SUBJECT 3: The Need of Injury...

SUBJECT 3: The Need of Injury Prevention FWC REFEREES PROGRAMME (RAP)

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SUBJECT 3: The Need of Injury Prevention

1. OUTLINE OF THE SUBJECT (see file Presentation of Medical Area)

Do injuries just simply occur in athlete participating in sports? > Yes... but It is just destiny, bad luck, or else? > Not only … Can sports injuries, or some of them be prevented? > YES ! The amount of scientific literature is growing since about 10 years. To outline the importance of this topic in sports medicine, a World Congress on Sports Injury Prevention took place in Olso, Norway in 2005 (a second one will be held in 2008 > www.ostrc.no).

2. OBJECTIVES OF THE SUBJECT

The referee should know the background of the general preventive measures and the

rationale behind the most important injury prevention programs.

The referee should practice and implement these exercises in his training routine.

3. OUTLINE OF THE CONTENTS

1 to 6 (see file Presentation of Medical Area)

FWC REFEREES PROGRAMME

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4. DESCRIPTION OF THE CONTENTS

1. Typical Injuries/Complaints/Physical Problems

The presented F-MARC study in Subject 1 (and other studies conducted by the same

research Center) on the selected referees for the 2006 FIFA World Cup showed clearly

that the injury/complaint issue is not an anecdotical, but has been documented in

facts and figures.

Referees, especially at the top level, are athletes, which should be best prepared to

match the demands of modern football.

The most common body parts at risk for injury or musculoskeletal complaint in

referees are: hamstrings (thigh), knee, calf, Achilles tendon, and ankle. Related

affected areas are: groin and low back.

Obviously many other injury types and locations may be experienced in match

officials. However, the data from the F-MARC studies offer the basis for developing a

specific injury prevention program for referees and assistant referees (focusing on

their most common physical problems).

The rationale behind this process is the following:

the type and location of injuries/complaints is known

scientific knowledge from published literature on sports injury prevention

(incidence, severity of injuries, risk factors, principles for prevention,

prevention programs, result from effectiveness studies) is available

empirical knowledge from experts in sports medicine, rehabilitation, training,

sports science is available

=> a targeted (basic) injury prevention program for referees and assistant

referees can be developed

F-MARC has conducted (and still does) several research projects in sports injury

prevention in football. One example (following the above mentioned considerations)

is the so-called “The 11”, a basic injury prevention for amateur football players


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(implemented in country-wide campaigns –with the national football associations and

the national insurance companies- in Switzerland and New Zealand).


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2. General Injury Prevention Measures

Few general principles of injury prevention apply to sport in general, and are here

outlined.

But there are some basic statements –coming out of scientific research, which should

be considered:

measures like massage and stretching are insufficient interventions for injury

prevention

stretching alone before exercise cannot reduce the risk of injury

one of the greatest risk factors for any type of injury is a previous similar injury

(the risk is even higher if this injury was not optimally rehabilitated!)

rather the strength potential (especially –eccentric-) of the musculature, than

the length, is important in injury prevention

proper and sports specific neuromuscular control of the body is one of the key

for preventing sports injuries

a) Warm-up and stretching

Proper warm-up before all training and competition is a prerequiste for peak

performance and for injury prevention. Warm-up should begin with a general exercise

at moderate intensity (such as jogging), in order to increase body temperature, and

should be followed by stretching to prepare muscles and joints for maximal exertion.

Stretching programs should include static stretching exercises, each lasting 10 to 15

seconds in duration, repeated at least 2-3 times for each muscle group. This type of

stretching (which is for the purpose of preparing the muscle and joint for maximal

effort) should be distinguished from flexibility training (which is for the purpose of

increasing the maximum of joint range of motion). All relevant muscle groups for

sport performance should be included. Additional specialized exercises adapted to a

particular sport should be included to gradually approach the desired intensity (see

the training programs in Physical Area).

Whether stretching is effective in preventing injuries is controversial, and not

supported by scientific evidence (see above).


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b) Proper progression of training

One of the most important risk factors for overuse injuries is increasing the training

load too rapidly. However, if an athlete is going to improve his performance, he must

increase his training load beyond that to which he is accustomed. To achieve this goal,

the intensity, duration, or frequency of training may be increased or new types of

training may be selected. Experience has shown that the risk of injuries is greatest in

connection with changes in the training program –for example, at training camp,

where the total amount of training may reach twice the normal level. Changes in

training load should be well-planned, and special attention should be paid to the risk

of overload injuries. Also changes in surface (from a soft to a hard field surface) may

result in changes in the loading patterns that can lead to injuries.

c) Protective gear

Protective gear is one of the most well-documented injury prevention measure in

sports. As an example: helmets, glasses, mouth guards, braces, padding. The

effectiveness of wearing protective gear (a proper fit is crucial, and worn/damaged

gear should be replaced) has been shown in many research studies.

The role of bracing (especially for instable ankle joints) is of importance also for

referees and assistant referees: as we have seen, ankle injuries ranked second in their

injury profile. The combination of bracing (semi-rigid orthosis / tape) and

neuromuscular training is the most effective measure to prevent ankle sprains

(especially in cases of recurrent ankle sprains).

d) Fair Play

Considerations about “Fair Play” are obviously directed to the athletes (football

players), as the match official has to ensure the respect of the Laws of the game.


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e) Physical exams

Physical exams can play a key role for health personnel who are responsible for a

specific team or training group. An examination before the beginning of the season

may uncover potential problems that may increase the athlete’s risk of injury, such a

sequelae from a previous injury, joint instability, generalized deconditioning, or

biomechanical considerations (e.g., malalignement). This type of screening may be

accomplished by means of a single examination, or it may include advanced

physiological tests for high-level athletes, where access to laboratory testing and

resources allow it.

3. 3. Preventing Hamstring Strain

Please refer to Subject 2 / Part 2 for more information about hamstring strains.

The injuries usually occur during maximum sprinting, when resisting knee extension,

or at foot strike, when the muscles is close to its maximum length and eccentric power

generation is at its maximum.

An important risk factor is poor warm-up. Two other (less documented) risk factors

are reduced range of motion and poor strength.

In some individuals, a previous strain that caused scar tissue to form in the hamstring

musculature may result in reduced range of motion.

If the quadriceps musculature is strong but the hamstring muscles are weak, in

relation (ratio), the risk of hamstring injuries is also increased.

HAMSTRING PROGRAM

1) Warm-up exercises

Hamstring stretching: the goal is to prepare for maximal effort

During warm-up before every single training session and game, stretch your

hamstring musculature before beginning sprinting (or shooting) exercises.


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Use support, preferably from another partner or a firm object (stool, tree). Allow your

ankle to relax. Press your heel against the ground for 5 -10 seconds, to activate the

hamstring muscles, then relax and use your hand to straighten out your knee. If

necessary, bend forward slightly at your hip until you feel the stretch in the

hamstrings, but be sure to keep your back straight. Stretch each leg three times.

2) Flexibility training

Hamstring stretching: the goal is to increase range of motion in the hip joint

If your range of motion is limited, stretch your hamstring muscles regularly for 5 to 10

minutes at a time, at least three times a week during the preseason period and twice a

week during the competitive season.


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Your partner lifts your leg with the knee slightly bent, until you feel stretching on the

posterior side of your thigh. Hold this position for a while before actively pressing your

leg against your partner’s shoulder, so that your knee straightens. Hold for 10

seconds. Then relax completely while your partner carefully stretches, by leaning

forward. Hold that position for at least 45 seconds. It is important to relax your ankle,

so you stretch the posterior side of the thigh, and not the lower leg. Stretch each leg

three times.

3) Strength training

Eccentric strength training: the goal is to hold the descent as long as possible, to

achieve maximal eccentric strength of the hamstrings.

Perform eccentric strength training for the hamstring group regularly, at least three

times a week during the preseason period and twice a week during the competitive

season.

The resistance exercises are partner exercises, in which your partner stabilizes your

legs. Lean forward in a smooth movement, keep your back and hips extended, and


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work at resisting the forward fall with your hamstring muscle as long as possible until

you land on your hands. Go all the way down so that your chest touches the ground

and push off immediately with your arms until the hamstring muscles can take over

and you can straighten up into a kneeling position again (this second part of the

exercise is for individuals familiar with this type of training).


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4. Preventing Ankle Sprains

Please refer to Subject 2 / Part 3 for more information about ankle sprains.

Ankle injuries are typically caused by internal rotation and supination of the ankle

when landing in plantar flexion, such as when running or landing on an uneven

surface.

The main intrinsic risk factor for ankle injuries is a history of previous ankle injury,

particularly a relatively recent injury. Ankle sprains may result in mechanical instability

if the lateral ligaments do not heal, or they may impair neuromuscular function –that

is, the ability to register and correct the position of the foot. Some athletes with

previous injuries may have both mechanical instability and reduced neuromuscular

function.

Teaching appropriate training technique is an important preventive measure. It is

crucial to take the athlete’s skill level into consideration when introducing risky

exercises that emphasize basic movement skills, such as lateral movements, takeoffs,

and landings, as a supplement to more sport-specific training.

For athletes who have had prior ankle injuries and have developed secondary

instability, neuromuscular training has been shown to have a significant effect on

ankle function while reducing the incidence of new injuries. For athletes with a history

of ankle sprains, the use of a ankle tape or a brace has also been proven to be an

effective preventive measure (the reason may be that ankle tape/brace work not by

providing mechanical support, but by stimulating neuromuscular function).

ANKLE PROGRAM

Athletes with previous ankle sprains should complete a balance training program on a

wobble board according to the “10-5-10” rule (= 10 minutes, 5 times a week, for 10

weeks). This type of training is/may also be useful for preventing injuries in athletes

with “healthy” ankles.

In the basic position, the athlete stands on one leg (knee extended) while the other leg

is lifted in the air with the knee bent at 90°.


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The arms are crossed in front of the chest, and the goal is primarily to use an “ankle

strategy” to maintain balance and –that is, to attempt to make all balance corrections

using the dynamic ankle joint stabilizers only, while repositioning the arms, hips and

knees as little as possible. At first, balancing on the floor may represent an adequate

training challenge, particularly if the athlete has his/her eyes closed. The difficulty of

the training program can be progressively increased by having the athlete stand on an

unstable balance mat or on a balance board. As the athlete progresses, ball or partner

exercises may be added to make training more challenging and fun.


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5. Preventing Knee Injuries

Please refer to Subject 2 / Part 5 for more information about knee sprains.

Knee injuries are classified as contact and noncontact injuries.

Noncontact injuries result from landings or cutting maneuvers that place the knee in a

vulnerable position, where the stabilizing ligaments (especially the ACL) may be torn.

The most common noncontact mechanism for knee injury seems to be sudden,

powerful foot plant on a nearly extended knee that then collapes into a valgus

position. A long list of risk factors for knee injuries is available in the literature

(anatomical variations, hormonal effects, poor neuromuscular control, poor strength,

inappropriate sport-specific technique, …), but ultimately the causes are still

unknown.

An individualized program emphasizing neuromuscular training of the knee has been

demonstrated to reduce the risk of ACL injuries. This program used balance exercises

to enhance control and awareness of knee positioning during fakes and landings. The

goal is to train athletes to avoid situations in which the knees are subject to valgus

loading.

KNEE PROGRAM

Balance exercises - knee control: the goal is to make all balance corrections using the

knee.

The main exercise is a balance exercise that emphasizes knee control, keeping the

knee over the toes. The basic position is with the hands on the hips and the knee

slightly bent (about 20°-30° of knee flexion).


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The goal is primarily to use a “knee strategy” to maintain balance –that is, to attempt

to correct balance in the knee joint as much as possible and to minimize the use of

arms, hips, and ankles. The exercises are normally done standing on a balance board

or an unstable balance pad, with the knee slightly flexed. Ball or partner exercises may

also be included to make the training more challenging and fun. The exercises can be

adjusted to the relevant sport, incorporating faking and landing exercises that imitate

the requirements of the sport, while continually emphasizing knee control. The

exercises are well suited for use as a part of a warm-up program. During an initial

training period of at least 5 weeks, the exercise should be done at least 3 times a week,

training 10 to 15 minutes at each session. Maintenance training is done one or twice a

week throughout the competitive season.


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6. The Core and its Role in Preventing Lower Extremity Injuries

The “core” represents a functional unit, which include not only muscles of the trunk

(abdominals, back extensors), but also of the pelvis -hip region.

One of the main characteristics of human gait is the coordinated stability of the

different body segments during motion. The preservation of core stability is one of

the keys for an optimal functioning of the upper and –even more- of the lower

extremities. With the athletes (as football players and match officials), pushing normal

function to its limits, the demands on the body in term of absorbing and controlling

forces and motions are greater. The required core stabilization in sports is

consequently higher. Athletes must have sufficient strength and neuromuscular

control of the hip and trunk muscles to provide core stability in all planes of motions.

Research has demonstrated the contribution of different muscles groups. Abdominal

muscles and extensor muscles control selectively and synergistically the stability of

the spine and also of the pelvis. The importance of hip abductors and hip rotators

(specially external) in maintaining lower extremity alignment has been emphasized by

several researchers. Recent research indicates that hip muscle activation affect the

ability of the thigh muscles to generate force and dissipate forces experienced by the

leg during jumping.

In summary: Core stability and strength is crucial in controlling the trunk, upon which

limb activity is optimally performed. Pelvic stability and strength influences the

biomechanics of the lower extremity (especially the knee joint).

Core training: role in injury prevention

Core instability can therefore have dramatic influence of the alignment and

neuromuscular control of the lower extremity. A destabilized lumbo-pelvic unit

initiates hip adduction and femoral internal rotation, leading to knee valgus, with

associated external tibial rotation and foot pronation. In other words, core instability

can lead to the typical knee injury mechanisms (especially in a non-contact situation).


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This destabilized body position, also due to poor core strength and control, may put at risk the

lower extremity for injuries (Bizzini 2000)

Not only a strong empirical evidence support these statements: there is growing

scientific evidence, that core stability has an important role in injury prevention.

Researchers found an association between injuries of the lower extremity and low

back with insufficient hip muscle strength, while other showed similar correlations

between symptomatic patellofemoral pain and poor hip muscle strength. Strength

exercises of the trunk and the hip were also part of successful preventive programs

(including F-MARC “The 11” and “The 11+”): the overall program was found to be

effective in reducing the incidence of injuries in youth amateur female and soccer

players. A recent prospective study showed that trunk and hip muscle weakness were

associated with higher risk for lower extremity injury.

Basic core training

The „bench“ (Nr 1) and the „side-lying“ position (Nr 2) are the two basic exercises (see

Physical Training Area). These are really basic exercises meant to train strength and

stabilization of the dorsal, ventral and lateral core muscles groups. The key for an


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effective training is the optimal aligned body position: this allows a proper

stabilization work of the abdominal, spine and hip muscles.

Other exercises may also include core stability training, even if the focus is set on

another goal: the strength exercise for the hamstrings is a typical example. It requires

a controlled body position, which relies on optimal core stability. The lumbo-pelvic

unit is therefore also trained during these exercises.

1. The “bech” (ventral core muscle chains)

2. The “side-lying” bench (lateral core muscle chains)


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5. ACTIVITIES

a) Read the contents of subject 1 b) Practice the basic injury prevention exercises (as presented in this subject: hamstring, ankle, knee, and core) c) Practice the basic injury prevention program (as presented here and in the Physical Area) d) Complete the self-evaluation exercise

6. BIBLIOGRAPHY

R. Bahr, G. Maelhum (Ed.) Clinical Guide to Sports Injuries. Human Kinetics, Champaign,

2004

L.Peterson, P. Renström. Sports Injuries. Their Prevention and Treatment. 3rd Ed. Martin

Dunitz Ltd, London, 2001

The Football Medicine Resource Kit. F-MARC Football Medicine Manual, FIFA, Zürich, 2005

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