Medscape Orthopedics
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New Study Finds Link Between Injury Prevention and Winning
Bert R. Mandelbaum, MD, DHL (Hon)
November 19, 2015
You Can't Win With an Injured Team
Injury prevention works.
A study my colleagues and I published this month in the
American Journal of Sports Medicine shows that the Fédération Internationale de Football Association
(FIFA) 11+ warm-up program can cut injuries—not just knee or ankle
injuries but all injuries—by about half.[1] It can cut missed days by one third.
Moreover, from unpublished data, presented in this column for the first
time, we know that teams using this program win more games.
What coach wouldn't want to put a program like this in place? As it
turns out, most of them. Coaches across the country are shirking their
responsibilities.
For this study, we wrote to every National Collegiate Athletic Association
(NCAA) Division I and II men's soccer team to solicit their participation.
We emailed them. We called them. We told them we had strong evidence already
that the program was working in women and that the preliminary evidence
in men was extremely positive as well.
Tepid Response From Coaches
I had a lot of those conversations myself, and the responses broke down
into three categories:
- "Thank you for calling. We're using the program. It's the
best in the world."
- "I don't know what you're talking about. We have a short season.
I don't have time."
- "Let me get our trainer to call you."
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The trainers seldom called. In the end, only one in six teams took the
opportunity we were offering.
A Game-Changing Program
To understand what the opportunity is, we need a little context: Back in
the 1990s, many of us who practice sports medicine began noticing a spike
in the rate of knee injuries. The injuries seen in my practice went from
80% male to 80% female as a surge of girls began playing competitive sports—and
blowing out their anterior cruciate ligaments (ACLs) at a shocking rate.
The number of ACL injuries more than tripled in NCAA soccer players from
1990 to 2000.[2]
I and other researchers from around the world watched many hours of video
to determine how these injuries were happening. Again and again, we documented
that they were most likely to take place when knees are in dynamic valgus
alignment.[3]
In force-plate studies, we confirmed that a stiff valgus landing delivers
more force to the joint.[3]
The problem was most striking in adolescent female soccer players, but
we have also observed it in males playing basketball, team handball, and
American football.[4]
In addition, there is evidence that athletes whose hamstrings are relatively
weak in relation to their quadriceps are also more likely to sustain ACL injuries.[5]
From these observations, we developed programs to strengthen the relevant
muscles, teach athletes better movement techniques, and improve proprioception.
After years of testing, these efforts culminated in the FIFA 11+ warm-up
program. The just-published study on its effectiveness mentioned earlier
is only the latest validation of the program. The program has proved itself
not only in boys' and girls' soccer but in basketball as well.[6] I believe that the same program could help athletes in just about any
sport where knee injuries are a problem.
And not only injuries to knees. In the new study, we were able to show
a reduction in injuries to almost every body part—including the
head, wrist, and hand.[1]
Why Adoption Has Been Slow
We've been sharing such results from our previous studies for years.
Our group has won NCAA awards. We have published articles and books. But
we still have failed to convey our points about players' safety to
a great many coaches. Why aren't teams eagerly embracing this approach?
There appear to be several reasons. Many teams don't have medical staff.
Recreational teams often have no access even to a professional trainer.
That means that everything falls on the coach. Coaches feel intense pressure
to satisfy their constituents—athletic directors, parents, alumni,
and fans—who too often think only of winning. For too many coaches,
winning means a tunnel-vision focus on strategy and skills.
If coaches had to choose between preventing injuries and winning games,
I'd still argue that safety should come first. What most young athletes
learn about how to tackle, throw, or run in team competition won't
matter a few years from now when high school and college are behind them.
But knowledge of fitness and safety will serve them for a lifetime.
But we now know that programs like the FIFA 11+ meet both goals. Analyzing
the win/loss ratio, our research group—led by physical therapist
Holly Silvers-Granelli at the University of Delaware—found that
NCAA Division I teams using the FIFA 11+ program had an average record
of 9.86 wins, 5.71 losses, and 2.43 ties, while the control teams had
an average record of 7.6 wins, 8.48 losses, and 2.57 ties (Silvers-Granelli
H, Mandelbaum B, Adeniji O, et al, unpublished data, 2015). The difference
in wins and losses was statistically significant, and when we looked at
Division II teams, we found a similar pattern.
Recommendations for Coaches
Of course, safety goes far beyond the FIFA 11+ program. At FIFA, we're
trying to raise awareness about coaches' responsibilities by disseminating
a number of key points. We recommend that coaches:
- Coordinate with physicians, trainers, biomechanists, nutritionists, and
other experts to acquire and implement the best safety and performance
information available;
- Maintain constant and complete communication with the medical team;
- Insist on electrocardiogram screening before athletic participation to
ensure that all team members have healthy hearts;
- Obtain baseline psychoneurologic data on team members by using instruments
that I discussed in a previous column, such as the ImPACT® and King-Devick
tests for diagnosing concussion or the Sports Concussion Assessment Tool (SCAT 3);
- Use an evidence-based program like FIFA 11+ to strengthen and train athletes
to avoid injury;
- Teach players about healthy food choices;
- Be aware of the limits to training imposed by the climate in which players
train and offer them ample opportunity for hydration;
- Teach players how to play hard without hurting each other;
- Be aware that players' needs will vary depending on their level of
fitness, age, body mass index, the nature of the sport in which they're
participating, and the climate in which competition occurs;
- Honor the gradual steps by which players can return to sports after injuries; and
- Insist that players avoid the nonmedical use of performance-enhancing and
other drugs.
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Injury Prevention: A Licensing Requirement?
Many coaches will shake their heads when they see this list. I might have
had the same reaction when I was the lacrosse coach at Johns Hopkins University.
Whatever you read about the outsized salaries of a handful of elite coaches,
most do their essential work for too little compensation.
As a society, we don't value our coaches and other teachers enough.
I'd like to see injury prevention included in licensing requirements—and
higher pay for those coaches who obtain the licenses.
Many families can afford to chip in—say, $100 each—for a program
like FIFA 11+. Philanthropists or public health programs could also lend
financial support.
The investment would pay off on many levels. If we can create safe, competitive
sports opportunities for disadvantaged kids, with coaching that addresses
issues of health and character, such kids will be less likely to join
gangs, have children before they are ready, or become addicted to drugs.
They will be more likely to build balanced lives.
In addition to creating financial incentives for coaches, we need our opinion
leaders to speak out. We must implore the Surgeon General, sports celebrities,
and physician celebrities like Dr Oz to provide practical, evidence-based
information on preventing sports injuries.
As sports physicians, let's all begin by reaching out to the coaches
in our orbits and by taking every opportunity to speak in public about
the powerful opportunities available to protect and instruct young athletes.
With these kinds of initiatives, I believe that we will see a dramatic
reduction in the rate of injuries in every sport.