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Prevention of severe knee injuries in men’s elite football by implementing specific training modules

  • Werner KrutschEmail author
  • Jennifer Lehmann
  • Petra Jansen
  • Peter Angele
  • Birgit Fellner
  • Leonard Achenbach
  • Volker Krutsch
  • Michael Nerlich
  • Volker Alt
  • Oliver Loose
KNEE

Abstract

Purpose

Injury prevention of knee injuries by means of training and warm-up exercises has been investigated in several studies in amateur football. However, the number of investigations in elite football is limited despite the currently higher injury incidence of severe knee injuries. Therefore, the purpose of this study was to investigate whether specifically adapted preventive training modules may reduce severe knee injuries in elite football.

Methods

In a prospective controlled cohort study of elite football players in Germany, an injury prevention programme with 5 modules was implemented in the season of 2015–2016. The training modules were specifically adapted to this skill level and based on scientific evidence, team coach preferences, and the specific environment of this playing level. Of the 62 teams taking part in this study, 26 used the new trainings modules and 36 continued their standard programme as a control group. Success of the programme was documented by means of an injury report over one season. The primary outcome was reduction in severe knee injuries.

Results

A pre-seasonal investigation had identified five modules to be implemented in the training routine. Postural stability, mobilisation of lower extremity joints, leg and trunk stabilisation, jumping, and landing exercises as well as agility movements were incorporated into the programme to prevent severe knee injuries in elite football. Over the season, the study group (529 players) with the adapted training modules had sustained 52 severe knee injuries (incidence: 0.38 per 1000 h football exposure; prevalence: 9.8%) compared to 108 severe knee injuries in the control group (601 players) using the standard programme (incidence: 0.68 per 1000 h football exposure; prevalence: 18.0%; p < 0.05). The overall injury incidence for any other type of injury was comparable between the two groups (3.3 vs. 3.4 in h 1000 football, n.s.).

Conclusion

Appropriate preventive training modules reduce severe knee injuries in elite football significantly. The key for the sustainability of preventive training measures are programmes specifically adapted to the demands of the playing level and to the preferences of the coaches

Level of evidence

II.

Keywords

Injury Knee ACL Soccer Prevention Training 

Introduction

Severe knee injuries such as ACL ruptures or meniscus lesions are a common problem in football [30] that frequently leads to time-loss with long absence [10]. Severe knee injuries are defined by the duration of absence from football. These injuries not only have short-term or mid-term effects, for instance, loss of the preinjury performance level [22], but may also result in long-term consequences such as early osteoarthritis of the knee joint [39, 41].

Injury prevention has become a major subject in football over the past few years [6, 16, 24, 31, 36, 40]. The success of injury prevention exercises, particularly to prevent knee injuries, has been published several times [4, 25, 33]. Beside training and warm-up programmes for preventing general injuries [4, 38], specific programmes for the prevention of knee injuries have been published for various types of sports [1]. Particularly injury mechanisms of and risk factors for severe knee injuries have been identified, which has resulted in the consequent development of specific exercises and neuromuscular interventions [25]. Key aims of intervention programmes for preventing severe knee injuries are knee adduction in the form of ‘functional valgus’, ‘leg dominance’ of the preferred kicking leg, ‘ligament dominance’ with insufficiency of the knee-stabilising ligaments, and insufficiency of hamstring muscles with consecutive domination of quadriceps [1, 25, 33].

Most successful injury prevention programmes have an injury-reducing effect, which is measured by epidemiological injury statistics and by comparing the results of specific prevention programmes with those of standard training programmes of control groups [4, 16, 33]. Nearly, all studies investigated the effect of injury prevention programmes in amateur football populations such as junior football, women’s football and recreational football [4, 5, 12, 13, 36, 37]. However, hardly, any scientific research on this topic has been published with regard to elite football. One important difference between elite and amateur football from the scientific point of view is the respective basic standard training programme, which served as control in this study. Such basic programmes are traditionally of less intensive and of lower quality in amateur football than in professional football. In addition, insufficient team compliance and time pressure in training sessions are reasons for the lack of preventive programmes in elite football. Because of the high incidence of severe knee injuries in elite football [10, 30], training programmes for preventing knee injuries are urgently required and thus the topic of this study. The purpose of this study was to quantify the incidence of severe knee injuries in elite football over one season by comparing the injury incidence between the implementation of training modules and standard training programmes for the prevention of knee injuries. The hypothesis was that players with access to targeted training modules have a lower incidence of severe knee injury. Thus, training modules were implemented which had been specifically adapted to the playing level according to the evidence found in the literature as well as to team coach preferences and the specific setting of elite football.

Materials and methods

Study population and design

This study is part of a large cohort study to investigate football-specific strategies in national elite football, which includes a sub-project of implementing an injury prevention programme for severe knee injuries. The study was approved by the Ethics Committee of the University of Regensburg (Number: 15-101-0137). Study participants were men’s elite football teams from Bavaria in Germany. The invitation to participate in this study was sent to all teams of the 4th to 7th league and to the highest junior levels with salaried players. The elite football level represents a specific semi-professional football level below the three professional football leagues. A player of a participating football team was included if his team played at this level of elite football and if he had at least played one official match for the team during the season. Exclusion criteria were an incomplete questionnaire, no playing time during the investigated season and injuries prior to the start of the season. Sixty-two teams with 1527 players took part in this investigation. All players and coaches received written information material about the aim of the study, and a written consent form had to be signed. The teams were divided in two groups: an interventional group following the newly implemented football-specific training modules and the control group conducting their usual training programme. Randomisation of the study teams was not possible because of the missing compliance for a randomised study design in this elite football population. Therefore, the distribution of the study group and the control group was based on the decision of the team coach of each participating team.

Preventive intervention programme

Programme development

Well-established preventive training programmes such as FIFA 11+ have already shown their positive effect on preventing injuries in football [4, 16, 33]. With respect to sustainability, compliance of the participating players is extremely important, especially in elite football. Therefore, a pre-study was carried out to investigate the point of view of both players and coaches on injury prevention with the aim to conduct an interventional study project and to implement specific training modules. This prior investigation [32] showed a time span of 12 min as the maximum acceptable period for preventive exercises. The approach to implementing a preventive programme was different to that of previous studies [4, 16, 33]. The adaptation of the interventional training programme was thus not only based on team coach preferences, but also on scientific evidence and the investigators knowledge and experience in elite football. The selection of exercises for the preventive training programme was based on the scientific evidence on injury prevention through training and warm-up programmes in football [4, 33, 36] and the known risk factors for sustaining a severe knee injury in football published by Hewett et al. and others [8, 25, 27]. To ensure the compliance of players and team coaches, it was also necessary to integrate their expectations and preferences—which may differ across countries, playing levels and teams—into the new programme. The pre-study had not only investigated the knowledge of coaches and players [32], but had also revealed typical deficits in training contents that could prevent severe knee injuries at this football level. The frequency of exercises for trunk stability, balancing exercises as well as jumping and landing was low and needed to be improved. Based on these findings, a prevention programme was developed.

The maximum period for additional training exercises to prevent knee injuries given by the team coaches involved in this study was an average of 12 min per training session. The interventional programme consisted of five selected modules, which reflected the expectations of the participating teams and the investigators. These modules were used in the team training sessions for a minimum of two times per week over the entire season. Every module consisted of one main exercise and several alternative exercises with specific variations in movements and techniques but with as similar overall aim. Adapted to the main risk factors for severe knee injuries in football, this programme included the following five modules with the main principles of injury prevention: mobilisation, core stability, leg axis stability, jumping, and landing exercises and agility (Fig. 1).
Fig. 1

Prevention modules consisting of the main training exercise (modules I–V) and alternative exercises

Implementation of the preventive programme

After the development of the preventive training programme, the study leaders asked all participating team coaches about their interest in being integrated into the interventional group. The team coaches of the interventional group were free to decide which exercises of the modules that they would like to use. The coaches only wanted their players to carry out one of each module in every prevention training session. Compliance was frequently monitored by telephone calls, and support was provided upon request. The training programme material sent to the coaches included an illustration video on DVD, pictures of the exercises on posters and informational booklets with instructions on the technique, pitfalls and aims of each exercise. Furthermore, the teams were instructed on site by a member of the study staff before the start of the season.

Injury statistics and data collection

The success and preventive effect of the interventional programme was analysed by generating an injury statistic of each participating team over the study period. Data collection was based on the injury analysis of each participating player by means of a self-administered questionnaire on individual information such as football exposure and on the medical report of the medical team staff about injury data. All teams had medical staff in the form of a physiotherapist or a medical doctor, but only doctors’ diagnoses were used for the classification of injuries. Injury data and football exposure were documented and sent as a half-season report to the study coordinator. The pseudonymous questionnaire contained anthropometric, personal, and football-specific data, such as football exposure in training sessions and matches, as well as injury data, for instance, the type of injury or the injured body region. Informed consent was obtained from every participant. Data collection and injury definition corresponded to the consensus statement on injury definition and data collection in football [14, 17] and to previous epidemiological research projects in football of the study group [30, 31]. Every injury that disallowed the player to participate in a training session or match was counted towards the total number of injuries. Based on the assumption that salaried semi-professional football involves a high rate of overuse injuries, often without any time loss, overuse injuries—defined as injuries without any specific trauma mechanism—were analysed separately. Injury incidence was calculated as injuries in 1.000 h of football exposure; the overall incidence was the sum of incidences of all traumatic and overuses injuries. This interventional prevention study was focussed on injuries to the knees. The main focus, however, was on severe knee injuries subdivided into ruptures of ACL or PCL, ruptures of MCL or LCL, cartilage and meniscus injuries, fractures of the knee joint and patella dislocation. Other injuries to the knees such as skin lesions, contusions, sprains, or overuse complaints were registered as slight knee injuries, but not assessed for the main question of this study. The same procedure was carried out for categorising thigh and ankle injuries: only time-loss injuries were registered as severe injuries. Contusions or skin lesions were listed as slight injuries.

Statistical analysis

All teams of the investigated study population were invited to participate in the study; therefore, no formal sample size calculation was carried out. The number of participants depended on the number of players of the teams taking part in this study. Continuous data are expressed as mean and standard deviation (SD). Categorical data are shown as frequency counts (percentages). The two groups were compared with the Fisher’s exact test, and continuous data by means of the t test. Incidence rates were shown using an exact test based on the Poisson distribution. The level of significance was set to p < 0.05. All analyses were conducted using IBM SPSS Statistics, Version 24.

Results

The study population included 62 teams with 1527 players. Twenty-six teams with 529 players took part in the intervention group, and 36 teams with 601 players represented the control group. A total of 397 players of both groups (35.1%) had to be excluded because of incomplete injury reports, missing match exposure or changing teams during the season (Fig. 2). The anthropometric data and the overall football exposure in both the interventional and the control group were comparable (Table 1).
Fig. 2

Flow chart of study participants

Table 1

Anthropometric and football-specific data

 

Intervention group (n = 529 players)

Control group (n = 601 players)

Anthropometric data

Mean (+/ − SD)

Mean (+/ − SD)

Height in m

1.8 (± 0.5)

1.8 (± 4.4)

Weight in kg

76.2 (± 7.5)

76.4 (± 7.2)

Age in years

22.7 (± 4.3)

21.9 (± 4.1)

Football-specific data

n (%)

n (%)

Playing level per team

 4th

5 (8.1%)

13 (21.0%)

 5th

7 (11.3%)

8 (12.9%)

 6th

10 (16.1%)

8 (12.9%)

 7th

1 (1.6%)

3 (4.8%)

Elite junior

3 (4.8%)

4 (6.5%)

Dominant leg

 Right

456 (86.3%)

485 (80.8%)

 Left

73 (13.7%)

116 (19.2%)

Position on field

 Goalkeeper

49 (9.3%)

73 (12.2%)

 Defender

205 (38.7%)

248 (41.2%)

 Midfielder

199 (37.6%)

195 (32.5%)

 Striker

76 (14.4%)

85 (14.1%)

 Overall exposure (in h)

138 249

157 065

 Training (in h)

111 090

126 210

 Match (in h)

27 159

30 855

The overall injury incidence in the study group was 3.27/1000 h and not significantly different to the injury incidence of the control group with 3.23/1000 h (n.s.). The body regions most affected by traumatic injuries in both groups were the lower extremities (52.9%) and for overuse injuries the back (18%), the thighs (15%), and the groin (13%). Both groups had mainly sustained their injuries in the months from August to October (51%) and mainly on the two weekend days, Saturday and Sunday (50%). Typical and most frequent football injuries such as ankle injuries showed no significant differences in overall incidence rates between the intervention group and the control group, whereas the overall injury rate of thigh injuries was higher in the intervention group (ankle 0.73/1000 h vs 0.70/1000 h; thigh 1.86/1000 h vs. 0.89/1000 h; Table 2).
Table 2

Overall injury incidence and injury pattern

 

Intervention group (n = 529 players)

Control group (n = 601 players)

p value

Number of injuries (in n)

Prevalence (in %)

Incidence (in 1000 h)

Number of injuries (in n)

Prevalence (in %)

Incidence (in 1000 h)

Overall

452

100

3.27

507

100

3.23

 

Traumatic injuries

315

69.7

2.28

361

71.2

2.30

n.s

Overuse injuries

75

16.6

0.54

84

16.6

0.53

n.s

Undefined injury type

62

13.7

0.45

62

12.2

0.40

n.s

Thigh injuries

258

57.1

1.86

140

27.6

0.89

 < 0.05

Severe thigh injuries

80

17.7

0.58

85

16.8

0.54

n.s

Ankle injuries

101

22.4

0.73

110

21.7

0.70

n.s

Severe ankle injuries

69

15.3

0.50

90

17.8

0.57

n.s

Knee injuries

83

18.4

0.60

143

28.2

0.91

n.s

Severe knee injuries

52

11.5

0.38

108

21.3

0.68

 < 0.05

Severe knee injury as the primary outcome parameter was significantly reduced in the study group who had frequently used the interventional prevention programme in comparison to the control group (0.38 vs. 0.68/1000 h; p < 0.05). Most severe knee injuries in the intervention group were meniscus lesions (0.14/1000 h), whereas the incidence of MCL and LCL lesions was significantly higher in the control group (0.30/1000 h and 0.10/1000 h; p < 0.05; Table 3).
Table 3

Severe knee injuries in salaried elite football

 

Intervention group (n = 529 players)

Control group (n = 601 players)

p value

Number of injuries (in n)

Prevalence (in %)

Incidence (in 1000 h)

Number of injuries (in n)

Prevalence (in %)

Incidence (in 1000 h)

Overall severe knee injuries

52

9.8

0.38**

108

18

0.69

 < 0.05

ACL/PCL

15

28.8

0.11

28

25.7

0.18

n.s

MCL/LCL

14

26.9

0.10*

47

44

0.30

 < 0.05

Meniscus injuries

19

36.5

0.14

25

32.9

0.16

n.s

Traumatic cartilage injury

4

7.7

0.02

6

5.5

0.038

n.s

Fracture

0

0.0

0.0

1

0.9

0.006

n.s

Patella dislocation

0

0.0

0.0

0

0.0

0.0

n.s

*p < 0.05 significant; **p < 0.01 high significant

Discussion

The most important finding of this study is that the implemented prevention programme reduced severe knee injuries in elite football. Although the implementation of other training programmes for preventing knee injuries, such as FIFA 11+  and the PEP [15, 26, 28, 33, 36], has been supported in the literature, no study has yet investigated the effect of these programmes in elite football. The success of such programmes has been highlighted by this study as the number of severe knee injuries could be reduced by 50%.

Injury prevention in elite football

The prevention programme described in this study is the first programme that has been specifically adapted to the playing level by means of a pre-seasonal investigation and according to the request of the involved team coaches [32]. This programme included parameters such as scientific evidence on preventing knee injuries based on the previous research and the knowledge of risk factors for and injury mechanisms of severe knee injuries, but also the experience and preferences of the managing persons, for instance, team coaches and players of the investigated football level. The specific adaption of a prevention programme to the requirements and circumstances of the playing level is of particular importance in elite football. Therefore, the method of adapting injury prevention exercises, which was applied for the first time in this study, may be an example and potential fundament for the future implementation of injury prevention programmes. Adapting injury prevention programmes may not only improve the implementation of such programmes in football [9]—and compliance to such programmes is traditionally low after the end of the interventional period [7]—but may also improve the sustainability of the programme within football teams. The exchange and communication among the persons responsible for injury prevention in football clubs is essential and a necessity for the success and sustainability of prevention efforts. Such communication was essential in this study project [11]. In the knowledge that team coaches are the most important persons for ensuring the sustainability of injury prevention programmes in football teams [2, 29, 32], both this study and the pre-study investigating currently used programmes and the preferences of coaches started with this novel approach. The detailed investigation of preferences and already established exercises as well as the current deficits in scientifically evidenced basics of neuromotorical injury prevention of knee injuries [25] were fundamental for this study project. These aspects should be implemented in the design of injury prevention concepts in every football club.

Sustainability for practical routine

The injury prevention modules of this study were specifically adapted to prevent severe knee injuries, which are the most common reasons for long absence from football at all skill levels, for the end of football careers or for the development of osteoarthritis in the knee joints [34]. The five implemented training modules included neuromotorical exercises such as mobilisation of the joints of the lower extremities, core stability, standing and leg axis stability, jumping, and landing techniques as well as agility training. These exercises are based on scientific evidence to prevent severe knee injuries such as ACL injuries in football [25, 33]. The newly adapted training modules of this study reduced severe knee injuries by up to 50% and had, therefore, a significant impact on preventing severe knee injuries. The use of only five exercises with alternatives and the duration of the programme of only 12 min could have the potential of being implemented into the practical routine of football clubs in the long run, because this concept also allows the addition of exercises to prevent other typical injuries such as ankle or muscle injuries. The possibility of adding specific prevention exercises to complete injury prevention programmes, for instance, an exercise to prevent groin injuries in 11 + , was recently published by Harøy et al. [23]. For practical routine in elite football clubs, this study recommends analysing the specific requirements and deficits in detail and designing a specific injury prevention programme by means of scientifically established football-specific exercises. In contrast to elite football, frequent use of a complete prevention programme adapted to the playing level or the situation of the teams is still recommended for junior and amateur football; however, such programmes should include the complete compilation of exercises in consideration of the general types of injury [4].

Epidemiology of injuries

The overall injury incidence of around 3.2/1000 h football in both groups was comparable to previously published injury incidence rates in elite football and partly lower than that of international professional football that is marked by other influencing factors [10, 18, 19, 20, 21]. In addition, typical injuries such as ankle injuries found in this study were comparable to those of the previous literature reports [42]. The distribution of the types of knee injuries in this study showed collateral ligament injuries of the knee (MCL/LCL) as the most common type of injury, but the type of knee injuries also differed between the two study groups. The study group using interventional prevention exercises showed a lower incidence of collateral ligament injuries but a higher incidence of meniscal injuries than the control group. Potential reasons for this finding may be the selection of prevention exercises in the implemented programme derived from the previous studies on ACL injury prevention. These exercises may, therefore, be more efficacious in reducing MCL or LCL injuries rather than meniscal injuries of the knee. In the overall comparison of the effect of the implemented injury prevention programme, this study showed injury reduction rates comparable to those reported for the previous prevention programmes [36, 38].

This study has some limitations, for instance, the high dropout rate of football players. From over 1500 players, more than 300 had to be excluded because of incomplete questionnaires. However, dropout rate calculatedin this study is similar to that of the previous studies in elite football. In addition, team coaches and other staff traditionally change frequently in elite football, which may complicate prospective research protocols [9, 35]. Another methodical limitation of this study is the lack of randomisation of the study groups, which was not possible in this study population of elite football players. It was a compromise to skip randomisation of the groups and avoid risking a much higher dropout rate, which could result in the termination of the study because of the lack of an adequate number of participating teams. Therefore, we decided against randomisation and for higher team compliance and attendance. The subsequent decision to be part of the interventional or control group was made by the respective team coaches. This decision was based on multifactorial criteria, which may represent a further bias of the study results. However, in our experience, this decision was without alternative in elite football. A further limitation is the change of the team coach and contact person of the participating teams for the study, which may have influenced the training contents in the control group; however, this topic has not been addressed in this study. The homogeneity of the different leagues at the semi-professional football level in Germany, which was described in the methodical part, also presents a potential bias. Another potential bias is the use of a half-season report as injury registration, which represents the best compliance at this football level (not professionals). Another aspect is that the main outcome parameter of this study was the reduction of severe injuries, which is not only one type of injury such as ACL injury but a sum of different types of injuries. The original motive for summarising the entire range of severe knee injuries was the typically comparable injury mechanism of ACL injuries and other injuries to the knee, for instance, injuries to the meniscal and collateral ligaments [3]. The fact that the incidence of severe muscle or ankle injuries was not affected in the prevention programme shows the specificity of the programme and additionally the potential and necessity of adding further exercises to the programme if other injury types should also be addressed.

This study shows the positive effect of implemented training modules to reduce knee injuries, allowing the direct implementation of these training modules in every training session in elite football. The clinical relevance of this study for team medical staff has been described by effective prevention modules for training sessions; however, the study also shows that prevention strategies need to be adapted to the respective level of football.

Conclusion

The implementation of preventive training modules in elite football reduced the rate of severe knee injuries significantly. Adapting existing prevention programmes according to the preferences of the respective coaches, and therefore, integrating coaches into the decision process will attenuate well-known methodical limitation factors and lead to meaningful results.

Notes

Acknowledgements

Thank you very much to the Verwaltungsberufsgenossenschaft VBG, and to Dr. Patrick Luig, Christian Klein, and Hendrik Bloch for the support in the study. Thank you also to the participating players and team coaches of the elite salaried football in Germany. We also thank Florian Zeman and Gunnar Huppertz of the Clinical Study Center (ZKS) and Esther Kiszler of the University Medical Centre Regensburg.

Funding

Obligatory Trauma Insurance for elite salaried athletes in Germany: Verwaltungsberufsgenossenschaft (VBG).

Compliance with Ethical Standards

Conflict of interest

The authors of this study confirm that there is no conflict of interest.

Ethical approval

The study design was approved by the ethical comittee of the University of Regensburg, Germany.

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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  • Werner Krutsch
    • 1
    Email author
  • Jennifer Lehmann
    • 2
  • Petra Jansen
    • 2
  • Peter Angele
    • 1
  • Birgit Fellner
    • 2
  • Leonard Achenbach
    • 1
  • Volker Krutsch
    • 3
  • Michael Nerlich
    • 1
  • Volker Alt
    • 1
  • Oliver Loose
    • 4
  1. 1.Department of Trauma SurgeryUniversity Medical Centre RegensburgRegensburgGermany
  2. 2.Institute of Sport ScienceUniversity of RegensburgRegensburgGermany
  3. 3.Department of OtorhinolaryngologyParacelsus Medical University NurembergNurembergGermany
  4. 4.Clinic of Orthopedic SurgeryOlga HospitalStuttgartGermany

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