Phys. Ther. Rev.

1997; 2: 135-151

Sports injuries: incidence,

causes, prevention

Physical. therapists have an important role to play in the

prevention of sports injuries. The process is effectively one of
risk management and should be based on a proper risk analysis.
Many older studies give a misleading impression of the incidence Sports Injuries Research Centre,
and consequences of different sports injuries, due to poor study University of Limerick, Ireland
design and the use of an inadequate definition· of sports injury:
this should always be formulated from the perspective of the
athlete who suffers the injury. Older studies on the causes of sports
injuries were also often poorly designed and misconceptions
concerning injury risk factors are common. For example, there is
little hard evidence that poor flexibility and hamstring-quad
muscle imbalance are significant sports-injury risk factors.
Analysis of the literature on the causes of sports injuries suggests
that individual sub-groups of the athletic population may have
unique and distinctive risk profiles. There is a need to investigate
this proposition using high-quality, empirical research.

Key words: flexibility; footwear; injury-prevention programmes; muscle balance; orthoses; physical fitness;
physique; playing-surfaces; posture; warm-up

the information available on sports injuries. With so

much ground to cover it has not been possible to
Introduction provide a detailed analysis of the methodology of
individual research papers-as is available in some
The training of physical therapists places them in a reviews that confine themselves to a single topic.
unique position to understand and manage sports Although not discussed in detail, considerable at-
injuries. A substantial number of sportsmen and tention has, in fact, been given to the scientific quality
women recognize this and now view the profession of the studies reported. Matters considered include:
as their first choice for the treatment of sports injuries. type of study, e.g. case study, prospective, retro-
Increasingly, physical therapists are also being given spective, randomized control trial etc., design of the
an important role in injury prevention-through study, number of subjects (cases), selection of sub-
work as advisors on training programmes, the phys- jects, randomization, conduct of the study, precision
ical preparation for sport, and the implementation of the observations made and whether the reliability
of specific injury prevention measures. It is to this was reported, analysis of the data, presentation of
latter role of the physical therapist that the present the data, conclusions drawn, clarity and completeness
review is primarily directed. of descriptions. Some papers on sports injuries con-
The scope of this review is extremely broad. This tain serious errors and omissions and readers need
is deliberate and is considered appropriate for an to be critical of what they read. Altman! has provided
early edition of a new journal, as this article is a useful check list of what to look for in medical
intended to provide the reader with an overview of papers and Harf provides guidelines for evaluating

1083-3196/97/030135+ 17 $12.00/0 © 1997 W.B. Saunders Company Limited

135
136 A. W. S. Watson

material on sports injuries. Sports medicine should The effects of sports injuries are suffered by ath-
be based on sound evidence and should avoid the letes. This is a truism: but in past research this basic
use of intuition, unsubstantiated patho-physiological fact has often been overlooked and the definition of
predictions, and unsystematic observations made by injury has been formulated from the perspective of
clinicians, athletes and coaches. the person who treated the injury (usually a phys-
ician), rather than from that of the athlete who suf-
fered from it. In some research only conditions that
Risk analysis approach to the prevention of received medical treatment were counted as injuries
sports injuries (for example Schafle et aI, ref 4). In other studies
medical treatment or a one-week loss from sport
Six steps in the implementation of a successful injury were demanded.5,6 All of the above definitions are
prevention programme are summarized in Fig. 1. too clinically oriented and far too exclusive to be
The process begins at the top left-hand corner of the adequate definitions of injury from the standpoint of
diagram with well designed studies on the incidence the athlete or coach. For example, none of them
and consequences of sports injuries. This is effectively would count as injured a marathon runner with
risk analysis3 and the process allows activities of high shinpain who was forced to run at half pace-
risk to be identified. A large number of papers on provided that he or she did not consult a doctor.7 In
the incidence of sports injuries have been published. the past, overuse injuries did not receive the attention
Some are of a high standard but many others were or the sympathy that they deserved and were often
poorly designed and sometimes give misleading in- excluded from research studies.
formation on the relative dangers of different ac- Athletic success demands a commitment to a sys-
tivities. Once the risks have been quantified it is tematic training programme that extends over a
necessary to identify the causes of injury. Again, the period of years. It normally consists of a series of
standard of research is very variable. Some recent phases in which different aspects of fitness are pro-
research studies have analysed the causes of injuries gressively developed. Individual training sessions
using appropriate multivariate statistical techniques; consist of workouts at carefully controlled intensities
but in many older papers, the analysis of injury that are designed to produce peaks of fitness at times
causes is very unsatisfactory. in the season that are normally beyond the athlete's
Even when the causes of injury have been satis- control. In the context of such a programme, injuries
factorily identified, it is not a simple matter to trans- that are clinically minor have the potential for serious
late this information into effective injury prevention disruption of competition and training.8
strategies. Firstly, hypotheses on how to reduce the
Papers that used exclusive definitions of sports
incidence and seriousness of injury need to be for-
injury were common until quite recently. They res-
mulated and their effectiveness investigated em-
ulted in an underestimate of the true incidence of
pirically. Secondly, ways of imparting this
injury in sport and gave a misleading impression of
information to athletes and of ensuring that they
the types of injuries that were most common and
adhere to it, need to be devised and then researched.
troublesome to the athlete. For example, strains and
This matter is far from straightforward and empirical
overuse injuries account for more time loss from
studies that demonstrate a reduction in sports injuries
sport than sprains;8but hospital-based research gives
as a result of the implementation of prevention strat-
the opposite impression. More useful definitions of
egies are surprisingly hard to find.
sports injury are discussed in the following section.
Some of the individual steps listed in Fig. 1 are
discussed in detail in the sections which follow. McLennon and McLennon9 and Watson8have sug-
gested:

The incidence of sports injuries Sports injury: A mishap occurring during sporting
activity which results in the inability to train or
The literature on sports injuries has expanded con- compete normally.
siderably over the last five years. The design of studies
has tended to improve and the statistical analysis of Requa and GarricklOhave extended the definition
data has become more soundly based and more soph- of sports injury to four categories-the first four rows
isticated.Somerecent research casts doubt upon certain of Table 1 below. Three other, more serious types of
assumptions of injury prevention and physical training injury are also referred to in the literature-those
practices that are widely held. Some of the mis- which result in the individual having to give up
understandings result from a matter as basic as dif- sport, very serious or catastrophic injuries which result
ficulties with the definition of the term sports injury. in permanent, severe neurological disability,l1 and
 Sports injuries 137

Figure 1. Six steps in a strategy for reducing the incidence and seriousness of sports injuries. The cycle begins with
the top left-hand box-(l) studies on the incidence of sports injuries. Following this, (2) research into causes is undertaken
leading to (3) the formulation of hypotheses concerning injury prevention. These are first tested (4) in a laboratory
setting before (5) research is undertaken on how best to educate athletes and coaches in the use of the new techniques.
(6) Large scale use of the injury prevention measures then completes the cycle.

injuries which result in death. These categories of 10,000 hours of exposure. In this review I have used
injuries are summarized in Table I, next page. the latter as this always results in numbers that are
Injuries of levels 2, 3 and 4 equate with Watson's8 greater than 1. (For more detailed information see,
and McLennons'9 definition of a sports injury. refs 1-3, 12, 17; 86).
Not all injuries are of equal seriousness. Factors
that have been used to define the seriousness of
Number of and incidence of sports injury
injury include the following:
The number of injuries is a simple count. Com-
parisons between different sports and groups require
• Nature of the injury
adjustment for the number of athletes and for their
exposure to the sport. Many papers express the in- • Duration and nature of treatment required
cidence of injury as:
• Sporting time-loss
incidence = (number of injuries) . (athletes)-l. (time)-l
• Work time-loss
This allows a comparison to be made between dif-
ferent sports and between different activities in a • Nature of any permanent damage
single sport. In order to produce convenient numbers • Cost of the injury (Van Mechelenl2)
it is usual to express the incidence per 1000 or
138 A. W. S. Watson

Table 1. Levels of sports injuries. To qualify as a sports Table 2. Left-hand columns: number of sports injuries
injury the condition must have arisen during, or as a per 10,000 hours of exposure for males and females aged
result of, sports participation 16 to 45 in the UK. Right-hand columns: deaths per 100
million exposures. Data from Nicholl et al13
Levell: Injury or pain not affecting sport or fitness Activity Injuries per Activity Deaths per
activities 10,000 hours 10,000,000
exposures
Level 2: Injury or pain resulting in modifying the duration
or intensity of sport or fitness activities Rugby 636 Climbing >793
Soccer 422 Air sports >640
Level 3: Injury or pain that results in missing part or all 402 Motor sports 146
Hockey
of a sport or fitness activity Cricket 147 Water sports 68
Level 4: Injury or pain that results in missing part or all Badminton 193 Horse riding 34
Squash 242 Rugby 16
of a sport or fitness activity and in temporary alterations
Tennis 134 Soccer 3.8
in daily life (e.g. results in the use of crutches or in missing Running 179 Running 1.2
work or school)
Level 5: Injury that results in the individual giving up
sport
Level 6: Catastrophic injury of respondents reported participation in sport over
the previous four-week period, the most common
Level 7: An injury that results in death
activities being swimming or diving (16%) keep fit
(12%) soccer (10%) and running (7.2%). One-thou-
sand-four-hundred-and-twenty-nine subjects re-
ported 1803 separate injuries over the previous four
Watson8 found that injuries to athletes involved in weeks. This corresponds to an average of 2.76 injuries
explosive sports (jumping, sprinting and throwing) per participant per year. Three-quarters of the injuries
took much longer to resolve than those occurring in occurred in men and half in the age-group 16 to 25
other athletes. The results of his study suggested that years. Twenty-nine percent of the injuries occurred
the number of days lost to injuries per 1000 hours of in soccer but this was to some extent due to the high
participation was a useful guide to the seriousness participation rates for this activity. Injury rates per
of injuries in a particular activity. Using this index 10,000 hours of different activities are listed in Table
explosive athletes lost 283 days per 1000 hours as 2 above.
opposed to 71, 65 and 95 days, respectively, for Nicholl et al13 also provide an estimate of the risk
athletes involved in endurance, contact and non- of death in sport in the UK, computed as risk per
contact sports. This index of the seriousness of injury 10,000,000 exposures. The data above shows that
is useful and should be more widely employed when mountaineering, air sports and motorized sports
comparing injuries in different sports. carry a relatively high-risk. Activities carried out on,
Many writers advocate the need for a uniform or near, water are of moderate risk. Such activities
definition of a sports injury to be used in all future carry a much lower risk of a non-fatal injury than
studies. In my view this is not a practical suggestion do team sports which, in contrast, carry a low-risk
because the term has such different meanings in the of catastrophic injury. When using the word danger
context of different sports, different situations within in the context of sport, it is necessary to specify the
a single sport, and from the perspective of different nature of the risk that is implied.
sport and health-care professionals. A more realistic Mueller and Cantu 11 review catastrophic sports
approach is to use one or more of the ways of injuries in US high schools and colleges during the
quantifying injuries and their effects that are listed period 1992-8. They report 40 traumatic fatalities, 85
in Table 1, and then to use statistical techniques to non-traumatic fatalities and 80 catastrophic injuries:
make comparisons between different studies. 36 of the traumatic fatalities, 37 of the non-traumatic
fatalities and 61 of the catastrophic injuries were
sustained in one sport-American football.
Incidence of injuries
In an Irish study of injuries to high-level par-
Van Mechelen12 summarizes the incidence of injuries ticipants in 10 different sports} a mean of 1.17 acute
in European countries. Nicholl et al13 provide a com- and 0.93 overuse (total =2.1) injuries per athlete per
prehensive account of the incidence of sports injuries year was reported. The athletes were affected by
in the UK (a sample of 17,564 individuals aged injury for 52 days per year, just over half the time
between 16 and 45 years was used). Fifty-one percent loss being due to overuse injuries. The time-loss due
 Sports injuries 139

0/0 OF TOTAL INJURIES

35

30
.... ..... .....1 - MALE [Z::J FEMALE I..
--_ .
25 .'

20

15

10

o
UNDER 10 10-19 20-29 30-39 40-49 50-59 60-69 70 & OVER

AGE OF CASUAL TV (YEARS)

Figure 2. The incidence of sports injuries in relation to age and gender. Data for the figure is based on that in
Tenvergert et al.89 The majority of sports injuries are suffered by individuals aged between 15 and 30 years of age.7,13
Males suffer more sports injuries than females, particularly in the 20 to 30 age-group.

to overuse injuries was particularly high in the case that damage occurs. However the reason that this
of sprinters, jumpers and throwers and this led to situation arises is usually much more complex.
the conclusion that time loss per 1000 hours of par- Excessive intensity of force generally results in
ticipation was a better guide to the effects of sports acute injury while excessive repetition is more likely
injuries than the number of injuries. to lead to an overuse injury. Injuries can thus be
Many studies have been carried out into the in- due either to tissue weakness, excessive force, or a
cidence of sports injury in the general population. combination of the two. In sports injuries research,
Typical results are illustrated in Figure 2. The age the causes of injuries are generally divided into two
and gender difference in the incidence of injury is main groups: intrinsic causes-those attributable to
due mainly to differences in participation rates. characteristics of the individual who suffers from the
injury, and extrinsic causes-those attributable to
external factors.
Studies on the causes of sports injuries The premise that any particular injury is at-
tributable to a single, isolated, cause is seldom ten-
Many of the studies that have so far been published able. Most result from a complex interaction of both
on the causes of sports injuries leave a great deal to internal and external factors. An example of some
be desired. Although causation is often implied in hypothetical factors that might be implicated in an
the sports medicine literature, most of these as- ankle sprain to a soccer player are summarized in
sociationsare based upon evidence that is insufficient Fig. 4, p.41.
to 'advance the cause of true causation' (Harf). The extrinsic causes of injuries are seldom studied
At the simplest level, the causes of sports injuries scientifically. The most common practice is to ask the
are extremely straightforward: they occur when the subject to state the cause of his or her injury. In a
forces applied to a body tissue are excessive so few studies coaches, officials or teachers have also
140 A. W. S. Watson

Figure 3. Sports injury is due to the application of excessive intensities or repetitions of forces mainly to bone, muscle
or connective tissue. Forces of low intensity tend to have negligible effect while those of moderate intensity may have
a training effect, particularly on muscle (see Watson7 for details). Forces of excessive intensity tend to cause acute
injuries such as fractures, dislocations, strains, sprains and contusions. Excessive repetitions of moderate forces are
more likely to result in overuse injuries.

been consulted, and in some studies, more than one There are a number of requirements for satisfactory
cause has been allowed.14 Studies on similar groups research into the intrinsic causes of sports injuries.
of subjects can produce wildly different estimates of (1) The study must have been prospective-cohort
the influence of factors such as foul play (for example or randomized-trial in design, in order to establish
see Stokes et a[l5 and Watson16). In future studies, cause and effect.
some objective evidence on the extrinsic causes of (2)The reliability of the anatomical or physiological
injury is desirable. Video evidence of the behaviour measurements that were taken on the subjects must
of players might be of assistance in some instances.16 have been established and reported in a satisfactory
In other cases, mechanical analysis of equipment, manner. Correlation coefficients are seldom satis-
surfaces and footwear should be carried out. Such factory as they are influenced by the amount of
evidence is already routinely used in personal injuries variation between the subjects as well as by the
litigation. experimental error, and they are not reported in the
The intrinsic causes of sports injuries have oc- units of the measurement under investigation.7,17
casionally been systematically investigated and some (3) Measureme!l-terror must be taken into account
authors have carried out statistically sophisticated when the relationships between variables is evaluated.
analyses of the interaction of a number of different Intrinsic factors whose influence on the incidence
factors using discriminant analysis or logistic re- of sports injuries have been investigated include the
gression analysis. following.
 Sports injuries 141
':: ..<.:-; .
...... :::

Poor refereeing
'::': ..:.":' .:.. '. \:.: .. : .

Uneven playing area

.... :···;·.;.·.··f .:.':;:': : : ..

Bad weather
..': ::'.:.' ":. :.: .:: .... :.

Foul play a push

.;....,:.... ..... \

Poor footwear
:. :.' :: . ~:.. '., , :.... : '

Previous injury

Figure 4. Most sports injuries do not have a single cause. This diagram summarizes some of the factors that might
contribute to an ankle injury sustained during a soccer match. (Diagram modified from Watson7.) For example, poor
refereeing might increase the chances of foul play in the match. Other extrinsic factors that would lead to an increased
risk of injury include: an uneven playing surface, bad weather and poor footwear. Intrinsic factors increasing the risk
include: previous injury, a very tall or overweight player, poor preparation, poor endurance and previous damage to
the ligaments of the ankle joint.

Intrinsic risk factors for sports injuries studies suggest that moderately high levels of body
weight may be associated with an increased risk of
Physique
injury,23but the issue is not clear and may be sports-
There are a number of difficulties in attempting to specific. It is clear, however, that morbidly obese
relate the incidence of sports injuries to physique. individuals are at a greatly increased risk of back,
The first is the difficulty in quantifying physique? The hip, knee, ankle and foot pain, and of osteoarthritis.23
second is that individuals with particular physiques
tend to gravitate towards specific sports.7 Rugby
players and long-distance runners usually have very
Previous injury
different body shapes. They also tend to suffer from
different injuries but this is more likely to be at- Previous injury has been reported to be an important
tributable to the sports they play rather than to predictor of future injury in soccer,6 running,18,24
their physique. This makes it difficult to relate the American footba1l25and dance,26but apparently not
incidence of injury to body size and shape. There is in cyclingP This topic has received relatively little
some evidence that tall athletes may be at a slightly attention from researchers and it is not clear whether
increased risk of injury.7,18,19,20 Low levels of ec- the subsequent injuries are due to insufficient re-
tomorphfl and high levels of mesomorphy7,22may covery from the first injury or to intrinsic char-
also be equated with increased risk of injury. Some acteristics of the individual that predispose them to
142 A. W. S. Watson

injury. This is an important topic and one that de- Static balance and proprioception
serves the attention of physical therapists.
The ability to balance on one leg is reduced by ankle
injury and the deficit persists for several months.3D,31
It is not clear to what extent tests of static balance
Strength can be used to identify athletes who are at high
It is attractive, and logical, to deduce that high levels risk of injury; different researchers have obtained
of static strength and muscle development will sup- conflicting results. Balance is mediated via a variety
port joints and help to protect the athlete from in- of receptors: cutaneous, joint, muscle, visual and
jury-particularly from sprains. Strengthening of the vestibular. An excellent review of the topic has been
muscles that surround the knee joint is frequently provided in a previous issue of this journa1.32
advocated as a means of preventing knee sprains,
but I have been unable to find any prospective study
Fatigue
that demonstrates the effectiveness of this practice.
Following an injury, strength may deterioriate at a After two hours of skiing, the risk of injury apparently
rate of up to 5 percent per day7 so that thorough rises and is particularly high late in the day. This has
rehabilitation is essential if re-injury is to be avoided. been attributed to fatigue due to loss of muscle
glycogen.33Other sports do not seem to exhibit such
a clear relationship, perhaps because their duration
Dynamic strength and jumping ability is usually shorter. In basketball, injury-rates are lower
in the first quarter but then remain constant during
A small study of 72 female netball players found that the other three,34while in ice-hockey,35Gaelic foot-
individuals were more likely to have suffered an ball16and school sports14the incidence of injury ap-
injury if they had better jumping ability and higher pears to remain constant throughout the duration of
scores on a test of anaerobic power.21Similar results the activity.
have been obtained in Ireland and The Netherlands.7

Flexibility
Muscle balance Development of flexibility is often considered as one
Strength imbalances between the knee-flexors and of the most important measures for the prevention
knee-extensors are widely measured and reported. of sports injuries. It is logical to anticipate that im-
There are a number of methodological problems with proving flexibility through stretching will result in a
many of the published studies, some of which are lengthening of the muscle-tendon unit which, in
discussed in a review by Knapik et al.28 It seems tum, will reduce the likelihood of muscle strain
possible that many of the reported flexor-extensor during physical activity. The situation may be some-
imbalances may have, in fact, been due to left-right what more complex than at first supposed because
imbalances in strength. This is an area of interest both the muscle and its associated tendons contain
to physical therapists but one which has not been connective tissue which store energy when the muscle
effectively researched. There is a need for well-de- is stretched by the contraction of agonist muscle
signed and well-executed studies in this area: ones groups. Increasing flexibility will alter the dynamics
that take into account the characteristics and re- of the stretch-shorten cycle and this is likely to have
liability of the measurement procedures used.? unpredictable effects upon the athlete and his or her
susceptibility to injury.7Research that convincingly
links high levels of flexibility to a low-incidence of
injury is hard to find. Knapik et a128 reviews studies
Joint laxity
of the relationship between flexibility and injury.
The terms joint laxity and joint hyper-mobility are Many were poorly designed or analysed, or give
used somewhat loosely in the literature: both are insufficient information for the reader to carry out a
difficult to define and measure. It is logical to predict proper evaluation of the research. A few studies that
that lax joints would predispose the athlete to joint link the risk of injury to left-right flexibilityimbalance
injury but it is difficult to find recent prospective are more convincing. Walter et ap8 found that runners
studies which support this proposition. Recent stud- who sometimes stretched were at greater risk of
ies have failed to identify ligamentus laxity as pre- injury than those who usually or never stretched:
dictors of injury in female volleyball players21 and Jacobs and Berson36 found that injured runners
American college athletes.29 stretched before running as opposed to the non-
 Sports injuries 143

injured runners. Prospective studies on basket- Training

ballers,37hurlers38 and Gaelic footballers39 have all
It is popular to attribute running injuries to training
failed to link the incidence of sports injuries to meas-
errors such as excessive amounts of, or sudden in-
ures of flexibility, whilst at the same time producing
creases in, intensity and duration of training. Some
evidence of a link with defects of body mechanics:
authors have attributed 60 to 70% of running injuries
in dancers the level of flexibility was not found to
be linked to the incidence of injury.26The relationship to training errors (see Taunton45 for a summary). It
between flexibility and the incidence of injury is is difficult to be precise about what constitutes a
clearly more complex than is often supposed and training error and this is one of the difficulties in
there is a need for more, and better, work in this attempting to quantify their effects. Two large and
area. Texts that glibly recommend stretching as the well-designed prospective studies looked at running
cure for sports injuries need to be treated with con- injuries in relation to training.18,46It was found that
siderable caution. the incidence of injury was increased in competitive
(as opposed to recreational) runners, if the weekly
mileage exceeded 65 km, with the number of running
Posture and body mechanics days per week, and if the athlete ran all-the-year
The hypothesis that structural abnormalities are a risk round. None of these findings are particularly sur-
factor for running injuries is frequently advanced. prising. Factors such as the pace of running, the type
Surprisingly, there is little direct evidence of such a of running surface, hill-running and intense training
relationship in runners at present:24 there is better seemed to have no effect on the injury rate. Pre-sport
evidence in team-game players. Shambaugh et al37 training was found to be associated with a reduced
took nine different structural measures on basketball risk of overuse injury in cycling27but the information
players prior to the start of the season and found was obtained by questionnaire and the quantification
that individuals who suffered lower-extremity in- of training by such a method is notoriously difficult.
juries were more than one standard deviation above
the mean for non-injured players in: bilateral weight,
quadriceps girth, Q-angle, rear-foot valgus, and leg Warm-up
length measures. A logistic regression equation de-
Strickler et al47 found that rabbit tibialis anterior
veloped from the data was able to correctly predict
the injury status of 91.5%of the players. The equation muscle warmed to 39°C achieved a greater increase
contained the variables: weight difference, left Q in length before failing than similar muscle at 35°C.
angle, right Q angle. Rosenbaum and Hennig48 investigated the in-
In a study on top-level hurlers,38it was found that fluence of stretching and warm-up on the force-
lumbar lordosis was a predictor of hamstring strain, development in human triceps surae muscle. Stretch-
and Powers et al40 report that rear-foot posture is ing was found to reduce the peak force, suggesting
related to the incidence of patello-femoral pain. In a improved muscle compliance. After warm-up, the
two-year prospective study, Watson41examined the peak-force remained unchanged but the rise rate
relationship of 15 posture variables to the incidence increased. The increase in compliance might be ex-
of sports injury in a group of 52 footballers. He found pected to reduce the risk of muscle strain during
that four types of injuries-strains, back injuries, sport while the increase in rise rate could have the
ankle injuries and knee injuries were each associated opposite effect. Warm-up for sport is more complex
with particular posture defects, the most important than many people appreciate and many current
of which were defects of: ankle mechanics, lumbar warm-up practices are unlikely to be effective.? The
lordosis, back and shoulder symmetry and knee inter- topic is one in urgent need of some well-executed
space. Cowan et al42 have reported similar results in research.
army cadets. When predictions regarding the effects of warm-
up have been tested during training and competition
no clear effects have been demonstrated. Van Me-
Skill and experience
chelen et al49 carried out a well-designed randomized
There is some evidence that injury rates are higher control trial of the effects of 16 weeks of education,
in inexperienced athletes. Experienced skiers,43run- warm up and stretching on the incidence of injuries
ners24and cyclists27appear to be injured less often in runners. They found that the programme increased
and Jackson et al44 found Canadian footballers in their knowledge of warm-up and cool down in the ex-
first 2 years of play have 5.8 times the number of perimental group but that the number of injuries
injuries of more experienced players. remained unchanged.
144 A. W. S. Watson

Extrinsic risk factors for sports injuries Orthotics

Playing area furniture-goal posts and baseball Shock absorbing insoles significantly reduced over-
bases use injuries in military recruits.58
Orthotics have a place in injury prevention but are
Janda et al50 report that padding soccer goal posts
probably over-prescribed and there are unwanted
reduces the horizontal and vertical impact forces by
potential side effects. The prescription of orthotics
31 % and 63%, respectively. No injuries were recorded
based only on anatomical factors is controversial and
over a three-year period despite seven player-col-
it is prudent to encourage the patient with mis-
lisions with padded posts.
alignment to use appropriate footwear and an effect-
Janda51 reviews a series which shows that in the
ive training programme.59 Some of the interactions
game of baseball, substitution of plastic break-away
between shoes, orthotics and playing surfaces are
bases for fixed bases significantly reduced the in-
summarized in Fig. 5.
cidence of injuries.

Ankle taping
Surfaces
There has been much work on the effectiveness of
Hard surfaces are associated with an increased risk taping in reducing the incidence of ankle injuries and
of jumper's knee in volleyball players.52The incidence readers interested in the topic are referred to recent
of injury is also apparently higher on synthetic floors reviews on the subject.6o,61
It appears that the principle
than on those made of maple-wood that have some mechanism of ankle taping may be in the facilitation
elasticity (see ref 34 for a review). In tennis, the of proprioception.62 However, its effectiveness di-
frequency of pain and injuries was found to increase minishes rapidly due to stretching of the tape and
as below.53 reviewers tend to conclude that: (1) other methods
Clay<synthetic-sand <synthetic<asphalt<felt carpet of protecting the ankle from injury are more effective;
<synthetic-grill and (2) more research in this area is necessary.

Surface-related injured were higher on artificial

turf than on grass in American football, soccer and Ankle orthotics
field-hockey (NCCA data quoted in ref 53). Studies have shown that ankle orthoses limit joint
Possible links between surface type and gradient, motion/3 and others demonstrate a reduction in the
and the incidence of injury in runners is not clear: incidence of injury.64
various studies have come to different conclusions.24
Heidt et al54 have reported that mis-matches between
surface and shoe friction are a serious source of Knee supports-taping and prophylactic bracing
injury. The knee is frequently' supported and protected from
injury' by a number of means: elasticated taping,
bandages and prophylactic knee supports. The only
Shoes
demonstrated effect of taping is to restrict the range
Laboratory studies show that three-quarter top bas- of motion.65No research on the use of elasticbandages
ketball shoes can significantly increase the active could be found when preparing this review: and no
resistance to an inversion movement in moderate mechanical advantage in their use would be an-
ankle-plantar-flexion-equivalent to the early phase ticipated. In contrast, prophylactic knee braces have
of an ankle sprain. 55 received a lot of attention from researchers and a
In a randomized trial, 622 intramural basketball number of recent reviews are available. Pinkowski
players wore either low-top basketball shoes, high- and Pauolos60 quote seven studies: three obtained
top shoes or high-top shoes with inflatable air cham- favourable results with the use of braces, another
bers. It was concluded that there was no strong three report unfavourable results (more injuries) and
relationship between shoe type and the incidence of the final study found that the braces had no effect.
ankle sprains.56Barrett and Bilisko57review this and Moore and Frank33 review 16 studies of which 10
two earlier studies in which shoe height constituted a found that the braces were effective, five that they
variable. They conclude that although biomechanical were either harmful or ineffective and one concluded
studies have shown increased stability of the ankle that more work had to be done to address the prob-
in high-top shoes and boots, this has not translated lem. After looking at the individual studies it is clear
into a lower-rate of ankle sprains. that a multitude of uncontrolled variables exist that
 Sports injuries 145

SPORTS

SHOES

AND/OR

ORTHOTICS

WORN BY

THE

ATHLETE

Figure 5. Summary of some of the possible interactions between shoes, orthotics, playing surface and the athlete's
tissues. The top two rows summarize the effects of the shoe on the forces developed by the athlete. High levels of
friction between shoe and surface allow greater force to be developed but may increase the risk of ankle and knee
sprains. Very low levels of friction will increase the risk of injury due to slipping. Shock absorbing insoles limit the
vertical component of the force that the athlete can develop and may reduce the incidence of certain overuse injuries.
Orthotics and some types of shoe may enhance proprioception at the ankle joint: this may influence the incidence of
injury (middle row). The bottom two rows of the diagram illustrate that shoes and orthotics may also influence the
ability of the athlete's tissues to withstand force: by supporting the ankle and foot or by limiting the range of motion.

are capable of confounding the results, and that direct forces to another part of the subject's body
widely different definitions of injury have been used. such as the cervical spine, or produce changes in
Biomechanical studies cast doubt on the mechanical the game which bring other dangers. In American
protection that knee braces provide.66-68Both the football, the introduction of helmets reduced inter-
present author and previous reviewers conclude that cranial haemorrhages by 66% and cranio-cerebral
more research is necessary in order to establish the deaths by 42%, while over the same period the rate
true role of knee braces. of spinal injuries increased by 204%and the incidence
of quadriplegia increased by 116%.72 A similar in-
crease in ice-hockey neck injuries occurred in Canada
Helmets
when helmets were first introduced there.73 Because
This is one of the better researched areas of injury the introduction of helmets may result in alterations
prevention and considerable information is available in play and the redirection of forces, laboratory tests
on helmet design (see ref 69 for a summary). Properly of helmet function may not be a good predictor of
designed helmets have been shown to reduce the the protection offered when used in a particular
incidence of head injury in American football,69ice sport.74
hockey70 and bicycling.71 However, a helmet may re- The above shows how difficult the design and
146 A. W. S. Watson

prescription of protective equipment is and what in another 25%.14 Other research has shown
pitfalls there are. Some helmets, and other protective inexperience of an activity to be an injury risk fac-
devices used in this country, have been introduced tor.24,27,43,44
These results indicate the importance of a
without any kind of research and are of very doubtful high standard of supervision, particularly of young
value. Before recommending any piece of protective athletes. The supervisor's legal duty of care is also
equipment, the prudent professional will protect higher when the participants are children.3
themselves from possible litigation by looking for
high quality research that justifies its use. Injury prevention programmes
In order to be effective, injury prevention pro-
Rule changes
grammes need to operate at (at least) three levels
One of the advantages of properly conducted epi- simultaneously:
demiological research is to identify situations where
the incidence of injury is high. Rule changes can then • personal level-e.g. personal screening, examination,
be made to make the sport safer. This has been done risk analysis and advice for the individual athlete;
in a number of sports including American foot-
• sport or group level-e.g. rule changes, educational
ball, ice hockey and gymnastics and has been shown programmes, research;
to be effective in reducing the number of sports
injuries.72,73,75 • national level-e.g. societal planning, legislation,
investment, research (Kannus23).

Foul or illegal play

Few specific studies on the effectiveness of injury
Illegal play is one of the major causes of injury in prevention programmes have been carried out. Ett-
contact sports. It is reported to account for 29% of linger et a182 claim to have achieved a 62% reduction
school injuries,14as much as 62% of school football in serious knee sprains in a group of ski patrollers
injuries,1640% of senior hurling injuries,7624.5% of and instructors as a result of a training programme
intercollegiate ice hockey injuries35and 30% of senior that covered the following: avoiding high risk be-
soccer injuries.6Jones77states that the main preventive haviour, recognizing potentially dangerous situ-
measure to be addressed in the prevention of orbital ations, and responding quickly and effectively. This
blowout fractures is a reduction in aggressive play trial had a control group but was not randomized
or deliberate injury. and is open to different interpretations. Ekstrand and
Gillquist also report success in the prevention of
Match or practice soccer injuries.5,6Their reports are lacking in detail
and now seem dated. Inklaar83 considers that 'se-
Some examples of match and practice injury rates
lection bias should be considered in the interpretation
from the literature are listed in Table 3 below. It is
of these results.'
clear that in most team games the injury rate during
Van Mechelen et a149 carried out a well-designed
matches far exceeds that during practices. Thus injury
randomized control trial of the effects of 16 weeks
prevention measures should thus be directed par-
of education, warm up and stretching on the in-
ticularly at the match situation.
cidence of injuries in runners. They found that the
Table 3. Injury rates per 10,000 hours of matches and programme increased the knowledge of warm-up
practice in selected sports and cool down of the experimental group but that
Sport Practice Match Ref the number of injuries remained unchanged. In a
study of an injury prevention programme on school
American football 40 355 NCAA78 children Backx84obtained broadly similar results-
Basketball 10 230 Backx et aF9
increases in knowledge but no reduction in the actual
Ice hockey 14 784 Lorentzon et al80
Soccer 5.1-7.6 130-240 Larson et al81 number of injuries.
Hurling 44 370 Watson76 It is apparent that increases in knowledge do not
Gaelic football 31 176 Watson16 directly equate with a reduction in sports injuries.
Other steps that seem to be necessary in a successful
injury prevention programme are summarized
above.
Supervision
A useful account of the principle of health edu-
In school sport, reckless behaviour was found to be cation as it applies to the prevention of sports injuries
the major cause in 28% of injuries and a minor one is provided by Damoiseaux and Kok.85
 Sports injuries 147

STEPS IN AN INJURY PREVENTION PROGRAMME

MAINTENANCE OF BEHAVIOUR
CHANGE
~ ~~~~

~ 1 C.HA,.N.G.E_IN.B.E.H.AIIIIIIIIIlV.IO.U.R •• 1
~ 1 I
CIIIIIIIIIlHIIIIIIIIIlA.N.G.EIIIIIIIIIlIIlllllllllN.A.TT_ITIIIIIIIIIlU.D.E.TIIIIIIIIIlO.IIIIIIIIIIlNJ.U.RIIIIIIIIIlIE

KNOWLEDGE OF INJURY PREVENTION MEASURES

KNOWLEDGE OF THE PROBLEM OF SPORTS INJURIES

Figure 6. Steps necessary for an injury-prevention intervention to achieve long-term success. (Diagram modified from
Watson7.) Putting up a poster or giving the athlete a list of exercises is unlikely to constitute a successful injury
prevention programme. In addition to providing information on injury prevention measures, it is necesssary to produce,
and maintain, changes in the attitudes and behaviour of athletes, coaches and officials.

Sport and position review87,88also deal with the incidence of injuries in

different sports.
In a study of Dutch children,79 it was found that
sports-related factors were much more important
predictors of injury than personal factors. High-risk
sports were characterized by body-contact, jumping Concluding section
and being based outdoors; these three factors ac-
counted for 78% of the variance in incidence, contact In a recent review of soccer injuries, Inklaar83 con-
being the most important. In intercollegiate ice cludes 'Generally, the epidemiological information
hockey, 97% of the injuries appear to involve some on the sport medical aspects of soccer injuries appears
kind of contact.35 Contact and jumping are also to be inconsistent and far from complete. The aeti-
important risk factors in Gaelic football and ology of soccer injuries may differ between different
hurling. 16,76 subgroups of the soccer population. As a con-
The sport undertaken by the athlete is likely to be sequence, different subgroups of soccer players may
the single most important factor in determining both need different prophylactic programmes to achieve
the incidence and the nature of the injuries sustained. a major reduction in incidence and severity of soccer
Caine et al have produced a 450-page account of injuries'.
injuries in 24 different activities.86It is unfortunately The above sentiment is also likely to apply to other
trans-Atlantic in outlook (rodeo receives seven pages sports and to other groups of athletes. The literature
while rugby is not mentioned at all), but it is a useful on sports injuries is indeed far from complete, but
starting point none the less. Two other texts on sports the information published so far suggests that there
injuries that have been extensively quoted in this may be no universal principles concerning the causes
148 A. W. S. Watson

WARM UP

PERSONAL
EQUIPMENT
~1f
·~l.:
;".' FIXED EQUIPMENT
"::::::' .
.:.:'
ATTITUDE OF
OPPONENTS

FOUL PLAY

Figure 7. Summary of intrinsic and extrinsic factors postulated to have an influence on the incidence and seriousness
of sports injuries. An individual factor can either (1) influence the force developed and applied to the athlete's tissues
or (2) influence the ability of the athlete's tissues to withstand an applied force. The influence of individual factors is
discussed in the text of this review.

and prevention of sports injuries. Different sports- the case, future research should become more highly
even different events or playing positions within a focused on specific groups of athletes and particular
particular sport-make different demands upon the types of individual.
human body. The response of the individual to these
stresses is likely to be mediated by a large number
of factors which will differ from individual to in- Conclusions
dividual. They include: age gender, physique, pre-
vious injury, medical factors, body mechanics, levels 1. The literature concurs with the view that health
of the various components of physical fitness, ex- care professionals should be as concerned with
perience of the sport and skill levels. A large number the prevention of sports injuries as much as with
of extrinsic factors will also influence the risk of their treatment. A sound knowledge of the in-
injury. The more important factors mediating the cidence, causes and principles of prevention is
risk of injury that have so far been investigated or obviously necessary in order to fulfil this function.
proposed are summarized in Fig. 7. 2. Many of the earlier papers on the incidence of
My personal interpretation of the literature on the sports injuries were poorly designed and provided
causes and prevention of sports injuries is that it misleading information. A number of well de-
suggests that there are no universal principles. Each signed studies are now available and, although
sub-group of the athletic population is likely to have more research is necessary, a picture of which
its own distinct risk-profile. If this turns out to be sports injuries are most common is emerging.
 Sports injuries 149

3. Sports injury research has tended to be conducted 3 Koehler RN. Law Sport activity and Risk Management.
from the prospective of the healthcare pro- Champaign Illinois, Stipes, 1991
4 Schafle MD, Requa RK, Patton WL et al. Injuries in the
fessional. Future research needs to take a greater 1987 national volleyball tournament. Am J Sports Med
account of the effects of injury on the athlete: 1990; 19: 624-3l.
disruption to training and competition and de- 5 Ekstrand J & Gilquist J. The frequency of muscle
gradation in performance need to be considered. tightness and muscle injuries in soccer players. Am J
4. The literature on the causes of sports injuries Sports Med 1982; 10: 75-8
6 Ekstrand J & Gilquist J. The avoidability of soccer
is generally unsatisfactory. A few well-designed injuries. Int J Sports Med 1983; 4: 124-8
studies on the intrinsic causes of particular injuries *7 Watson AWS. Physical Fitness and Athletic Performance
exist. But studies on extrinsic causes often rely (second edition). London: Addison, Wesley, Longman,
on the opinions of the injured athletes and their 1995
coaches. There is a need for objective studies on *8 Watson AWS. Sports Injuries in Ireland: an analysis of
four different types of sport. Am J Sports Med 1993; 21:
the causes of sports injuries and acknowledgement 137-43
of the fact that many injuries have multiple causes. 9 McLennan JG & McLennan JE. Injury patterns in
5. The majority of papers on sports injuries append Scottish heavy athletes. Am J Sports Med 1990; 18:
statements on prevention. These usually advocate 529-32
the attenuation of factors that have been identified 10 Requa RK & Garrick JG. Adult recreation fitness. In:
Caine DJ, Caine CG & Linder J (eds) Epidemiology of
(oftenon flimsy evidence)as causes.Few researchers Sports Injuries. Champaign, Illinois: Human Kinetics,
have investigated the effectsof such advice on injury 1996
rates using properly designed empirical studies. 11 Mueller FO & Cantu RC Catastrophic injuries and
Where this has been done, a reduction in injury rate fatalities in high school and college sports, fall 1982
has seldom been demonstrated. to spring 1988. Med Sci Sports Exerc 1990; 22: 737-41
12 Van Mechelen W. Incidence and severity of sports
injuries. In: Renstom PAFH (ed) Clinical Practice of
The present literature on sports IDJuries clearly Sports Injury Prevention and Care. Oxford: Blackwell,
leaves considerable scope for further investigation. 1994
There is room for more research on the epidemiology 13 Nicholl JP, Coleman P & Williams BT.Injuries in Sport
of sports injuries; in particular, the magnitude of and Exercise. London: Sports Council, 1991
their effects on athletes needs to be quantified. Re- 14 Watson AWS. Sports injuries in one academic year in
6799 children. Am J Sports Med 1984; 12: 65-7
search into the causes of injuries is still at a very 15 Stokes MA, McKeever JA, McQuillan RF et al. A season
basic stage and needs to be considerably developed. of football injuries. Ir J Med Sci 1994; 163: 290-3
It should employ rigorous empirical methods and be 16 Watson AWS. Sports injuries in school Gaelic football:
focused on a small, carefully identified section of a study over one season. Ir J Med Sci 1996; 165: 12-6
the athletic population. Advice on injury prevention *17 Bland M. An introduction to Medical Statistics (second
edition). Oxford: Oxford Medical Publication, 1995
should be based on empirical research into the es- 18 Walter SD, Hart LE, McIntosh JM et al. The Ontario
tablished causes. The effectiveness of such advice cohort study of running-related injuries. Arch Int Med
then needs to be tested using properly designed 1989; 149:2561-4
controlled-trial studies. 19 Taimela S, Kujala UM & Osterman K. Intrinsic risk
Physical therapists have an important role to play factors and intrinsic injuries. Sports Med 1990; 9: 205-15
20 Watson AWS. Factors predisposing to sports injuries
in injury prevention. At the moment they should in schoolboy rugby players. J Sports Med Phys Fitness
exercise considerable caution in the advice that they 1981; 21: 417-22
offer on injury prevention. They should do all they 21 Hopper DM, Hopper JL & Elliott BC Do selected
can to encourage the collection of data that is soundly kinathropmetric performance variables predict injuries
based and can be relied upon. in female netball players? J Sports Sci 1995; 13: 213-22
22 Steel VA & White JA. Injury prediction in female
gymnasts. Br J Sports Med 1986; 20: 31-3
23 Kannus P. Types of injury prevention. In: Renstrom
References PAFH (ed.) Sports Injuries. Oxford: Blackwell, 1993
24 Van Mechelen W. Injuries in running. In: Renstrom
1 Altman DG. Practical Statistics for Medical Research. PAFH, Clinical Practice of Sports Injury Prevention and
London: Chapman and Hall, 1991 Care. Oxford: Blackwell, 1995
2 Hart 1. Guidelines for evaluating future research in 25 Muller F, Zemper ED & Peters A. American football.
the epidemiology of sports injuries. In: Caine DL, In: Caine DL, Caine CG & Lindner KJ (ed) Epidemiology
Caine CG, Lindner KJ (eds) Epidemiology of Sports of Sports Injuries. Champaign Illinois: Human Kinetics,
Injuries. Champaign, Illinois: Human Kinetics, 1991 1995
26 Wiesler ER, Hunter DM, Martin DF et al. Ankle
flexibility and injury patterns in dancers. Am J Sports
Med 1996; 24: 754-7
The most important references are denoted with an asterisk. 27 Dannenberg AL, Needle S, Mullady D et al. Predictors
150 A. W. S. Watson

of injury among 1638 riders in a recreational long- 48 Rosenbaum D & Henning EM. The influence of
distance bicycle tour. Am J Sports Med 1996; 24: 747-53 stretching and warm-up on Achilles tendon reflex
28 Knapik H, Jones BH, Bauman CL et al. Strength, activity. J Sports Sci 1995; 13: 481-90
flexibility and athletic injuries. Sports Med 1992; 14: 49 Van Mechelen W, Hlobil H, Kemper HCG et al.
277-88 Prevention of running injuries by warm-up, cool-
29 Baumhauer JF, Alosa DM, Renstrom FH et al. A down, and stretching exercises. Am J Sports Med 1993;
prospective study of ankle injury risk factors. Am J 121: 711-9
Sports Med 1995; 23: 564-70 50 Janda DH, Bir C, Wild B et al. Goal posts in soccer.
30 Goldie PA, Evan OM & Bach TM. Postural control Am J Sports Med 1995; 23: 340--4
following inversion injuries of the ankle. Arch Phys 51 Janda DH. Injuries in baseball and softball: a study of
Med Rehab 1995 75: 969-75 preventive measures. In: Renstom PAFH (ed.) Clinical
31 Zaetterstroem R, Friden T, Lindstrand A et al. The Practice of Sports Injury Prevention and Care. Oxford:
effect of physiotherapy on standing balance in chronic Blackwell, 1994
anterior cruciate ligament insufficiency. Am J Sports 52 Ferretti A, Paddu G, Mariani PP et al. Jumper's knee: an
Med 1994; 22: 531-6 epidemiological study of volleyball players. Physician
*32 Waddington GS, Shepherd RB. Ankle injury in sports: Sports Med 1984; 12: 97-106
role of motor control systems and implications for 53 Nigg BM. Excessive loads and sports-injury
prevention and rehabilitation. Phys Ther Rev 1996; 1: mechanisms. In: Renstrom PAFH (ed) Sports Injuries.
79-87 Oxford: Blackwell, 1993
*33 More KW & Frank CB. Traumatic knee injuries. In: 54 Heidt RS, Dormer SG & Cawley PW. Differences in
Renstom PAFH (ed.) Clinical Practice of Sports Injury frictional and torsional resistance in athletic shoe-turf
Prevention and Care. Oxford: Blackwell, 1995 surface interfaces. Am J Sports Med 1996; 24: 834--42
34 Minkoff J, Simonson BG, Sherman OH et al. Injuries 55 Ottaviani RA, Ashton-Miller HA, Kothan SU et al.
in basketball. In: Renstom PAFH (ed.) Clinical Practice Basketball shoe height and the maximum, muscular
of Sports Injury Prevention and Care Oxford: Blackwell, resistance to applied ankle inversion and eversion
1994 movements. Am J Sports Med 1995; 23: 418-23
35 Pelletier RL, Montelpare WJ & Stark RM. 56 Barrett J, Tanji J, Drake C et al. High- versus low-top
Intercollegiate ice hockey injuries. Am J Sports Med shoes for the prevention of ankle sprains in basketball
1993; 21: 78-81 players. Am J Sports Med 1993; 21: 582-5
36 Jacobs SJ & Berson BL. Injuries to runners: a study of 57 Barrett J & BiliskoT.The role of shoes in the prevention
entrants to a 10,000 metre race. Am J Sports Med 1986; of ankle sprains. Sports Med 1995; 20: 277-80
14: 151-5 58 Schwellnus MP, Jordan G & Noakes TD. Prevention of
37 Shambaugh JP, Klein A & Herbert JH. Structural common overuse injuries by the use of shock absorbing
measures as predictors of injury in basketball players. insoles. Am J Sports Med 1990; 18: 636--41
Med Sci Sports Exerc 1991; 23: 522-7 59 Craton N & McKenzie DC. Orthotics in injury
38 Hennessy L & Watson AWS. Flexibility and posture prevention. In: Renstrom PAFH (ed) Sports Injuries
assessment in relation to hamstring injury. Br J Sports Oxford: Blackwell, 1993
Med 1993; 27: 243-6 60 Pinkowski JL & Paulos LE. Prophylactic knee and
39 Watson AWS & Hennessy L. Days of injury related to ankle orthoses. In: Renstrom PAFH (ed.) Sports Injuries
measures of flexibility and body mechanics in top- Oxford: Blackwell, 1993
level players of Gaelic football. J Strength Conditioning 61 Barnes RA & Smyth PD. The role of footwear in
Res (in press) minimising lower limb injury. J Sports Sci 1994; 12:
40 Powers CM, Maffucci R & Hampton S. Rearfoot 341-53
posture in subjects with patello-femoral pain. J Orth 62 Robbins S, Waked E & Rappel R. Ankle taping
Sports Phys Ther 1995; 22: 155-60 improves proprioception before and after exercise in
41 Watson AWS. Sports injuries in footballers related to young men. Br J Sports Med 1995 29: 243-7
defects of posture and body mechanics. J Sports Med 63 Lofvenberg R & Karrholm J. The influence of an ankle
Phys Fitness 1995; 35: 289-94 orthosis on the talar and calcaneal motions in chronic
42 Cowan DN, Jones BH, Frykman PN et al. Lower limb lateral instability of the ankle. Am J Sports Med 1993;
morphology and risk of overuse injury among male 21: 224-30
infantry trainess. Am J Sports Med 1996; 24: 945-52 64 Sitler M, Ryan J & Wheeler B.The efficacyof a semirigid
43 Johnson RJ, Ettlinger CF & Campbell JR. Trends in ankle stabilizer to reduce acute ankle injuries in
skiing injuries. Am J Sports Medicine 1980; : 106-13 basketball: a randomised clinical study at West Point.
44 Jackson RW, Reed SE & Dunbar F. An evaluation of Am J Sports Med 1994; 22: 454-61
knee injuries in a professional football team-risk 65 McLean DA. Use of adhesive taping in sport. Br Sports
factors, type of injury and the value of prophylactic Med 1989; 23: 147-9
bracing. Clin J Sports Med 1991; 1: 1-7 66 Baker BE, Van Hanswyk E, Bogosian SP et al. A
45 Taunton JE. Training errors. In: Renstom PAFH (ed) biomechanical study of the static stabilizing effect of
Clinical Practice of Sports Injury Prevention and Care. knee braces on medial stability. Am J Sports Med 1987;
Oxford: Blackwell, 1994 15: 566-70
46 Macera CA, Pata RR, Powell KE et al. Predicting lower- 67 Baker BE, Van Hanswyk E, Bogosian SP et al. The
extremity injuries amongst habitual runners. Arch Int effect of knee braces on lateral impact loading of the
Med 1990; 18: 141--4 knee. Am J Sports Med 1989; 17: 182-6
47 Strickler T,Malone T,Garrett WE. The effects of passive 68 Erikson A, Yasuda K, Beynnon B et al. A dynamic
warming on muscle injury. Am J Sports Med 1990; 18 evaluation of the effectiveness of prophylactic knee
141-5 braces. Trans Orthop Soc 37th Annu Meet 1991; 1: 186
 Sports injuries 151

69 Van Mechelen W. Head injuries. In: Renstom PAFH risk persons and high-risk sports: a longitudinal study
(ed.) Clinical practice of Sports Injury Prevention and of 1818 children. Am J Sports Med 1991; 19: 124-30
Care. Oxford: Blackwell, 1994 80 Lorentzon R, Wedren H, Pietila T et al. Injuries in
70 Montelpare WJ, Pelletier RL & Stark RM. Ice hockey. international ice hockey. Am J Sports Med 1988; 16:
In: Caine DJ, Caine CG & Lindner KJ (ed) Epidemiology 389-91
of Sports Injuries Champaign, Illinois: Human Kinetics, 81 Larson M, Pearl AJ, Jaffet R & Rudawsky A. Soccer.
1986 In: Caine DL, Caine CG, Linder KJ (eds) Epidemiology
71 Wasserman RC & Buccini RY. Helmet protection from of sports injuries Champaign Illinois: Human Kinetics,
head injuries among recreational cyclists. Am J Sports 1996.
Med 1990; 18: 96-7 82 Ettlinger CF, Johnson RJ & Shealy JE. A method to
72 Torg JS. Cervical spine injuries in American football. help reduce the risk of serious knee sprains incurred
In: Renstom PAFH (ed.) Clinical Practice of Sports Injury in alpine skiing. Am J Sports Med 1995; 23: 531-7
Prevention and Care. Oxford: Blackwell, 1994 83 Inklaar H. Soccer injuries. Part II: aetiology and
73 Micheli LJ & Lynch M. Spinal injuries. In: Renstom prevention. Sports Med (Auckland, N.Z.) 1994; 18:
PAFH Clinical Practice of Sports Injury Prevention and 81-93
Care. Oxford: Blackwell, 1994 84 Backx FJG. Sports Injuries in Youth: Etiology and
74 Bishop PJ & Wells RP. The inappropriateness of helmet Prevention. Papendaal: Nationaal Instituut voor de
drop tests in assessing neck protection in head-first Sportgezondheidszorg, 1955
impacts. Am J Sports Med 1990; 18: 201-5 85 Damoiseaux V & Kok G. Principles of health education.
75 La Prade RF, Burnett OM, Zarzour R et al. The effects In: Renstrom PAFH (ed.) Sports Injuries. Oxford:
of the mandatory use of face masks on facial lacerations Blackwell, 1993
and head and neck injuries in ice hockey. Am J Sports *86 Caine DJ, Caine CG & Linder J. Epidemiology of Sports
Med 1995; 23: 773-5 Injuries. Champaign, Illinois: Human Kinetics, 1996
76 Watson AWS. Sports injuries in the game of hurling. *87 Renstrom PAFH (ed.) Sports Injuries: Basic Principles of
Am J Sports Med 1996; 24: 323-8 Prevention and Care. Oxford: Blackwell, 1993
77 Jones NP. Orbital blowout fractures in sport. Br J Sports *88 Renstrom PAFH (ed.) Clinical Practice of Sports Injury
Med 1994; 28: 272-5 Prevention and Care. Oxford: Blackwell, 1994
78 NCCA. Injury Surveillance System: Football. Overland 89 Tenvergert TEM, Ten Duis HJ & Klasen HJ. Trends in
Park KS: National Collegiate Athletic Association, 1990 sports injuries 1982-88. J Sports Med Phys Fitness 1992;
76 Backx FJG, Beijer HJM, Bol E et al. Injuries in high- 21: 214-20