass

density; ROM, range of motion (Bahr et al, 2005).

Regard to the model, a precise description of the incident event is of the

critical importance. The point is to describe accurately the incident event,
for truly understanding of injury mechanism. To complete description of
mechanism for the occurrence of certain injuries, it should be added
described situation which leads to the formation of certain injuries (game
situation, the behavior of players and his opponents), but also a detailed
description of the entire biomechanical movements of the body and the joint
movement in the moment of injury. For prevention, it is important to know
how external and internal risk factors modify the risk of injury.

41

Review of internal and external risk injury factors, and causes of

injuries founded by reviewing of the scientific literature:
8.1. Internal injury risk factors
8.1.1. Aging
The aging process is changing anatomical and physiological properties of
athletes. Puberty is a period of life when large changes in the body occur,
especially physically and mentally maturing of the child (Klemeni, 2008;
Markovi, 2009). Most studies show that the highest incidence of injuries is
present in older adolescents and seniors. Cause of the increased incidence of
injuries, due to aging, may be because of maturity, as well as the increased
number of competitions in the older adolescent age and increased load
during games. Adolescents in that time go further (grow up), to professional
clubs with entire duration of the trainings or matches.
Football: All reviewed reports confirm that the relative risk for injuries in
football increases with the age of the athlete (Brito et al, 2012; Olsen et al,
1985; Junge et al. 2003; Price et al, 2004; Kucera et al, 2005; Froholdt et al,
2009). Brito et al., 2012 found that the greatest risk was at U19 population,
compared with younger age groups. Similar information was given by Price
et al, 2004, who shows that the players in the older age group (17-19 years)
were more exposed to the risk of injuries than in younger age group (9-16
years). In his research exceptions in the incidence of injuries were the
goalkeepers, where the highest incidence of injury was between 14-15
years.

42

Froholdt et al, 2009 also shows that the incidence of injury is greater in
older adolescent population aged 13-16 years. Injuries classified among the
younger population were mostly lightweight nature. Kucera et al, 2005
study is consistent with previous research.
Handball: Olsen et al, 2005, 2006 believe that aging is one of the main
factors for the occurrence of injuries in handball. Unfortunately, in handball
there are just few studies dealing with this issue, to confirm this hypothesis.
Author reports that incidence of injuries in handball in adolescents aged
between 12-14 years is very similar to the incidence of injuries in seniors.
Moller et al, 2012 argues that seniors had a higher incidence of injury
compared with players aged 15-18 years. The incidence of injury grows
with age. Dirx et al., 1992 confirmed that older players (more than 20 years)
had significantly greater risk of injury than players under20 years of age.
Basketball: Increased incidence of injuries in older adolescents between 1519 years of age may reflect the fact that adolescents of this age are more
firmly loyal to basketball than younger age groups. Physical development
has an impact on the rate of injury because adolescents tend to be faster,
stronger and bigger with growing up (Randazzo et al, 2007).
8.1.2. Sex
Many authors do their researches on oynl one sex, and it is very difficult to
determine accurately whether or not is a specific injury more common at
the male or the female population (Luigi & Henke, 2010). A typical
example is the large number of researched ACL injuries, especially on
females.

43

Handball: Dervievi, 2005 found out that in Slovenian athletes gender is

not a key factor for the occurrence of injuries. A similar result presented
Frisch et al., and Seil et al, 2008, which explored the girls and boys from
different sports disciplines who were aged up to 19 years. Olsen et al, 2006
in his study also noted that there were no gender differences in the rate of
incidence of injury.
Looking only on team sports Dervievi found that girls have more injuries
than boys of the same age, especially in the area of the knee and ankle. On
increased incidence of injuries in adolescent female players influence the
factor of psychological stress and emotional instability (Medveek et al,
2011). Myklebust 1998 and 2003 reported an eight times higher incidence
of injuries during the match at the girls.
Henke 2003 showed that the largest number of injuries in Germany
happened to female players of handball, looking at a variety of team sports
(22%), (Luigi & Henke, 2010). Injuries of ACL occurred 3-5 times more at
adolescents females than in adolescent males (Myklebust et al, 1998;
Myklebust et al, 2003; Olsen et al, 2005; Arendt & Dick, 1995; Hutchinson
& Ireland, 1995; Arendt et al, 1999 Wedderkopp et al, 1999). The causes for
such a big difference between sexes in the occurrence of knee injuries are
still not completely understood. It is possible that girls are easier susceptible
to the occurrence of injuries due to their inferior morphology.
Moller et al, 2012 told that sex was only risk factor for injuries at U18
population, where boys had 1.8 times higher risk for injury than girls.
Reason for this result may be a relatively small sample.

44

Basketball: Basketball injury rate was highest in the 13 annual girls and 15
year old boys. This result may lead to think that the older girls reduces
interest in sports, compared with boys who later in life have constantly
increasing number of injuries (Randazzo et al, 2007).
8.1.3. Factors associated with growth
One of the main characteristic of adolescence is growth and development of
the psycho-physical attributes of the adolescent. During this period,
cartilaginous structures are particularly vulnerable to heavy loads and to
forces generated during sporting activities. Due to rapid growing of long
bones which does not follow the proper extension of the muscle tendon
structures, muscle imbalances and injuries in muscle structure can occur.
As a consequence, some sudden acute injuries are possible, such as muscle
and tendons ruptures caused by excessive force that athletes body can not
handle, and different chronic deformations may appear, like traction
apophysitis (for example anterior knee pain). Due to not coalesced
cartilage, the possibility of fractures is increased. Coaches must be aware of
the characteristics of adolescent growth and loading during training.
8.1.4. Body composition
Football: Bastos et al, 2013 did not found a significant difference in body
mass index and incidence of injuries among groups that have been injured,
and among these which have not been injured. However, it was confirmed
that a tendency that increased body mass index can lead to injury. The
higher players reported more knee and ankle injuries in comparison with the
body. There was no statistically significant difference.

45

Basketball: Heavier players had a greater incidence of injury, which is

particularly pronounced in players who play at position of the center
(Meeuwisse et al, 2003).
8.1.5. Poor biomechanical relationships and anatomical variation
Biomechanical dysfunctions are very common in adolescence, respectively
in period of peak height velocity and body development. Some better known
anatomical and biomechanical deformations are varus and valgus of the
knee, high positioned patella (patella alta), external rotation of the tibia, etc.
These anatomical variations can be a risk factor for the occurrence of
injuries (Agel et al, 2007).
Compensatory activities and improper movement patterns, may lead to the
injury in athletes who are extensively involved in sports, Disturbed
biomechanics affects on the occurrence of problems in proprioception.

Proprioception is a mechanism that involves a sense of motion in the joint

and a sense for joint position, which is very important for the functional
stability of the joint. Decrease of proprioception causes a loss of
neuromuscular control, leading to functional instability and possibly to
frequent injuries of joints. It seems that proprioception is changing during
adolescent period, especially during the most intensive phase of growth
(peak height velocity) in puberty (Brzi et al, 2012). Studies that examine
other sports indicate that hypermobility of joints affects on the increased
risk of injury in rugby or netball (Smith et al, 2005).

46

8.1.6. Individual motor abilities

Football: It seems that players with lower capacities have increased risk for
occurrence of injuries (Frisch et al, 2011; Peterson et al., 2000; Junge et al.,
2002).
8.1.7. Physiological factors
During adolescence, with the growth and development of the body,
hormonal status of the organism also suffers changes. This is particularly
present in girls in which occurs the first menstruation - menarcha. High
intensity workouts and eating disorder can lead to delays of menarche
(amenorrhea). The consequence of this situation is reduced secretion of the
hormone estrogen, which can cause decreased bone density and occurrence
of fracture, stress fractures and similar. This syndrome is called female
athlete triad (amenorrhea, eating disorders and osteoporosis) (Malina et al,
2004; Markovi et al, 2009).
8.1.8. Psychological risk factors
Participation in competitive sports have a very positive impact on the
personal and social development of children and adolescents, because it
encourages the development of self-esteem, self-confidence, self-control
and help adolescents to make autonomous decisions. Because of a lot
pressure on athletes and unfulfilled desires in sporting achievements, it can
lead to very serious anxiety and depressive episodes. In this sense, young
athletes may not report pain or injury and dissimulate injury, in order to
fulfill the expectations. This approach may lead to even greater worsening
of injury.

47

Similar effects may occur due to problems in love life and relationships in
the team, where is present the importance of relationship between coaches
and players, and the players between themselves. In all of this very essential
role play the stage of the maturity of a person which have psychological and
emotional problems.
8.1.9. Previous injuries
Previous injuries are a common risk factor for their recurrence. Athletes
want a rapid recovery and fast return to activities and competition. Injured
body part needs necessary time to recover and to adapt on the high efforts
and loads that was accustomed before the injury.
Football: Kucera et al, 2005, has made a study, whose aim was to
determine whether players from the USA at the age of 11 - 18 years old with
previous injuries have a higher incidence of injury than athletes without any
injuries, based on the player's reports completed independently. More than
half of the reported had previous injuries (59.7%). By multivariate
generalized Poisson regression model was found that players with a
previous injury have a double risk of injury, and those players with two or
more previous injuries have three times higher risk of injury. Previous
injuries were associated with an increased rate of injury. This suggests that
young football players have increased risk for injury. Gall et al, 2006 and
Price et al, 2004 reported an identical incidence (3%) of recurring injuries.
They suggest that repetitive injuries may indicate inadequate rehabilitation
after injury or premature return to sports activities. Ergn et al, 2013
reported 25% of recurring injuries at elite Turkish players.

48

Reccurens injuries were more often during trainings than in matches (p =

0.078). All injuries that were repeated was overuse injuries. The fact that
number of recurring injuries is lower in adolescent population than among
seniors suggests less pressure on adolescents for returning to competition
than on seniors. In a Turkish study, it is likely to be a bad training and too
much loading of the adolescents, no matter what they are top quality
footballers. Handball: Yde and Nielsen, 1990 found that in 32% of injured
handball players injury occurred on the same place. In female handball
players, with operated ACL were recorded 12% of new ruptured ligaments
on before operated knee, while in 16% of cases the pain occurred on the
other knee.
From this data it can be concluded that injuries and pain in the knee do not
have to always appear on the already injured knee. Due to altered kinetics of
movement and different loads, pain and injuries can occur on the other limb
or on the other joint. In handball with male players there is a similar
situation, where the incidence of re-rupture of ACL was 13%. In both
studies revealed, previous injury of ACL is not necessarily one of the key
risk factors for injury on the same knee (Olsen et al., 2005). Moller et al,
2012 stated that athletes with two or more previous injuries that caused
absence from handball more than 4 weeks have an increased risk of new
repeated injuries at U16 population. Wedderkopp et al, 1997 and Myklebust
et al. 2002, also found a great correlation between previous injuries and new
injuries, especially in terms of injuries of the lower extremities.

49

Basketball: Reports of various studies show that the rate of recurrent

injuries in basketball can go up to 70%, while in Agel study the rate was
30% (Agel et al, 2007). When looking on recurrence injuries, knee was the
most problematic part of the body (Meeuwisse et al, 2003). The most
frequently repeated injuries are in the ankle area, and the history of ankle
injury is a major cause of recurrence of an ankle injury (Bruce et al, 2010).
8.2.External risk factors
8.2.1. Length of sports participation
In order to determine whether the length of sports participation affect on
injury factor, further researchings are necessary, due to lack of data and their
contradictory.
Football: Players who practiced football for more than 5 years have been
suffered more injuries than those who are engaged in football for a shorter
time (Bastos et al, 2013).
Contrary to this, Kucera et al, 2005 noted that longer engagement in football
is shown as a protective factor and uninjured players were usually those
who are practicing sports for a longer time. Handball: Playing handball
longer than 5 years has affected on the increase of injuries in handball, but
the incidence did not reach statistical significance (Dirx et al, 1992).
Basketball: It is established that participants who train longer have more
injuries than those who train less. The increased number of performances
can be a risk factor for the new injuries due to accumulated repetitive and
cumulative trauma during many years of trainings (Vanderlei et al, 2013).

50

8.2.2. Matches as risk factor

Football: Gall et al, 2006 amounts information that there was a significant
difference in the incidence of injuries when comparing the incidence of
injury in training and matches (P <.001). The risk of injury was three times
higher in matches. The incidence of injury was 11.2 injuries on 1000h at
match and 3.9 injuries per 1000h at training. The incidence of all types of
injuries was higher in matches, especially fractures and contusions. The
highest incidence of injuries in training was at the U14 population, and
highest incidence of injury in matches at the U16 population (Gall et al,
2006). Brito et al, 2012 also agrees with this statement, who got the result
that the incidence of injury was 4.2 times higher in matches than in
training.Similar results were also obtained by: (Agel et al, 2007; Ergn et al,
2013; Frisch et al, 2011; Peterson et al., 2000; Emery et al., 2005).
Deehan et al, 2007 and Price et al, 2004 reported an equal incidence of
injuries in matches and training sessions.
There was no statistically significant difference in the incidence of injury
between competition and training. Ergn et al, 2013 says that overuse
injuries were doubly present during trainings than in the matches.
Handball: According to the information received by the coaches, it was
found that the injury rate in matches was 9.9 at 1000h of matches, which is
11 times more than in training (females 10x, males 12x), (P <0.0001),
(Olsen et al., 2006). This trend is also seen in other studies: (Nielsen & Yde,
1988; Wedderkopp et al., 1997, 1999; Myklebust et al, 2004).

51

Luigi & Henke, 2010 indicate that injuries in early adolescents between
training and matches are equally distributed, which is changing during
maturation and aging.
In professional athletes, injury in matches can represent up to 85% of all
injuries. This supports the conclusion that the match in adulthood has a
much greater significance. In order to achieve a good result, players in
adulthood played on all or nothing during matches and under the
imperative of victory. In these ways players want to prove themselves on the
field and to ensure further progress and advancement. To achieve their
desires, players have to invest much more loading, force and willing to win
during matches than in training, which results with stronger, more
aggressive and dirtier game. Sometimes the role at adult players and cause
for that game has existential factors, e.g. money.
Players during training are investing less energy and are preserving each
other under control conditions, and that results with a smaller number of
injuries during training. Basketball: Similar data are also visible in
basketball. Randall et al, 2007 and Agel et al, 2007 reported that double
number of injuries occur during matches than during training. The
participants had double number of knee and ankle injuries in matches than
in training. Comparing the matches and trainings, there was in basketball at
the matches three times more concussions and three times more internal
injuries of the knee and twice more ankle sprains (Agel et al, 2007). A still
greater difference reports Meeuwisse et al, 2003 who said that about 3.7
times more injuries occur during matches than during training.

52

8.2.3. Preseason as a risk factor

Most of researches found out that the incidence of injuries in analyzed team
sports are of interval nature. The most common injuries occur at the
beginning of the season (the preseason) in August and September and at the
beginning of the second part of the season, after winter break in January to
March, depending on the beginning or ending of the season.
Factors associated with an increased possibility of injury are the weaker
condition due to dead season, increased intensity of players who learn the
starting position, and fatigue due to start of the season.
Many players practice during the dead season, but without control and in
different ways, with bad equipment and so on. This can affect on
appearance of different injuries at the beginning of the season, including a
stress fracture.
Football: Brito et al, 2012 says that the incidence of injuries in training and
matches was not significantly different when looking at the season, but
claims that the overall incidence of injuries is greater in September than in
May and June. The incidence of injuries in training was higher in September
than in May and June, while the highlight of injury in a game was in
October.
About similar incidence of injuries reported also: (Agel et al, 2007; Deehan
et al, 2007; Price et al, 2004; Gall et al, 2006). Deehan et al, 2007 shows
that the peak of injuries occurrence was at the beginning of September and
March, and that similar incidence of injuries was visible during all five
years of researching.

53

Gall et al, 2006 and Deehan et al 2007, suggested that injuries occurred at
the beginning of the season are consequence of unequaled appropriate
conditioning and non optimal physiological and physical condition of the
players. The hypothesis that could explain the increased incidence of
injuries after the holiday is increased physical activity or changes in activity.
The incidence of injuries is growing swiftly after the summer or after the
winter break and then decreases until the next period of inactivity. It seems
that during this time players do not achieve sufficient level of condition or
their training program is inadequate or too intensive, that body adjust to new
condition (Price et al, 2004). Period with clenched football calendar can also
lead to increased risk of injuries (Gall et al, 2006). Basketball: Randall et
al, 2007 shows that the injuries in the preseason were three times more
present than in the season, while the number of injuries in training during
the season was significantly higher than in the postseason. During the
season, the number of injuries was significantly higher than in the
postseason. (10.1 versus 6.4 per 1,000 seasons). Agel et al, 2007 also agrees
with this study, showing that the injuries during the preseason were more
than double more than during the season.
8.2.4. Players position
Comparison of different studies that analyze the player position is difficult,
due to different study designs and the fact that young players have not yet
determined a definitive position on the field. After age of sixteen years the
position of some player can be definitively determined.

54

Position can be changed during the season, and players often find
themselves at the other positions. Due to these facts, the interpretation and
analysis of data related to the occurrence of injuries that correlated with
players position is very difficult. Football: Deehan et al, 2007, calculated
the relative risk of injuries to a specific position in a way that the number of
injuries occurred on a certain position was divided with the number of
players who play on that position in relation to the total number of players,
with the goalkeeper that is set as the initial value 1. According to his
calculations, the risk of injury by looking at the goalkeeper position was:
goalkeeper 1; defenders 1.2; midfield players 1.45; attackers 1.1. Data
indicated that the greatest risk of injuries is on the middle of the field.
Gall et al, 2006 presented different data, where defenders had the most
injuries, 2.2 injuries per player in the season, compared with goalkeepers
who had 2 injuries in the season, 1.6 injuries of midfield players and 1.5
injury of the attackers. Data was similar when looking at age of the player.
This study show very common hurting of goalkeepers (14.1%), what is in
totally contrary to the previous study. Goalkeepers have the highest rate of
moderating severe injuries, especially of the upper body (in this study,
50.9%) and hands (21.5%) compared with players at other positions, which
suggesting that this is a very high-risk position in football. Goalkeepers had
the highest rate of injuries in training, and defensive players on the matches.
The increased number of injuries on goalkeepers may be due to increased
physical contact during the confrontation with an opponent player.

55

In that moment it is necessary to react with fast, short and explosive

anaerobic actions. This suggests that goalkeepers need to improve skills for
avoiding injuries. Therefore goalkeepers need special intervention trainings.
Other studies have established the highest incidence of injuries at defensive
players and midfield players too. Attackers are injured less than midfield
and defensive players (Price et al, 2004; Kucera et al, 2005).
Handball: Wedderkopp et al., 1999 found that young female handball
players have a higher number of injuries on the backcourt positions in
comparison to other positions on the field. The most common injuries were
non-contact injury of the ankle or knee. Myklebust et al, 2003 found similar
results, between 188 anterior cruciate ligament of the handball players (of
both sexes) most injuries were at the players who played on backcourt
positions (60%). 28% injuries had wingers, 4% circular attackers and least
number of injuries had goalkeepers. Causes of large number of injuries at
the backcourt positions are numerous. The first is that external players
numerically dominated pivot and winger players. As the main cause are
presented handball specific movements with or without the ball and very
active role in the game. Backcourts are looking for quick changes of
direction at short intervals, with lot of landing and jumps which can
influence on the high probability for the occurrence of knee injuries
(Myklebust et al., 2003; Olsen et al., 2005). Henke et al. 2005 has stated that
the attack backcourt is the most often injured player, followed by pivot and
central backcourt. Seil et al reported the opposite, that the wingers and
pivots are more injured than backcourts (Luigi & Henke, 2010).

56

Basketball: The centers at university basketball players had the highest rate
of injuries, followed by guards and fowards. The centers had the highest rate
of injury for all injuries compared with fowards (ankle, knee, etc.). Centers
had also the large number of injuries, when contact and non-contact injuries
are compared. Guards had more injuries than fowards but the rate of injury
was not statistically significant (Meeuwisse et al, 2003).
Moreira et al., 2003, analyzed professional players at the age of 24.5 years
and also found a higher frequency of injuries in the centers, followed by the
shooting guards and point guards. Similar data received from Agel et al,
2007. Vanderlei et al, 2013 states different results, that shooting guard
players had the most injuries (45%), followed by centers (37%), and point
guard players (18%).
Individual features and characteristics of the training were the risk factors
for injuries at shooting guard and center, while body mass was cited as a
risk factor for all positions.
The centers are responsible for the shot under the basket, which includes
jumps in offensive and defensive activities. These activities require a lot of
force in fighting for space. Centers may have a higher rate of injury during
landing because they tend to be in the area with the highest concentration of
players, and the area under the basket. Centers need more weight to take
better position under the basket and to block opponents during defensive
activity. Absorption of forces during constant jumping and landing acts as a
major risk factor for traumatic and overuse injuries, especially in heavier
players (Meeuwisse et al, 2003; Vanderlei et al, 2013).

57

Shooting guards are responsible for the preparation of shots and

comparatively with the speed they should have a lot of power and energy.
As pure offensive players, shooting guard players suffer a lot of kicks and
attacks. Athletes who are closer to the basket and have more physical
contacts with others, have increased chance of injury.
Point guards are responsible for a speedy transfer in the game from defense
to attack in order to achieve a shot. This kind of game for point guards
creates big opportunity for the development of ankle sprains. Point guards
play away from the basket and therefore have fewer rebounds and suffer
less force, although the dynamics do not explain why also heavier players at
this position tend to have more injuries (Vanderlei et al, 2013).
8.2.5. Training and improper technique of training
It is essential to individualize the training and adapt it to the requirements of
individual player, if possible. It is necessary to teach young athletes the
proper conduction of exercises, and the implementation of all components in
the training, especially those components essential for prevention of
injuries, such as warming up and stretching exercises. Inadequate training
regime is probably the most important risk factor for the injury.
The most common cause for the development of overuse injuries is the
sudden increase of intensity, according to the "too much too soon."
This usually happens during the summer camps, while preparing for various
championships, training programs before the season, or when switching to
the higher rank of competitions (e.g. from junior to senior rank level).

58

Insufficient rest and sleep between trainings can lead to overtraining and
chronic fatigue of the body, what can result in reduced concentration and
coordination during training. This is one of the major risk factors of injuries.
The use of improper technique is also an important risk factor for sports
injury. Handball: During analysis of the prevention program, it was
concluded that inadequate trainings can affect on the large number of
injuries in the control group (Wedderkopp et al, 1999).
8.2.6. Poor condition
Football: It has been proven that lower muscular strength increases the risk
for occurrence of muscle strain (Emery et al, 2003; Frisch et al, 2011).
Handball: Players with poor condition have an increased possibility of
injuries (Luigi & Henke, 2010).
8.2.7. Neglecting of stretching and non-use bandages
Basketball: Neglecting of stretching and not wearing of bandages may be a
potential risk factor for injuries. There is no statistically significant evidence
of the impact of these factors on the occurrence of injuries (Bruce et al.,
2010).
8.2.8. Poor postural control of the body
Handball: It has been reported that players with weaker postural control are
more vulnerable to be injured. Poor balance increases the risk of injury
(Wedderkopp et al., 1999).
Even very light contact during jumps, turns, pivoting and feinting can make
that player loses body control (Luigi & Henke, 2010).

59

8.2.9. Dominant side of the player

Football: Most of the injuries occur on the player's dominant side (54%:
35%; p <0.05), (Price et al, 2004). Handball: Beli et al, 2011, carried out
measurements of the motion velocity, flexibility, specific power, basic
strength and coordination, by doing a test of amortization with handball ball.
The obtained results in all tests show a significant difference between the
dominant and non-dominant side of the body.
These differences are most evident during throwing, due to constant
unilateral training in the most common actions in handball as shooting and
passing. This type of exercise can lead to the onset of traumatic and overuse
injuries of the shoulder on the dominant side of the body, that can be
prevented by equally load and with exercising with both sides of the body.
8.2.10. Jump and landing (drop jump)
Basketball: Two similar, a potential element for injuries in basketball at
American soldiers (Air Force) including a jump, or a clumsy landing and
landing on someone else's foot. This is a very common cause of injury in
basketball (Bruce et al, 2010).
8.2.11. Pivoting and cutting maneuvers
These maneuvers are cited in all studies as a big potential risk factor for
non-contact injuries, looking at all three sports. These movements in
particular can affect on the occurrence of injuries of the knee and lower
limbs in general.

60

8.2.12. Contact and non-contact

It has not yet been strictly defined a matter that exactly constitutes noncontact injuries. For example, a player who is fighting for position has a
very short contact with the player, and falls (there is no need for a contact),
it is very tricky question whether this situation qualifies as a contact or not.
Studies differentiate mainly contact situations like permitted contact or fouls
and non-contact situations which are typical for running with sudden
changes of direction, cutting maneuver, starts and stops, as well as jumping
and landing on one or both legs.
Research shows totally different and contradictory data analyzed by looking
at all sports, and it is not possible to bring a better conclusion. There is a
tendency that non-contact injuries are usually of much more difficult nature,
and that is definitely necessary to work on their prevention. Football: Brito
et al, 2012 states that the majority of injuries are of contact nature. 71% of
contact injuries include collision with another player (P <.001). Agel et al,
2007, found out that the contact between players was the primary cause of
injury in the matches (61%), except for strained thigh muscles.
The majority of injuries in training occurred without direct contact with the
injured body part (47%). Most other contact injuries are caused by contact
with the ground. Less than 1% of injuries over 15 years as study lasted
resulted from the contact with the gate. Noncontact mechanism was the
biggest cause for the occurrence of serious injury during training. Deehan et
al, 2007, present opposite data which states that the contact injuries
occupied 31% of injuries, and 69% of non-contact injuries.

61

Frisch et al, 2011 show that 36.8% of injuries were contact injuries and
58.3% non-contact injuries. The author claims that the personal
characteristics and behavior of the players are a major cause for a large
number of contact injuries, which has not been proven in this study. Yde et
al, 1990 provides an equal share of contact and non-contact injuries in
football.
Handball: Handball is a sport that allows physical contact during the game.
Therefore, it is not surprising that 2/3 injuries occur during official matches
and 13% during the training, and in a variety of situations involving
situation one on one (Henke & Heck, 1995). In sports where physical
contacts are predominant, rapid direction changes and fight for space and
because of that there is quite high chance for occurrence of injury (Hopkin,
2007; Yde and Nielsen, 1990; Seil et al., 1998). The young female handball
players have a very high frequency of injuries, up to 40 injuries at 1000h
games. More than half of injuries occur without any external factors. More
than 50% of injuries were traumatic injuries to the lower extremities, and
half of them were without known external factors (Wedderkopp et al, 1999).
Yde et al, 1990 found out that the majority of injuries were of contact
nature, caused mainly by the contact between the players (31%).
A significant cause of injury occurrence in handball is contact with the ball
(19%) and contact with the ground (17%), the rest were non-contact
injuries. Seil et al 1998 reported that 53% of injuries in matches were a
consequence of the contact with an opponent, while in training only 19% of
injuries are a result of a contact.

62

Holdhaus thinks that the cause of a large number of contact injuries is the
poor coordination between players and the high pace of the game. In most
situations, contact injuries affect the upper body, especially the head and
fingers. In contrast, non-contact injuries are mostly oriented to the lower
body. Jumping, landing and cutting maneuvers during running are dominant
situations that lead to non-contact injuries (Luigi & Henke, 2010).
Noncontact injuries are usually much serious than contact injuries, and one
of the most obvious examples are injuries of ACL.
Basketball: Hootman reviewed 15 university sports in the USA, and found
out that the player's contact was the most common mechanism of injury for
all sports and produced most of the damage, even in the sports which punish
contacts, such as basketball (Bruce et al, 2010). Percentage of contact
injuries among players during the matches was 52.3% and in trainings
43.6%. In the matches non-contact injuries occupied 22.3% and in trainings
36.3% injuries, as the second largest mechanism of injury during training.
Other important factors that contributed to the occurrence of injuries are:
player drop to another player, players drop on injured players and contact
with the floor.
Contact with the ball and contact with other things outside the field were of
very small importance for injuries in basketball players (Randall et al,
2007).
Research conducted at the US Air Forces has presented a result that the
contact with another player was at second place of appearance, immediately
after landing (Bruce et al, 2010).

63

Meeuwisse et al, 2003 argues that the most frequent contact between the
players is under the basket in key. Ratio between contact and non-contact
injury was about 4 vs 3.
Agel et al, 2007 says that noncontact knee injuries are the most common
cause of lost time injury, longer than 10 days. Most ankle injuries that cause
absence from the field longer than 10 days are associated with a contact way
of injury. Gerard et al, 2006 conveys the fact that noncontact injuries take
up more injuries in recreational players than in the professional players,
where most injuries are of contact nature.

Graph 1: Game and practice injury mechanisms, all injuries, university

mens basketball, 19881989 through 20032004 (n = 4211 game injuries
and 7833 practice injuries). Other contact refers to contact with items
such as balls, standards, or the ground. Injury mechanism was unavailable
for 1% of game injuries and 2% of practice injuries (Randall et al, 2007).

64

8.2.13. Tackling
Football: Tackling caused 9% to 16% of the injury during the matches
(Deehan et al, 2007; Agel et al, 2007).
8.2.14. Fatigue
Insufficient amount of rest and sleep between training can lead to
overtraining and chronic fatigue of the body, which may result in reduced
concentration and movement coordination during games, which is one of the
major risk injury factors. Football: In order to establish the fatigue (either
muscular or nervous origin) in cause of injuries in football, it is necessary to
consider the time of injury in training or match.
The incidence of injuries increases as the game progresses, with the
majority of injuries occurred during the last 15 minutes of each half (p
<0.05). More damage occurred in the second half than in the first 50%:
41%. The cause is probably multiple, including the previously mentioned;
neuromuscular fatigue, adolescence and immaturity physical and
physiological muscle systems (Price et al, 2004).
The only variable matter that significantly contributed to the emergence of
injuries in football was the physical fatigue. In addition to unvariate
analysis, this is also confirmed by multivariate analysis. Other numerous
variables did not show any tendency or statistical confidence (Frisch et al,
2011). Muscle fatigue is also shown as a risk factor in female athletes in the
study at the American College of Sports NCAA (Borotikar et al., 2008), and
is presented as a critical factor in professional male players (Greig et al,
2008).

65

Handball: Asembo et al, 1997, found out that 56% of injuries occur in the
second half, while Myklebust et al, 1997 received different data, and said
that 53% of injuries occur in the first half of the game. Langevoort et al,
2007, said that the risk of injury increases, from half of the first half of the
game, onwards. Dirx et al, 1992 states that the incidence of injury is the
largest in the last quarter of each half. Momeni et al, 2008 considers that the
incidence of injury depends on the degree of competition (semi-finals,
classifications, etc.).
8.2.15. Running
Football: Running turns and other non-contact activities were the cause of
all injuries in 34% of the competitive or non-competitive period.
Information does not include data whether during emergence of injury was
present an acceleration or deceleration (Price et al, 2004). In football, 27%
of injuries are caused by running, while in handball and basketball, percent
was 33% (Yde J et al, 1990). Basketball: Running is presented as the third
cause of injury in basketball after landing and contact between players
(Bruce et al, 2010).
8.2.16. Shooting in the target
Shooting in target in handball and basketball causes more injuries than
shooting in football (Yde et al, 1990).

66

8.2.17. The surface quality

Football: Changing the playing surface may cause overuse injuries,
especially during switching from natural to artificial grass (Ivkovi, 2009).
Research from 2007 shows that the risk for injury was equal in young
female football players, comparing artificial and natural grass (Steffen et al,
2007). Aoki et al, 2010 reports similar results, but show higher incidence of
chronic complaints in adolescents, especially in the lower back region.
Implementation of ongoing supervision is recommended, regardless of
better quality of artificial surfaces during lasts years. In contrast, report that
investigated the occurrence of injuries in the Turkish players adolescent and
adult says that most common injuries on the artificial surface was injury of
anterior talofibular ligaments of the ankle (Akkaya S, 2011).
Handball: Olsen et al, 2003 study shows the incidence of anterior cruciate
ligament on artificial surfaces than on wood is significantly higher among
girls. It seems that number of injuries increased over the last 10-15 years.
The high friction between sports shoes and surfaces for playing was shown
as significant external risk injury factor.
Handball is played on different surfaces with different friction
characteristics and the possibility of shock absorption is different. Usually,
there are two types of flooring surfaces (the wood) and artificial substrates.
Myklebust et al., 2003 in their study said that risk of ACL injury is 2.4 times
higher on artificial surfaces with an increased coefficient of friction than on
the wooden floor.

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Figure 16, 17 and 18. Different types of surfaces

8.2.18. Size of the playing court

Basketball: Smaller size of the playing court in the NCAA league may have
the potentiality to raise the number of injuries, and the court should be
extended to international normal measures (Agel et al, 2007). According to
this fact, further studies are required to see the relation between the size of
the field and number of injuries, especially of the ankle.
8.2.19. Inadequate sports equipment
Faulty and inadequate sports equipment significantly increase the risk of
injury (Ivkovi et al, 2009).
8.2.20. Phase of the playing
Handball: Most researches show that most injuries happen during the
attacking phase of handball game (Piry et al, 2011; Wedderkopp et al, 1999;
Nielsen & Yde, 1988; Wedderkopp et al., 1997, 1999; Olsen et al., 2006;
Lereim, 1999; Reckling et al., 2003; Asembo et al, 1997). The reason may
be in the higher speed and the plant and cut movements in attacking
situations. Totally contrary opinion had Seil et al., 1998 who states that 2/3
of injuries among the adult population occurs during the defense activities.

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2.8.21. The level of competition

Handball: Norwegian researchers found that in female teams are recorded
more knee injuries at players in the highest levels of competition than those
in the lower leagues (2 to 4 league). A similar result is established with men.
Strand 1990, reported that playing in the top three divisions caused greater
incidence of injury than in the lower divisions.
The reason for this is greater load during matches when the possibility of
injury is bigger. In the higher leagues and for professional players the
rhythm of training is harder and stronger, professional and medical
assistance is also better organized (Wedderkopp et al, 1999).
Myklebust et al, 2003 argues that correlation between the level of
competition and sex can be determined only at matches, not in training.
2.8.22. The visiting team
Handball injury rate was higher among visitors, (57%) (Piry et al, 2011).
8.2.23. Athletic shoes
It is required to regularly change the athletic shoes, considering the fact that
after 500-700 km of training, shoe loses up to 40% of the capacity
absorption of reactive power surface (Ivkovi, 2009). Basketball: The
specific design of shoes can play a role in the kinematics of the lower
extremities during daily and sports specific activities. Some factors, such as
heel height can take place in compromising positions, which can be one of
the risk factors for ankle injury.
Basketball shoes with too increased height of the heel can prevent normal
pronation and increase the risk of lateral ankle sprains (Claudia et al, 2008).

69

Bruce et al, 2010 did not find an increased incidence of ankle sprains by
looking at the type of sports shoes.

Figure 19.Proper position of the foot in the shoe

Figure 20. Proper loading of the foot to the ground

8.2.24. Education of parents

Football: Relationship between education of athletes parents and risk of
injury is not statistically confirmed. However, boys whose parents had a
higher level of education suffered from more injuries than girls. (Dahlstrm
et al, 2012).

8.3. Causes of injuries by looking at the body part and diagnosis

8.3.1. Causes of concussion
Basketball: A concussion is large injury. Female athletes are under greater
loads and increased opportunities for the development of concussion
because of their smaller size, more fragile structure and less strength of
neck. Females have significantly higher number of knee injuries and
concussions, than boys who are dealing with more lacerations, fractures and
dislocations (Randall et al, 2007).

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Deitch et al also reported that the incidence of concussions in female

basketball player are up to three times higher. The major factor for the
development of a concussion is rough match. During the match and the
competition the play is being more aggressive than in training, and contacts
are more frequent and harsher. Agel et al, 2007 state in their study that
players are under 13 times greater risk of concussion in matches compared
with training. 80.6% of concussions occur due to contact with another
player, 8% due to contact with the ball and 8% due to the ground contact.
Randall et al, 2007 shows that the participants in his study had three times
more concussions in matches than in training.
It is very worrying the fact that the number of concussions during a
basketball game in the last two decades has dramatically increased,
especially among female adolescents. Randazzo et al, 2007 facts that the
number of concussions during the 11 years of researching has doubled for
boys and tripled for girls. A similar data was also in Agel et al, 2007 study
where injuries of head and neck grew constantly during 16 years of research
period, with average annual growth of 6.2%.
In the last three seasons of researching, turned up 65% more injuries
compared with the first three seasons of 16 annual survey. The increased
number of injuries among female adolescents can be explained by the
increasing size of players, more powerful basketball games and increased
intensity of trainings.
Using of the elbow also affects on the increased number of concussions.

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It can be expected a further increasing of the incidence of concussions

because of the increasingly aggressive game. Large problem is that one third
of athletes do not recognize the symptoms of a concussion or not report it to
coaches (Agel et al, 2007).
8.3.2. Causes of shoulder injury
Handball: Shoulder pain is a significant problem in young handball players
of both sexes. In professional handball players significant are overuse
injuries of shoulders, but very little is known about the factors of origin.
The average incidence of injuries in male professional handball player in the
season was 28% (Clarsen et al, 2014).

Figure 21. Paining shoulder during handball game

Moller et al., 2014 reported that at the time of testing 14% of the
adolescents handball players have reported current pain in the shoulder, and
33% of previous shoulder injuries and pain. 56% of pain in shoulder had a
gradual onset.

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There was no statistically significant difference between sexes (P = .783)

and age (P = .187). 78% of the pain was felt in throwing or dominant hand.
19% of the players who said they have a shoulder pain, have pain for more
than a year. There was a significant relationship between scapular
dyskinesia and shoulder problems (OR 6.11, 95% CI 2.0-68.4, P <.05).
Players with problems in shoulder had reduced movement in the
glenohumeral joint (mean difference 9 , P <.05). There was no significant
difference between isometric strength and problems in the shoulder.
8.3.3. Causes of the upper limbs injury
Football: Injuries of upper extremities often occur during falls or catching a
ball (Deehan et al, 2007). Handball injuries of upper limbs are most
frequently at goalkeepers, but also at the players due to sudden moves and
falls. Most typical injuries for goalkeepers are elbow due to repetitive
trauma during defensive reactions. This injury is noticeable in handball too.
8.3.4. Causes of finger injuries
The reason of finger injuries is contact with the ball in different situations.
Finger sprains are frequently in basketball with 43% injuries and handball
with 25% injuries (Yde et al, 1990).
Basketball: Term finger jam is most commonly associated with injury of
the proximal interphalangeal joint (PIP), after a rapid axial load when ball
hits outstretched finger. Such force can hurt any part of the wrist. There are
also other types of fingers injuries that are specific for basketball (Gerard et
al, 2006).

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Figure 22. Way of finger injuries in basketball, handball or football

8.3.5. Causes of groin and hip injuries

Football: Previous injuries, strong trainings and loads during the matches
can be an important factor for the development of injuries of the hip and
groin (Brito et al, 2012). More multivariate studies on Iceland's senior
players have shown that decreased range of motion of hip abductor muscles
increases the risk of strained groin (Gall et al, 2006).
8.3.6. Causes of thigh injury
Football: Most injuries of the thigh were strains, at quadriceps and
hamstrings. 43% of injuries occurred at the quadriceps, and 57% at the
hamstrings (Price et al, 2004). A high percentage of thigh injuries in football
are most likely due to the incomplete muscle development in adolescents
and limited absorption of stress on the developing muscles (Gall et al,
2006). Price at al, 2004 states that exposure of adolescents to high loads,
which are necessary for shooting and acceleration can lead to injury.

74

Another important factor is use of thigh muscles as stabilizers of pelvis and

as balance factor between trunk and abdomen muscles.
8.3.7. Causes of knee (Anterior cruciate ligament - ACL and meniscus)
injuries
Knee is a complicated joint that is under heavy loads during sporting
activities. Players during football game on average make a thousand
changes of actions (Price et al, 2004), that can overload ligaments and the
knee due to high forces, which may lead to multiple injuries. Interior knee
injuries are the most common cause of absence from the sports
performances for more than ten days (Agel et al, 2007).
Causes and mechanisms of injury of anterior cruciate ligament (ACL)
The function of the ACL is to stabilize and direct the knee and to prevent
abnormal movement of the knee. The ACL prevents hyperextension and
anterior translation of the tibia referring on the femur. ACL also stabilizes
the knee against the rotation of the tibia.
Studies on cadavers have shown that at 30 degrees of knee flexion, ACL
give 85% of capsular ligament resistance. These studies show that lack of
ACL results in significant valgus and varus knee instability between 20 to
40 degrees of knee flexion (Olsen et al, 2004). Serious knee injuries,
particularly of ACL are a big factor for concern.

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The highest incidence of ACL injuries was seen in adolescents in pivoting

sports like football, handball and basketball with incidence of injuries two to
eight times higher in girls than in men, confirmed by reports of almost all
studies dealing with this topic (Olsen et al, 2004; Bahr et al, 2005; Agel et
al, 2007; Arendt and Dick 1995; Deitch et al university basketball; Gerard et
al, 2006).
ACL injuries have a major impact not only on costing of the treatment, or
lack of recreational activities, but also on the emergence of osteoarthritis
later in life. After 10 years of injury, half of injured athletes will show signs
of osteoarthritis, and approximately all injured will have osteoarthritis
through next 15-20 years (Bahr et al, 2005). Scientific studies dealing with
this issue, did different researches of movements of human body
(acceleration and deceleration), analyzing influence of valgus forces on the
knee and researched movements in the knee between femur and tibia,
especially during landing or jumping.
Potential mechanisms for the development of ACL injury, which
differentiate male and female, can be: anatomical, hormonal and
biomechanical. The risk for injury is multifactorial, without only one factor
that can cause injury (Ford et al, 2013).
In all three described sports (football, handball and basketball) non-contact
manner of injury occurrence in 70 - 95% of the cases stands as the most
common factor for ACL injury (Price et al, 2004; Myklebust et al., 2003;
Olsen et al, 2004; Randall et al, 2004; Agel et al, 2007; Bruce et al, 2010;
Gerard et al, 2006; Ford et al, 2013).

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Studies that analyzed team sports and anatomy of the knee have established
that the valgus position of the knee (high torque abduction of knee) or when
knee collapse inward is most common mechanism of ACL injury. Two main
mechanisms for ACL injury are - cutting maneuver and landing on one leg
after jump. (Price et al, 2004; Myklebust et al., 2003; Olsen et al, 2004).

Figure 23.Occur of ACL injury after landing phase

Results of the study, which were conducted in biomechanical laboratory

found that sidestep cutting technique explains in 62% moment abduction of
the knee.
Sidestep cuts combined with large valgus position of the knee, landing on
the heel and wide stance result with a high moment abduction of the knee
(Myklebust et al., 2003). Similar results as in the previous study were
obtained in another study which was done by video analysis of motion
during occurrence of ACL injury. Injured players often reported that injury
occurre during cutting movement or landing from a jump without any direct
physical contact and during movements that were done countless times
before.

77

Leaders of that study have tried to get a reason for this, and some of the
answers were: imbalance, the player is pushed or held, an attempt to avoid a
collision with an opponent, unusual position of the feet, unprepared landing
on the foot etc. (Olsen et al, 2004). Injuries usually happened when the foot
was easily fixed on the surface and foot was in all cases outside of the knee.
It was concluded that ACL injuries most frequently occurred at 7 - 8
flexion of the knee, 5 - 6 varus-valgus angle, and 8 -10 rotation of the
tibia (Olsen et al, 2004).
Muscle activation could not be seen appropriately from this video, but it can
be hypothesized that a strong eccentric activation of ACL can play an
important role in disrupting of the movement and cause the injury. In other
studies, it was reported that too strong quadriceps can overload the ACL
through the entire range of motion of the knee and can be seen as the
antagonist of the ACL. The greatest load on the ACL is at15 degrees of knee
flexion which agrees with the position that can lead to the injury.
These studies have shown that good coordination between quadriceps and
hamstrings is very important and that only hamstrings contraction has not
influence on ACL strain (Ebstrup and Boysen-Moller; Gerard et al, 2006).
Simonsen et al proved that even the maximum contraction of the hamstrings
would not be able to reduce the load on the ACL during cutting movement
in young well-trained handball players.

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Figure 24. Mechanism of ACL injury due to rotation of tibia

Ford et al talks about three neuromuscular deficits associated with

neuromuscular and biomechanical coordination, and involves the
dominance of the ligament, dominance of quadriceps and dominance of
the legs, especially thighs. Andrews and Axe explained the concept of
ligament dominance when lower limb muscles do not adequately absorb
forces during sports activities, resulting in increased forces on the knee
ligaments particularly ACL, which give resistance to anterior tibial
translation and to knee valgus.
Dominance of the ligaments is resulting in high forces - ground reaction
forces, valgus knee moments, and excessive knee valgus motion.
Domination of quadriceps means imbalance in the work of the quadriceps
and hamstrings, respectively flexor and extensor of the knee. Females tend
to rely more on the quadriceps than on hamstrings during jumping or
landing.

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Domination of leg is an imbalance between strength of muscles and form of

movement is moved on the opposite leg, one side of the body shows greater
dynamic control than other. Over-reliance on one leg can cause increased
stress on the knee, while the weaker side is not able to effectively absorb
large forces associated with sports activities (Ford et al, 2013). Boden et al
reported about mechanisms of the ACL injury on the basis of 100 ACL
injuries in different sports, mainly basketball, American football and soccer.
Non-contact mechanisms have been classified as a sharp slowdown before
changing direction or landing, while injuries occur as a result of the valgus
collapse of the knee.
It was also examined video review of 27 ACL ruptures and was founded
that injuries occur in the position with the knee close to full extension
during sudden deceleration before changing direction or landing. All
injuries were incurred during the competition, 19 in attack phase, and 1
during defense. All players had the ball in the hands and made 0-3 steps
before the injury. Attention was focused on the opponent or on the goal.
Plant-and-cut mechanism was the most common mechanism of injury with
12 cases, other mechanism was one-leg landing.
The injuries happened when the foot was easily fixed on the surface and in
all cases, the foot was outside of the knee. The knee was almost flat in the
valgus position combined with internal or external rotation of the tibia.

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Figure 25. Mechanism of ACL injury due to valgus collapse of the knee

Powell and Barber-Foss found out that rebound basketball is the cause of
the most ACL injuries at university female basketball players (Ford et al,
2013). In female university athletes greater valgus torque of the knee and
higher ground reaction forces are established, as well a smaller angle of
knee flexion compared with the male population during tasks that require
deceleration and change of direction.
It is believed that reduced flexion of the knee combined with ground
reaction forces that is directed posteriorly during delaying landing phase,
increases the force on the ACL which can result in its rupture and increasing
of front tibia sliding. ACL injuries often occur after hyperextension injury
or at the moment of significant valgus or rotational forces on the knees
(Gerard et al, 2006).

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Cutting maneuvers may present additional challenges for young athletes

compared with landing, because it requires much more precise locomotors
performance during circumventing of obstacles. Data show that less mature
athletes show biomechanical patterns during cutting movement, which is
putting them in bigger risk of injury than older peers. This difference may
be due to better development of complex locomotion skills in older athletes.
Biomechanical differences between males and females are visible through
all stages of maturation.

Figure 26. Difference between male and female in leg biomechanics as risk
ACL injury factor
During landing at puberty and post puberty at athletes was shown increased
loads on the knee in the frontal plane, compared to prepuberty athletes. It
was also found out that prepuberty athletes have higher moment of knee
adductor and ground reaction force compared with puberty and adolescence
athletes.

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According to the findings of this study, prepuberty athletes suffer greater

force than their older peers, which contributes to a greater load on the knee
in this group (Sigward et al, 2012).
A factor that may affect on the occurrence of ACL injuries among females
is their posture during landing. Ireland studied the posture of both sexes
during landing and found out that females land in a more upright position
than males (with greater hip extension, adduction, and internal rotation, with
more forward momentum; and with increased valgus at the knee.). It is
argumented that proximal position of the hip during landing transmitted
forces distally down to the kinetic chain which can lead to knee injuries.
Other risk factors for ACL injury:

Contact cause

Big cause of ACL injury was contact with the opposing player (Randall et
al, 2007 (23.1%); (Agel et al, 2007 (27% player's contacts and 8% other non
players contacts).

Neuromuscular control and joint laxity

A possible reason for greater risk of ACL injury states less neuromuscular
control and large laxity of joints (Renstorm et al, 2008).

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The surface and footwear

Olsen has shown that there is an increased risk of ACL injuries on high
friction surfaces in handball but only in female players. This author found
out that there was a relationship between the sexes (internal risk factor) and
surface friction (external risk factor) as risk injury factor, which suggests
that there may exist a difference in the characteristics of incident events
between the sexes. Bahr et al, 2005 shows that there exists a difference
between male and female players during landings and during cutting
movements. That can put the female knee in hurting position, especially
when the friction between athletic shoes and surface is high. It is necessary
to do an additional research about impact of footwear on level of ACL and
MCL injuries in order to show the rotational forces at the knee as a result of
different footwear (Price et al, 2004). Boden et al reported that most ACL
injuries in handball originated on artificial media, and only a small part of
subjects on the parquet.

Hormones and maturation as a risk for knee injury

Development of potentially dangerous movement within the female

population is associated with physical maturation. The increased circulation
of hormones during puberty increases body weight and height. Current
researches show that differences between genders during adolescence,
increases the risk of injury to the ACL in the female athletes. Reduced
strength of ligaments or altered muscle strength, due to cyclic hormonal
changes in females, may cause increased rate of injuries in female athletes.

84

Experimental studies that examined the impact of hormones on the

occurrence of injuries provide poor and confusing results (Ford et al, 2013).

Relationship training match

In players exist six fold greater risk of internal knee injuries during matches.
Most ACL injuries in matches are associated with the player's contact (Agel
et al, 2007).
Causes of meniscus injury
Meniscus acts as absorber of shock forces that influence on the knee.
Meniscus can be injured with other structures of the knee.
These injuries occur as a direct blow to the knee or due to the twisting type
of injury. Menisci are susceptible to compression and rotation forces
(Gerard et al, 2006).
8.3.8. Patellar tendinopathy and epiphyseal injuries of the knee
Sindig-Larsen-Johansson (SLJ) disease may develop at the proximal patella
attachment. Patella tendinopathy is often interpreted as a jumper's knee and
was seen in about 31.9% of elite adolescent basketball players. On the
patellar tendon attachment for tuberculum of tibia may develop Osgood
Schlater disease (OSD). These diseases are actually injuries caused by
overuse and excessive eccentric forces acting on the knee. Injuries occur in
the weakest point in the chain. In the development of adolescents the
weakest point is the junction between the muscle tendons and insertions of
the bones. These epiphyseal injuries are specific in athletes who are
growing, and are particularly specific for those athletes involved in jumping
activities such as basketball.

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OSD is usually present in young people between 10-15 years of age,

especially in active male adolescents who participate in bound sports. SLJ
disease occurs in some younger population, aged 10-12 years (Gerard et al,
2006). Backman et al, 2011 states that reduced range of motion of the ankle
is a big factor for development of patellar tendinopathy in basketball.
Previous ankle injury could affect on the reduced range of motion
(dorsiflexion) of the ankle.
8.3.9. Causes of the overuse injuries at lower leg
Overuse injuries are more frequently in football and handball than in
basketball. The most common are: medial tibial stress syndrome (MTSS),
stress fractures, and compartment syndrome. MTSS syndrome is most often
associated with excessive load of soleus due to excessive eccentric forces
and the correction of biomechanics is required. Soleus is a plantar flexor and
inventor of the ankle, and it works eccentrically to prevent excessive
pronation of the ankle (Gerard et al, 2006).
8.3.10. Causes of Achilles tendon injuries
Basketball: Tendinitis of Achilles tendon can occur in basketball because
of frequent concentric loads (when jumping) and eccentric loads (during
landing) that occur during a basketball game. These injuries are frequently
caused by microtrauma and overuse (Gerard et al, 2006).

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8.3.11. Causes of ankle injury

Football: Cause of ankle injury in 63% was collision or shoving with
opponent, which is constantly present in football (Brito et al, 2012). Similar
information was given by Yde et al, 1990, which says that in football 10 of
15 ankle sprains are caused by tackling.
At the U19 population higher levels of aggression and a number of tackling
were observed, which may affect on a higher percentage of ankle injury
(Yde et al, 1990).

Figure 27. Show correlation between ankle injuries due to trauma to the
knee

76 injuries of the ankle and foot were established in a study where the
medical team prospectively recorded injuries in professional soccer players
at four World Cups to 2003. From the total number of ankle injuries, 72
injuries were caused by direct contact between players. Significantly higher
number of injuries resulting in absences from matches if the foot was
loaded. Position of the feet at loaded leg during injury was in the neutral
position and at unloaded leg in the position of plantar flexion / neutral in the
coronal plane (Giza et al, 2003).

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Price et al, 2004 states that the highest rates of ankle injuries in adolescents
make ankle sprains (72%), with a very high percentage of injuries of
talofibular ligament (83%). Most injuries occurred at the dominant leg.
Higher incidence of ankle injuries is presumably due to greater participation
of players in action of landing, blows, turns, tackles, turning down and the
like.
Hitting the ball can often lead to symptoms of overuse injuries and
impingement of the ankle (Gall et al, 2006).
Basketball: It is anatomically determined that the talar arch is firmly
connected between the distal tibia and fibula when is ankle in the position of
dorsiflexion. For this reason, ankle sprains are more common for the
position of plantar flexion. Lateral ligaments are often hurt, because of the
relatively stronger deltoid ligament on the medial side of the ankle.

Figure 28 and 29. Mechanisms of ankle injury (inversion foot positioninjured lateral ligaments and eversion foot position injured medial
ligaments)

88

Most often injured ligament in ankle is anterior talofibular ligament. Also

exist a high ankle sprain, which is essentially the injury of interoseal
membranes and anterior inferior tibiofibular ligament.
This injury is not as common as the lateral ligament sprain, but it is quite
common in basketball (Gerard et al, 2006). Player contact was the most
common cause for the occurrence of severe ankle sprains (Randall et al,
2007). There is four times greater risk of ankle sprains in matches than in
trainings in the basketball (Agel et al, 2007). McKay et al found out that
45% of ankle injuries occur during landing, while 30% is generated during
sudden cutting maneuver or twisting movement.
Bruce et al, 2010 found that 58% of ankle sprains are caused by the landing.
Basketball players often land on the other competitor's foot, causing the
plantar flexion of the foot, which is a trigger for a sprain of the lateral
ligaments of the ankle. This sprain causes pain and swelling but it can also
cause long-term problems such as loss of strength, joint instability, delayed
muscle reaction time and disability (Claudia et al, 2008).Fall causes ankle
injury in more than 50% of the cases (Gerard et al, 2006).

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Figure 30.Ankle injury as a result of landing on someone else's foot

NCAA survey found out that 45% of ligamentous injury occurs when the
injured player falls on another player (Agel et al, 2007). Players with a
previous ankle injury are more likely to develop other injury than those
without previous injury (Agel et al, 2007; Gerard et al, 2006). 24% of ankle
injuries was recurring ankle injuries (Agel et al, 2007).
Hosea et al reported that women's basketball game at the university level
have a lower incidence of ankle sprains than men's basketball. Adolescent
females have a 25% higher risk for first-degree ankle sprains compared with
men's basketball, but there was no difference in the second and third degree.
Gerard et al, 2006 argue that mild ankle injuries usually occur in female
players, while the incidence of serious ankle injury is higher in adolescent
male players. The incidence of ankle fractures is also higher among male
players. Ankle injuries are quite common in the participants with higher
body mass index.

90

McGuine et al, 2013 evaluated the balance of the body. Sway has been
tested during standing on one leg (10 sec with open and 10 sec with closed
eyes). Everything was repeated by standing on another leg. Average
swinging was defined by average angle of deviation of the body per second.
Through 12 repetitions the sum of data - COMP index was obtained. It was
found that increased postural sway is associated with increased incidence of
ankle sprains (p = 0.001).Subjects with poor balance and greater postural
swaying had seven times more chance to the emergence of an ankle injury
than those subjects with smaller deviation (p = 0.0002).
A similar result is obtained by Wang et al, 2006, who shows that large
variations in postural sway in anteroposterior and mediolateral direction are
correlated with the occurrence of ankle injury, while all other studied
variables were not associated with the occurrence of injuries.
The author conveys information from various studies, citing different
intrinsic factors for ankle injury: an unstable postural sway, muscle
weakness and imbalance, poor flexibility, ankle hypermobility, poor
proprioception or bad sensation in the joint, previous injury and gender.
Milgrom et al and Beynnon et al said that in addition to these factors, there
are also others, such as extreme body height and weight, anatomical
irregularities of the ankle and foot,which increase the risk of ankle injury in
athletes. E.g. cavus position of the foot may be a risk factor in terms of the
occurrence of lateral ankle sprains because such foot is usually less mobile,
with lower stability and reduced contact with the surface (Wang et al, 2006).

91

On the performance in basketball affects stability during standing and any

abnormalities or inability to control of postural sway in any direction can
mean functional instability and poor quality of the performance, which may
lead to an ankle injury.
8.3.12. Causes of chronic injuries
Handball: Various studies indicate that chronic injuries in fact are the result
of the repetitive stress on tissues such as joint capsules, tendons and
ligaments, which can lead to the instability of the affected joint.
In handball, chronic overuse injuries are very common, e.g. low back pain
that occur most likely because of muscles imbalance, periositis of the shin,
and chronic pain in the shoulder or elbow (Wedderkopp et al 1997, Pieper
2002, Olsen 2006). Periositis is very often the result of hard surfaces, poor
footwear and inability to withstand high repetitive forces that occur during
sports performances.
Approximately goalkeepers felt the pain in the elbow caused by frequent
ball blocking, which can eventually lead to chronic hiperextension trauma
(Tyrdal et al. 1996, 1998; Popovic and Lemaire 2002).
8.3.13. Causes of stress fractures
Stress fracture most often occurs in persons in whom rapidly increases loads
on their bone, without allowing that these bones adapt to the load, which
causes the formation of the micro fracture in bones. A number of studies
shows that university athletes have less and less time to rest after the season
or between games than before, which may affect on the occurrence of
overtraining and to inability of recovery after the injury.

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Normally, broken bone is quickly replaced with a new one, but because of
overload, there is no enough time for bone growth, that ensures the
continued existence of the microfracture. This usually happens at the
beginning of basketball season. The most common stress fracture occurs in
the tibia (30 - 50%) and metatarsal bones (18%).
Girls should pay attention to the appearance of stress fractures in the pelvic
area. A stress fracture has a tendency to form itself in the area of insertion of
muscles where loads are the highest. The risk of stress fractures decreases
with athlete's age. A stress fracture partly occurs, because the muscles of the
body are not able to absorb ground reaction forces to the stretched foot.
Forces are then transferred further to the proximal bones which absorb that
energy. Each biomechanical activity that limits the ability of muscles to
absorb energy can be a predisposing factor for the development of stress
fractures.
Some factors associated with stress fracture are strong pronation and
inflexible instep, the difference in leg length, practice on surfaces where the
body is not accustomed to - the new pads, shoes with inadequate
amortization (Gerard et al, 2006). Arendt et al found that nearly half of the
athletes, 30 of 61 with a stress fracture, were in the process of regime
training changing, not only in quantity but also changing specific
components of the training (e.g. increased torsional stress, an increased
amount of pivoting) which can have a major impact on the formation of a
stress fracture during time.

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Potential risk factors for a stress fracture in physically active girls are low
cardiorespiratory fitness, bad strength training, weak, poor diet (little
calcium, a negative energy balance) and menstrual dysfunction. Better
training techniques and better monitoring can affect on reduction of the
number of stress fractures (Agel et al, 2007).

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9. GENERAL INFORMATION ABOUT INJURIES PREVENTION

Prevention (from the Latin. Praevenire = prevention) means a set of
measures to prevent any adverse effects (Wikipedia). It is important to
understand the complexity and multidisciplinary nature of injury prevention
when addressing to variety of sporting activities (Agel et al, 2007). Injury
prevention should be adapted to athlete and performed individually. Before
injury prevention, it is necessary to know the extent of injury incidence,
nature and seriousness of the injuries, and the characteristics of the sport. It
is necessary to identify those groups that are under the risk of injury and to
determine the variables that contribute to injury occurrence.
A structured plan of preventive measures can be applied through four
main steps:
1. Gathering information - identification of incidence and severity of
injuries.
2. Identification and description of the risk factors and mechanisms of
injuries.
3. Introducing of prevention program based on findings found.
4. Review of the achieved, in order to see the success of prevention
strategies (Gall et al, 2006; Mechelen et al, 1992; Backx et al, 1991; Olsen
et al, 2006; Myklebust et al, 2013).
The observational model should be longer than one season. Continuous data
are needed in order to identify specific trends and to put them in the study
(Price et al, 2004).

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Injuries should be systematically recorded and annotated at national level, in

terms of identification of individual and situational risk factors in order to
oversee the trend of injuries and evaluate the effect of prevention programs.
It would be useful to determine which components are most effective and
most valuable in the prevention of injuries, create a protocol to determine
the standards and to confirm similar effects in other ages, different sex, and
when looking at the different skills (Luigi& Henke, 2010). Timely
inclusion of preventive procedures in younger category may reduce the
number of injuries and later in life create the habits in any sports activity
(Olsen et al, 2005; Myklebust et al, 2003; Steffen et al, 2009). Myklebust et
al, 2013 pointed that success of preventive measures is possible, but
extremely important is their acceptance among the coaches and players.
Basic preventive measures can be grouped into several categories:

Diagnostic Measures

Primary preventive measures

Secondary preventive measures

Training measures

Ergonomic measures

Educational and control measures

Measures of recovery (revised, Markovi et al., 2009)

In addition to these major measures, preventive measures can be also

divided on:

Basic prevention measures

Additional measures of prevention (Brzi, 2012)

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Basic injury preventive measures are carried out by all players in the team,
while the additional measures are reserved for the already injured players, as
well as for players with established increased risk of injury.

9.1. Diagnostic measures

First significant impact on the prevention of injuries in sports has a
diagnosis and determining of the anthropological status of athletes.
9.1.1. Preventive medical examinations
High-intensity activity increases the risk of injury, which is particularly
evident during high loads, and not enough mature organism. Prevention of
injuries in younger players should lead to reduction of long-term functional
poor health and to faster solving of health problems in order to prevent
degenerative joint disease, which unfortunately can affect on the younger
population. Injury prevention begins with a detailed medical examination,
best before start of the new season. Luigi & Henke, 2010 and Vukeli et al,
2011 state that medical control should be done four to six weeks before the
start of the preliminary period, to solve every health problem. Medical
examination should include musculoskeletal examination, analysis of the
player's previous injuries, and detailed testing of functional abilities.
Attention should be paid to possible muscle imbalance, flexibility and
instability of joints (Markovi et al., 2009).
Behrman, 2000 says that medical examination should put an emphasis on
possible hidden injuries that are difficult to diagnose and to untreated
injuries that an athlete did not report to medical staff.

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Preventive examination is crucial, especially for recognizing and treating of

overuse injuries (Ivkovi et al., 2009). It would be good to develop a subspecialization of local orthopedist in terms of treatment of sports injuries,
with an emphasis on early diagnosis, quickly performed MRI scan and
involvement in the educational process (Deehan et al, 2007).
9.1.2. Functional diagnostic methods
On the base of initial diagnostic screening may be obtained a detailed
information about basic and specific preparedness of the players, and
information about possible presence of an increased injury risk for the
players (musculoskeletal or neuromuscular muscle deficiencies).
Diagnosis and testing of athletes performance, technique, speed and quality
of execution of certain movements can help to improve athlete performance
and to correct potential irregularities. Serious motor, functional and
morphological testing is required. Information about motor deficits and their
taking into account in creating of training procedures, reduce the possibility
of asking too much from players during the training process. Testing can
detect possible hidden injuries and problems, and therefore it is advisable to
make the testing before the season.
Testing and diagnosis can be very simple in the form of tests which
establish the athlete's aerobic and anaerobic fitness (Beep test, Cooper test,
etc.), to the very expensive and precise way intended for testing.

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Functional diagnostics conducted on cutting-edge technology give us

information about cardio-respiratory system during heavy loads, which
indirectly may find out an important information about the athlete's potential
critical energy zones. One very specific testing is the testing of postural
swaying in athletes. Players with higher postural swaying have a greater
possibility of an ankle injury. Obtained data can serve as recommendations
for increased training of balance and stability (Wang et al, 2006).

Figure 31. Measurement of the postural swaying

Anthropometric procedures are helping us to get the information about the
structure of the body, somatotype and critical zones in athlete's constitution.
9.1.3. Psychological diagnostics
Psychological diagnostics can also have an impact on the prevention of
sports injuries. Timely information to direct implementers of sports training,
(coach, club director) about athletes personality dimensions and about
possible injury risks that occur due to athletes behavior in training, can
reduce undesirable consequences (Ekstrand et al, 2003).
Results of previously examinations are base for planning and designing of
the training, as well as organizing of additional measures to prevent injuries
(Ekstrand et al, 2003).

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9.2. Primary injury prevention

Primary prevention of injuries involves using of protective equipment such
as kinesiotapes, helmets, knee pads, elbow pads, mouth guards etc.,
depending on sport and position due to increased risk for injury (Wiliams et
al, 2012).
9.2.1. Orthoses
Handball: Players with previous ankle
injuries should use the external support
for the ankle to prevent the repetition
of the ankle sprains (Oksizoglou et al,
2005; Luig & Henke, 2010).
Figure 32. Example of ankle orthosis
Basketball: Many basketball injuries can be at least partially prevented,
especially an ankle sprain and internal knee rotation by using of different
orthosis (Randall et al, 2007). Agel et al, 2007 says that semi-rigid orthoses
provide protection of the ankle in patients with previous injury, but it does
not reduce the number of new sprains. Thacker et al reported that semi-rigid
ankle brace can be effective in the prevention of ankle injuries and that such
orthosis does not reduce performances. Using of orthosis in the West Point
Military Academy reduced for 64% of ankle injuries (Bates at al, 2013).

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9.2.2. Shin pads

Football: Shin pads 1991 have become an integral part of the equipment in
football players. This is usually only type of protection used by football
players during the game. By grouping of all fractures and contusions of the
lower leg, three years before change and 12 years after the change, in 2002
significant difference between these two groups in the incidence of lower
leg injuries was not visible statistically (Junge et al, 2003).
9.2.3. Mouth guard
Handball: In Turkey, the number of players who were aware of the
importance of teeth protecting was very small and none of the adolescents
did not wear protection for teeth (Ozbay G, 2013). The results show that
handball players need more knowledge and education about prevention of
dental injuries. It is strongly recommended that handball players, particular
pivots and backcourts wear mouth guards (Luigi & Henke, 2010).
Basketball: In the basketball dental injuries are very common. The best
preventive measure is wearing of mouth guards, which showed very good
effects in American football and ice hockey (Gerard et al, 2006). Randall et
al, 2007 says that wearing of mouthguard is a good preventive measure to
protect the teeth, and besides that it have an impact on the reducing of
concussions. Agel et al, 2007 states that except effective protection of the
teeth, there was no evidence that mouthguard have preventive effect on the
concussion prevention.

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9.2.4. Eye protection wearing of safety glasses

Basketball: To prevent eye injury, many authors recommend wearing of
special polycarbonate glasses. Ordinary glasses are not enough because they
contain polycarbonate which can withstand only 5% of the forces that may
occur during sports activities. Safety glasses also allow the transfer of forces
to the wider area (Gerard et al, 2006).
9.3. Secondary injury prevention
Secondary injury prevention of athletes includes recognizing of the earliest
signs of the damage to the locomotive apparatus or recognizing of the
overtraining symptoms. Further development of the injury or disease can be
prevented with intervention on time. This requires teamwork and full
responsibility of each team member (athletes, parents, coaches,
physiotherapists and doctors). If during preventive examinations is
determined that an athlete is not safe from injury and that primary
prevention measures are insufficient, it should be provided other, secondary
methods for preventing of the injury (exercises, neuromuscular training,
medical rehabilitation). Parents should be active and constantly cooperate
with the professional team. Athlete has to be responsible to tell the truth
about his condition. A big problem may be problem diminishing
(dissimulation) in order to continue with sports activities. (Brzi, 2012).

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9.4. Training measures

The training measures for the prevention of injuries are an integral part of
the overall system of training and competition in sport. These preventive
measures are presented at every practice and game.
Training measures can be divided into two categories:
a) General training measures, aimed to reducing of all injuries
9.4.1. Improving of physical skills
The main emphasis in injury prevention should be put on improving of
physical skills (Deehan et al, 2007). Each sport has a form of specific
movement which is very important for the athlete's game but some of them
increase risk of injury. The technique of training needs to be improved in
order to safer movement and performance. The proper techniques of
jumping and landing (control of knee and ankle) help athlete to pass through
a crucial situation (eg. landing on one leg). Proper leading of the ball is a
very important factor for prevention of finger injuries. Controlled rapid
movement of the foot helps during pivoting activities.
Player and coach should be aware that proper technique is very important
factor in prevention of exercise. With aging, level of performances and
technique of training should be more proper and easier during complicated
task for the athletes. Better performances in the game also help athletes to
achieve a better efficiency (Luigi & Henke, 2010).

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9.4.2. Conditioning of players

The main aim of preventive physical training is to reduce the number and
severity of injuries at athletes (Keul, 1984, Milanovic, 1997). Important
condition for the successful implementation of modern sports training
systems in everyday training regime is the respect to the main sports
training principles. Among them, most common principles are: adaptation,
individualization, gradualism and progressiveness, cycles, intervality,
specificity, continuity, flexibility, controllability and others. Each of them
can contribute to the implementation of well-designed training programs
and achieving of desired results in sport. Most of the principles in sports
training indirectly impact on reducing of the number and severity of injuries
at athletes (Dick et al, 1997; Milanovi, 1997; Bompa et al, 2000).
Solid physical base quality is a precondition for achieving an integrated
preparedness. For such achievement, it is necessary to realize an optimal
level of all other components of training and to consolidate them into a
single integrated structure. It can be said that the level and type of training is
in high positive correlation with the prevention of injuries. A well planning,
programming and implementing of the training are of crucial importance.
Regular control of the training quality is also important. One of the aims of
the condition training is successful submission of training and competition
loads during the season. In order to achieve this, it is necessary to prepare
the body in the preseason (Wedderkopp et al, 2003; Agel et al, 2007).

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Training in the preseason should be carefully planned because of the better

performances that optimize and reduce the possibility for the occurrence of
injuries during the season. Strength, agility and flexibility should be
developing all the time, both in the pre-season and during the season. In
order to be a good training program, athletes, coaches and the entire team
should include in training both components - improving of performances
and reducing the risk of injury (Agel et al, 2007).
The body of physically inadequately prepared athletes gets tired quickly,
which results in disruption of neuromuscular control and increasing the risk
of injury. The skeletal muscles with lack of strength, flexibility and
endurance are particularly vulnerable when performing an intensive work on
the field. The primary focus of preventive condition training relates to the
improvement of muscle tissue, connective tissue, and to the implementation
of proprioceptive training. Therefore it is necessary to increase muscle
mass, which automatically acts on the improvement of the muscle strength
(Markovi et al., 2009). Structurally positive changing of muscle tissue is
directed to the optimal relationship of pure muscle mass and body fat, and
on the optimization of the total amount of muscle mass in relation to the
requirements of a particular sport. If it is increasing in muscle mass
(hypertrophy) adequately incorporated into the system of sports training, it
is very likely to expect the contribution to injury prevention. One of the
functions of quality muscle mass is to protect the joint system from risk
movements and accidental injuries.

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It is important to take into account the dynamics of increasing of the muscle

mass, due to the possible negative impact on the athlete performance or on
some technical elements in certain sport. Deehan et al, 2007 states the
importance of proper adolescents and children training by looking at their
age. Children between 8-11 years of age develop coordination, balance and
body awareness. From 12 to 16 years of age, training should follow the
range of motion in the joints and other anthropometric measures of the
adolescents. Those players with delayed bone development should be under
special attention during training and conditioning, in order to reduce
possible injuries. Above 16 years, training should be based on the increasing
of strength and endurance in training that lasting in the full extent.
Importance also should be placed to the aerobic and anaerobic training.
Depending on the age, on the absolute athlete initial state, on position in the
game, on training experience, on history of injuries and other parameters of
anthropological status, recommended annual growth of lean muscle should
range from one to four kilograms. Caution is required due to different
impact of increasing muscle mass on other motor and functional abilities.
Hypertrophic program should be based on proper planning and
programming of the training, proper selection of exercises and their
distribution in the short-term and long-term periods of sports preparation.
Adapting of exercises to athlete as an individual with respect to age, gender,
type of sport is important. On the other side, exaggeration in these trainings
can bring more harm than good, so it is important to balance the level of
weight training, and adapt them to young athlete (Brzi, 2012).

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Functional aspect of improving of athletes muscles is reflected in the level

of intramuscular and intermuscular coordination (Siff & Verhoshanskij,
1998).
Intramuscular coordination is described as control mechanisms which
include and exclude different number and type of muscle fibers within one
muscle.
Intermuscular coordination involves synchronization between multiple
muscle groups during the performance of a certain movement or series of
movements.
In order to improve the preventive measures, it is good to perform exercises
with information required for the athletes, where athletes will be asked to
pass known or unknown motor situations with precise and coordinated
performance, or implementation of exercises that require conscious
relaxation of antagonistic muscle groups. By increasing of the athletes
physical condition, besides reducing of the athlete injury risk, it is also
influencing on athletes functional performances and capabilities in
competitions (Brzi, 2012). One of the basic assumptions and characteristics
of athletes preparation should be an optimum health. Preventive strength
and conditioning programs largely contribute to health optimization.

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9.4.3. Proper stretching and warm-up at the beginning of each trainings

/ matches
Stretching and warming should precede to all intensive efforts, trainings and
matches (Agel et al, 2007).
Warming up is an important element of any training and match. Too cold
muscles are less flexible, more slowly contracted and produce less muscle
strength and power.
When the nervous system is not warmed up enough, nerve impulses are
slowly carried out and the proceeding of information received from the body
and the environment is also slower. Warming up is best way to introduce
preventative measures (Luigi & Henke, 2010). Performance of any activities
including high intensive sports activities, with insufficient heated
neuromuscular system significantly increases the risk of injuries, especially
injuries of muscles and tendons (Markovi et al, 2009). Fradkin et al, 2006
has done systematic review of articles from 1966 until April 2005 on
influence of warming up on injury prevention in sports. Author found
insufficient evidence to endorse or discontinue routine of warm-up prior to
physical activity to prevent injury among sports participants. Nevertheless,
the most of evidence is in favor of a decreased risk of injury.
Important item with which begins or ends each workout is stretching
(Markovi et al, 2009; Aronen et al, 1991, 1995; Schneider et al, 2013).
Performing of stretching should be standard for all teams (Gerard et al,
2006).

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Exist dynamic and static stretching of muscles.

At the beginning of each game processing of dynamic stretching and
warming up of the body are recommended. Dynamic (ballistic) stretching
includes variety of fast movements of a particular joint to the end in range
of motion (Mahler et al., 2010). It is recommended that stretching and
strength exercises continue to be implemented few days after the occurrence
of injury as prevention of their recurrence and preservation of elasticity.
Before the beginning of training, the muscles are stiff and shortened. Their
elasticity allows them to better withstand blows. Heating and stretching of
the muscles increases flexibility and elasticity, increases blood flow to the
muscle, establishing a better neuromuscular innervation, and thus the
coordination of movements (Braunstein et al., 2003).
9.4.4. Calming (cooling) down of the body at the end of each training /
match
Important training measures for prevention of injuries are calm of the body.
By calming of the body at the end of the game, begins the players recovery
from the training or competing efforts. For injury prevention, it is important
that the skeletal muscles return to their initial length before training or
matches. This is achieving by static stretching as one of the components of
body calming (Markovi et al., 2009). Static stretching is a common way of
stretching, and is carried out by slowly moving of the joint to the end
position and keeping the same position from 5 to 60 seconds (Mellion et al,
2003).

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Avoiding the implementation of body calming at the end of training and

competition can result with chronic reduction in muscle flexibility, and thus
increasing the risk of their injury. The trainer's job is to educate players
about the importance of preventive measures, and to take into account that it
is regularly and correctly carried out.

9.5. Ergonomic measures

b) Training measures specifically directed to preventing of specific
injuries in certain sports
9.5.1. Training measures for prevention of the players contact injuries
The most important training measure for prevention of contact injuries is
training of maximum explosive strength (Markovi et al., 2009).
Strength is ability of the muscles to create maximum force, strength
indicates how fast an athlete can develop muscle force, it is the result of
force per unit of the time (Brzi, 2012).
Strength training reduces the time needed for muscle response. This
suggests that functional strength training increases the player's ability to
react quicker to avoid a potentially dangerous situation and occur of an
injury during training or matches. The stronger and more explosive muscles
absorb easier impact forces during contacts with opponent, and thereby
reduce the possibility for the development of contact injuries(Aagaard et al,
2002).

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9.5.2. The training measures for preventing non-contact injuries of

muscles and tendons
The most important measures for prevention of non-contact injuries of
muscles and tendons are training of flexibility and specific eccentric
strength training. Those muscles that work in eccentric conditions such as
hamstrings are very vulnerable (sprinting, hitting of the ball in football),
quadriceps (stopping), gastrocnemius (landing) and adductors (change of
direction). The lack of flexibility and insufficient eccentric strength of these
groups significantly increase the risk of their injury, or injury of their
tendons. It is therefore essential to combine eccentric muscle exercises
and flexibility exercises.

Figure 33. Nordic hamstring exercise, that have component of eccentric

hamstring strengthening
A special form of prevention training represents isokinetic training. By
specially constructed apparatus, the athlete performs movement with same
angular velocity as in conducted sports activities. This training helps to
balance the strength of the muscles of the same articular system. First act in
this procedure represents isokinetic diagnostics, which determines the
possible imbalances between muscle groups.

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Figure 34 and 35. Isokinetic testing of the thigh muscles and shoulder
muscles

9.5.3. The training measures for preventing of non-contact injuries to

the lower limbs
Preventive measures of non-contact injuries of the joints (especially knees
and ankles) include training of speed and agility, plyometric training,
balance and neuromuscular training and functional stabilization
training of the joints. The development of connective ligament tissue in
adolescents occurs slower than muscle, but it is sufficient to contribute to
the harmonious development of all segments of locomotion apparatus. This
is a fundamental prerequisite for the prevention of sports injuries.
Main stimulus for changing the properties of connective tissue are
mechanical forces generated during physical activity. Basic categories of
training designed to improve the connective tissue are: isometric exercises,
physical therapy, weight-bearing exercise, stretching exercises, plyometric
low intensity exercises, exercise in the sand, exercise in the water.
Training of speed and agility should be gradual.

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The first step is training of movement, looking specifically to the

particular sport. This type of training improves players risk movements jumps, landings, turns and sudden changes of direction. Research has shown
that incorrect performances of the mentioned movements are a significant
injury risk factor for knee, particularly ACL. It is possible to significantly
reduce of injury risk with such training.
The next step is training of deceleration, stopping and dictated training
of agility. Players perform previously learned, default risk movements with
maximum intensity. In this way, neuromuscular control of fast and agile
movement is improving, and musculoskeletal system is also preparing for
competitive loads.
The final step is random agility training. Here players perform different
random unforeseen changes of direction. With random agility training,
activation of the muscles around the knee can be increased and thus reduce
the risk of knee ligament injury.
Plyometric training of explosive strength reduces the impact force during
foot contact with the surface (e.g. landing), reduces the rotational torque
force at the knee and increases the activation of muscles that surround the
knee and foot. The result is a reduction in the risk of injury to the knees and
ankle joint. It is important to take into account the state of sophistication of
individual performance and technique during exercises. This is especially
oriented to training with loads, plyometric training, and all other high-risk
movements.

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Biomechanical incorrect exercises, depending of the degree of loads can

cause micro-traumas of the locomotion apparatus, and consequently get
athletes for a longer time away from training.
9.5.4. Proprioceptive and neuromuscular training
Proprioception is the ability of muscles to respond to the specific and often
unusual positions and situations (Potach & Borden, 2000). By placing the
body of athletes in a large number of training situations which provoke an
activation of proprioceptors, it will happen that athlete react optimally in
incidence situations. Secondary effects of proprioceptive training are aimed
to strengthening of the ligaments and tendons, but also to increase range of
motion in the joints. Kynsburg, et al, 2009 examined the proprioceptive
neuromuscular mechanism and the impact of training on the joints at
handball players in Hungary. Long-term neuromuscular training (20
months) improved sense for ankle joint position at the studied athletes.
This improvement may be one explanation to the neuromuscular trainings
acting on the reducing in number of injuries. Basketball: A study that is
examining the effects of neuromuscular training has determined that
neuromuscular control and balance training can help reduce the incidence of
injury to the lower limbs at the university basketball players, including
ankle sprains and ACL injury (Agel et al, 2007).
Randall et al, 2007 also states that by implementation of neuromuscular
exercise in training can be prevented many ankle sprains and injuries caused
by internal rotation of the knee (Agel et al, 2007).

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Handball: Neuromuscular training can be introduced in the program of

training or warm-up before the game and has a greater effect in athletes who
are not tired (Luigi & Henke, 2010). Exercising on unstable surfaces,
combined with the strengthening of the trunk is very useful as prevention of
injuries in handball if are conducted properly (at least 2 -3 times a week),
(Bahr et al, 2005; Myklebust et al , 2013, 2009, 2003; Olsen et al, 2006).
Many authors suggested that this type of training become an everyday part
of the training process (Myklebust & Steffen 2009; Bencke et al, 2008;
Dervievi, 2006; Olsen et al, 2005; Wedderkopp et al, 2003, 1999;
Hrysomallis, 2007; Lagevoort & Myklebust, 2007).

Main objective of preventive proprioceptive exercises and

neuromuscular training is to reduce the incidence of injuries in sport and
consequently influence on the improvement of neuromuscular sensation,
motor control of the body, improving muscle balance and movement of the
entire body.

Neuromuscular (proprioceptive) type of training can be divided into the

following segments:

Training with balance boards

Training with big balls

Maintenance and disturbance of balance position during standing,

walking, running, jumping

Move across uneven surfaces

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Proprioceptive training with external load

Training with medicine ball

Training on trampolines

Training on soft mats

Figure 36. Some components of neuromuscular training

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Balance training and training of functional stabilization of joints increases

joint stability by improving conscious and reflex activation of the
surrounding muscles. These changes can be very helpful in the prevention
of knee and ankle injury (Markovi et al., 2009).
Research shows that exercising on balance board not only reduces the
number of injuries of the lower limbs but also at upper limbs (Wedderkopp
et al, 2003).

In the following tables are being presented prevention programs

designed for reducing of injuries in football and handball, methods of
implementation and their effectiveness, Football: (Soligard et al, 2011;
Soligard et al, 2012; Daneshjoo et al, 2012; Steffen et al, 2013; Owoeye et
al 2014) Handball: (Wedderkopp et al, 1999; Wedderkopp et al 2003;
Olsen et al, 2005; Myklebust et al, 2005):

Table 4. PEVENTION PROGRAMS IN FOOTBALL

117

Table 5. PREVENTION PROGRAMS IN HANDBALL

118

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9.5.7. The impact of the equipment on the occurrence of injuries in

sport
Training equipment, equipment for the players and type of surface are
necessary to adapt to the type of sport and to age. Safety aspects of
aforementioned are also important (Beach, and Earle, 2000). The use of
safer sports equipment in young and inexperienced athletes can reduce the
incidence of injury in sports. This primarily refers to the shin pads, athletic
shoes and orthopedic inserts.
9.5.8. Choosing of footwear
When talking about choosing of footwear, we should take into account an
optimal grip of e.g. football shoes to the surface. If the friction between
footwear and the surface is too high, increased external forces affect on the
knee and foot. If friction is too small, it leads to excessive sliding of the
players. In both cases, the risk of injury to the lower limbs is increasing. The
shoes should be designed to prevent inversion stress on the ankle, which is
highest during combined inversion and plantar flexion of the foot (Curtis et
al, 2008). Players with foot deformities should definitely use a specially
designed shoe with insoles for correction. For handball and basketball game
are recommended shoes whose sole on the surface has a relatively medium
friction, as an important tool for avoiding ankle and knee injury (Andren et
al, 1994; Biener & Perka, 1980; Tittel et al, 1974).

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9.5.9. Quality of the surface

Studies that compare the incidence of injuries on artificial and on natural
grass, present contradictory information. But, it is known that during bad
weather (rain, snow) it is safer to play on artificial surface, than on natural
grass (Markovi et al., 2009). When looking at indoor sports such as
basketball and handball, surface cleaning maintenance affects on the friction
of the surface (Myklebust et al, 2003). As a preventive measure before
training or competition, it is recommended to clean the surface and in that
way reduce the surface slippery. If it is very hot in sports hall it would be
necessary to remove the sweat or water from the parquet in order to reduce
the risk of injury.
9.6. Educational and control measures
One of most important educational measures is learning the process of the
correct technique during sports preparation and training (Myklebust et al,
2003 ; Brito et al, 2012). Myklebust et al, 2003, asking himself: Why not
use the best trainers in adolescents and children? With best trainers,
children will learn the correct technique, a way of training, and
consequently, they will have fewer injuries. It is very important to educate
players about the risk factors for injury and possible preventive
interventions in this regard. Players should be aware of it, and it is necessary
to warn them about typical motor movements that are associated with injury
risk, such as jumping, landing, and pivoting, especially in combination with
a contact, in the way to enhance the physical control of athletes (Luigi &
Henke, 2010).

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Athletes with previous ankle injury should be educated about the

importance of proper rehabilitation and should respect the preventive
strategy to avoid the re-injuring (bandage, orthotics, balance training), (Agel
et al, 2007). One thing that is also very important is players education about
importance of fair play, proper nutrition, quality sports lifestyle and about
importance of regular medical check-ups and systematic records of all
injuries (Wolf et al, 1974; Myklebust et al, 2003; Asembo & Wekesa,
1998). Systematic recording of all injuries in the season allows evaluation
and control of the success of applied preventive measures. With educating
the players about the importance of self-discipline, sports behavior, and
about using of protective equipment the risk of injury can be significantly
reduced. On injury reducing can affect continuous work in order to prevent
aggressive and deviant behavior of players. Beside athletes, also coaches
and referees should also be educated about injury prevention (Tittel et
al, 1974). The way of the referring influence on incidence of injuries during
matches. Rough and dirty game should be prevented and punished on time
in accordance with the rules. Authors note that players should have a sense
for clean play, while the task of referees is to see the smallest irregularities,
illegal game and hits, especially while the player is in the air. Education of
referees should be continuously and oriented to prevention of injuries.

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9.6.1. Rule changes

Randall et al, 2007 and Agel et al, 2007 stated that it is necessary to
examine the effects of the change of rules on the incidence of injuries. This
can also be one way of preventing injuries
9.6.2. Frequency controls of trainings and matches
The incidences of injury at matches are significantly higher than in training.
The audit of the number of matches and different competitions can help to
reduce number of injuries. Better regulation of national and international
competition is essential. Longer rest and recovery of players reduces the
chance for developing of overuse injuries and decreasing the number of
acute injuries caused by fatigue or inadequate treated injuries (Luig&Henke,
2010). In the future, attention should be payed to the frequency of played
matches in order to timely prevent possible injuries caused by overtraining
and fatigue (Agel et al, 2007; Myklebust et al, 2003).
9.7. Measures of recovery and additional measures for the prevention of
injuries
By systematic application of appropriate measures of recovery, it is possible
to significantly reduce the occurrence of injuries especially resulted due to
fatigue of the players. Today exist different recovery measures for athletes,
such as healthy eating and supplementation, massage, hydrotherapy, light
exercise, cryotherapy, and others.

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9.7.1. Physiotherapy measures

Additional preventive measures are applied only on injured player, and on
the player with the high risk of injury. Additional physiotherapy injury
prevention measures are primarily related to the immediate preparation of
players for training and match. A typical example is bandaging of the player
with an established mechanical instability of the joint.
9.7.2. Supplementary training measures
These measures are related to the individual supplementary training focused
on the correction of those neuromuscular defects that increase the risk of
injury. This type of training is occurring outside the regular training under
guidance of the trainers. Example: players with functional problems or
mechanical instability of the ankle joint should implement additional
strength training of the surrounding muscles of the ankle, and
supplementary balance and stabilization training (Markovi et al., 2009).
9.7.3. Rehabilitation measures
The goal of treatment and rehabilitation should be the return of muscle and
ligament functions and mechanical stability of the joints in the condition
that preceded the injury. Studies have shown that a large number of injuries
(more than 40% of all injuries in football) are repeated injuries within one
calendar year. This can be due to, too early return of the athletes to the field;
before the injury healed well. This leads to deterioration of the injury and
prolonged recovery (Rolf, et al., 2007).

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The strong association between previous injury and injuries in young

population suggests that rehabilitation should be better and that it is
necessary to ensure more effective mechanisms for young athletes
protection (Kucera et al, 2005). Inadequate rehabilitation can be a result of
the desire of players and coaches for faster return to the field, but the final
decision about returning to the field should give the doctor or
physiotherapist. If the rehabilitation at previous injury was not fully
implemented or it was performed poorly, exists a higher possibility for the
emergence of new injuries (Murphy et al, 2003).
9.7.4. Prehabilitation and proper periodization of training
Long-term sports preparation is the best way to achieve the high set goals in
sport and to preserve of the health. During the matches and trainings coach
has to be sensitive to the effects of fatigue, and has to know that when
players are tired the risk of injury also increases (Agel et al, 2007).
Prehabilitation is a term to describe a program that is used in the
preparation of athletes before the season.
The aim of this program is to discover and correct the potential imbalance
in the strength and tonus of the musculoskeletal system, as well as the
preparation of athletes for the efforts during the season that follows.
Prehabilitation may reduce the incidence of injury up to 63% (Ivkovi et al.,
2009). It should be noted that a good relationship and understanding
between the athletes, coaches and parents are the key to the prevention of
acute and overuse injuries.

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The main goal of training in team sports has to be the physical and
psychosocial well-being of the children and adolescents involved in
organized sports activities.
9.8. Specific forms of prevention, looking at the body localization and
diagnosis
9.8.1. Prevention of ankle injuries
The most common injury among adolescents in football, handball and
basketball is the injury of the ankle. A large number of recurring ankle
injury is a warning that every athlete should strictly adhere to the preventive
methods and techniques. In everyday practice, proprioceptive and
plyometric exercises should be included in order to improve neuromuscular
work and sensation, balance and strength, and also exercise of mobility for a
better range of motion in the ankle. Acute ankle injury can lead to a chronic
instability of the ankle, osteoarthritis, reduced physical activity, and lower
quality of life. Interventions that offer benefits in terms of prevention are
bandage, tape and orthoses wearing, and implementation of proprioceptive
training on balancing boards. Basketball: Measurement of balance and
postural swaying of the body at high school basketball players is a good
predictor for the occurrence of the ankle injury (Mc Guine et al, 2013).
Players can benefit from prehabilitation program that includes strengthening
of the peroneal muscles and learning of proper landing to better stability.
Ankle brace can help reducing incidence of injuries but not their seriousness
in male and female high school basketball players, with and without
previous acute ankle injury (Mc Guine et al, 2011).

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Gerard et al, 2006 states that ankle brace wearing most benefit to the
prevention of recurred ankle injuries in athletes with previous ankle injury,
but there is no enough data about subjects who had not an ankle injury.
Use of lace up orthosis reduced the incidence of ankle injury over three
times without looking at gender, age, level of competition, body mass index
etc. This type of orthoses is made of synthetic fibers, can be put on the leg,
and is worn over socks. It is consolidated with stronger straps that go around
the ankle (Oksizoglou et al, 2005). Sitler et al reported that the Air-Stirrup
orthosis significantly reduces the incidence of ankle injury at cadets in the
army.
Future research should look how orthoses wearing combined with
neuromuscular training will react to the occurrence of ankle injury. It was
found that stretching of the lower leg muscles has a good preventive effect
on the reduction of ankle injury.
The impact of the athletic shoes type, especially shoes with air cushions on
the occurrence or prevention of ankle injury is still not sufficiently
understood. The current research suggests that the airbags in athletic shoes
are associated with a higher rate of injury of the ankle (Gerard et al, 2006).
More researches are required.
9.8.2. Prevention of Achilles tendon injuries
The Achilles tendon is a very sensitive problematic area in humans because
it withstands and transmits very high loads during walking, running,
jumping or landing.

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The most common cause of injury is a less supply of blood and often lack of
flexibility, especially in adolescents during the growth phase. Prevention of
an Achilles tendon injury should involve muscle stretching of the lower leg
and eccentric strengthening of the Achilles tendon which is very important
for the healing of the tendon, extension of muscles, muscle strength and for
muscle speed contraction. Increasing the speed of contraction helps to
increase the strength of contraction (Gerard et al, 2006).
9.8.3. Prevention of ACL injuries
Despite numerous studies, it is still not known exactly which components of
a prevention programs acts to prevent knee injury (Bahr et al, 2005).
Various measurements, testing and interventions that are addressed to the
detection of potential risk factor for ACL injury are most poorly
implemented into prevent procedures. Until today, unfortunately, a method
for high-quality has not been discovered, fast and practical testing of
athletes in order to detect an increased risk of ACL injuries. Testing of
valgus knee movements may be just part of the answer by looking at this
issue. Significant number of female athletes has decreased stability of the
knee, and it is certainly necessary to find a better intervention.
Numerous studies highlight the necessity of implementation of
neuromuscular training on unstable surfaces and to exercising of stability
and strength of trunk and lower limb, in order to prevent the possibility of
ACL injury (Agel et al, 2007; Olsen et al, 2006; Scavenius, 1999;
Wedderkopp et al, 2003; Kaltoft, Lundgaard, Rosendahl & Froberg, 1999).

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Exercise should be focused on optimizing the biomechanics of the hip

during the squat and plyometric activities, and on the static movements that
may affect the dynamic movements, such as landing from the jump.
Training should go in the direction of the keeping and strengthening of
flexion, external rotation and abduction in the hip through complete range of
motion to help prevent more valgus moments that will be transmitted to the
knee. Neuromuscular training should prevent side to-side imbalances in
hamstrings torque. If knee goes inward when squatting, it can mean poor
biomechanics of the hip and weak muscles around the knee. When athlete
achieves adequate movements and good biomechanics within closed kinetic
chain, he can access plyometric training and exercises such as jumpings and
cutting exercises, in order to gain the proper biomechanics of the activities
that await him on the field (Gerard et al, 2006; Ford et al, 2003). Handball:
Hewett et al. following their program of neuromuscular training reduced the
rate of serious knee injuries by 62%, and demonstrated significantly
reduction of the landing forces and valgus and varus forces on the knee.
There was also present a significant increasing in strength of hamstrings,
and reducing of imbalances in the strength of hamstrings in female
adolescent athletes.
Previous factors are believed to reduce the loads on the ACL (Olsen et al,
2004). Similar results were obtained by other authors who have examined
the effects of different neuromuscular trainings on the knee and ankle.

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Prevention of ACL injury has multiple benefits in terms of longer

participation at sporting events, but also to avoiding long-term
complications, such as osteoarthritis.
9.8.4. Preventing of stress fractures
Improvement of training technique and better supervision, especially during
dead season can reduce the risk factors for stress fractures. Basketball: At
adolescent female players, great influence on the formation of a stress
fracture has an anatomic position of their legs and it is recommended to
wear shoes adapted to this fact. In order to prevent the problem of stress
fractures in the USA, the army is using reduced running protocol (Agel et al,
2007). Another good strategy is involvement of athletes in cross training,
because different forms of stress can help prevent overuse injuries caused by
same repeated activity (Gerard et al, 2006). Future research should examine
the impact of hormone therapy on reducing the possibility of stress fractures
in adolescent female players (Agel et al, 2007).
9.8.5. Prevention of tibial syndrome
Prevention of tibial syndrome (frequent pain syndrome in adolescents in
basketball and handball) should develop in the direction of correcting
excessive ankle pronation in order to limit excessive eccentric load of soleus
muscle, that release its attachment for tibia. It is necessary to examine the
athlete shoes in the way to prevent excessive pronation of the foot (Gerard
et al, 2006).

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10. DISCUSSION
The diversity and inconsistency in the way of formatting data, in the setting
of hypotheses, in choosing of the type of statistical analysis, and lack of
some detailed information about data and their ending values prevent me, on
the basis of so far acquired knowledge, to sort the data and execute a metaanalysis of articles in a way to arrive to the sufficiently reliable conclusions
about the overall results of the study.
Accordingly to the fact that in most of the observed articles the sample size
was greater than 100 subjects, and observations have been mainly done on
enough large intervals with 95% confidence interval, can be concluded the
following;
Incidence of injuries and the most common causes of injury
Through articles the most pervaded hypothesis is that the incidence of injury
is largest in the preseason period and the smallest at the very end of the
season.
According to Bahr view, and by overviewing of most of the scientific
literature dealing with these issues, can be concluded that for the injury
occurrence several cause-related risk factors are necessary, which in certain
point, due to "ideal incident situation" can give rise to injury. So, only one
risk factor is not enough for the emergence of injury.
Looking at all three sports it was found out that the number of injuries
increases with age, highest incidence was at seniors. Most injuries
regardless of sex occur in matches in the ankle and knee.

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Ankle injuries are most common, but these injuries are minor, compared
with knee injuries. Knee injuries in most cases are quite complicated and
cause long-term rehabilitation and lack of players from the pitch.
Most common type of injuries are strains of thigh muscles (most often in
football), and sprains of ankle ligaments in all three analyzed sports.
Most studies talk about a higher incidence of injuries on the female
population of adolescents than among males. The highest incidence of knee
injuries and injuries of ACL was reported in females. In that way, in South
Europe exist different tendencies, than these obtained in North Europe.
The reason for this, besides the anatomy, may lie in the structure of the
sample; in the north of the Europe the incidence of injuries in females is
more analyzed than on the south.
The most likely cause of ACL injury is excessive valgus force on the knee
during landing on one leg or during sudden side cutting movements.
The assumption is that the biggest cause of the increasing incidence of ACL
injuries is primarily a modern sedentary lifestyle. This kind of lifestyle
affects on the young athletes, and causes a shortening of hamstrings muscle.
The result is an imbalance in the power and flexibility of the muscles in the
hip and knee, and overstressing on ACL. This fact indicates that probably
the modern way of life influences on the change of the entire body
biomechanics at all population, including youth athletes too.
One of big factors for the occurrence of injuries in analyzed sports (which is
nowhere mentioned) can be "flabbiness".

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When player is not interested in the game, or certain game at that moment
does not represent a challenge for that player (e.g. some training sessions or
friendly matches) there is an increased possibility for occurrence of injuries.
These situations can lead to decreased muscle tone, and under the influence
of the above described risk factors can cause the appearance of injuries.
Besides to specific static and dynamic stresses related to specific sports,
anthropological impact, rules, ways of training, on the incidence of injuries
most influenced some external factors like the way the trial, sports
equipment and overall technical and architectural solutions of the
environment in which sports activities take place.
In the available articles I did not find the analysis of architectural solutions
and incidence of injuries. During the building playgrounds, as well as when
releasing players on the field, it is necessary to avoid potentially risks, also
perilous conditions around the field. It is highly recommended to make
some empty space that allows the stopping during acceleration of players or
in the case of players drop.
2. Prevention
Most authors were based on developing of better neuromuscular training to
improve the proprioceptive mechanisms in sports players, in order to
prevent better injuries in sports. In handball and football neuromuscular
prevention programs give a very good results. In football featured FIFA 11+
prevention program is particular, and it is most accepted among the players
and coaches. The effect of this program has also been tested at basketball,
where it has confirmed its effectiveness too.

133

Unlike football and handball, authors that analyzed basketball did not put so
much attention on designing of prevention programs for adolescents and
youth in this sport. In the NBA there is some prevention program, but it is
not described in details in scientific articles.
In basketball it is definitely necessary to find a better way to prevent a
concussion or TBI (trauma brain injury). The rules should be changed and
any drastic moves of elbow to the face or head should be punished.
None of the authors considered the possibility that the improving of the
movement from other sports can reduce the number of injuries incurred in
football, handball or basketball.
For example, by learning of proper stretching, walking and running, which
is the basis of athletics, it can be improved overall biomechanics of
movement and the possibility of injury is likely to be reduced.
I think that learning and improving techniques and skills of falling (which is
the basis of wrestling or judo) can result in reduction in number of injuries
in all three sports, but especially in handball. Those skills maybe can
improve their performance too.
In addition, changing coaches may also increase or decrease the number of
injuries. Referring to the coaches, by continuously monitoring it can be seen
the difference between type and incidence of injuries. In the case of an
increased number of injuries, the coach may change the modality of training
in order to reduce and prevent of new injuries.

134

It is recommended to organize a congress in near future, with a topic about

adolescents injuries in sports because current situation is troublesome. It is
also necessary to make certain guidelines and directives for future
researching, that data can be qualitative and mutually comparable, not only
within one sport, but more of them.
In making the above mentioned conclusions I am fully aware that statistical
and scientific decisions can not be reliably based on the "so-called. logical
conclusions "or an observer's" previous experience ". This means that all the
conclusions (hypotheses) must be confirmed or disproved by more
researches, preferably in equal conditions, by applying identical ways to
access to the sorting and processing of data.

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11. CONCLUSION
This work analyzed topics about injury and injury prevention in adolescents
which on semi elite or elite level deal with football, handball or basketball.
By reviewing of the literature, in adolescents was founded less incidence of
injury than in the seniors, but there is also a visible growing trend in the
number of injuries with aging and maturing. Once occurred injury can be a
major predisposing factor for the development of a new one, which can
cause in adolescents a disaster in terms of interruption of sports career or
chronic health problems in older age. Increased number of injuries in later
adolescence leads to the conclusion that at this time number of trainings and
matches is becoming more frequent, and games are becoming stronger and
more aggressive. One of the causes of the high number of injuries is that
adolescents become stronger and bigger, and have a greater desire to
compete and succeed, which is especially pronounced at matches at the elite
sports level. One of the problems can also be parents or coaches which can
put great demands and expectations on the adolescents. Because of the
current phase of adolescents maturation or his/her own abilities, sometimes
is unable to achieve expected results. The highest incidence of injuries in
adolescents is on the lower limbs, especially on the ankle and knee, with
higher incidence in females. The increased number of injuries among female
players suggests that females have a different anatomical structure, lower
strength and explosive power of muscles during game.

136

In the analyzed sports, possibly female players have some weaker motor
coordination, which can be a crucial factor in the increased number of
injuries compared to the male gender.
Exercising of power, coordination, precision, and proprioceptive
neuromuscular exercises on irregular surfaces are proved to be a significant
factor in improving of motor performances and in reducing aforementioned
deficits looking at both genders. In order to protect players from injuries, it
is necessary to educate them about risk factors and causes of injuries. For
prevention of injuries, an important factor is a good, well-timed and
structured training. An integral part of each training should be warming up,
cool down, passive and dynamic stretching, strength and proprioception
exercises.
In the end, the clean game with few contacts between rival teams and
implemented fair play at matches is also very important.

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13. LIST OF FIGURES

1.

Figure 1. Stages of growing (Dudoniene V, 2012).

2.

Figure 2: Stages in growth and development up to adulthood

(Dudoniene V, 2012).

3.

Figure 3: Peak height velocity and peak bone mass growth

(Dudoniene V, 2012).

4.

Figure 4: Changes in the size and shape of the body during growing
(Dudoniene V, 2012).

5.

Figure 5. Description of bone growth in length

http://apbrwww5.apsu.edu/thompsonj/Anatomy%20&%20Physiolog
y/2010/2010%20Exam%20Reviews/Exam%202%20Review/Ch%206
%20Modes%20of%20Ossification.htm

6.

Figure 6: Difference in bone ossification between boys and girls at

different adolescent age (Dudoniene V, 2012).

7.

Figures 7.and 8. Measuring of hamstrings flexibility (Sattler et al,

2010)

8.

Figure 9. Football field with standard measurements

http://en.wikipedia.org/wiki/Football_pitch

9.

Figure 10. Show of body position during change of direction in

football
http://en.wikipedia.org/wiki/Luka_Modri%C4%87

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10.

Figure 11. Show of different movements of the body related to

handball game
http://learnenglish.britishcouncil.org/en/english-for-thegames/eftg/worksheets/handball

11.

Figure 12. Show od dangerous positions in handball

http://www.zimbio.com/photos/Domagoj+Duvnjak/Olympics+Day+
4+Handball/_KuF4eKe8XD

12.

Figure 13. Basketball court

http://hr.wikipedia.org/wiki/Ko%C5%A1arka

13.

Figure 14. Position of players in basketball

http://hr.wikipedia.org/wiki/Ko%C5%A1arka

14.

Figure 15. Typical basketball situation for centers during shooting in

the basket
http://www.hks-cbf.hr/vijesti/liga-za-prvaka-cibona-i-zagrebpriredili-najvece-iznenadenje-u-4-kolu

15.

Scheme 1. Management of injuries (Fuller et al, 2006)

16.

Scheme 2. Complex interaction between internal and external risk

factors that leading to injury (Bahr et al, 2005)

17.

Scheme 3. Comprehensive model for injury causation. BMD, Body

mass density; ROM, range of motion (Bahr et al, 2005).

18.

Figure 16, 17 and 18. Different types of surfaces

http://gaspra.hr/podloge

19.

Figure 19. Proper position of the foot in the shoe

http://atomicaerobik.hr/pravilan-odabir-sportske-obuce

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20.

Figure 20. Proper loading of the foot to the ground

http://atomicaerobik.hr/pravilan-odabir-sportske-obuce

21.

Figure 21. Paining shoulder during handball game

http://www.ezadar.hr/clanak/ne-dajte-da-vas-ozljeda-zaustavi

22.

Figure 22. Way of finger injuries in basketball, handball or football

http://www.hughston.com/hha/a_16_4_2.htm

23.

Figure 23. Occur of ACL injury after landing phase

http://www.foundrysportsmedicine.com/ourblog/?Tag=sports+medic
ine&BBPage=1

24.

Figure 24. Mechanism of ACL injury due to rotation of tibia

http://www.beantownphysio.com/pt-tip/archive/acl-tears.html

25.

Figure 25. Mechanism of ACL injury due to valgus collapse of the

knee
http://www.braceability.com/blog/anterior-cruciate-ligament-aclinjury/

26.

Figure 26. Difference between male and female in leg biomechanics

as risk ACL injury factor
http://www.braceability.com/blog/anterior-cruciate-ligament-aclinjury/

27.

Figure 27. Show correlation betweenankleinjuriesdue totrauma to

theknee
http://www.kwfoot.com/anklesprains.html

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28.

Figure 28 and 29. Mechanisms of ankle injury (inversion foot

position- injured lateral ligaments and eversion foot position
injured medial ligaments)
http://www.eorthopod.com/content/adult-ankle-fractures-types

29.

Figure 30. Ankle injury as a result of landing on someone else's foot

http://dubinchiro.com/features/ankle1.html

30.

Figure 31. Measurement of the postural swaying

http://bstrong4life.com/science/balance/

31.

Figure 32. Example of ankle orthosis

http://bauerfeind.hr/kategorija-proizvoda/ortopedskiprogram/zdjelicni-obruc-i-donji-ekstremiteti/potkoljenica-i-glezanj/

32.

Figure 33. Nordic hamstring exercise, that have component of

eccentric hamstring strengthening
http://www.aspetar.com/journal/viewarticle.aspx?id=27#.VXxJdUYp
p2A

33.

Figure 34. and 35. Isokinetic testing of the thigh muscles and
shoulder muscles(Sattler et al, 2010)

34.

Figure 36. Some components of neuromuscular training

http://sph.sagepub.com/content/2/6/460/F3.expansion.html
35.

Graph 1. Game and practice injury mechanisms

(Randall et al, 2007)

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1. APPENDIX - PRESENTATION OF TWO PREVENTIVE

PROGRAMS
1. FIFA 11+ Prevention program

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2. Warm up program for ACL injury prevention for female athletes

http://www.mkillustrations.com/portfolio.php?cid=7