Documente Academic
Documente Profesional
Documente Cultură
MASTER THESIS
2015
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.
CONTENT:
1.
2.
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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2
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9.
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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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11.
12.
13.
14.
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.
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.
reducing their frequency and severity, in relation to age, gender and type of
the sport.
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.
3.
METHODS
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.)
Selection of sports (football, handball, basketball, mixedfootball and rugby, football American football, sports in
general ...).
2.
3.
10
growth,
maturation
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).
11
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.
12
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).
13
14
15
16
17
4.6.
18
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.
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.
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).
19
20
21
22
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).
24
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).
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").
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.
according to duration
29
30
Strain (Distension)
31
Contusion
Injuries of joints
Contusions
Avulsion
Rupture
Contusions
Lacerations
Abrasions
Cuts
Blisters
32
33
7.
INCIDENCE OF INJURIES
34
U14, younger than 14 years; U15, younger than 15 years; U16, younger than 16 years.
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
U14, younger than 14 years; U15, younger than 15 years; U16, younger than 16 years.
35
Better comparison are impossible due to the lack of necessary data for
statistical analysis.
36
8.
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:
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).
There are three models that describe the risk injury factors in sports:
Biomechanical model
38
External risk factors also affect on the force; protective equipment such as
helmets reduces force, while training on hard surface increases the force.
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40
41
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.
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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.
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46
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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.
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49
50
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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.
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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.
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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
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).
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60
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.
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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.
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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).
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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).
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Bruce et al, 2010 did not find an increased incidence of ankle sprains by
looking at the type of sports shoes.
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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).
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 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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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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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).
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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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.
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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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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)
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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).
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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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Diagnostic Measures
Training measures
Ergonomic measures
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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.
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105
106
107
108
109
110
111
Figure 34 and 35. Isokinetic testing of the thigh muscles and shoulder
muscles
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Training on trampolines
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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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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.
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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.
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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.
137
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