Injuries, Risk Factors and Prevention Initiatives in Youth Sport

Published Online September 24, 2009
Injuries, risk factors and prevention initiatives

in youth sport
Anne Frisch, Jean-Louis Croisier, Axel Urhausen, Romain Seil,
and Daniel Theisen*
Sports Medicine Research Laboratory, Public Research Centre for Health, 1a-b, rue Thomas
Edison, L-1445 Strassen, Grand-Duchy of Luxembourg; Centre de lAppareil Locomoteur, de
Medecine du Sport et de Prevention du Centre Hospitalier de Luxembourg, Luxembourg, and
Departement des Sciences de la Motricite, Faculte de Medecine, Universite de Lie`ge, Belgium
Sources of data: A systematic literature search on injury prevention in youth

sport was performed in the MEDLINE database.
Areas of agreement: For prevention programmes to reduce sports injuries,
critical factors must be considered, such as training content, duration and
frequency, as well as athlete compliance.
Areas of controversy: Home-based programmes could be inferior to supervised
training, but are efficient if compliance is high. So far prevention programmes
have focused on team sports and their efficiency in individual sports remains to
be proven.
Growing points: Active prevention programmes focusing specifically on the
upper extremity are scarce. Initiatives enhancing the awareness of trainers,
athletes and therapists about risk factors and systematic prevention measures
should be encouraged.
Keywords: sports injuries/young athlete/prevention strategies/compliance/

risk factors
Accepted: August 20,

2009
*Correspondence to:
Daniel Theisen, Sports
Medicine Research
Laboratory, CRP-Sante,
1a-b, rue Thomas Edison,
L-1445 Strassen, GrandDuchy of Luxembourg.
E-mail: daniel.theisen@
crp-sante.lu
British Medical Bulletin 2009; 92: 95121

DOI:10.1093/bmb/ldp034
& The Author 2009. Published by Oxford University Press. All rights reserved.
For permissions, please e-mail: journals.permissions@oxfordjournals.org
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Background: Sports injuries in young athletes are a public health issue which
deserves special attention. Effective prevention can be achieved with training
programmes originating from the field of physical therapy and medicine.
A. Frisch et al.
Introduction
96
British Medical Bulletin 2009;92
Promotion of a physically active lifestyle is encouraged worldwide, particularly with regard to the many health benefits.1 In children and adolescents, regular sports practice facilitates the development of fundamental
movement skills,2 helps prevent obesity and its long-term consequences3
and has long-lasting benefits on bone health.4 Unfortunately, increased
intensity and volume of sport practice lead to a higher rate of acute and
overuse injuries. For the young athlete, the consequences of sports injuries could be numerous, ranging from re-injury to career-ending.5
Long-term impacts of sports injuries are frequently found in adulthood,
such as an accelerated development of osteoarthritis.6
In addition to the potentially long-term outcomes of sports injuries
on later life, the related healthcare costs constitute a substantial economic burden. In a recent study, Cumps et al.7 showed that the ensuing
total direct medical costs of sports injuries in Flandren (i.e. rehabilitation, medical care, hospitalization, medication, bandages, transport,
crutches) amounted to 15 027 423.00], which represents 0.07 0.08%
of the total budget spent on health care. In the USA, the estimated
total hospital charges for sports injury hospitalizations among 5
18-year-olds were $485 million over a period of 4 years, with a steady
increase each year.8 The highest medical costs are mostly found for
knee injuries, especially for anterior cruciate ligament (ACL) injuries.7,8
The costs for one ACL surgery plus rehabilitation were estimated to up
to $17 000. Gianotti et al.9 analysed knee ligament injuries in New
Zealand and found that the mean treatment costs were $885 for nonsurgical knee injuries, $11 157 for ACL surgeries and $15 663 for
other knee ligament surgeries. The socio-economic impact should also
be viewed under the light of indirect costs of sports injuries, such as
absence from work and long-term health consequences, which add to
the direct costs.7
Reduction of only a moderate proportion of all sports injuries is of
significance for the young athletes health and could have a long-term
economic impact regarding health-care costs.10 It is therefore important
to convince medical doctors, physical therapists, trainers and coaches,
as well as the athletes themselves, of the necessity to implement active
prevention measures into their therapy and training programmes, thus
decreasing the (re-)injury rate and enhancing athletic performance.
Indeed, recent scientific literature based on a systematic injury prevention approach suggests that well-designed programmes do have positive
effects, provided that a number of conditions are fulfilled.
Van Mechelen et al.11 proposed a general four-step model (Fig. 1) for
sports injury surveillance. The first step comprises the description and
Preventing sports injuries in the young athlete
the extent of the injury problem. In a second phase, the aetiology and
mechanisms of sports injury are being investigated. A third stage concerns the introduction of preventive measures, which will then be
assessed regarding their effectiveness by repeating step 1. The purpose
of this paper is to review the state-of-the-art knowledge on injury prevention in child and youth (,19 years) sports based on that model. In
the first part, the incidence and frequency of particular sports injuries
will be briefly recalled, highlighting the specificities of the young age
group related to biological maturation. The second part will discuss
intrinsic risk factors of that population, with special emphasis on those
which are modifiable and can be targeted by intervention. In the last
part, active prevention programmes will be critically presented regarding their implementation, characteristics and efficiency. This analysis
will make it possible for practitioners of different areas to draw relevant recommendations for their work.
Search strategy and methods

A systematic search of relevant publications was performed for the
section on active prevention strategies via the MEDLINE database
(1966 May 2009). The keywords used were adolescent OR youth
AND sports injury AND prevention, yielding a total of 1953 hits.
Additional searches were performed in the authors personal databases.
Relevant papers were selected on the basis of the following criteria:
exclusive focus on organized sports;
separate results for young athletes under the age of 19 years;
longitudinal studies: only prospective designs;
major focus on intrinsic risk factor;

97
Fig. 1 Sequence of prevention in four steps, adapted from Van Mechelen et al.11
A. Frisch et al.
intervention studies using active prevention programmes;
search limited to English papers only.
Figure 2 provides an overview of the search strategy used. On the basis

of these selection criteria, 14 studies were retained for further analysis.
Injuries in youth sport

Before investigating the effectiveness of prevention measures, it is mandatory to get a global overview of the injury problem. This is, however,
a difficult task for any person confronted with the considerable
amount of literature that has accumulated in recent years. It appears
that the sports injury issue can be addressed from multiple points of
views (Fig. 3). Most studies12 24 have focused on one specific sport discipline highlighting injuries related to the inherent characteristics of the
sport in question. Other investigations25 28 have addressed a particular
body region or injury type, which again only provides a rather limited
view of the sports injury problem. The aim of this section is therefore
to briefly summon up the main acute and chronic injuries related to
youth sports to present a general picture, taking into account the specificity of this population, the sport-specific context and the anatomical
location. Previous reports have shown rates of injury per 1000
exposure hours between 0.5 and 34.4, with highest rates for boys in ice
hockey (5 34.4 injuries/1000 h), rugby (3.4 13.3 injuries/1000 h) and
soccer (2.3 7.9 injuries/1000 h), and for girls in soccer (2.5 10.6
injuries/1000 h), basketball (3.6 4.1 injuries/1000 h) and gymnastics
(0.5 4.1 injuries/1000 h).5,29 For a more detailed analysis of injury
98
Fig. 2 Flow-chart illustrating the search strategy used for investigations dealing with active
prevention strategies.
incidence rates in different sport disciplines, the reader is kindly

referred to some excellent reviews that have been recently published.5,29 31
When analysing different studies on sports injury prevention, some
methodological issues arise, the most important being the way of
reporting injuries (e.g. absolute number of injuries, injury proportion
or injury incidence) as well as injury definition.32 The latter may
explain part of the sometimes large variations in the reported injury
rates.33 The time of sports practice has been frequently used in the literature with minor distinctions,33,34 such that some caution is warranted when interpreting the results presented here (Tables 1 and 2).
Recently, consensus statements on injury definitions and data collection
procedures have been published for soccer35 and rugby.36
Epidemiology of acute injuries
The main acute injuries in youth sports are sprains, strains, fractures,
dislocations and contusions. Overall, sprains account for 27 48% of
all injuries in the young athlete,19 21,37 with the ankle and knee being
the two most common anatomical locations for sprains.20 Ankle and
knee sprain rates are particularly high in sports involving sharp cutting
manoeuvres, running and pivoting movements, stopping and starting
movements or jumps and landings on one foot. Typically, disciplines
such as tennis, volleyball, handball, basketball and soccer are especially
concerned here.18,23,37,38 In youth soccer, ankle sprain incidence
reaches up to 1.50/1000 h.39 These results are comparable to the 1.56
ankle sprains/1000 h found in youth basketball.40 Considering knee
sprains, higher incidences were found for females compared with
males, both in soccer39 (0.72/1000 h versus 0.14/1000 h) and in
99
Fig. 3 Multiple perspectives to analyse the sports injury problem.
A. Frisch et al.
Epidemiology of chronic injuries
Overuse injuries are due to repetitive stress on a biological tissue,

which leads to microtrauma in this specific body region. In adolescent
soccer, overuse injuries account for 10 34% of all reported injuries.20,22,37,39,46 In youth basketball, 38% overuse injuries were
reported,16 whereas in youth handball, they represented 7 21% of
total injury number.21,24 Many overuse injuries in adolescents are due
to traction apophysitis.47
Some chronic injuries are specifically associated with children and
adolescents. Concerning the upper extremity, the main overuse injuries
are the little leaguers shoulder, the rotator cuff tendinopathy and the
little leaguers elbow. The former is a stress fracture of the proximal
epiphyseal plate,45 which is specific to young overhead sports athletes
with open growth plates, involved in sports such as baseball, volleyball
and tennis.48 Shoulder impingement and rotator cuff tendinopathies
are frequent in swimmers due to excessive internal shoulder rotation.
Rotator cuff tendinopathy also occurs as a result of chronic repetitive
hitting and overhead serving in young tennis players.49 Little leaguers
elbow is a traction apophysitis of the flexor/pronator muscles origin on
100
basketball41 (0.09/1000 h versus 0.02/1000 h). Finger injuries,

especially finger sprains, are frequent in team ball sports such as
netball42 (15%), basketball16 (4.9%) and handball21 (1018%).
Strains are very common in adolescent soccer, where they account for
17 53% of all injuries.17,20,34,37 The groin region seems to be most
often concerned (0.57 strains/1000 h), followed by the thigh region
(0.36 strains/1000 h) and the calf and back regions (both 0.21 strains/
1000 h).39 For some sports, concussions are relatively frequent. For
soccer, the incidence found was 0.36 concussions/1000 h,39 whereas
for ice hockey, it was 0.74 concussions/1000 h,15 thus representing
the most common specific injury type (18% of all injuries).
Fractures were found to represent between 2% and 37% of all injuries related to soccer,17,20,34,37,43,44 mostly at the wrist, foot and ankle
region.20 A similar large proportion was found in basketball (17
36%),43 volleyball (7 21%)43 and gymnastics (2 40%).12,19,43
Dislocations accounted for 29 39% of all injuries in basketball,43 for
14 35% in volleyball,43 for 1 35% in gymnastics19,43 and for 0.3
30% in soccer.17,20,43 In the young athlete, dislocations are often recurrent and can lead to post-traumatic instability.26,45 Contusions are also
relatively frequent, especially in team sports and gymnastics (up to over
50%).43
101
the medial epicondyle and can be found in young baseball players, performing excessive throwing training.50
Regarding the lower extremity, a common cause for anterior knee
pain in young athletes is the OsgoodSchlatter lesion, a traction apophysitis of the tibial tuberosity. It is mostly found in children who are
in a growth spurt and engaged in cutting and jumping sports, such as
soccer, basketball, gymnastics and volleyball.48,50,51 In elite junior
figure skating, the Osgood Schlatter disease was found in 9% of all
the girls and 14% of all the boys.14 Kujala et al.27 showed that 21% of
the active student population suffered from OsgoodSchlatter and that
the knee pain caused complete cessation of training for an average of
3.2 months over a 5-year period. At the ankle, Severs disease is frequent in young athletes participating in basketball, soccer, track and
other running activities.48 This calcaneal apophysitis affects the insertion of the Achilles tendon and the plantar fascia50 and is secondary to
repetitive microtrauma or overuse of the heel. Severs disease is the
second most common osteochondrosis found in the younger athlete
after the Osgood Schlatter lesion. Investigating young soccer players
aged 9 19 years, Price et al.52 reported that Osgood Schlatters and
Severs disease accounted for 5% of all injuries. In the age group of
11 13 years, these two conditions accounted even for 14% of all injuries. Another specific chronic injury at the knee joint in adolescence is
the Sinding Larsen Johansson disease, a tensile stress that affects the
proximal attachment of the patella tendon.51
Stress fractures also belong to the overuse injury category. Owing to
mechanical overloading the balance between osteoclastic resorption and
bone formation is disrupted. In tennis, stress fractures are often found
at the lower extremity, more precisely at the foot, where the fifth metatarsal, the metatarsal diaphysis and navicular neck are most often concerned.49 In gymnastics, most stress fractures were found at the spine
(42%), followed by the lower extremity (35%) and the upper extremity
(23%).13 Stress fractures at the lumbosacral spine are also called spondylolysis. They are often secondary to repetitive hyperextension of the
spine, as found in gymnastics, ballet, volleyball, diving and serving in
tennis.45 In basketball, stress fractures of the lower limb were found to
be the third most frequent diagnosis (5.4%) after lateral ankle sprains
and patellar tendinitis.16 In elite junior skating, all stress fractures were
located at the lower limb, except one that was found at the lumbar
spine.14 Stress fractures were the most frequent overuse injury in female
skaters with 19.8%,14 whereas in male skaters they amounted to
13.2%, the third most frequent diagnosis of overuse injuries. Generally,
female athletes could potentially be more prone to stress fractures than
males,13,14,47 an aspect that will be further addressed below.
A. Frisch et al.
Long-term consequences of sports injuries
102
The immediate outcome of a serious acute or chronic injury is the

interruption of sports practice. A severe injury immobilizes the athlete
up to several months and may require surgery or/and intensive and prolonged rehabilitation. On a long-term basis, the consequences of a
sports injury may include decreased sports participation in later life, as
well as loss of function and chronic pain, as discussed below. However,
the literature on long-term consequences of injuries in youth sports is
scarce, most investigations having focused on the adult population.
Furthermore, only few types of injuries have been followed up on a
long-term basis, which precludes any detailed analysis in relation to the
different types of injuries specific to the younger population.
The injury type that has received most attention is the knee sprain,
resulting in ACL or meniscus tears. Gonarthrosis, as diagnosed by radiography, is significantly increased after all knee injuries compared with
the uninjured joint of the same patient.53 Half of the patients with a
diagnosed ACL or meniscus lesion have osteoarthritis with associated
pain and functional impairment 10 20 years after the diagnosis.54 In
operatively treated handball players, the rate of return to sport at preinjury levels was relatively good (58%), but the re-injury rate was as
high as 22%, with half of the players reporting pain, instability or
reduced range of motion 6 11 years after their ACL injury.55 A recent
study56 showed that on an average 11.5 years after ACL reconstruction,
14 27% of the patients suffered severe loss of function and some 16%
declared having rigorously modified their lifestyle. Among a group of
non-operated children (average age 10.1 years) with ACL injury, 35%
had not returned to their pre-injury activity level after an average of
3.9 years.57
The consequences of ankle sprains and shoulder dislocations have
also been investigated on a long-term basis, but not as frequently as
knee injuries. In a group of young patients (mean age 20 years) followed up 2.5 years after inversion ankle injury without surgery, 74%
were found to have persisting symptoms such as pain, perceived
instability, weakness or swelling, and 16% were unable to return to
their original sport.58 No relation was found between age, sex and type
of sport with respect to long-term consequences in that study. Another
5-year follow-up of the functional outcome after surgery of chronic
ankle instability revealed that only half of the patients regained their
pre-injury ankle function.59 A major long-term risk after anterior
shoulder dislocation is chronic instability. Re-dislocation rate after
primary traumatic dislocation ranges from 14%60 to 67%61 after 12
and 5 years follow-up, respectively, often associated with functional
impairment.
From the preceding discussion, it appears that the long-term consequences of a severe injury can be substantial. Although most results
presented above stem from the young adult population, it is likely that
they also apply to children and adolescents. It should be noted,
however, that the literature lacks systematic long-term prospective
follow-ups of sports injuries in the younger population. Furthermore,
concerning chronic injuries in youth sports, long-term impacts on later
life do not seem to have been investigated and could represent a fruitful
area for future research.
Intrinsic risk factors
Non-modifiable risk factors
The risk factor most consistently associated with a greater injury risk is
previous injury. Considering all injuries, soccer players with a history
of injury had a 1.739 to 3.044 times greater risk to sustain a new injury.
When specifically looking at ankle sprains in youth soccer, Tyler
et al.62 found an even greater relative risk of 6.5 associated with previous injury. Across different sport disciplines, McHugh et al.63
reported that the association between previous injury and injury occurrence was significant, but only for male athletes.
The young athlete is particularly vulnerable to sports injuries because
of the physical and physiological processes of growth.50 Body areas
especially affected in adolescents compared with adults are the bone
tissue and the muscle-tendon units. The muscle-tendon units elongate
secondarily in response to bone growth leading to tightness of the
103
The second step of van Mechelens sequence of prevention consists in

the description of the aetiology and mechanisms of injury (cf. Fig. 1),
which are population-specific. Risk factors that could increase the
potential for sports injuries may be qualified as extrinsic (environmentdependent) or intrinsic (athlete-dependent). Extrinsic factors that influence sports injury risk include sports context, protective equipment,
rules and regulations, playing surface and coaching education and
training.30,31 They will not be further developed here, because our
main focus is on intrinsic risk factors. Some intrinsic risk factors
cannot be changed and will only be addressed briefly hereafter. Others
are potentially modifiable, which is of specific interest in the injury prevention context. The identification of intrinsic factors which could be
potentially altered forms the basis for designing effective prevention
programmes.
A. Frisch et al.
104
muscles, especially those muscles which cross two joints, such as the
rectus femoris and gastrocnemius.47 Even if the metaphysis of long
bones is more flexible and elastic in children than in adults, resulting in
greater bone deflection without fracture,45 there are two areas which
are especially susceptible to fractures. First, there is the line of weakness between the epiphyseal plate and the formed bone. Second, there
is the apophyseal cartilage, which is often exposed to high pulling
action from the muscle-tendon unit, resulting either in acute avulsion
fracture or in traction apophysitis, depending on whether the muscular
traction applied is sudden and intense or chronic and repetitive.47
Growth plates in the epiphyseal regions may be injured by repetitive
physical loading and stress. These physeal injuries could produce permanent injury to the cells in the zone of hypertrophy resulting in
growth disturbance.64 Bailey et al.25 demonstrated that the incidence of
fracture of the distal end of the radius was highest at the time of peak
velocity of growth in both sexes. Thus, they concluded that during the
adolescent growth spurt, there is a discrepancy between bone growth
and bone mineralization, which results in a temporary period of relative weakness of the bone. In a recent study, Sugimori et al.28 also
showed that the incidence of fractures in a large cohort of Japanese
children was highest at the age of growth spurt.
Considering the influence of gender, girls seem to be more prone for
some injuries than boys. For example, in figure skating, the relative
number of stress fractures (with respect to the numbers of athletes) was
11% in girls, but only 8% in boys.14 In gymnastics, an even greater
difference was found, with 30% for girls versus 21% for boys,13 which
could reflect different practice patterns. Unfortunately, none of the two
studies reported whether these differences were statistically significant,
so the answer is not definite. Regarding knee injuries, especially ACL
injuries, girls were found to have a significantly higher incidence than
boys [0.43 injuries/1000 athletes exposures (AE) versus 0.09 injuries/
1000 AE].65 Other studies further suggest that ankle injuries are more
frequent in girls than in boys.66,67 Possible reasons for higher injury
risk in girls have been put forward, such as greater joint laxity,68 lower
muscle strength30,67 and poorer proprioception and coordination.38
Finally, there are maturity-associated variations that may influence
sports injury risk.64 The adolescent athlete is more susceptible to injury
than the prepubescent athlete because circulating androgens promote
the fast development of muscle mass and enhance movement velocity
and power. These rapid changes are likely to influence self-control and
risk perception. Additionally, because of the non-linear growth
process, children of the same chronological age may vary considerably
in biological maturity status. As a consequence, there are early and late
maturity children. As classification for participation in youth sport still
relies on chronological age, great variations with respect to height and

weight can be found within a team, which increases the risk of sports
injuries.64
Modifiable risk factors
105
Beside the non-modifiable risk factors, some authors have pointed out
specific risk factors in children and adolescents that can be modified by
prevention.29 31 Potentially implicated factors are fitness level, flexibility, muscle strength, joint stability, balance, coordination, psychological and social factors.30 Concerning cardiovascular fitness, Heidt
et al.69 showed that preseason conditioning significantly lowered injury
incidence in female adolescent soccer players. Regarding muscle flexibility, it has been found that inflexible muscles can produce pain on
the opposite side of a joint; in competitive swimmers, tightness of the
posterior shoulder muscles was associated with anterior impingement.47 Moreover, as previously discussed, inflexible muscles could
cause episodes of traction apophysitis and of overuse syndromes related
to excessive strain, but this hypothesis still remains to be tested.47
Flexibility deficits, which are particularly common in adolescents suffering from overuse injuries, could be improved by regular stretching
exercises. Stretching following appropriate warm-up prior to athletic
activity may also prevent muscular injuries as was concluded in a
recent review article.70
The high incidence of ACL injuries in females has lead Hewett
et al.38 to evaluate neuromuscular control and joint loads in 205 young
female athletes participating in soccer, basketball or volleyball. They
used three-dimensional kinematics and kinetics to evaluate performance during a standardized jump-landing task. Those athletes who
acquired a confirmed ACL injury during the 13-month follow-up had
significantly different pre-study knee posture and loading characteristics compared with the athletes who did not develop an ACL rupture.
The knee abduction angle during landing was significantly greater in
ACL-injured compared with uninjured players. Moreover, ACL-injured
athletes had a 2.5 times greater knee abduction moment and 20%
higher ground reaction force than their uninjured counterparts. Hence,
female athletes with increased dynamic valgus and high abduction
loads are at increased risk for ACL injury.
Balance and coordination have been evaluated in high-school basketball players in a prospective follow-up study.40 Subjects who demonstrated poor balance (high postural sway scores) had nearly seven times
as many ankle sprains as subjects who had good balance (low postural
sway scores). As a result, the authors concluded that preseason balance
A. Frisch et al.
Interventions for sports injury prevention

The previous section has described a series of intrinsic risk factors that
are potentially modifiable. They are the specific focus of interventions
aiming at preventing sports injuries and appear in step 3 of van
Mechelens prevention model (Fig. 1). The efficiency of such prevention
programmes must, of course, be evaluated using injury statistics from a
long-term prospective follow-up (step 4 of the injury prevention
model).
Basically, there are two different kinds of prevention strategies, the
passive and the active. Passive strategies do not require active adaptations from the athlete during practice. Once the prevention strategy is
adopted (e.g. compliance with new rules or wearing protective equipment),77,78 the athlete is automatically protected. In contrast, active
strategies imply that the athlete cooperates and modifies his behaviour
within the sports context. An example of an active prevention programme is the 11-programme, designed by the FIFA-Medical
Assessment and Research Centre (F-MARC).79 This intervention has
been developed in cooperation with international experts. It promotes
fair play and encompasses 10 sets of exercises which focus on core
stabilization, eccentric training of thigh muscles, proprioceptive
training, dynamic stabilization and plyometrics with straight leg
106
measurement ( postural sway) could serve as a predictor of ankle sprain

susceptibility. Similar conclusions were reached in another study,71
where ankle injuries were more commonly found in physical education
students with decreased postural control.
Considering the influence of psychological factors on sports injuries,
several studies suggest that life stress could be a significant predictor of
injury.72 75 For example, major life events, such as the death of a close
friend or family member, or the separation from girl/boy-friend, could
increase the risk for a sports injury by up to 70%.72 Steffen et al.72
showed that injured soccer players had undergone significantly more
stressful life events than the uninjured players. Beside life stress, coping
resources, personality traits and competitive anxiety could have an
effect on sports injuries, as discussed in a recent review.74 Williams and
Anderson76 have shown that the response to life stress is modulated by
the personality of the athlete, the history of stressors and the coping
resources. These factors could be easily evaluated by means of standardized questionnaires. Although athlete personality and history of stressors cannot be modified, psychological interventions could be useful in
improving the athletes attitude and coping resources. This discussion
is however beyond the scope of the present review.
alignment. More recently, a revised version of this programme (11)

has been successfully applied on young female soccer players,37 as will
be detailed later on.
In this paper, only studies dealing with active prevention strategies
are presented based on our systematic literature search (cf. introduction). Before describing different programmes in greater detail, it is
worthwhile to discuss a number of issues related to the implementation
of such programmes into the athletes training schedule.
Challenges to implement injury prevention strategies
107
The effectiveness of an injury prevention programme depends not only

on its content but also on the success of its more or less permanent
acceptance and implementation within the sports community. Great
efforts are sometimes required to convince trainers and coaches to
adopt a specific prevention programme over longer periods of time.
Compliance to prevention training at the level of the team as well as
the level of the individual athlete is critical. Therefore, the organization
of large-scale randomized controlled trials demands a long preparation
time and many resources.
One of the first premises for an effective prevention programme is the
cooperation from trainers. The latter must be fully briefed with respect
to programme duration and content, correct execution of exercises, frequency and the importance of athlete compliance. The intervention
programme should be designed in such a way that it does not interfere
too heavily with the usual training activities. Furthermore, additionally
required material (exercise books and DVDs, balance mats, wobble
boards etc.) should be made available taking into account the financial
implications.
In some studies, teams are supplied with instructional videotapes at
the beginning of the intervention training, demonstrating the correct
execution of the prevention exercises.37,55,65,80 Sometimes the athletes
are asked to control each other by watching the accomplished exercise
and giving each other feedback.37,81,82 Regular checks from the study
instructors are nevertheless needed to verify the appropriate execution
of the programme, the implementation of which can take up to 1.5
months.82
The success of an injury prevention programme also greatly depends
on compliance of the individual athletes to the intervention, as will be
discussed hereafter. Adherence can be influenced by the sport- or
study-specific context, since in team sports the trainer or coach bears
greater responsibility, whereas in individual sports the athletes own
commitment is critical. Another difficulty of evaluating the role of
A. Frisch et al.
Outcome of prevention initiatives
Injury prevention programmes focusing on the young athlete have been

mainly tested in the context of team sports, such as soccer,37,80,82,86 88
basketball,83 handball81,89,90 and multiple sports.65,84,85 To the
authors knowledge, no prevention programmes for individual sports
have been presented in the literature. This could have practical reasons,
in that implementation and high compliance are easily achieved in
team sports compared with individual disciplines. Furthermore, in
team sports, more athletes can be targeted at one time.
Tables 1 and 2 summarize the main results from studies investigating
the effects of different prevention programmes. In Table 1, only results
with a significant positive effect on sports injuries are reported,
whereas Table 2 reviews observations with no significant reduction of
injuries. Regarding content, it appears that injury prevention in youth
sports has mainly focused on the lower extremity and the trunk.
Components which often appear in successful programmes are plyometrics,37,65,69,80 functional strength24,37,65,69,80,81,86,89,90 or conditioning exercises,69 sport-specific agility drills,37,69,80 activities to improve
balance and body control37,81,83 85,87 90 and flexibility exercises.65,69,80 Great emphasis is generally placed on neuromuscular
control, core stability, lower limb alignment, hip control and proper
landing technique (e.g. knee over toe position, decreased impact
forces, bilateral landing). Close supervision and feedback (oral and
visual via ordinary video analysis) by a proficient trainer or at least by
peers seem to be of particular importance to guarantee proper
execution of the exercises.37,81 This critical aspect may put home-based
108
compliance results from the fact that some studies do not specify what
kind of compliance was evaluated. Different indexes have been
reported, such as the percentage of training sessions in which the programme was used (training session compliance),37,82 compliance of
participants to the training sessions ( participant compliance)37,65,82 84
or the percentage of teams adhering to the programme (team compliance)80,81 (Tables 1 and 2). None of these variables necessarily reflect
the compliance of the individual athletes to the entire intervention programme. These aspects are of particular importance when interpreting
the results of sports injury prevention initiatives. Close collaboration
with the study group is also needed regarding data collection and determines, what has been termed, the collecting data compliance.85 The
latter is also important regarding the gathering of information about
sports injuries, which requires prior briefing or even training of one or
several local contact persons.
Table 1. Summary of studies reporting on successful active prevention programmes.

First author
Sport
Age
(years)
Sex
Injury definition
Prevention programme
Content
Emery83 (CRCT)
Basketball
12 18
mf
Multiple
14 19
mf
Heidt69 (RCT)
Soccer
14 18
Injuries in the
intervention
group
Compliance
Acute-onset
injuries: 3.83/
1000 player
hours
2.77/1000 player
hours*,
RR 0.71 (95%
CI: 0.50 0.99)
100% of
participants
for
sport-specific
training
60.3% of
participants
for wobble
board activities
(participant
compliance)
43.3%
(collecting
data
compliance)
Frequency/
duration
Sport-specific
balance training
warm-up for practice
sessions
5 min during one

basketball season
(5 times/week)
Home exercise
programme using a
wobble board
20 min (frequency
NR).
A progressive,
home-based,
proprioceptive
balance-training
using a wobble
board
Daily training for

6 weeks and then
weekly for
maintenance for
the rest of the
6-month study
period
17%
participants
with injury
3% participants
with injury,
RR 0.20 (95%
CI: 0.05 0.88),
OR 0.15 (95%
CI: 0.03 0.72)
(multiple logistic
regression)
Cardiovascular
conditioning,
plyometrics, sport
cord drills, strength
training and
flexibility exercises
to improve speed
and agility
7-week training
programme
before the start
of the season (20
sessions)
33.7%
participants
with injury
14.3%
participants with
injury*
NR
109
Continued
Emery85 (CRCT)
All injuries
occurring during
basketball that
required medical
attention and/or
caused a player to
be removed from
that current
session and/or miss
a subsequent
session
Any injury
occurring during a
sporting activity
that required
medical attention
(i.e. visit to an
emergency
department or
physicians office,
chiropractic,
physiotherapy or
athletic therapy)
or resulted in the
loss of at least 1
day of sporting
activity, or both
An injury that
caused the athlete
to miss a game or
a practice session
Injuries in the
control group
First author
Sport
Age
(years)
Sex
Injury definition
Content
Hewett65 (CNRCT)
Multiple
(soccer
basketball
volleyball)
14 18
Junge86 (CNRCT)
Soccer
14 19
Malliou87 (CRCT)
Soccer
15 18
NR
Frequency/
duration
Injuries in the
intervention
group
Compliance
Neuromuscular
training programme,
incorporating
flexibility,
plyometrics and
weight training to
increase muscle
strength and
decrease landing
forces
6-week preseason
training sessions
that lasted 60
90 min a day, 3
days a week, on
alternating days;
1 season
follow-up
0.43 knee
injuries/1000
AE (untrained
females) 0.09
knee injuries/
1000 AE (male
athletes)
0.12 knee
injuries/1000
AE*
4 weeks:
100%; 6
weeks: 70%
(participant
compliance)
Improvement of
warm-up, regular
cooldown, taping of
unstable ankles,
adequate
rehabilitation,
application of the
11
two 1-year season

intervention (no
other details
indicated)
low-skill
group: 11.1/
1000 h
6.95/1000 h*
NR
Proprioceptive
balance training
program, which
included
sport-specific
exercises on the
Biodex Stability
System, on the
mini-trampoline and
on the balance
boards
20-min balance
training twice a
week during the
competition
period
88 lower limb
injuries
60 lower limb
injuries*
NR
A serious knee
injury was defined
as a knee ligament
sprain or rupture
that caused the
player to seek care
by an athletic
trainer and that
led to at least 5
consecutive days of
lost time from
practice and
games
Any physical
complaint caused
by soccer that
lasted for more
than 2 weeks or
resulted in absence
from a subsequent
match or training
session
An injury was
defined as any
mishap occurring
during scheduled
games or practices
causing an athlete
to miss a
subsequent game
or practice session
Injuries in the
control group
A. Frisch et al.
110
Table 1. Continued
Soccer
14 18
McGuine84 (CRCT)
Multiple
(soccer
basketball)
16
mf
McHugh88
(prospective
cohort study)
Soccer
15 18
NR
Non-contact ACL
tear was
confirmed by
history, physical
examination by a
physician and MRI
and/or
arthroscopic
procedure
An ankle sprain
was defined as a
trauma that (i)
disrupted the
ligaments of the
ankle, (ii) occurred
during a
coach-directed
competition,
practice or
conditioning
session and (iii)
caused the athlete
to miss the rest of
a practice or
competition or
miss the next
scheduled
coach-directed
practice or
competition
An inversion ankle
sprain was defined
as an ankle injury
with an inversion
mechanism
requiring the
player to miss at
least one game or
practice
Proprioceptive and
neuromuscular
programme,
including warm-up,
stretching,
strengthening,
plyometrics and
soccer-specific agility
drills
Balance exercises on
a flat surface or on a
board such as
single-leg stance
with eyes open and
closed; performing
functional sport
activities such as
throwing, catching
and dribbling on
one leg; maintaining
double-leg stance
while rotating the
balance board
20-min warm-up
before each
athletic activity
during two
one-season
interventions
Season 1: 0.47
ACL injuries/
1000 AE;
Season 2: 0.51
ACL injuries/
1000 AE
0.05 ACL
injuries/1000
AE*, RR 0.114
(95% CI NI);
0.13 ACL
injuries/1000
AE*, RR 0.259
(95% CI NI)
96.52100%
(team
compliance)
Progressive
five-phase
balance training
program; phases
1 4: five exercise
sessions/week for
4 weeks before
the start of the
season; in phase 5
(maintenance
phase), three
10-min sessions/
week
1.87 ankle
sprains/1000
AEs
1.13 ankle
sprains/1000 AEs;
the rate of ankle
sprains was
significantly
lower in the
intervention
group as shown
by Kaplan
Meier survival
analysis,
RR 0.56 (95%
CI: 0.33 0.95)
91.2%
(participant
compliance)
Single-limb balance
training on a foam
stability pad
Balance training
was performed
for 5 min on each
leg, 5 days/week
for 4 weeks in
preseason and 2
times/week for 9
weeks during the
season
2.2 ankle
sprains/1000
exposures
0.5 ankle
sprains/1000
exposures*
91% (training
session
compliance)
Continued
111
Mandelbaum80
(non-randomized
prospective cohort
study)
First author
Sport
Age
(years)
Sex
Injury definition
Content
Handball
15 17
mf
Any injury
occurring during a
scheduled match
or training session,
causing the player
to require medical
treatment or miss
part of the next
match or training
session
Soligard23 (CRCT)
Soccer
13 17
Wedderkopp90
(CRCT)
Handball
16 18
An injury occurred
during scheduled
match or training
session, causing
the player to be
unable to fully
take part in the
next match or
training session
Any injury
occurring during
scheduled games
or practices,
causing the player
to either miss the
next game,
practice session or
being unable to
participate
without
considerable
discomfort
Frequency/
duration
Exercises with the

ball, including the
use of the wobble
board and balance
mat to improve
running, cutting and
landing technique as
well as
neuromuscular
control, balance and
strength
Application of 11
During an
8-month season,
15 20-min
programme at the
beginning of
every training
session for 15
consecutive
sessions and then
1/week during the
rest of the season
20-min
programme at all
training sessions
and prior to
matches for one
8-month season
Ankle disc practice

and two or more
functional strength
activities for all
major muscle groups
10 15-min
programme at all
training sessions
for one 10-month
season
Injuries in the
intervention
group
Compliance
1.8 acute
injuires/1000
player hours
(0.6 in
training 10.3
in match)
0.9 acute
injuries/1000
player hours*,
RR 0.51 (95%
CI: 0.39 0.66)
(0.4 in training
4.7 in match*)
87% (team
compliance)
4.8/1000 h
3.2/1000 h*,
RR 0.68 (95%
CI: 0.56 0.84)
77% (training
session
compliance);
58%
(participant
compliance)
1.17/1000 h of
practice,
23.38/1000 h
of match
0.34/1000 h of
practice*,
OR 0.17 (95%
CI: 0.089 0.324);
4.68/1000 h of
match*
NR
Olsen81 (CRCT)
Injuries in the
control group
A. Frisch et al.
112
Table 1. Continued
Wedderkopp89
(CRCT)
Handball
14 16
Any injury
occurring during
scheduled games
or practices,
causing the player
to either miss the
next game,
practice session or
being unable to
participate
without
considerable
discomfort
Ankle disc practice

and two or more
functional strength
activities for all
major muscle groups
10 15-min
programme at all
training sessions
for one 10-month
season
0.6/1000 h of
practice,
OR 4.8
(95% CI: 1.9
11.7); 6.9/
1000 h of
match
0.2/1000 h of
practice*; 2.4/
1000 h of
match*
NR
113
AE, athletes exposure; NR, not reported; m, male; f, female; CNRCT, cluster-non randomized controlled trial; CRCT, cluster randomized controlled trial; RCT, randomized
controlled trial.
*Significantly different from the control group (P , 0.05).
A. Frisch et al.
114
Table 2. Summary of studies reporting on unsuccessful active prevention programmes.
First
author
Sport
Age
(years)
Sex
Injury definition
Content
83
Emery
(CRCT)
Basketball
12 18
mf
Junge86
(CNRCT)
Soccer
14 19
Steffen82
(CRCT)
Soccer
13 17
All injuries occurring

during basketball that
required medical
attention and/or
caused a player to be
removed from that
current session and/or
miss a subsequent
session
Any physical complaint
caused by soccer that
lasted for more than 2
weeks or resulted in
absence from a
subsequent match or
training session
An injury was
registered if it caused
the player to be
unable to fully take
part in the next match
or training session
Frequency/Duration
Injuries in
the control
group
Injuries in the
intervention
group
Compliance
All injuries:
4.03/1000
player
hours
3.3/1000 player
hours,
RR 0.80 (95%
CI: 0.57 1.11)
100% of
participants for
sport-specific
training
60.3% of
participants for
wobble board
activities
(participant
compliance)
NR
5 min during one

basketball season (5
times/week)
Home exercise
programme using a
wobble board
20 minutes (frequency
NR)
Improvement of
warm-up, regular
cooldown, taping of
unstable ankles,
adequate
rehabilitation,
application of the 11
Application of the
11
Two 1-year season

intervention
high-skill
group:
6.78/1000 h
6.35/1000 h
During one soccer

season (8 months),
20-min warm-up
programme (including
5 min of jogging before
starting the exercises)
every training session
for 15 consecutive
sessions and thereafter
1/week for the rest of
the season
3.7/1000 h
3.6/1000 h,
RR 1.0 (95%
CI: 0.8 1.2)
52% (training
session
compliance) 67%
(participant
compliance)
AE, athletes exposure; NR, not reported; m, male; f, female; CNRCT, cluster-non randomized controlled trial; CRCT, cluster randomized controlled trial; RCT, randomized
controlled trial.
Sport-specific balance
training warm-up for
practice sessions
115
interventions at a disadvantage, since the quality of the execution (and

the compliancesee below) cannot be easily verified. Another factor to
consider is the possibility for variation and progression in the exercise
set, which will avoid ceiling effects, enhance motivation among trainers
and athletes and favour compliance.81 Indeed, the 11-programme
applied by Steffen et al.82 in a group of young soccer players did not
provide the possibility for variation and progression, was characterized
by a low compliance and had no significant effect on injury incidence.
Similarly, Junge et al.86 did not find significant improvements in injury
statistics with this prevention method in already skilled soccer players
(cf. Table 2), only the low-skilled group had a decreased injury incidence (cf. Table 1). On the other hand, the revised 11 version
including additional exercises to provide variation and progression,
plus a new set of structured running exercises, reduced the risk of
severe injuries, overuse injuries and injuries overall in young female
soccer players.37
Globally, there is a strong tendency of interventions with a high compliance to bring about significant reductions in injury incidence,37,65,80,81,84,88 whereas studies in which compliance to the
programme was low showed only marginal effects.82,83 It should be
noted here that a home exercise programme may be less motivating
and result in poorer compliance than a supervised and structured training agenda followed in a group of peer athletes. Considering the fact
that the young athletes behaviour can be easily influenced by the
environment, the attitude of the trainers and probably also of the
parents may be of particular importance here. The investigation of
Mandelbaum et al.80 had a team compliance of almost 100%, which
lead to an 88% reduction in ACL injuries in female soccer players.
Similarly, in the study of Olsen et al.,81 87% of the participating clubs
applied the proposed intervention programme throughout the study
period, which yielded a 50% decrease in acute injuries in young handball players. Hewett et al.65 found a 72% reduction in knee injuries in
female athletes from team sports after a specific 6-week preseason
preparation. All the girls from the intervention group followed the prevention programme for 4 weeks, and 70% of them accomplished the
full training programme. McGuine and Keene84 reported a compliance
of 91%, which lead to a 38% reduction in ankle sprains in male and
female high-school basketball and soccer players. In the study of
McHugh et al.88 91% of the athletes followed the entire balance training. The authors observed an overall reduction in injury incidence of
77%. In contrast to the previous studies, Steffen et al.82 noted a low
training session compliance among young soccer players (52%),
despite regular contacts with the coaches during the study period and
encouragements to continue the intervention programme. Accordingly,
A. Frisch et al.
Conclusion
Acute injuries and overuse syndromes in the young athlete deserve
specific consideration. Detailed knowledge about injury incidence,
injury type and modifiable and non-modifiable risk factors makes it
possible to design pertinent prevention programmes. Their effectiveness
depends on a number of characteristics related to content, compliance,
duration and frequency. Practical issues regarding implementation of
and adherence to these prevention exercises require special attention.
The proposed programmes should be time-efficient for the trainers and
motivating for the athletes.
There seem to be no systematic analyses about the effectiveness of
injury prevention programmes directed to the upper extremity, despite
well-described injury patterns. The latter are rather sport-specific and
concern, e.g. the young overhead athlete. The reasons why this area
may have raised less interest in the field of sports medicine are not
clear. Attention should be drawn here to interventions aiming at
decreasing muscle dysbalances and restoring appropriate ranges of
motion. The modalities and efficiency of such training programmes are
yet to be investigated by long-term prospective follow-ups.
Finally, it is important to take into account the education of trainers
and coaches. Indeed, few coaches consider sports injuries as an issue
116
the results did not reveal the expected training effects of reduced sports
injury risk (cf. Table 2).
Given the previous findings, it appears that appropriate content and
high compliance are critical, yet insufficient factors for a successful
intervention. Another important aspect seems to be the frequency and
duration of the prevention sessions, for which some fundamental differences can be noted (cf. Tables 1 and 2). Some programmes with significant reductions in injury statistics have encompassed an initial high
volume phase of prevention exercises, i.e. 15 40 sessions of 15
20 min, performed either daily or in every practice, followed by one
weekly session for maintenance.81,85 Another successful approach has
been to introduce a pre-season preparation programme of 18 20 sessions over 6 7 weeks, with durations of up to 90 min.65,69 Finally, a
strategy of continuous, moderate volume prevention training of 10
20 min in each practice session (e.g. during warm-up) also yielded positive results.37,80,89,90 From these results, it can be concluded that frequency and duration of preventive training sessions should guarantee
certain minimal criteria. All in all, the final choice will depend on practical considerations of feasibility and acceptance by trainers and
athletes.
they can impact on.37 It is also regrettable that injury prevention seems
to have a rather low priority and has been cited by some trainers as a
reason for non-participation in injury prevention studies.37 This indicates the necessity to include the topic of injury prevention in the curricula of trainers and coaches. Furthermore, information and education
of the parents and the young athletes themselves should be reinforced.
Only an uninjured athlete is able to perform at his/her best.
Funding
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Published Online September 24, 2009

Injuries, risk factors and prevention initiatives

Departement des Sciences de la Motricite, Faculte de Medecine, Universite de Lie`ge, Belgium

Sources of data: A systematic literature search on injury prevention in youth

Keywords: sports injuries/young athlete/prevention strategies/compliance/

Accepted: August 20,

British Medical Bulletin 2009; 92: 95121

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British Medical Bulletin 2009;92

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Preventing sports injuries in the young athlete

Search strategy and methods

British Medical Bulletin 2009;92

exclusive focus on organized sports;

separate results for young athletes under the age of 19 years;

longitudinal studies: only prospective designs;

major focus on intrinsic risk factor;

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intervention studies using active prevention programmes;

search limited to English papers only.

Figure 2 provides an overview of the search strategy used. On the basis

Injuries in youth sport

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Preventing sports injuries in the young athlete

incidence rates in different sport disciplines, the reader is kindly

Epidemiology of acute injuries

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Fig. 3 Multiple perspectives to analyse the sports injury problem.

Epidemiology of chronic injuries

Overuse injuries are due to repetitive stress on a biological tissue,

British Medical Bulletin 2009;92

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basketball41 (0.09/1000 h versus 0.02/1000 h). Finger injuries,

Preventing sports injuries in the young athlete

British Medical Bulletin 2009;92

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Long-term consequences of sports injuries

British Medical Bulletin 2009;92

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The immediate outcome of a serious acute or chronic injury is the

Preventing sports injuries in the young athlete

Intrinsic risk factors

Non-modifiable risk factors

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The second step of van Mechelens sequence of prevention consists in

British Medical Bulletin 2009;92

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Preventing sports injuries in the young athlete

relies on chronological age, great variations with respect to height and

Modifiable risk factors

British Medical Bulletin 2009;92

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Interventions for sports injury prevention

British Medical Bulletin 2009;92

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measurement ( postural sway) could serve as a predictor of ankle sprain

Preventing sports injuries in the young athlete

alignment. More recently, a revised version of this programme (11)