Effect of neuromuscular warm-up on injuries in female soccer and basketball athletes in urban public high schools: cluster randomized controlled trial.

LaBella CR, Huxford MR, Grissom J, Kim KY, Peng J, Christoffel KK.  Arch Pediatr Adolesc Med. 2011 Nov;165(11):1033-40.

Knee injuries account for a large amount of season-ending injuries and surgeries among high school female basketball and soccer players. Furthermore, injuries increase the risk for adverse long-term outcomes; for example, osteoarthritis. One way of reducing the acute and long-term implications of injuries would be to implement injury prevention programs. There is, however, only limited data about the effectiveness of coach-led neuromuscular training among mixed-ethnicity, predominately low-income, urban populations (a population that often does not have an athletic trainer). Therefore, the purpose of this cluster randomized control trial was to determine the effectiveness of one season of coach-led neuromuscular warm-ups on reducing lower extremity injuries among female soccer and basketball athletes in urban public high schools (Chicago). Ninety-five coaches (37% of the invited coaches) were randomized by school and 90 coaches completed the study (with 1492 athletes). Coaches assigned to the intervention group attended a 2-hour training session that instructed them on how to implement the 20-minute neuromuscular warm-up before practices and a shorter version before games. The warm-up consisted of jogging, dynamic motion (e.g., skipping, side shuffle), strengthening exercises (e.g., heel raises, squats), plyometrics (e.g., squat jumps, tuck jumps), and agility runs. The athletes were instructed to avoid dynamic knee valgus and to land from jumps with flexed hips and knees. Coaches were also taught to distinguish proper and improper form, and how to use verbal cues to promote proper techniques. Finally, coaches were provided a tool kit with DVDs, laminated cards, and printed educational materials. Research assistants attended practices biweekly to collect exposure and injury data (coaches kept record of who participated in games/practices), observe warm-up, and answer questions. Control coaches were advised to perform their usual warm-up routines. Injuries during games and practices were recorded if they resulted in time loss from practice or game. The intervention coaches used the neuromuscular warm-up in ~80% of practices (only 6 of 53 coaches used the neuromuscular warm-up at < 50% of practices). Athletes performing the neuromuscular warm-up had lower rates of gradual-onset lower extremity injuries, acute-onset noncontact lower extremity injuries, noncontact ankle sprains, and lower extremity injuries treated surgically. Further analyses showed that the athletes performing the neuromuscular training warm-up had lower incidence rate ratios (incidence among intervention group divided by incidence among control group) for acute-onset noncontact lower extremity injuries (ratio = 0.33), noncontact ankle sprains (ratio = 0.38), noncontact knee sprains (ratio = 0.30), and noncontact anterior cruciate ligament (ACL) injuries (ratio = 0.20). The number of athletes needed to treat to prevent 1 injury ranged from 46 athletes for acute, noncontact lower extremity injuries to 191 athletes for noncontact ACL injuries.

This is an exciting study that demonstrates the potential effectiveness of a coach-led injury prevention program to reduce the risk of lower extremity injuries. A common concern about injury prevention program is how can they be implemented on a large scale. This study demonstrates that it can be done in an urban public school district that typically has limited access to athletic trainers. As the authors note, this study only followed the teams for one season so it is unclear if the coaches can implement the warm-up over several seasons or if they will require retraining. While more research will help answer key questions (e.g., do coaches need to be retrained? do these programs work in other sports?) perhaps it is time that we ask ourselves an important question as clinicians: Is it time to start talking to our coaches, athletic directors, and school districts about implementing injury prevention programs? Have you initiated an injury prevention program in your school?

Written by: Jeffrey Driban
Reviewed by: Kyle Harris

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LaBella CR, Huxford MR, Grissom J, Kim KY, Peng J, & Christoffel KK (2011). Effect of neuromuscular warm-up on injuries in female soccer and basketball athletes in urban public high schools: cluster randomized controlled trial. Archives of Pediatrics & Adolescent Medicine, 165 (11), 1033-40 PMID: 22065184