Causes and Prevention of Injuries in Football (Soccer), Handball and Basketball at Adolescents...

8/18/2019 Causes and Prevention of Injuries in Football (Soccer), Handball and Basketball at Adolescents Master_thesis_Mlad…

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EUROPEAN MASTER IN HEALTH AND PHYSICAL ACTIVITY

M A S T E R T H E S I S

CAUSES AND PREVENTION OF INJURIES IN FOOTBALL

(SOCCER), HANDBALL AND BASKETBALL AT ADOLESCENTS

Supervisor: Prof. Karsten Froberg Student: Mladen Pranić

2015


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KEY WORDS:

Adolescents, youth, injury, injury risk factor, causes of injury, mechanisms

of injury, injury prevention, football, handball, basketball

ABSTRACT:

Based on available literature, the occurrence and prevention of injuries in

adolescents is analyzed in intensive and semi-intensive sport activities

related to football, handball and basketball. Injury risk factors and their

causes /mechanisms of injury in adolescents, who participate in these sports,

are described in the thesis. Methods of prevention that may leave an impact

on reducing the number of injuries, along with their intensity and duration

of injury, are also presented.

In all three mentioned sports most often injuries are injuries of lower limbs,

respectively ankles, thighs and knees. One of the most serious injuries in

adolescents (especially of female adolescents) that occur, in above

mentioned sports, is rupture of anterior cruciate ligament (ACL) in the knee,

which can cause long-term and demanding recovery periods. Another

reason for concern, over the last two decades, is the drastic increase of

incidence of concussion injuries in basketball.

Most common reasons and risk factors of injuries for adolescents involved

in mentioned sporting activities are: aging and maturation (the number of

injuries increases with age), female sex, improper training, matches, sudden

cutting movements, landing, falls, irregular biomechanical relationships,

contacts between players, preseason, and so forth.


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Most effective way to reduce the number of injuries is to maintain

prevention measures/activities, especially concerning the knee and ankle

through a neuromuscular training, strength training and usage of unstable

exercise platforms.


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CONTENT:

1. Acknowledgment 12. Preface and main objectives 2

3. Methods 64. The physiological background of adolescence 9

4.1. Terms relevant to adolescence 9

4.2. Adolescence 10

4.3. Growing in adolescent age 11

4.4. Sexual maturation in adolescent age 15

4.5. Changing of aerobic capacity in adolescent age 16

4.6. Changing of anaerobic capacity in adolescent age 17

4.7. Heart rate in adolescent age 18

4.8. Strength, endurance, speed and agility during

adolescent age

18

5. Basics of football, handball and basketball 215.1. Football 215.2. Handball 235.3. Basketball 25

6. Injuries in sports (sports injuries) 286.1. Types of injury 28

6.1.2. Divide of injuries according to duration 28 Acute injuries 28Chronic injuries 29

6.1.3. Divide of injuries according to the place of

origin30

Soft tissue injuries 30 Injuries of hard structures 31 Injuries of the skin and mucosae 31 Eye and dental injuries 32

6.2. Specific definitions of injuries 326.2.1. Time loss injury 306.2.2. Medicine attention injury 326.2.3. Repetitive injury 32

7. Incidence of injuries, Table (1,2,3) 338. Risk injury factors, causes and mechanisms of injury

occurence

36

8.1. Internal injury risk factors 418.1.1. Aging 418.1.2. Sex 428.1.3. Factors associated with growth 448.1.4. Body composition 448.1.5. Poor biomechanical relationships and

anatomical variation45

8.1.6. Individual motor abilities 468.1.7. Physiological risk factors 468.1.8. Psychological risk factors 46

8.1.9. Previous injuries 47


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8.2. External risk factors 498.2.1. Length of sports participation 498.2.2. Matches as risk factor 508.2.3. Preseason as risk factor 52

8.2.4. Players position 538.2.5. Training and improper technique of training 578.2.6. Poor condition 588.2.7. Neglecting of stretching and non-use bandages 588.2.8. Poor postural control of the body 588.2.9. Dominant side of the player 598.2.10. Jump and landing (drop jump) 598.2.11. Pivoting and cutting maneuvers 598.2.12. Contact and non contact 608.2.13. Tackling 648.2.14. Fatigue 64

8.2.15. Running 658.2.16. Shooting in the target 658.2.17. The surface quality 668.2.18. Size of the playing court 678.2.19. Inadequate sports equipment 678.2.20. Phase of the playing 678.2.21. The level of competition 688.2.22. The visiting team 688.2.23. Athletic shoes 688.2.24 Education of parents 69

8.3. Causes of injuries by looking at the body part and

diagnosis

69

8.3.1. Causes of concussion 698.3.2. Causes of shoulder injuries 718.3.3. Causes of the upper limbs injuries 728.3.4. Causes of finger injuries 728.3.5. Causes of groin and hip injuries 738.3.6. Causes of thigh injuries 738.3.7. Causes of knee (ACL and meniscus) injuries 74

8.3.8.

Patellar tendinopathy and epiphyseal injuries of

the knee84

8.3.9. Causes of the overuse injuries at lower leg 858.3.10. Causes of Achilles tendon injuries 858.3.11. Causes of ankle injuries 868.3.12. Causes of chronic injuries 918.3.13. Causes of stress fractures 91

9. General information about injuries prevention 949.1. Diagnostic measures 96

9.1.1. Preventive medical examinations 969.1.2. Functional diagnostic methods 979.1.3. Psychological diagnostics 98

9.2. Primary injury prevention 99

9.2.1. Orthoses 99


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9.2.2. Shin pads 1009.2.3. Mouth guard 1009.2.4. Eye protection – wearing of safety glasses 101

9.3. Secondary injury prevention 101

9.4. Training measures 102a) General training measures aimed to reduce of all

injuries

102

9.4.1. Improving of physical skills 1029.4.2. Conditioning of players 1039.4.3. Proper stretching and warm-up at the beginning

of each training / match107

9.4.4. Calming (cooling) down of the body at the end

of each training / match108

9.5. Ergonomic measures 109 b) Training measures specifically directed at preventing

of specific injuries in certain sports

109

9.5.1. Training measures for the prevention of the

player contact injuries109

9.5.2. The training measures for preventing non-

contact injuries of muscles and tendons110

9.5.3. The training measures for preventing of non-

contact injuries to the lower limbs111

9.5.4. Proprioceptive and neuromuscular training 1139.5.5. Table 4. Prevention programs in football

(soccer)117

9.5.6. Table 5. Prevention programs in handball 1189.5.7. The impact of the equipment on the occurrence

of injuries in sport119

9.5.8. Choosing of footwear 1199.5.9. Quality of the surface 120

9.6. Educational and control measures 1209.6.1. Rule changes 1229.6.2. Frequency controls of trainings and matches 122

9.7. Measures of recovery and additional measures for the

prevention of injuries

122

9.7.1. Physiotherapy measures 123

9.7.2. Supplementary training measures 1239.7.3. Rehabilitation measures 1239.7.4. Prehabilitation and proper periodization of

training124

9.8. Specific forms of prevention, looking at the body

localization and diagnosis

125

9.8.1. Prevention of ankle injuries 1259.8.2. Prevention of Achilles tendon injuries 1269.8.3. Prevention of ACL injuries 1279.8.4. Preventing of stress fracture 1299.8.5. Prevention of tibial syndrome 129

10. Discussion 130


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11. Conclusion 13512. Literature 13713. List of figures 16614. Appendix - presentation of two preventive programs 170


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1. ACKNOWLEDGMENT

I would like to thank Prof. Karsten Froberg for helping me to develop this

master's thesis.

I would also like to express my gratitude to Prof. Daniela Caporossi who

was helping me during my study in Rome.

Biggest thanks to my family and friends for supporting and helping me

during study and writing of this thesis.

Mladen Pranić


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2. PREFACE AND MAIN OBJECTIVES

This study is focused on adolescent athletes, who are dealing intensively or

semi-intensively with football, handball and basketball.

Football, handball and basketball are the most widespread common team,

contact ball sports that adolescents are dealing with.

All these sports have changed recently. In adolescent age, matches between

athletes become faster and more aggressive. As adolescents mature, their

trainings and matches are becoming longer and more difficult. Frequency of

trainings and matches with aging are increasing too.

These factors from adolescent players require the best possible conditioning

and excellent motor skills. Good coordination of the body, good control of

the ball, good motor communication between ball and players, and an

adequate space control are very necessary. For the recreational athlete, all

these facts are probably less significant.

Adolescence is the time of growing up, the transition from a phase of the

immaturity in childhood, to the maturity in adulthood from the age of 12 to

19 years old. It can be divided in: early, middle and late adolescence

(Malina et al, 2004). This transition involves biological, anatomical,

cognitive, psychological and social changes. Onset of puberty marks a

significant acceleration in the growth of body size, with the average

annual growth of children in the height of 8-12 cm (Marković et al, 2009).

In adolescent period, bones are still not merged (Malina et al, 2004).


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According to this, it can be assumed that injuries often occur during sport

activities in adolescence, which can significantly influence on the mental

and physical development of athlete as whole person.

The objective of this master thesis is that by review of the available

scientific literature, which analyses injuries in adolescents, occurred during

football, handball and basketball present following:

• To present injury risk factors and most common causes and

mechanisms of injury during football, handball and basketball in relation to

the adolescent age and gender;

• To present ways of preventing the occurrence of injuries and

reducing their frequency and severity, in relation to age, gender and type of

the sport.

Sports injury is most often defined as an incident during a match or

training, causing a lack of players at least one next game or training (Brooks

& Fuller, 2006; Kofotolis et al., 2007; Frisch et al., 2011)

Most of the articles have shown that the most frequent injuries in all three

analyzed sports are injuries of the leg - ankle, knee and upper leg. Looking

on diagnosis, ankle strain is the most frequent. One of the most serious

injuries that cause long absence from the pitch is injury of anterior cruciate

ligament of the knee.


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Adolescent female athletes are being injured more often (especially knees)

in comparison with male athletes. In basketball, increasing incidence of

concussion and brain injuries is very worrisome.

Bahr et al, 2005 concludes that occurrence of injury is consequence from

the complex interaction between the external and internal risk factors.

The internal injury risk factors are specific to each athlete individually

and it is very difficult to influence on them. Contrary on that, external

injury risk factors reflect on the environment in which an athlete exercises

and it is much easier to influence on them. Some important internal risk

factors are: age, female sex, previous injuries, poor biomechanics, and

external risk factors are: matches, preseason period, muscle imbalance,

jump, landing etc.

Randall et al, states that the cause of the increased incidence for the

development of concussion in females is because of their smaller size,

more fragile structure and less strength of neck.

Cause of knee injury can be of contact and noncontact nature. Serious

injuries often occur due to noncontact injuries.

Ankle injuries arise in most cases due to collision between players or

during landing. Specifically for basketball is landing on someone else foot,

which can lead to the ankle injury (Agel et al, 2007).

In these three sports overusing injuries and stress fractures occur, due to

growing or maladjusted training.


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Prevention (from the Latin. Praevenire = prevention) means a set of

measures to prevent any adverse effects (Wikipedia).

Structured plan of preventive measures can be applied through four main

steps: Gathering information, identification and description of preventive

measures, their implementation and review of achieved (Gall et al, 2006;

Mechelen et al, 1992; Backx et al, 1991; Olsen et al, 2006; Myklebust et al,

2013). The timely implementation of preventive measures is important.

(Olsen et al, 2005; Myklebust et al, 2003; Steffen et al, 2010). Before the

beginning of the new game season it is recommended to make diagnostic

measures (medical control, functional tests etc.) in order to detect potential

health problems. The most productive of all preventive measures is proven

to be neuromuscular training on unstable surfaces.

Also, each sport has its own characteristics and rules, and it is certainly

necessary to achieve good technique in order to avoid possible injury.

The use of protective equipment such as protective glasses, mouthguards

or wearing of ankle braces has also shown some preventive effect in

preventing of sports injuries.


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3. METHODS

In this thesis descriptive methods and methods of compilation are being

used. (not original work, but composed from material collected by another

author ).

In the purpose of this thesis, 230 scientific articles and few abstracts have

been analised,while much more abstracts, articles and books were

overviewed. A scientific literature search was performed during March 2015

in Pubmed, Google Scholar and from the Croatian and Slovenian national

library base. Notes from lectures during the study in Odense are also used.

Looking on the topic of thesis, search is performed based on the following

key words: adolescence, injuries, causes of injury, mechanism of injury,

injury prevention, football, basketball and handball.

The data from the literature was analised according to the following criteria:

originality of the data, the amount of data, the size of the sample, the period

of observation, and the method of data processing.

Characteristics of analysed articles and data from those articles:

Number of articles:

I included all relevant available articles related to the topic, regardless to the

adolescent age. This thesis presents the most recent data, but in the case of

lack of such data I used some older sources. Most found scientific articles

were about football. Articles on injuries in basketball and handball were in a

significantly less number and because of that, for the purpose of this thesis,

articles with a similar topic or similar keywords were searched (high school,

university, youth, young, children, etc.).


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Finally, I analised 60 articles dealing with causes and prevention of injuries

in football, 46 in basketball and 40 in handball.Other analyzed articles are

describing adolescents, injury causes and their prevention, regard to the type

of the sport. The exclusion of articles was mainly due to the lack of data

and an inappropriate age (not adolescence) or due to analysis of different

sports without detailed processing information, separately for each sport or

for each age. In some cases I used data from other sports or with other

certain age group due to their importance or to their mutual comparing.

Localization

With analysis of scientific articles, their large territorial localization is being

established. Almost all studies dealing with the topic of injuries in

basketball are from the USA, and those dealing with handball are from the

Scandinavian countries, respectively Norway and Denmark. Articles about

injuries in football cover some more widespread area, though most of these

articles come from richer countries (Western Europe or USA).

Data from the reviewed articles

Reviewed articles are characterized by lack of data and unevenness (no

consistency), in terms of data collection and analysis.

Unevenness is manifested through:

Selection of the sample; e.g .:

By sexes (only males, only females, males and females

mixed)

By observed age (e.g. U13; U14;U15;U16;U17;U19; U13-

15; U15-U17;from 15 to 25 year; from 5 to 19 year etc.)


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By the size of the sample

Selection of sports (football, handball, basketball, mixed-

football and rugby, football – American football, sports in

general ...).

The way of performing activities (competitive, recreational,

school activities…).

Selection of the observation period (e.g. pre-season, season,

postseason, certain number of competitive games, certain

number of months or years and the like.).

Way of getting an injury (e.g.: every incident event, injuries

that prevent players to participate in the certain numbers of

matches and / or trainings; or in certain period (24h, 48h,

72h…) etc.)

Way of analysing of injury localization (e.g., hip, groin,

mixed hip and groin, hip and thigh, etc.).

Way of injury diagnose analyzing (conscious, head injury,

face injury, conscious and head injury…)

Way of obtaining information (coach, physiotherapist,

doctor, clinic, athlete, parents …)

Types and organization of data (nominal, ordinal, interval or

ratio)

Types of study (retrospective or prospective)

The way of statistical tests selectioning

The way of interpretation of the obtained results


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4. THE PHYSIOLOGICAL BACKGROUND OF ADOLESCENCE

4.1. Terms relevant to adolescence:

Growth refers to measurable changes in size, physique and body

composition, and various systems of the body (Malina et al, 2004).

There are three underlying cellular processes during growing:

1. Hyperplasia – increasing in number of cells

2. Hypertrophy – increasing in cell size

3. Accretion - increasing in the substances that hold the cells together;

found between cells (ex. bone mineral, collagen), (Dudoniene V, 2012).

Growth in stature is rapid in infancy and early childhood, rather steady

during middle childhood, rapid during the adolescent spurt, and then slow as

adult stature is attained. Final adult height is usually reached at 20 year of

age (Malina et al, 2004).

Figure 1: Stages of growing during childhood and adolescent period


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Maturation refers to progress toward the mature state. Maturation is

variable among bodily systems and also in timing and tempo of progress.

The processes of growth and maturation are related, and both influence on

physical performance (Malina et al, 2004).

Development is more general process, including aspects of:

• growth,

• maturation

• Learning/training/evolution from novice to expert

• Experiences in micro & macro environment

Development can be on biological, behavioral, cognitive, emotional, social,

moral and motor way (Dudoniene V, 2012).

4.2. Adolescence

Adolescence begins with an onset of the puberty and ends with the

formation of identity. It can be divided in: early, middle and late

adolescence. Early adolescence covers the period from 12 to 14 years,

middle from 15 to 16, and late from 17 to 19 years of life. After that age

starts perod of early adulthood (Malina et al, 2004).

Figure 2: Stages in growth and development up to adulthood


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Division of adolescence fits the way that our society groups young people in

educational institutions: the first group comprises of pupils of higher class in

the elementary school, second are high school pupils, and third students on

the universities. Cognitive development does not always follow physical

changes in adolescent age. Adolescence is a period of rapid changes of

mood, internal conflicts and quarrels with the environment, rebelliousness,

and researching of environment (Šoljaga, 2010).

4.3. Growing in adolescent age

Onset of puberty marks a significant acceleration in the growth of body size,

with the average annual growth of children , approximately they grow 8-12

cm . Generally speaking, a phase of rapid growth (peak height velocity),

first affects girls (12 ± 1year), and then the boys (14 ± 1 year). This period

lasts for a year or two. Peak height velocity is maximal growth in stature

and also maturity indicator. After puberty, children continue to grow but

with much slower pace (Malina et al, 2004).

Figure 3: Peak height velocity and peak bone mass growth


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Growing of body in girls is lower than in the boys and ends approximately

with 16.5 years. Boys grow up until they turn 19 years. Girls are usually

maturing two years faster than boys (Marković et al., 2009). Besides the

differences between the genders, there also exist considerable variations in

maturation inside the gender (Malina et al, 2004).

Although, growth is largely characterized by genetic factors. Height of the

child can not be determined based on the height of the parents (Marković et

al., 2009).

Figure 4: Changes in the size and shape of the body during growing

As chronological age is not supported by the actual age of every child,

there is also term biological age (Marković et al., 2009).

Skeletal age is determined by the ossification of the bones, reflects more of

the physiological age (Dudoniene V, 2012). Skeletal maturation means a

fully ossified skeleton and determine age of the skeleton (Malina et al,

2004).


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In order of reaching the height of adult, children and adolescents go through

periods of linear growth which is taking place in the region of the

epiphyseal growth plates of long bones (Higins et al., 2009). Growth

occurs at the each end of the bone around the growth plate. When a child

becomes full-grown, the growth plates harden into solid bone (Malina et al,

2004).

Result of the higher volumes of cartilage tissue in the bones is their greater

flexibility, but on the other hand, children's bones have significantly lower

bone strength than adults. By injuring of growth plate, standstill in growth

and development of the bone may occur. (Marković et al., 2009). The most

prevalence of epiphyseal growth plate injuries is between 10 and 16 years

and high vigorous activities should be avoided (Dudoniene V, 2012).

Bone is growing first and precedes to elongation of muscles, tendons and

nerves. Possible delay in growth and development can lead to a reduction in

flexibility, muscle imbalance and poor coordination (Higins et al., 2009). In

that way, inappropriate load during exercises may cause injury of epiphyseal

regions on the bone, and complete cessation or slowing down of bone

growth in length.


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Figure 5. Description of bone growth in length

Figure 6: Difference in bone ossification between boys and girls at different

adolescent age


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As regards to soft tissue flexibility, girls deliver more performance than

boys in the overall growth and development. Flexibility in girls is constantly

increasing until 16 years, while in boys reaches its minimum during the

maximum phase of growth, at the age about13-14 years. After that, in boys

flexibility slowly increases until 18 years (Marković et al., 2009).

Figures 7 and 8: Slides show measuring of hamstrings flexibility

4.4. Sexual maturation in adolescent age

In adolescent age, sexual maturation is developing, which means fully

functional reproductive capability and changing of main gender features.

Girls: Breast development, pubic hair development, age at menarche

(axillary hair). Menarcha also depends about sports activities.

Boys: Genital development (testes, scrotum, penis), pubic hair development,

axillary hair, voice changes, facial hair (Dudoniene V, 2012).


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Onset of puberty indicates a significant increase of the testosterone in boys

and estrogen in girls.

Testosterone stimulates the development of muscle mass, while estrogen

development of body fat cells. Hormonal changes make the difference in the

shape of the skeleton and bone morphology (Marković et al., 2009).

4.5. Changing of aerobic capacity in adolescent age

Pubertal changes in functional abilities are apparent in boys especially in

terms of aerobic capacity according to body mass (ml/kg/min) while in

girls changes are less visible because a significant increase in body weight

occurred after puberty (Higins et al., 2009). Maximal uptake of oxygen

keeps increasing until the age about 17 to 18, but increases hardly at all

beyond age 14 in girls. It depends on respiratory and hemodynamic factors

and is also related to the oxidative enzymatic activity in the exercising

muscles and to the size of these muscles.

When maximal oxygen uptake of adolescents of different ages, but the same

body weight or body height is compared, it is positively related to the age.

Maximal aerobic power depends on maturity and not only on body

dimensions. Adolescent whose body mass is smaller may not need as much

absolute maximal oxygen uptake as the heavier adolescent or adult.

Majority of studies express maximal oxygen uptake per kg of body mass

(Bar-Or & Rowland, 2004).


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4.6. Changing of anaerobic capacity in adolescent age

An activity that depends predominantly on non oxidative energy turnover

is considered anaerobic. Such activity can be sustained for 1 min or less and

is of a very high intensity (for example, short and long sprints and jumps).

Energy source for this is high energy phosphate (creatin phosphate) that

is stored in the muscle, or ATP that is produced through anaerobic

glycolysis. The use of available ATP and CP is not accompanied by lactate

productions and is called “alactic”. Adolescent anaerobic activities are

higher than in children, but lower than in adults (Bar-Or & Rowland, 2004).

With increasing of age, absolute and relative anaerobic power also

increase. In boys during puberty anaerobic power develops and reaches its

maximum at the age of 18 years. In girls, anaerobic power is significantly

lower, and reaches its maximum between 15 and 16 years, and after that

absolute power is stagnant, and the relative decline (Bar-Or & Rowland,

2004) .

Children have lower anaerobic glycolytic capacity than adults. Full

development of the glycolytic energy system can be expected after 18 years,

or at the end stage of adolescence (Marković et al., 2009).

Possibile reasons for lower anaerobic performace in childhood and

adolescence are: smaller muscle mass per body mass, lower glycolytic

capability and deficient neuromuscular coordination. Anaerobic

characteristics depend on a certain extent of the persons genotype.


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Compared with adult athletes, prepubertal and early pubertal child athletes

are less specialized as anaerobic or aerobic performers. The nature is unclear

(Bar-Or & Rowland, 2004).

4.7. Heart rate in adolescent age

Maximal heart rate in adolescents and children ranges between 195 -210

beats per minute. It starts declining in age during the late teens. Such decline

is independent of gender, level of training, climate or other environmental

conditions. It is equivalent to 0,7- 0,8 beat per minute-1 a year. Females have

heigher rate than males at any given exercise level (Bar-Or & Rowland,

2004).

4.8. Strength, endurance, speed and agility during adolescent age

Years of the largest development of most fitness levels coincides with the

years of greatest growth in height (Marković et al., 2009). The growth spurt

in height happens first and it is followed by the growth spurt in weight and

then the growth spurt in strength (Malina et al, 2004)

Strength is the ability to acting through muscular activity and external

forces to overcome or not. It comes from the contraction of muscles and is

effective through the external skeletal system (Garopoulou et al, 2011).

Strength training is important for children and adolescents, for those

participating in sports, and also for those participating in physical

recreational activities. For boys, the development of strength increases

linearly up to 13 to 14 years, after which performs of this ability rapid

growth, while in girls, strength is increasing linearly (Marković 2009).


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Muscular endurance is the ability of a muscle or group of muscles to

sustain repeated contractions against resistance for an extended period of

time ( http://sportsmedicine.about.com/od/glossary/g/MuscleEndur_

def.htm ).

Muscular endurance develops linearly in both sexes until puberty, after

which in the boys it accelerates while in the girls it is slowing down. The

result is an increase of the difference in muscle strength between the sexes.

After 13 years in boys is slightly increasing explosive strength, while in

girls this trend is slowing down (Marković et al., 2009).

Speed and agility - the largest increase in development of speed and agility

in children is between 5th and 9th year, after which linear growth is present

until 13 to14 years.

Second acceleration of agility and speed in boys occurs at the same time,

while in girls slows down from the age of 16 to 17 years. During this period

significant differences are happening in the speed and agility in favor of

boys. This is associated with the rapid development of explosive and

maximum intensity during the phase of rapid adolescent growth (Marković

et al., 2009).

Due to these changes it is necessary to adapt training and the level of its

intensity to adolescents engaged in sports activities. This is particularly

important in the phase of intensive growth when it can happen that superbly

trained child suddenly becomes clumsy and awkward.

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Therefore, it is certainly necessary to allow adolescents to adapt to new

conditions in terms of understanding his body and knowing itself and his/her

new features.

This fact represents a challenge for coaches because of the fact that in these

situations it is necessary to reduce the load with special attention on

flexibility exercises and re-adoption of sport movements and technique.


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5. BASICS OF FOOTBALL, HANDBALL AND BASKETBALL

5.1. Football (Soccer)

Football is a team sport in which compete two teams with 11 members. The

aim of the game is to score more goals than the opponent with any part of

the body except the hand. Goalkeeper is the only player to whom is allowed

to play with hands. Football players are trying to achieve goals by the

individual control of the ball ("dribbling") that passes along the ground or in

the air by hitting the ball into the net. Team that scores more goals wins.

Venue can be natural or artificial grass. International matches are played on

the courts of the length of 100-110 m and a width of 64-75 m. A goal is set

on the each side of goal line, with dimensions 7.32 x 2.44 m (FIFA, 2015).

Figure 9.Football field with standard measurements

The ball's circumference is 68-70 cm and weights 410- 450 g. It is bloated

with air and covered with leather or suitable synthetic material. The game

lasts 90 minutes, and the players go to the fifteen-minute break after first 45

minutes (FIFA, 2015).


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Football is a complex sport which consists of cyclic and acyclic movements.

The cyclical movements include various forms of running and ball leading.

Acyclic forms of movement are hitting the ball, receiving and passing the

ball, cheating, jumps, shots, falling, etc.

Some movements have characteristics of both cyclic and acyclic

movements. Depending on the position in the game, players have certain

tasks and activities (defensive players – seizure of the ball, playing with

head; midfield players - dribbling and passing the ball, attackers - cheating,

shot on goal) (Elsner, 1997).

Aerobic and anaerobic capacities of the players are very important for the

football performance. Aerobic capacity enables player to overcome every

effort, and anaerobic during maximal or submaximal speeds and loads.

Although aerobic condition is necessary, as a base, while anaerobic

condition is becoming more and more important (Ekstrand, 2003).

Football is a sport in which very high loads on the joints of the lower limbs

are expressed, with frequent fouls and contacts, which can lead to the

occurrence of injuries.

Figure 10.Show of body position during change of direction in football


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5.2. Handball

Handball is a team sport with a ball, where two teams with 7 players (6

court players + 1 goalkeeper) are competing on each side. The aim of the

game is to achieve the goal and to have a better result than the opponent

team. The game consists of two halves of 30 or 20 minutes (depending on

the age of the players). Players can touch the ball with hands, and bandy ball

between each other, but the aim is to get the score. Dimensions of handball

courts are: length 40 m, a width of 20 m. The terrain consists of the playing

field and two goal areas. All players are free to move around the field,

except 6 meters in front of both goals. In this space may only stand one

member of the defense team – goalkeeper (IHF, 2010).

Figure 11. Show of different movements of the body related to handball

game

Two basic phases of the game are phase of the attack and the defense phase.

In the attack phase, players most commonly use a formation with two side

players (left and right winger), three external players (left, center and right

back player) and pivot or centerforward (Medvešek, 2011).


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In the defense phase, it is being used formation of several different players

in front of area of 6 m (formation 6-0, 5-1 etc.), (Medvešek, 2011). For

handball game significant are numerous changes of direction, accelerations

and decelerations and physical contact between the players. All mentioned

activities are intertwined in short time intervals, depending on the situation

in the game. Highly intensive workloads such as changing of direction,

jumping, landing, shots, defense activity, etc., require good condition and

fine motor skills of the players (Luzar K, 2011). Handball is agile game

associated with a number of unexpected situations, different loads and

disturbances that can easily lead to the injury during the movement in the

game. It can be concluded that a well-developed motor skills affect on the

performance of handball players and reduce the possibility of injury.

Figure 12. Show of danger position in handball due to landing on one leg

(potential ankle or knee injury) and valgus position of the right players knee

during jumping that can lead to ACL injury, especially in case of stronger

contact between players or fall.


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5.3. Basketball

Basketball is a sport in which two teams of five players are trying to score

more points by inserting the ball through the hoop of the basket in

accordance with prescribed rules. The team that wins is one that at the end

of the game has more points in comparison with the opponent. A successful

shot is valid with two points if the shot was released inside the arc radius of

6.75 meters in Europe or 7.24 meters in the NBA league. The shot out of

that arc is valid like three points. A free throw is 1 point, and it is performed

from the distance line of 4.5 meters.

The ball may be leaded to the basket as a shot, passing between players, as

throwing, rolling or dribbling (bouncing the ball from the ground during

running).

Regular basketball court in international basketball has measures 28 x15

meters, and in the NBA 29x15 meters. Most courts are made from the wood,

parquet. One basket is at the each end of the court. The top of the rim is

exactly 3.04 meters above the court and 1.21 meters inside the baseline at

almost all levels of the competition. (FIBA, 2014).

Figure 13. Basketball court


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Five players from each team may be on the court at the same time ( Point

guard, often called the "1" ; Shooting guard, the "2" ; Small forward the

"3"; Power forward, the "4" ; Center, the "5").

Figure 14. Position of basketball players

Games are played in four quarters of 10 (FIBA) or 12 minutes (NBA).

College games use two 20 minute halves, while United States high school

varsity games use 8 minute quarters. Fifteen minutes breaks are allowed for

a half-time under FIBA, NBA, and NCAA rules and 10 minutes in United

States high schools (FIBA, 2014).

On the professional level of basketball, most players are higher than 1.90 m,

and most females are higher than 1.75 m

(http://wiki.royalfamily.ba/wiki/Ko%C5%A1arka#.VaPJufkpr6k ).

Basketball is a sport which asks from the players a good spatial overview of

the game and between players. In the same time, excellent movement

coordination of legs and hands and control of the ball are also necessary.

http://wiki.royalfamily.ba/wiki/Ko%C5%A1arka#.VaPJufkpr6khttp://wiki.royalfamily.ba/wiki/Ko%C5%A1arka#.VaPJufkpr6khttp://wiki.royalfamily.ba/wiki/Ko%C5%A1arka#.VaPJufkpr6khttp://wiki.royalfamily.ba/wiki/Ko%C5%A1arka#.VaPJufkpr6k


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During the game, especially during adding the ball, players should consider

the size of the field.

At stage of adolescence, basketball players who are still in the stage of

development can be injured by different or repeated movements, like sudden

cutting movement changes, jumping and landing with high postural sway

etc. (Mc Gee et al, 2007; Bruce et al, 2010; Wang et al, 2006).

Figure 15. Typical basketball situation for centers during shooting in the

basket


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6. INJURIES IN SPORTS (SPORTS INJURIES)

Great variety of defining an injury was established during the examination

of scientific articles that cover the topic of injuries in sport.

Fuller et al., 2006, reported about achieved compromise in the term of

sports injury among scientists that deal with injuries in football:

Sports injury is defined as an incident during a match or training,

causing a lack of players at least one next game or training (Kofotolis et

al., 2007; Frisch et al., 2011)

This definition of sports injuries is most common. It is also partially

accepted by scientists that deal with themes of injuries in other sports, but

there are plenty of modifications of this definition. Fifteen ways of defining

sports injuries are recorded during examination of scientific articles.

6.1. Types of injury

Injuries can be divided:

according to duration

according to place of origin

6.1.2. According to duration

Acute injur ies

Acute injury is type of injury which occurs suddenly, unexpectedly, and

which causes disorder in the structure of the injured tissue. This type of

injury causes tissue damage and currently leads to the inability to participate

at sports activities. Luigi and Henke, 2010 defined acute injury as a result of

specific incidental event that can be documented.


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A similar definitions of acute injury are presented in some other articles,

too. Football: (Brito et al., 2012 ; Soligard et al., 2008 ; Froholdt et al.,

2009 ; Steffen et al., 2007) Handball: (Moller et al., 2012 ; Olsen et al.,

2005; 2006).

o Acute contact injur ies are caused by external loads and by

contact with other player, Football: (Frisch et al., 2011).

o Acute non contact inju ri es are sudden injuries without external

influence, Football: (Frisch et al., 2011).

Chronic injuries

Chronic injuries is defined as evolving gradually as a result of overuse, and

are caused by mikrotrauma without any exact event responsible for the

occurrence of injuries, Football: (Brito et al., 2012; Junge et al., 2003;

Soligard et al., 2008; Froholdt et al., 2009; Steffen et al., 2007), Handball:

(Moller et al., 2012; Olsen et al., 2005; 2006; Luig i Henke, 2010).

Overuse syndrome occurs as a result of repetitive mikrotrauma

accumulated beyond reparative ability of tissue.

In contrast to the acute injuries, where in a split of second very high

mechanical load leads to the destruction of the tissue, in the case of overuse

injuries, occurs much repetitive mikrotrauma. Tissue damage caused by

the impact of repeated microtrauma, are not enough to damage tissue, but

repetitive actions overwhelm the body's ability for regenerating tissue

(Đapić et al., 2001). Untreated overuse injuries over the time induce

degenerative processes in soft tissues.


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By neglecting the pain and movement restrictions, and by extensions of the

compensatory movements, it is possible to spread the impact of

microtrauma to other parts of the body. Common point for the injuries and

damages (overuse syndromes) is that they are at the end manifest in the

form of inability for athlete‘s further sports activities (Vukelić, 2011).

Some of the most common overuse injuries are: Osgood Schlater disease,

Sever‘s disease, tennis elbow, bursitis, stress fracture etc. (Vukelić, 2011).

6.1.3. Divide of injuries according to the place of origin

Soft tissue injuries – Injuries of muscles, tendons and ligaments (strain or

rupture of fibers).

Strain (Distension)

First degree rupture - Laceration - break in continuity of a small

number of muscle fibers with generally held muscle function for

normal activities of life that do not involve sports.

Second degree rupture – partial rupture

Third degree rupture – complete rupture

Muscle contusion – contusion of muscle without rupture of muscle

fibers, but with damage of blood vessels, which result with

hematoma.

Inflammation of tendons – tendinitis


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Injuries of hard structures

Injuries of bones

Fracture – Severe injury that describe bone fracture

Contusion

Injuries of joints

Contusions

Luxation / Dislocation - dislocation means shift a bone in relation to

the other bone in the joint without the possibility of spontaneous

return to the starting position.

Subluxation / Distortion (sprain) is actually a short-term dislocation,

with spontaneous return of two bones connected by joint to the more

or less its original position. After sprain, due to strain of joint soft

tissue (muscles, tendons, ligaments) in the joint may lapse

instability.

Injury of the cartilage and meniscus

Avulsion

Rupture

Injuries of the skin and mucosae

Contusions

Lacerations

Abrasions

Cuts

Blisters


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Eye and dental injuries

The most common eye injuries are corneal abrasions. Teeth injuries can be

of serious nature (Ivković, 2009; Brzić, 2012).

6.2. Specific definitions of injuries

Authors have also created some specific subgroups of injuries: Time-loss

injury, medicine attention injury, repetitive injury and others.

6.2.1. Bahr 2009, argued that the time loss injury definition is probably the

most used because it covers most of the relevant injury, and the use of this

definition is understandable especially when it conducts retrospective

studies, Handball: (Luig and Henke, 2010).

6.2.2. Medicine attention injury are those injuries which require medical

treatment Football: (Fuller et al 2006, 2007; Ergun et al., 2013), Handball:

(Luigi and Henke, 2010).

6.2.3. Repetitive injury is defined as an injury of the same type and on the

same part of the body, that occurs after the player‘s return to the full

participation after the initial injury Football: (Brito et al., 2012; Soligard et

al., 2008 ; Frisch et al., 2011; Steffen et al., 2007 ), Handball: (Moller et

al., 2012).

Football: Le Gall et al., 2006 reported that the repetitive injury is one that

appears on the same location within two months after the rehabilitation of

an earlier injury. Ergün et al., 2013 repetitive injuries still divide on early

repetitive injuries that occur within 2 months after initial injury and late

repetitive injuries that occur within 2 months to 12 months after the initial

injury.


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7. INCIDENCE OF INJURIES

By examining scientific papers, during football and handball matches was

recorded slightly higher incidence of injuries, compared with basketball.

The incidence of injuries in trainings is quite similar in all these sports, but

in handball are some fewer incidences of injuries.

The incidence of injuries in football match on 1000 hours amounts from 1.2

to 30.4 injuries while in training it is much lower, from 1.7 to 7.4 injuries at

1000 training hours. Highest incidence of injuries was reported in the

Turkish national team members (Ergun et al., 2013).

Studies in handball have shown that incidence of injury in matches range

from 8.3 to 17.1 injuries on 1000 match hours, and during trainings from 0.6

to 4.6 injuries per 1000 training hours. Wedderkopp has reported the

significantly higher incidence of injuries in female handball player (41

injury/1000h during matches) in comparison with other authors.

In basketball incidence of injury in matches amounts 3.2 to 14.9 injuries

per 1000 match hours. At training incidence is much lower and ranges from

1.6 to 6.45 injuries at 1000h of training.

In football the most common injury in the adolescent male players was

muscle strain with a 33% incidence of injuries, while adolescent female

players had 10.7% of the same type of injury. Ligament sprains were most

common in female football players with a mean incidence of 39%, while in

male players that incidence was 25%. Female football players had more

often appearance of contusion 29.7%, opposed to males with 22.3% of

injuries.


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Ankle injuries were most common localization of injury (m 27%: f 24.5%).

In football it can be seen a big difference between the sexes, looking on

thigh injury (m 22%: f 9.6%). The higher incidence of knee injuries is also

in the female population (f 17%: m 13%).

Table 1: Location of I njur ies Sustained According to Age Group Dur ing

the 10-Season Peri od- males (Le Gall , 2006)

U14, younger than 14 years; U15, younger than 15 years; U16, younger than 16 years.

Table 2: Nature of I njur ies Sustained According to Age Group Dur ing the

10-Season Period - males (Le Gall, 2006)

U14, younger than 14 years; U15, younger than 15 years; U16, younger than 16 years.

Nature n % n % n % Total %Contusion/hematoma 109 26 132 36,6 111 29,9 352 30,6

Sprain 76 18,1 58 16,1 58 15,6 192 16,7

Muscle strain 53 12,6 61 16,9 62 16,7 176 15,3

Tendinopathy 55 13,1 24 6,6 29 7,8 108 9,4

Vertebral lesions 22 5,2 26 7,2 30 8,1 78 6,8

Osteochondroses 50 11,9 16 4,4 6 1,6 72 6,3

Fracture 25 6 19 5,3 24 6,5 68 5,9

Meniscal lesion 9 2,1 8 2,2 8 2,2 25 2,2

Dislocation 2 0,5 4 1,1 4 1,1 10 0,9

Other overuse 5 1,2 5 1,4 9 2,4 19 1,6

Others 14 3,3 8 2,2 30 8,1 52 4,5

U14 U15 U16 All age groups

Injuries


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Ankle in basketball is being more often injured in adolescent males than in

adolescent females (f 43%: m 46%). Knee injuries are more serious in

female basketball players than in males (f 28%: m 10%). Unlike football, in

basketball incidence of concussion is significantly higher, (m 6.5%: f 7.5%).

Looking on both sexes, sprains and strains have occupied 48% of injuries

and fractures 11%. A large part has also occupied contusions with incidence

of 9.8%, looking on both genders.

In handball , incidence of injuries is similar to the previous two sports with

most often injuries on the lower limbs, ankle 28% and knee 21%. Handball

is different from other sports with higher percentage of finger (17%) and

shoulder injuries (6%). Looking at the type of injury, the most present are

sprained ligaments with a 46% incidence of injuries (Moller et al, 2012).

Table 3: Number of injuries and injury incidence in 346 elite handball

players by age group, injury type and body region (Moller et al, 2012).

Incidence is per 1000 athlete participation hours - 95% CI; Exp H,

exposure hours;

Better comparison are impossible due to the lack of necessary data for

statistical analysis.

No IR No IR No IR No IR

Shoulder / upper arm 8 0.4 (0.2 to 0.8) 5 0.2 (0.08 to 0.6) 6 0.2 (0.09 to 0.5) 7 0.3 (0.1 to 0.6)

Elbow / under arm 3 0.1 (0.03 to 0.4 3 0.1 (0.03 to 0.4) 3 0.1 (0.03 to 0.4) 1 0.04 (0 to 0.2)

Hand / wrist 1 0.05 (0.0 to 0.3) 3 0.1 (0.03 to 0.4) 0 0 4 0.2 (0.04 to 0.4)

Finger 1 0.05 (0.0 to 0.3) 8 0.4 (0.2 to 0.8) 0 0 6 0.2 (0.09 to 0.5)

Hip / Groin 3 0.1 (0.03 to 0.4) 2 0.01 (0.01 to 0.4) 7 0.3 (0.1 to 0.6) 4 0.2 (0.09 to 0.5)

Thigh 1 0.05 (0.0 to 0.3) 5 0.2 (0.08 to 0.6) 0 0 2 0.08 (0.0 to 0.03)

Knee 8 0.4 (0.2 to 0.8) 11 0.5 (0.3 to 0.1) 14 0.6 (0.3 to 1.0) 23 0.9 (0.6 to 1.4)

Lower leg 8 0.4 (0.2 to 0.8) 3 0.1 (0.03 to 0.4) 26 1.1 (0.7 to 1.5) 1 0.04 (0 to 0.2)

Achilles 0 0.00 0 0 1 0.04 (0 to 0.2) 0 0

Ankle / foot 3 0.1 (0.03 to 0.4) 27 1.3 (0.9 to 1.9) 4 0.2 (0.04 to 0.4) 26 1.1 (0.7 to 1.5)

Head / cervical spine 1 0.05 (0.0 to 0.3) 4 0.2 (0.05 to 0.5) 0 0 2 0.08 (0.0 to 0.03)

Thoracal spine 2 0.1 (0.01 to 0.4) 1 0.05 (0.0 to 0.3) 0 0 0 0

Lumbal spine 3 0.1 (0.03 to 0.4) 3 0.1 (0.03 to 0.4) 4 0.2 (0.04 to 0.4) 4 0.2 (0.04 to 0.4)

Pelvis 0 0.1 (0.01 to 0.4) 0 0.00 2 0.08 (0.0 to 0.03) 1 0.04 (0 to 0.2)

Total 42 2.1 (1.5 to 2.8) 75 3.7 (2.9 to 4.6) 67 2.7 (2.1 to 3.4) 81 3.3 (2.6 to 4.1)

Injury localization

u-18 (n=152, Exp h=20447) u-16 (n=194, Exp h= 24668)

Overuse injuries Traumatic injuries Overuse injuries Traumatic injuries


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8. RISK INJURY FACTORS, CAUSES AND MECHANISMS OF

INJURY OCCURENCE

Sport, apart from its positive effects on the physical body, also brings risks

of injuries. In order to reduce the existing risk, it is necessary to determine

the exact causes of injury and its components caused by sports activities. It

is necessary to recognize the risks of injuries and try to manage with them.

Fuller et al., 2011 quotes that it is important to set an objective target that

does not include the reduction of risk of injury to zero, but this risk should

be reduced to the acceptable levels. Fuller also made the scheme of

management injuries risks:

Scheme 1. Management of injury risks (Fuller, 2006).

This scheme shows that on the occurrence of injury may influence two types

of risk factors - external and internal risk factors. Bahr et al, 2005 has

asserted that injury can be caused by a single incident event that is the

consequence of the complex interaction between the external and

internal risk factors.


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Internal risk injury factors, such as age, sex and body composition can

affect on the increased injury risk and predispose an athlete to occurrence of

injury. The internal risk factors are specific for each athlete individually and

it is very difficult to influence on them.

External injury risk factors reflect the environment in which athlete

exercise and by omission or change of negative external factors, it is much

easier to influence on them. For example, risk factors such as friction

between surface and sport shoes can modify and change the risk factors that

can further increase the risk of injury in athletes. The existence of these risk

factors is not by itself sufficient for the occurrence of injuries. The sum of

these risks and the interaction between them lead athletes to the injury

that may occur in certain incidental situation (Bahr et al, 2005).

Scheme 2. Complex interaction between internal and external risk factors

that leading to injury (Bahr et al., 2005).

There are three models that describe the risk injury factors in sports:

Meeuwiss multifactorial model

Biomechanical model

Comprehensive injury causation model (Bahr et al., 2005).


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Meeuwisses model explains incidental event as a final content of chain that

causes injury, and this event is usually a trigger for the occurrence of that

injury.

Biomechanical model of injury mechanism takes into account the

characteristics of the tissue and characteristics of the forces. Mechanical

characteristics of the human body such as stiffness (relationship of stress

and strains) and the ultimate power, tell us about the way in which body

responds to physical loads. Features vary for each type of tissue and depend

on the nature and type of force, frequency and repetition of force, magnitude

of transferred energy and internal factors such as age, sex and physical

condition. The relationship between force and force tolerance determine

how will injury look after incidental events. The key issue is to explain how

mechanical forces are tolerated under normal circumstances or at the

reduced degree of tolerance, to the point where normal mechanical forces

can not be tolerated.

Tolerance of force is largely determined by internal risk factors, for

example, the properties of ligaments and their sizes are determined by age,

sex, body size and previous training. The same factors may also affect on

force – for example large male football player can submit more force than

smaller female gymnast when performing the same task.

External risk factors also affect on the force; protective equipment such as

helmets reduces force, while training on hard surface increases the force.


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McIntosh described the complex biomechanical model that describes the

interaction of force and force tolerance (positive or negative) with other

factors such as attitude / behavior of players, training, skill level,

quality and types of equipment, kind of training, influence of other

competitors and the environment.

The importance of this model is a description of how forces and tolerance of

forces can be changed through intervention. For example, exercising some

new skills can influence on different situations and allow that athlete

maintain a balance what can reduce the load on the knee in the frontal and

transverse plane.

Improved condition can protect tissue from injury and through the effects of

training change its properties, but also result in more loads that can be

applied on the tissue. For example, improved strength at handball player

also develops a stronger throwing of the ball. This can affect on the larger

forces in the shoulder, but also on the larger forces at the goalkeeper during

defense action.

Comprehensive injury causation model is based on Meeuwisse model that

besides the biomechanical factors also account for the factors of sport. In

this model the internal and external risk factors can affect on the force and

on the force tolerance (Bahr et al., 2005). The model is shown below in the

slide:


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Scheme 3.Comprehensive model for injury causation. BMD, Body mass

density; ROM, range of motion (Bahr et al, 2005).

Regard to the model, a precise description of the incident event is of the

critical importance. The point is to describe accurately the incident event,

for truly understanding of injury mechanism. To complete description of

mechanism for the occurrence of certain injuries, it should be added

described situation which leads to the formation of certain injuries (game

situation, the behavior of players and his opponents), but also a detailed

description of the entire biomechanical movements of the body and the joint

movement in the moment of injury. For prevention, it is important to know

how external and internal risk factors modify the risk of injury.


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Review of internal and external risk injury factors, and causes of

injuries founded by reviewing of the scientific literature:

8.1. Internal injury risk factors

8.1.1. Aging

The aging process is changing anatomical and physiological properties of

athletes. Puberty is a period of life when large changes in the body occur,

especially physically and mentally maturing of the child (Klemenčič, 2008;

Marković, 2009). Most studies show that the highest incidence of injuries is

present in older adolescents and seniors. Cause of the increased incidence of

injuries, due to aging, may be because of maturity, as well as the increased

number of competitions in the older adolescent age and increased load

during games. Adolescents in that time go further (grow up), to professional

clubs with entire duration of the trainings or matches.

Football: All reviewed reports confirm that the relative risk for injuries in

football increases with the age of the athlete (Brito et al, 2012; Olsen et al,

1985; Junge et al. 2003; Price et al, 2004; Kucera et al, 2005; Froholdt et al,

2009). Brito et al., 2012 found that the greatest risk was at U19 population,

compared with younger age groups. Similar information was given by Price

et al, 2004, who shows that the players in the older age group (17-19 years)

were more exposed to the risk of injuries than in younger age group (9-16

years). In his research exceptions in the incidence of injuries were the

goalkeepers, where the highest incidence of injury was between 14-15

years.


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Froholdt et al, 2009 also shows that the incidence of injury is greater in

older adolescent population aged 13-16 years. Injuries classified among the

younger population were mostly lightweight nature. Kucera et al, 2005

study is consistent with previous research.

Handball: Olsen et al, 2005, 2006 believe that aging is one of the main

factors for the occurrence of injuries in handball. Unfortunately, in handball

there are just few studies dealing with this issue, to confirm this hypothesis.

Author reports that incidence of injuries in handball in adolescents aged

between 12-14 years is very similar to the incidence of injuries in seniors.

Moller et al, 2012 argues that seniors had a higher incidence of injury

compared with players aged 15-18 years. The incidence of injury grows

with age. Dirx et al., 1992 confirmed that older players (more than 20 years)

had significantly greater risk of injury than players under20 years of age.

Basketball: Increased incidence of injuries in older adolescents between 15-

19 years of age may reflect the fact that adolescents of this age are more

firmly loyal to basketball than younger age groups. Physical development

has an impact on the rate of injury because adolescents tend to be faster,

stronger and bigger with growing up (Randazzo et al, 2007).

8.1.2. Sex

Many authors do their researches on oynl one sex, and it is very difficult to

determine accurately whether or not is a specific injury more common at

the male or the female population (Luigi & Henke, 2010). A typical

example is the large number of researched ACL injuries, especially on

females.


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Handball: Dervišević, 2005 found out that in Slovenian athletes gender is

not a key factor for the occurrence of injuries. A similar result presented

Frisch et al., and Seil et al, 2008, which explored the girls and boys from

different sports disciplines who were aged up to 19 years. Olsen et al, 2006

in his study also noted that there were no gender differences in the rate of

incidence of injury.

Looking only on team sports Dervišević found that girls have more injuries

than boys of the same age, especially in the area of the knee and ankle. On

increased incidence of injuries in adolescent female players influence the

factor of psychological stress and emotional instability (Medvešek et al,

2011). Myklebust 1998 and 2003 reported an eight times higher incidence

of injuries during the match at the girls.

Henke 2003 showed that the largest number of injuries in Germany

happened to female players of handball, looking at a variety of team sports

(22%), (Luigi & Henke, 2010). Injuries of ACL occurred 3-5 times more at

adolescents females than in adolescent males (Myklebust et al, 1998;

Myklebust et al, 2003; Olsen et al, 2005; Arendt & Dick, 1995; Hutchinson

& Ireland, 1995; Arendt et al, 1999 Wedderkopp et al, 1999). The causes for

such a big difference between sexes in the occurrence of knee injuries are

still not completely understood. It is possible that girls are easier susceptible

to the occurrence of injuries due to their inferior morphology.

Moller et al, 2012 told that sex was only risk factor for injuries at U18

population, where boys had 1.8 times higher risk for injury than girls.

Reason for this result may be a relatively small sample.


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Basketball: Basketball injury rate was highest in the 13 annual girls and 15

year old boys. This result may lead to think that the older girls reduces

interest in sports, compared with boys who later in life have constantly

increasing number of injuries (Randazzo et al, 2007).

8.1.3. Factors associated with growth

One of the main characteristic of adolescence is growth and development of

the psycho-physical attributes of the adolescent. During this period,

cartilaginous structures are particularly vulnerable to heavy loads and to

forces generated during sporting activities. Due to rapid growing of long

bones which does not follow the proper extension of the muscle tendon

structures, muscle imbalances and injuries in muscle structure can occur.

As a consequence, some sudden acute injuries are possible, such as muscle

and tendons ruptures caused by excessive force that athletes‘ body can not

handle, and different chronic deformations may appear, like traction

apophysitis (for example anterior knee pain). Due to not coalesced

cartilage, the possibility of fractures is increased. Coaches must be aware of

the characteristics of adolescent growth and loading during training.

8.1.4. Body composition

Football: Bastos et al, 2013 did not found a significant difference in body

mass index and incidence of injuries among groups that have been injured,

and among these which have not been injured. However, it was confirmed

that a tendency that increased body mass index can lead to injury. The

higher players reported more knee and ankle injuries in comparison with the

body. There was no statistically significant difference.


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Basketball: Heavier players had a greater incidence of injury, which is

particularly pronounced in players who play at position of the center

(Meeuwisse et al, 2003).

8.1.5. Poor biomechanical relationships and anatomical variation

Biomechanical dysfunctions are very common in adolescence, respectively

in period of peak height velocity and body development. Some better known

anatomical and biomechanical deformations are varus and valgus of the

knee, high positioned patella (patella alta), external rotation of the tibia, etc.

These anatomical variations can be a risk factor for the occurrence of

injuries (Agel et al, 2007).

Compensatory activities and improper movement patterns, may lead to the

injury in athletes who are extensively involved in sports, Disturbed

biomechanics affects on the occurrence of problems in proprioception.

Proprioception is a mechanism that involves a sense of motion in the joint

and a sense for joint position, which is very important for the functional

stability of the joint. Decrease of proprioception causes a loss of

neuromuscular control, leading to functional instability and possibly to

frequent injuries of joints. It seems that proprioception is changing during

adolescent period, especially during the most intensive phase of growth

(peak height velocity) in puberty (Brzić et al, 2012). Studies that examine

other sports indicate that hypermobility of joints affects on the increased

risk of injury in rugby or netball (Smith et al, 2005).


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8.1.6. Individual motor abilities

Football: It seems that players with lower capacities have increased risk for

occurrence of injuries (Frisch et al, 2011; Peterson et al., 2000; Junge et al.,

2002).

8.1.7. Physiological factors

During adolescence, with the growth and development of the body,

hormonal status of the organism also suffers changes. This is particularly

present in girls in which occurs the first menstruation - menarcha. High

intensity workouts and eating disorder can lead to delays of menarche

(amenorrhea). The consequence of this situation is reduced secretion of the

hormone estrogen, which can cause decreased bone density and occurrence

of fracture, stress fractures and similar. This syndrome is called female

athlete triad (amenorrhea, eating disorders and osteoporosis) (Malina et al,

2004; Marković et al, 2009).

8.1.8. Psychological risk factors

Participation in competitive sports have a very positive impact on the

personal and social development of children and adolescents, because it

encourages the development of self-esteem, self-confidence, self-control

and help adolescents to make autonomous decisions. Because of a lot

pressure on athletes and unfulfilled desires in sporting achievements, it can

lead to very serious anxiety and depressive episodes. In this sense, young

athletes may not report pain or injury and dissimulate injury, in order to

fulfill the expectations. This approach may lead to even greater worsening

of injury.


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Similar effects may occur due to problems in love life and relationships in

the team, where is present the importance of relationship between coaches

and players, and the players between themselves. In all of this very essential

role play the stage of the maturity of a person which have psychological and

emotional problems.

8.1.9. Previous injuries

Previous injuries are a common risk factor for their recurrence. Athletes

want a rapid recovery and fast return to activities and competition. Injured

body part needs necessary time to recover and to adapt on the high efforts

and loads that was accustomed before the injury.

Football: Kucera et al, 2005, has made a study, whose aim was to

determine whether players from the USA at the age of 11 - 18 years old with

previous injuries have a higher incidence of injury than athletes without any

injuries, based on the player's reports completed independently. More than

half of the reported had previous injuries (59.7%). By multivariate

generalized Poisson regression model was found that players with a

previous injury have a double risk of injury, and those players with two or

more previous injuries have three times higher risk of injury. Previous

injuries were associated with an increased rate of injury. This suggests that

young football players have increased risk for injury. Gall et al, 2006 and

Price et al, 2004 reported an identical incidence (3%) of recurring injuries.

They suggest that repetitive injuries may indicate inadequate rehabilitation

after injury or premature return to sports activities. Ergün et al, 2013

reported 25% of recurring injuries at elite Turkish players.


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Reccurens injuries were more often during trainings than in matches (p =

0.078). All injuries that were repeated was overuse injuries. The fact that

number of recurring injuries is lower in adolescent population than among

seniors suggests less pressure on adolescents for returning to competition

than on seniors. In a Turkish study, it is likely to be a bad training and too

much loading of the adolescents, no matter what they are top quality

footballers. Handball: Yde and Nielsen, 1990 found that in 32% of injured

handball players injury occurred on the same place. In female handball

players, with operated ACL were recorded 12% of new ruptured ligaments

on before operated knee, while in 16% of cases the pain occurred on the

other knee.

From this data it can be concluded that injuries and pain in the knee do not

have to always appear on the already injured knee. Due to altered kinetics of

movement and different loads, pain and injuries can occur on the other limb

or on the other joint. In handball with male players there is a similar

situation, where the incidence of re-rupture of ACL was 13%. In both

studies revealed, previous injury of ACL is not necessarily one of the key

risk factors for injury on the same knee (Olsen et al., 2005). Moller et al,

2012 stated that athletes with two or more previous injuries that caused

absence from handball more than 4 weeks have an increased risk of new

repeated injuries at U16 population. Wedderkopp et al, 1997 and Myklebust

et al. 2002, also found a great correlation between previous injuries and new

injuries, especially in terms of injuries of the lower extremities.


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Basketball: Reports of various studies show that the rate of recurrent

injuries in basketball can go up to 70%, while in Agel study the rate was

30% (Agel et al, 2007). When looking on recurrence injuries, knee was the

most problematic part of the body (Meeuwisse et al, 2003). The most

frequently repeated injuries are in the ankle area, and the history of ankle

injury is a major cause of recurrence of an ankle injury (Bruce et al, 2010).

8.2.External risk factors

8.2.1. Length of sports participation

In order to determine whether the length of sports participation affect on

injury factor, further researchings are necessary, due to lack of data and their

contradictory.

Football: Players who practiced football for more than 5 years have been

suffered more injuries than those who are engaged in football for a shorter

time (Bastos et al, 2013).

Contrary to this, Kucera et al, 2005 noted that longer engagement in football

is shown as a protective factor and uninjured players were usually those

who are practicing sports for a longer time. Handball: Playing handball

longer than 5 years has affected on the increase of injuries in handball, but

the incidence did not reach statistical significance (Dirx et al, 1992).

Basketball: It is established that participants who train longer have more

injuries than those who train less. The increased number of performances

can be a risk factor for the new injuries due to accumulated repetitive and

cumulative trauma during many years of trainings (Vanderlei et al, 2013).


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8.2.2. Matches as risk factor

Football: Gall et al, 2006 amounts information that there was a significant

difference in the incidence of injuries when comparing the incidence of

injury in training and matches (P


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Luigi & Henke, 2010 indicate that injuries in early adolescents between

training and matches are equally distributed, which is changing during

maturation and aging.

In professional athletes, injury in matches can represent up to 85% of all

injuries. This supports the conclusion that the match in adulthood has a

much greater significance. In order to achieve a good result, players in

adulthood played on ―all or nothing‖ during matches and under the

imperative of victory. In these ways players want to prove themselves on the

field and to ensure further progress and advancement. To achieve their

desires, players have to invest much more loading, force and willing to win

during matches than in training, which results with stronger, more

aggressive and dirtier game. Sometimes the role at adult players and cause

for that game has existential factors, e.g. money.

Players during training are investing less energy and are preserving each

other under control conditions, and that results with a smaller number of

injuries during training. Basketball: Similar data are also visible in

basketball. Randall et al, 2007 and Agel et al, 2007 reported that double

number of injuries occur during matches than during training. The

participants had double number of knee and ankle injuries in matches than

in training. Comparing the matches and trainings, there was in basketball at

the matches three times more concussions and three times more internal

injuries of the knee and twice more ankle sprains (Agel et al, 2007). A still

greater difference reports Meeuwisse et al, 2003 who said that about 3.7

times more injuries occur during matches than during training.


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8.2.3. Preseason as a risk factor

Most of researches found out that the incidence of injuries in analyzed team

sports are of interval nature. The most common injuries occur at the

beginning of the season (the preseason) in August and September and at the

beginning of the second part of the season, after winter break in January to

March, depending on the beginning or ending of the season.

Factors associated with an increased possibility of injury are the weaker

condition due to dead season, increased intensity of players who learn the

starting position, and fatigue due to start of the season.

Many players practice during the dead season, but without control and in

different ways, with bad equipment and so on. This can affect on

appearance of different injuries at the beginning of the season, including a

stress fracture.

Football: Brito et al, 2012 says that the incidence of injuries in training and

matches was not significantly different when looking at the season, but

claims that the overall incidence of injuries is greater in September than in

May and June. The incidence of injuries in training was higher in September

than in May and June, while the highlight of injury in a game was in

October.

About similar incidence of injuries reported also: (Agel et al, 2007; Deehan

et al, 2007; Price et al, 2004; Gall et al, 2006). Deehan et al, 2007 shows

that the peak of injuries occurrence was at the beginning of September and

March, and that similar incidence of injuries was visible during all five

years of researching.


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Gall et al, 2006 and Deehan et al 2007, suggested that injuries occurred at

the beginning of the season are consequence of unequaled appropriate

conditioning and non optimal physiological and physical condition of the

players. The hypothesis that could explain the increased incidence of

injuries after the holiday is increased physical activity or changes in activity.

The incidence of injuries is growing swiftly after the summer or after the

winter break and then decreases until the

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Causes and Prevention of Injuries in Football (Soccer), Handball and Basketball at Adolescents...

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