Lower Limb Injury Prevention Programme
Lower Limb Injury Prevention Programme
How frequent are sports injuries?
  • In the USA alone 9 million sports and recreation related injuries occur annually
  • That’s around 35 episodes per 1000 persons for those aged 5 years and over
  • It is estimated that more than half of sports injuries are preventable 

What is the financial impact of sports injuries?
  • Football is the most popular sport globally with approximately 400 million players worldwide generating ~$1 trillion per year
  • $20 billion is the financial impact of sports related injuries in US high school and collegiate level when medical costs and lost time are accounted for
  • In the professional leagues roughly one third of player salaries are lost due to injury
  • Popular team sports such as football, basketball, volleyball and handball account for about 2/3 of all sporting injuries

What is the impact of sports injuries on the young population?
  • Those under 25 years have the highest participation rates in sports
  • As a result sport is the leading cause of injury in the under 25 year olds
  • Sports injuries account for 20% of schoolchildren missing at least one day of school per year
  • 25% of those under 25 years seek medical attention per year for sports injuries

Which part of the body is most affected by sports injuries?
  • 60% of all sports injuries occur in the lower limbs
  • 60% of all lower limb injuries affect the knee and ankle joints

How does a sports injury affect an athlete?
  • The impact a sports injury has on an athlete depends on the location and its severity
  • The sports injury may cause the athlete to:
    • Reduce their training intensity (volume as well as frequency)
    • Drop out of a competitive game 
    • Miss part or a whole season
    • End their career prematurely
    • Adversely affect quality of life long term

What is the benefit of reducing sports injuries?
  • The benefits of reducing the risk to sports injuries are:
    • Prolonging a player’s career
    • Avoiding preventable deterioration in health and arthritis to the athlete
    • Reduced medical and insurance costs
    • Reduced workload to emergency departments and general practitioners
    • Reduced socioeconomic impact

What factors increase the risk of sports injuries?
  • Contact sports have higher risk of injury than non-contact sports
  • Most injuries (over 60%) occur during practice than during competition
  • Severe sports injuries are more common in individual sports and recreational activities
  • The following factors increase the risk of an athlete sustaining a sports injury:
    • Poor lower limb mechanics whilst running, jumping and landing
    • Asymmetrical strength in the lower limbs
    • Poor knee joint stability
    • Weak core strength
    • Inadequate endurance strength leading to early fatigue 

How does a sports injury affect an athlete?
  • The adverse impact of a sports injury is longer lasting than the healing of the injury
  • Aside from the health, financial impact and abstaining from training following a sports injury, it takes a long time to reach the same level of performance
  • Research has shown that for every week an athlete misses from training the chances of being able to achieve the season's performance goals are reduced by a quarter
Do sports injury prevention programmes need to be specific to each sport?
  • Whilst there are some sport specific injury prevention programmes, general ones are just as efficacious
  • Generalised sports injury prevention programmes have been shown to be effective across multiple sports as improving the position of the knee in order to avoid injury is the same for all sports

What does a sports injury prevention programme involve?
  • A typical sports injury prevention programme would involve exercises that focus on: 
    • Core stability
    • Eccentric thigh muscle training
    • Proprioception
    • Dynamic stabilisation
    • Plyometric exercises
    • Correct postural alignment
  • Strength and balance exercises should be prioritised in sports injury prevention programmes for team sport athletes
  • Other components to focus on are: 
    • Agility
    • Stretching
    • Warming up
    • Plyometric exercises
    • Technique
  • Use of a qualified trainer and medical monitoring improves effectiveness of the sports injury prevention programme
  • Results of these programmes are usually seen after three months of regular use
  • Essential for correct techniques to be used with particular attention to:
    • Body control
    • Leg alignment especially when landing
    • Knee position over foot
    • Smooth landing with bending at hip and knee
    • Landing on two legs rather than one
  • Sports injury prevention programmes are designed to improve strength, awareness and neuromuscular control, and can help reduce the risk of:
    • Injury by a third
    • Severe injury by half
  • Programme focuses to improve:
    • Biomechanical technique of movement
    • Awareness and control during:
      • standing, landing, running, planting, cutting, jumping
What are the benefits of a sports injury prevention programme?
  • Simple to implement
  • Little to no equipment
  • Can be incorporated into regular team training 2-3 times a week
  • Multicomponent exercise programmes have been shown to be effective in reducing injuries to: 
    • Knee
    • ACL
    • Hamstrings
    • Ankle
    • Lower extremity
    • But not groin injuries
  • Sports injury prevention programmes have been shown to: 
    • Reduce the risk of sports injuries
    • Improve sports performance 
    • May only need to take up 10-20 minutes of regular structured exercises
    • Federations and in particular coaches are key to implementing these programmes for their athletes
  • The more a sports injury prevention programme is followed  the greater the benefit:
    • Some studies have shown as much as 90% reduction in ACL injury
    • 60% reduction in new hamstring injuries
    • 85% reduction in recurrent hamstring injuries
    • >80% reduction in severe knee injury requiring more than 4 weeks absence from play
    • 50% reduction of any type of acute knee injury
What are the factors that affect the effectiveness of a sports injury prevention programme?
  • For these sports injury prevention programmes to be successful they need to be utilised and implemented: 
    • Regularly: 
      • 2-3 times per week
    • Consistently: 
      • For at least three months
    • Across all levels of competition
  • The more time spent on the programmes, the greater the benefit in: 
    • Injury reduction
    • Time lost from injury
  • Athletes who do not adhere to the programme regularly will see little to no improvement
What age group should a sports injury prevention programme be used?
  • Any age group would benefit
  • However, the younger the athlete is to adopt these, the bigger the benefit for them 
  • Children who have these programmes as part of their training develop and maintain optimal movement biomechanics that minimise the risk of injury
  • Children who complete these programmes versus those who have not, show improved:
    • Motor control
    • Balance
    • Agility
    • Performance 
Why are the sports injury prevention programmes not as widely used as they ought to be?
  • Unfortunately, despite increasing evidence showing that these programmes work to reduce injuries, the number of injuries continue to increase because: 
    • Increasing number of people of all ages and sexes are taking up sport
    • Reasons given by teams for not adopting these programmes: 
      • Lack of knowledge of their existence
      • Lack of understanding of their positive impact and effectiveness
      • Citing as taking up too much time (only 15-20 minutes  three times a week is required)
      • Less coaching experience
      • False perception that the programmes are too difficult to follow
      • Failure to follow evidence based sports injury prevention programmes
      • Failure to continue using the programme throughout the season
      • Failure to invest longer term in an athlete’s health which ultimately is for the benefit of the team itself
What should be the focus of rehabilitation?
  • Exercises that improve dynamic lower limb alignment:
    • This means improve balance whilst moving
    • A line drawn from the centre of the hip to the centre of the ankle should cross the centre of the knee  both when standing still (static lower limb alignment) and when moving, walking, jumping, landing (dynamic lower limb alignment)
  • Exercises that improve biomechanical patterns during movement
  • Rehabilitation must be thorough and regular
  • Progression should be gradual
  • Tailor the rehabilitation to the child’s physiology and psychology
  • Help mitigate child’s anxiety to re-injury 
  • Boost confidence in the injured knee
  • Promote participation in team training to gain social benefits of being part of a team
  • Encourage parental support and involvement throughout the rehabilitation process
What are the differences between the injuries of amateur and professional athletes?
  • Amateurs are more susceptible to injuries than professional athletes:
    • This could be due to: 
      • Inferior technical abilities
      • Inferior strength 
      • Inferior landing biomechanics
      • Less likely to incorporate sports injury prevention programme in their training
  • Amateurs are more likely:
    • To be injured during training
    • Sustain moderate and severe injuries
  • Professionals are more likely: 
    • To be injured during a competitive game
    • Sustain less severe injuries
How does the risk of sports injury compare during practice vs a competitive match?
  • Only ~16% of all acute knee injuries occur during practice
  • The risk of injury is 10-15 times higher during competitive matches
  • This raises concerns as to how physically fit an athlete should be before they play competitive matches
  • Professional athletes proportionally sustain fewer injuries than amateurs indicating that strength, fatigue and technique are key factors that amateurs should focus and improve on

How injuries affect team performance?
  • Quite simply the best ability is availability
  • This is testament to how important for team success is having players injury free throughout the season
  • This has been shown in multiple team sports such as basketball, football, and rugby
  • There have been numerous examples in the NBA, NFL and English Premier League where teams which on paper had fewer star players managed to become champions by having a more effective sports injury prevention programme and having their players available for more games
  • However good and well paid a star player is, if they are injured not only does the team lose out financially but they also reduce significantly their chances of winning a championship

Is it cost effective to invest in sports injury prevention programmes?
  • In cost-benefit analysis studies it has been shown across multiple sports that there is a large enough loss directly and indirectly related to injuries in order to invest time and resources into preventing injuries
  •  In such a study during the season 2016-2017 in the English Premier League a team on average: 
    • Paid £9 million in wages to players who were unable to play due to injury 
    • Lost £36 million in potential income due to loss of league points
    • Lost a total of £45 million revenue in one season showing how important sports injury prevention is for each club irrespective of their position in the English Premier League
  • In the NBA during the 2017-2018 season it was calculated that $125 million were lost to players' salaries due to athletes being unavailable due to injury:
    • Almost two thirds (63%) of all injuries were composed of ruptures, strains and sprains which are all commonly preventable
    • It was calculated that 9 games were lost due to injury and three places in the conference table
How important is strength training?
  • Strength training has been repeatedly shown to be the most important factor by far of any successful sports injury prevention programme
  • Regular strength training alone reduces the risk of:
    • Overuse injury by half 
    • All types of sports injuries by a third

What is eccentric strength training and its relevance to sports injury prevention?
  • Increasing evidence shows that progressive strength training and in particular eccentric strength training helps prevent sports injuries and improves flexibility significantly more than static stretching
  • Exercises can be categorised intro three groups in relation to what happens to the muscle length during an exercise:
    • Isometric strength training occurs when the muscle length remains the same as the muscle contracts:
      • For example holding a weight in your hand with the elbow staying still at 90 degrees and holding that position 
    • Eccentric strength training occurs when muscle lengthens as it contracts:
      • For example holding a weight in your hand close to your shoulder and bringing it down slowly until the elbow is straight 
    • Concentric strength training on the other hand occurs when the muscle shortens as it contracts:
      • For example holding a weight in your hand with the elbow straight and bringing it up towards your shoulder 
  • Eccentric exercises are the most effective at causing muscle hypertrophy
  • Eccentric strength training has the added benefit of enhancing:
    • Strength
    • Power
    • Endurance

How important is stretching in reducing the risk of sports injuries?
  • Static stretching involves stretching a muscle to its end range of motion and holding it for a period of time
  • Stretching alone has not been shown to effectively reduce the risk of sports injuries
  • A lot of research has been carried out on best ways to stretch in order to reduce injuries and what effect these stretches have
  • Studies have shown that injuries occur mainly during the first and last 15 minutes of the game:
    • This demonstrates the vital importance of a good warm up routine and the effect of fatigue on injuries
  • Static stretching has been shown to:
    • Not reduce injury
    • Not reduce delayed onset muscle soreness
    • Reduce athletic performance if used directly before an explosive movement like sprinting
  • The current evidence suggests that dynamic stretching is more beneficial pre-workout whilst static stretching would be beneficial post workout and should not be done if the muscles are not warmed up

Is static stretching beneficial to sport performance?
  • Static stretching can improve flexibility but they have not been shown to improve sport performance:
    • Static stretching are beneficial for sports where flexibility is required for good performance e.g. gymnastics, ballet, and martial arts
    • As no evidence has been found that static stretching reduces the risk of injury, they are not incorporated in sports injury prevention programmes
So how should you stretch?
  • 10 minute gentle aerobic workout to improve the blood flow to muscles
  • Followed by dynamic stretching:
    • This is where the body moves whilst muscles are stretched
    • The types of dynamic stretching carried out should be tailored to the sport the athlete is preparing for
  • Examples of dynamic stretching:
    • Combining lunges with upper torso rotational movement:
      • Lunges can be forward, backward and sideways
      • Upper torso rotation involves:
        • Turning shoulders sideways left and right
        • Turning shoulders downwards to reach the ground
    • High knees:
      • Running on the spot whilst bringing knees up close to your chest
    • Squat jumps:
      • Squat down and jump vertically up
    • Jumping jacks
    • Arm circles
  • Static stretching would be more beneficial after exercising than before



For more information on general lower limb and ACL injury prevention programmes please contact us

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