Sports Med (2014) 44:1733–1748

DOI 10.1007/s40279-014-0234-2

SYSTEMATIC REVIEW

Exercise-Based Injury Prevention in Child and Adolescent Sport:

A Systematic Review and Meta-Analysis
Roland Rössler • Lars Donath • Evert Verhagen •
Astrid Junge • Thomas Schweizer • Oliver Faude

Published online: 17 August 2014

 Springer International Publishing Switzerland 2014

Abstract and with respect to different characteristics of the target

Background The promotion of sport and physical activity group, injury prevention program, and outcome variables.
(PA) for children is widely recommended to support a Data Sources An Internet-based literature search was
healthy lifestyle, but being engaged in sport bears the risk conducted in six databases (CINAHL, Cochrane, EM-
of sustaining injuries. Injuries, in turn, can lead to a BASE, ISI Web of Science, PubMed, SPORTDiscus) using
reduction in current and future involvement in PA and, the following search terms with Boolean conjunction:
therefore, may negatively affect future health as well as (sport injur* OR athletic injur* OR sport accident*) AND
quality of life. Thus, sports injury prevention is of partic- (prevent* OR prophylaxis OR avoidance) AND (child* OR
ular importance in youth. adolescent OR youth).
Objective The aim of this systematic review was to Study Selection Randomized controlled trials and con-
quantify the effectiveness of exercise-based injury pre- trolled intervention studies in organized sport, published in
vention programs in child and adolescent sport in general, English in a peer-reviewed journal, analyzing the effects of
an exercise-based injury prevention program in athletes
younger than 19 years of age.
Data Extraction Two reviewers evaluated eligibility and
Electronic supplementary material The online version of this methodological quality. Main outcome extracted was the
article (doi:10.1007/s40279-014-0234-2) contains supplementary
material, which is available to authorized users.
rate ratio (RR). Statistical analyses were conducted using
the inverse-variance random effects model.
R. Rössler (&)
L. Donath
T. Schweizer
O. Faude Results Twenty-one trials, conducted on a total of 27,561
Department of Sport, Exercise and Health, University of Basel, athletes (median age 16.7 years [range 10.7–17.8]), were
Birsstrasse 320 B, CH-4052 Basel, Switzerland
included. The overall RR was 0.54 (95 % CI 0.45–0.67)
e-mail: [email protected]
[p \ 0.001]. Girls profited more from injury prevention than
E. Verhagen boys (p = 0.05). Both prevention programs with a focus on
Department of Public and Occupational Health, specific injuries (RR 0.48 [95 % CI 0.37–0.63]) and those
EMGO? Institute for Health and Care Research, VU University
aiming at all injuries (RR 0.62 [95 % CI 0.48–0.81]) showed
Medical Center, Amsterdam, The Netherlands
significant reduction effects. Pre-season and in-season
E. Verhagen interventions were similarly beneficial (p = 0.93). Studies
Australian Centre for Research into Injury in Sport and its on programs that include jumping/plyometric exercises
Prevention (ACRISP), Federation University Australia, Ballarat,
showed a significant better (p = 0.002) injury preventive
VIC, Australia
effect (RR 0.45 [95 % CI 0.35–0.57], Z = 6.35, p \ 0.001)
A. Junge than studies without such exercises (RR 0.74 [95 % CI
FIFA-Medical Assessment and Research Centre (F-MARC), 0.61–0.90], Z = 3.03, p = 0.002).
Zurich, Switzerland
Conclusions The results provide good evidence and
A. Junge clearly demonstrate beneficial effects of exercise-based
Medical School Hamburg (MSH), Hamburg, Germany injury prevention programs in youth sports as they can

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1734 R. Rössler et al.

result in statistically significant and practically relevant [18] show that organized sport is the main cause of injury
injury reduction. In particular, multimodal programs in adolescents. This is further supported by recent data
including jumping/plyometric exercises can be recom- from Sweden showing that sport is the most common cause
mended. However, there is a considerable lack of data for of injuries in 11- to 18-year-olds [19]. Prospectively
children (under 14 years of age) and for individual sports assessed injury incidences range between 0.50 (95 % CI
in general. Future research should include these groups and 0.29–0.71) per 1,000 h of physical education (PE) classes
focus on the effect of specific exercises and compliance. for 10- to 12-year-old children and 63.0 (95 % CI
57.5–69.1) injuries per 1,000 match hours in U18 male
rugby union football players [20, 21].
In the US, children aged 6–12 years spend an average of
Key Points
5–6.5 h per week doing sport [22]. It is estimated that each
year more than one-third of school-age children sustain a
There is good evidence that exercise-based injury
PA-related injury that needs medical care. Based on
prevention programs can result in an injury reduction
30 million children and adolescents participating in sports
of around 46 % in organized youth sport
in the US, the costs of treating these injuries were esti-
Jumping/plyometric exercises appear to be mated to be $1.8 billion per annum in 1997 [23]. In The
particularly relevant for injury reduction Netherlands. direct medical costs of PA injuries in children
The beneficial effects are independent of whether the were estimated at €170 million (plus indirect costs of €420
program is implemented during the pre-season or in- million) in 2003 [24]. In Australia. sport-related injuries in
season children younger than 15 years of age, accounted for 3.1
times the number of years lost to disability, 1.9 times the
number of bed-days, and 2.6 times the direct hospital costs
compared with road trauma. From 2002 to 2011, the
number of sports injuries leading to hospitalization showed
a significant yearly increase of 4.3 % (95 % CI 3.4–5.4)
1 Introduction
[25].
Injuries are an unfortunate consequence of participation
Physical inactivity is one of the leading causes of chronic
in sport, and every effort must be made to prevent their
diseases, and largely contributes to the burden of disease,
occurrence. The strong need for PA on the one hand and
death, and disability worldwide. Physical activity (PA) has
the negative outcome of sport-related injuries on the other
proven to cause immediate positive effects on health risk
hand clearly demonstrate the importance and necessity of
factors, skeletal and psychological health, as well as on
sports injury prevention in youth.
mental, cardiorespiratory, and neuromuscular fitness in
Few narrative [26–29] or systematic [12, 30–34] reviews
children and adolescents [1–3]. In addition, participation in
on risk factors and/or injury prevention in children and
organized youth sport is positively associated with a higher
adolescents have been published. To our best knowledge,
level of adult PA [4, 5]. It can be stated that youth sport has
no meta-analysis quantitatively investigated the effective-
important implications for long-term individual and public
ness of exercise-based programs to reduce sport-related
health benefits. Therefore, PA must be fostered starting at a
injuries in children and adolescents. Thus, the aim of this
young age [6, 7].
meta-analysis was to quantify the effectiveness of exercise-
However, participating in sports bears a risk of sus-
based injury prevention programs in organized sports in
taining an injury. Sport and recreational activities are the
athletes under 19 years of age. The detailed objectives
leading cause of injury in youth [8–10]. Injuries in young
were:
athletes can lead to a reduction in current and future
involvement in PA [11]. This, in turn, may have consid- 1. To quantify the effect of exercise-based injury pre-
erable impact on future health as well as on quality of life vention in children and adolescents based on a meta-
[12]. The economic burden associated with injury involves analysis of (cluster-) randomized controlled trials
medical, financial, and human resources at many levels. As (RCTs) and controlled intervention studies in orga-
such, it relates to the individual and society as a whole [13– nized sports.
15]. 2. To describe the characteristics of the study population
In a Swiss survey, sport-related injuries (organized and and the intervention.
non-organized sports) represented 55–60 % of all self- 3. To calculate cumulative effects and effects for specific
reported injuries in 9- to 19-year-olds [16]. Data from the subgroups.
US [17], Canada [8], France, The Netherlands, and the UK 4. To provide recommendations for future research.

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Exercise-Based Injury Prevention in Child and Adolescent Sport 1735

2 Methods results. In case of disagreement that arose between the first

two raters, a third rater (OF) was consulted and consensus
2.1 Literature Search Strategy and Selection of Studies was achieved.

The present meta-analysis was conducted without an open- 2.3 Data Extraction
access research protocol. Relevant studies were identified
using an Internet-based search in six databases from Relevant study data were independently extracted by two
inception until 14 October 2013 (electronic supplementary researchers (RR and TS). These data comprised, amongst
material [ESM] S1). The following search terms were used others, country, study design, number, age, and sex of the
with Boolean conjunction: (sport injur* OR athletic injur* athletes in the intervention and the control group, type of
OR sport accident*) AND (prevent* OR prophylaxis OR sport and level of performance, content, duration and
avoidance) AND (child* OR adolescent OR youth). The implementation of the prevention program, compliance,
search was conducted by two researchers (RR and TS) study duration, injury definition, number of injuries, and
independently. Moreover, citation tracking and hand exposure measurement.
searching of key primary and review articles were carried
out. 2.4 Statistical Analysis
The inclusion criteria were:
We used the data of the primary outcome of each study.
• full-text paper published in English in a peer-reviewed
Whenever reported in the publication, the rate ratio (RR)
journal;
adjusted for clustering was used. Otherwise raw data (num-
• prospective controlled intervention study (randomized
ber of injuries and exposure measure) were extracted and
RCT, quasi-experimental, case control, or cohort
used to calculate the RR of the study. In some cases [35–42],
design) with one group not receiving any intervention;
values had to be calculated (using the incidence rate and the
• assessing the effect of an injury prevention program in
number of injuries/the exposure measure). If necessary,
organized sports;
injury incidence rates were calculated for each study arm
• intervention program based on/utilized physical
(intervention and control group). These injury incidences
exercises;
represent a proportion of the injury frequency based on either
• participants were younger than 19 years of age;
a time component (e.g. per 1,000 player hours) or a countable
• Outcome variables include number of injuries and
number (e.g. per 1,000 athlete sessions). The RR was then
exposure data and/or injury incidence.
calculated by dividing the injury rate of the intervention
The exclusion criteria were: group by the injury rate of the control group.
A natural logarithm transformation of all RRs was
• combined injury data from organized and unorganized
conducted. According to the Cochrane Manual, the stan-
sports (e.g. global injury incidence of high-school
dard error of the natural-logarithm-transformed RRs was
sports and leisure time PA) without specifying sepa-
calculated [43]. The inconsistency statistic was used to
rated data;
measure the heterogeneity of the included studies. Because
• study on (only) currently injured athletes or sample with a
the observed value was moderate to high (71 %) within the
specific health problem (e.g. obesity, recurrent injuries).
group of eligible studies [44], the analysis was conducted
According to the above-mentioned criteria, final inclu- using a random effects model [45]. The inverse-variance
sion/exclusion decision was made by two researchers (OF method according to Deeks and Higgins [46] was calcu-
and RR). lated by means of the Cochrane Review Manager Software
(RevMan 5.1, Cochrane Collaboration, Oxford, UK; ESM
2.2 Assessment of Methodological Quality S3). To assess the risk of a potential publication bias, a
funnel plot was created (ESM S4).
The methodological quality of eligible studies was rated Three risk-of-bias-related sensitivity analyses to detect
using a study quality score developed by Abernethy and potential influences of methodological differences between
Bleakley for a review on the same topic [30]. The scale studies were conducted:
consists of a 9-item checklist whereby, for each item, 0, 1
• influence of study quality;
or 2 points are attainable, enabling a maximum rating of 18
• influence of randomization;
points (ESM S2).
• influence of type of exposure measurement.
To increase rating accuracy, two researchers (LD and
RR) independently conducted the rating process. The raters Comparison of effects between the following subgroups
were not blinded to study authors, place of publication, and was accomplished:

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1736 R. Rössler et al.

• boys/girls; and 3 met the exclusion criteria (Fig. 1). The remaining 21
• elite level/sub-elite level; studies were included in the quantitative analysis.
• football (soccer)/handball/basketball;
• pre-season/in-season/pre-season and in-season; 3.2 Characteristics of Study Population, Intervention
• balance exercises/jumping and plyometric exercises; and Outcome Variables
• all/specific injuries (lower extremity, knee, and ankle
injuries). The included studies comprised 27,561 athletes, with a
median sample size of 829 (range 50–5,703) per study
To test for a potential ‘shift in injury severity’ due to the
(Table 1). The median age of those studies that reported
intervention, three injury categories were compared—mild/
athlete age was 16.7 years (range 10.7–17.8). Only one
moderate/severe injuries.
study focused on primary-school children under the age of
14 years [47], and some others included children younger
than 14 years but did not report separate age-related data
3 Results [48–52]. Ten studies involved girls only [35, 36, 38, 40–42,
50, 52–54], four studies involved boys only [37, 39, 51,
3.1 Trial Flow 55], and seven studies involved both sexes [47–49, 56–59].
In total, just 12.7 % of participants were boys. Four studies
Of 1,835 potentially relevant articles, 94 full-texts were (10.5 %) investigated the elite level [39, 51, 53, 55, 56], 15
retrieved, of which 70 did not meet the inclusion criteria (82.2 %) investigated the sub-elite level [35–38, 40–42,

Fig. 1 Flow diagram of the

literature selection process

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 Exercise-Based Injury Prevention in Child and Adolescent Sport
Table 1 Overview of studies investigating exercise-based injury prevention programs (alphabetical order by first author)
References, Athletes (n), age Type of sport, Type and duration of prevention program Duration and time of Injury definition and data collection Study quality,
study type, (years)a, sex (% level of session, frequency, difficulty, compliance intervention method type of
country boys) performance injuries, rate
ratio (95 %
CI)

Collard et al. 2011 pupils Diverse sports, 5-min training (strength, coordination, 8 months’ Sports club injury leading to medical 14
[47], cluster (IG 1,015, CG 996), primary speed, and flexibility exercises) at intervention attention or time loss, weekly self- All injuries:
RCT, The age IG 10.7 (0.8), school beginning and end of each PE class and (19 months’ reported (questionnaire)
0.69
Netherlands age CG 10.7 (0.8), children pedagogic approach focusing on children follow-up during
(0.28–1.68)
49.1 and parents, twice per week, continuous school year,
difficulty, compliance 99.9 % January 2006–July
2007)
Cumps et al. 50 players Basketball, 5- to 10-min basketball specific balance 22 weeks Medical attention and time loss, weekly 10
[56], (IG 26, CG 24), age elite training on balance semi globes, three self-reported (questionnaire) Acute lateral
controlled IG 17.7 (3.9), age sessions per week, progressive difficulty ankle sprain:
clinical pilot CG 18.0 (2.7), 68 (four different phases), compliance NA
0.34
trial, Belgium
(0.12–0.96)
Emery et al. 114 pupils Diverse sports, 20-min proprioceptive home-based balance- 6 months (Autumn Medical attention or time loss, self- 13
[57], cluster (IG 60, CG 54), age PE classes, training program (static and dynamic 2001) reported (bi-weekly telephone calls to all All injuries:
RCT, Canada IG 15.9 high school balance) including wobble board exercises, participants by physiotherapist)
0.20
(15.6–16.1), age daily during 6 weeks then one session per
(0.05–0.88)
CG 15.8 week throughout season, progressive
(15.5–16.0), 50 difficulty, compliance did not have a
significant effect on change in dynamic
balance
Emery et al. 920 players Basketball, 15-min warm-up routine (including aerobic, 1 year (one 18-week Medical attention, removal from current 15
[49], cluster (IG 494, CG 426), sub-elite static/dynamic stretching and balance season: November session or time loss, assessed by blinded All injuries:
RCT, Canada age IG median 16 (high school) training); 20-min home exercise on wobble 2004–March 2005) therapist
0.80
(13–18), age CG board, before all practice sessions
(0.57–1.11)
median 16 (approximately five sessions per week),
(12–18), 50.4 continuous difficulty, compliance 60.3 %
(home training)
Emery [48], 744 players Indoor 15-min warm-up program with 1 year (one 20-week Medical attention, time loss or removal 15
cluster RCT, (IG 380, CG 364), football, sub- neuromuscular training (core indoor season: from a session, assessed by blinded All injuries:
Canada U13–U18 players, elite strengthening, single-leg jumps, single-leg October 2006– therapist
0.62
44.6 balance) at the beginning of each training/ March 2007)
(0.39–0.99)
match and 15-min home-based wobble
board sessions, continuous difficulty,
compliance NA
Heidt et al. [35], 300 players Football, sub- Pre-season conditioning program including 7-week pre-season Time loss, assessed by blinded athletic 10
RCT, US (IG 42, CG 258), elite (high two training sessions on (inclined) intervention trainer All injuries:
123

age 14–18 years, 0 school) treadmill and one plyometric training program, 1-year
0.42
session per week, progressive difficulty, follow-up
(0.20–0.91)
compliance NA

1737
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123
Table 1 continued
References, Athletes (n), age Type of sport, Type and duration of prevention program Duration and time of Injury definition and data collection Study quality,
study type, (years)a, sex (% level of session, frequency, difficulty, compliance intervention method type of
country boys) performance injuries, rate
ratio (95 %
CI)

Hewett et al. 829 players Football, 60- to 90-min pre-season neuromuscular 6 weeks pre-season Medical attention and time loss (at least 6
[36], (IG 366, CG 463), basketball training program (including flexibility, intervention 5 days), assessed by athletic trainer and ACL or MCL
prospective age not available, and plyometrics, and weight training), three program, one diagnosed by physician injuries:
study, US 0 volleyball, sessions per week, progressive difficulty, school year/season
0.27
high school compliance 70 %
(0.06–1.23)
Junge et al. [37], 194 players Football, high- Prevention program (including warm-up and 2 Seasons (1999 and Time loss or physical complaint for more 9
prospective (IG 101, CG 93), skill (45 %) cool-down, stabilization of knee and ankle, 2000) [1-year than 2 weeks, documented weekly by All injuries:
controlled age IG 16.7, age and low-skill flexibility, strength, endurance, observation period] physicians
0.79
intervention CG 16.3, 100 (55 %) coordination, and promotion of fair play),
(0.59–1.06)
study, players progressive difficulty, compliance NA
Switzerland
Kiani et al. [50], 1,506 players Football, sub- 20- to 25-min intervention program February–October Medical attention, documented weekly by 9
community- (IG 777, CG 729), elite including physical sessions (warm-up, 2007 (one entire study investigator Acute knee
based age IG 14.7 (range strengthening, landing exercises) and a season and injuries:
intervention 12.7–18.6), age pedagogic approach (one seminar for 12 weeks’ pre-
0.17
trial, Sweden CG 15.0 (range athletes, parents and coaches), two season training)
(0.04–0.64)
13.0–17.6), 0 sessions per week during pre-season, one
session per week during regular season,
continuous difficulty, compliance 78 % in
pre-season, 99 % in regular season
LaBella et al. 1,492 players Football and 20-min neuromuscular warm-up training 1 season (2006 and Time loss, documented by research 13
[38], cluster (IG 737, CG 755) basketball, (including strengthening, plyometrics, 2007) assistants Lower
RCT, US age IG 16.2 (1.5), sub-elite balance and agility exercises) [abbreviated extremity
age CG 16.2 (1.1), (high school) version before match], mean 3.3 (SD 1.5) injuries:
0 sessions per week, progressive difficulty,
0.42
compliance 80.4 %
(0.30–0.59)
Longo et al. 121 players Basketball, 20-min neuromuscular warm-up training 9 months (August Time loss, reported by coaches and 13
[51], cluster (IG 80, CG 41) age elite (third (including strengthening, plyometrics, 2009–April 2010) recorded by blinded orthopedic specialist All injuries:
RCT, Italy IG 13.5 (2.3), age league) balance and agility exercises) [abbreviated
0.44
CG 15.2 (4.6), 100 version before match], six sessions per
(0.22–0.89)
week during the first month and three to
four during the following months,
progressive difficulty, compliance 100 %

R. Rössler et al.
 Exercise-Based Injury Prevention in Child and Adolescent Sport
Table 1 continued
References, Athletes (n), age Type of sport, Type and duration of prevention program Duration and time of Injury definition and data collection Study quality,
study type, (years)a, sex (% level of session, frequency, difficulty, compliance intervention method type of
country boys) performance injuries, rate
ratio (95 %
CI)

Malliou et al. 100 players Football, elite 20-min proprioception training (balance 12 months Time loss, bi-weekly by orthopedic 8
[39], (IG 50, CG 50), age training, football-specific balance training (2001–2002) surgeon, physiotherapist and/or trainer Lower
prospective IG 16.7 (0.5), age including balance exercises with Biodex extremity
controlled CG 16.9 (0.7), 100 Stability System, mini trampoline and injuries:
intervention balance boards), two sessions per week,
0.68
study, Greece difficulty NA compliance n.a
(0.49–0.95)
Mandelbaum 5,703 players Football, sub- 20-min warm-up program (including 2 seasons (2000 and Medical attention and confirmation via 9
et al. [40], (IG 1885, CG 3818), elite stretching, strengthening, plyometrics and 2001) MRI and/or arthroscopic procedure, Non-contact
prospective age 14–18 soccer-specific agility drills), continuous reported weekly by coach ACL
controlled difficulty, compliance NA injuries:
0
cohort study,
0.18
US
(0.08–0.42)
McGuine and 765 players Football and 10-min balance training program with a 4 weeks pre-season Time loss, reported by certified athletic 14
Keene [58], (IG 373, CG 392), basketball, balance board, five times a week during and during the trainers Ankle sprains:
cluster RCT, age IG 16.4 (1.2), sub-elite pre-season, three times a week during subsequent season
0.56
US age CG 16.6 (1.1), (high school) regular season, progressive difficulty,
(0.33–0.95)
31.6 compliance 91 %
Olsen et al. [59], 1,837 players Handball, sub- 15- to 20-min warm-up program (including 1 season (8 months, Time loss or medical attention, recorded 16
cluster RCT, (IG 958, CG 879), elite running, technique, balance [with ball, September 2002– by ten blinded research physiotherapists Lower
Norway age IG 16.3 (0.6), wobble board or balance mat], strength April 2003) extremity
age CG 16.2 (0.6), and power exercises), once before the first injuries:
13.7 15 trainings, then one session per week,
0.51
progressive difficulty, compliance 87 %
(0.36–0.73)
Pfeiffer et al. 1,439 players Football, 20-min plyometric-based exercise program, 2 seasons/years Non-contact ACL injury resulting from a 6
[41], (IG 577, CG 862), basketball twice a week, progressive difficulty, mechanism of running and cutting or Non-contact
prospective age not available, and compliance NA landing (re-injuries excluded from the ACL
cohort study, 0 volleyball, statistical analysis), documented by injuries:
US high school coaches or athletic trainers
2.15
(0.44–10.66)
Scase et al. [55], 723 players Australian 30-min program (training of falling and 2 Seasons (2002 and Time loss (at least one game), documented 11
non- (IG 114, CG 609), rules landing skills), weekly during pre-season 2003), 8 weeks of by team doctor, physiotherapist or sports All injuries:
randomized age IG 17.0 (2.5), football, elite (eight sessions in total), progressive pre-season trainer
0.72
CT, Australia age CG 17.0 (2.6), U18 national difficulty, compliance NA intervention
(0.52–0.98)
100 competition
123

1739
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123
Table 1 continued
References, Athletes (n), age Type of sport, Type and duration of prevention program Duration and time of Injury definition and data collection Study quality,
study type, (years)a, sex (% level of session, frequency, difficulty, compliance intervention method type of
country boys) performance injuries, rate
ratio (95 %
CI)

Soligard et al. 1,892 players Football, sub- 20-min warm-up program during training 1 season (8 months) Time loss, recorded by physical therapist 16
[53], cluster (IG 1055, CG 837), elite (including running, strength, plyometrics (March–October and medical student Lower
RCT, Norway age IG 15.4 (0.7), and balance exercises) [abbreviated 2007) extremity
age CG 15.4 (0.7), version before match], approximately 2–6 injuries:
0 sessions per week, progressive difficulty,
0.71
compliance 77 %
(0.49–1.03)
Steffen et al. 2,020 players Football, sub- 20-min warm-up program (including 1 season (March– Time loss, recorded by blinded physical 16
[54], cluster (IG 1073, CG 947), elite U17 jogging, core stability, balance [with October 2005) therapists All injuries:
RCT, Norway age IG 15.4 (0.8), league balance mats], stabilization and hamstring including 2 months
1.00
age CG 15.4 (0.8), players strength exercises), once during the first 15 of pre-season
(0.83–1.20)
0 training sessions, then one session per
week, continuous difficulty, compliance
52 %
Waldén et al. 4,564 players Football, sub- 15-min neuromuscular warm-up program 1 season (7 months in Acute knee injury with time loss 16
[52], stratified (IG 2479, CG 2085), elite (including exercises focusing on knee 2009) (excluding contusions), recorded by ACL injuries:
cluster RCT, age IG 14.0 (range control, core stability, jumping and landing coaches
0.36
Sweden 12.0–17.0), age technique), two times per week,
(0.15–0.85)
CG 14.1 (range progressive difficulty, compliance 53 %
12.0–17.0), 0
Wedderkopp 237 players Handball, 10- to 15-min balance training with ankle 1 season (10 months, Time loss or considerable discomfort, 8
et al. [42], (IG 111, CG 126), recreational, disks and warm-up program including August 1995–May recorded by coaches All injuries:
cluster RCT, age 16–18, 0 intermediate jumps and medicine ball training, at all 1996)
0.26
Denmark and elite practice sessions (approximately one to
(0.14–0.45)
five times per week), progressive difficulty
possible, compliance NA
a
Data are mean (SD) except where otherwise stated
RCT randomized controlled trial, CT controlled trial, IG intervention group, CG control group, U13 under 13-year category, U17 under 17-year category, U18 under 18-year category, PE
physical education, NA Not available, MRI magnetic resonance imaging, ACL anterior cruciate ligament, MCL medial collateral ligament, CI confidence interval

R. Rössler et al.
Exercise-Based Injury Prevention in Child and Adolescent Sport 1741

48–50, 52, 54, 57–59], and one study (7.3 %) investigated To determine whether the methodological quality of
participants of PE classes at school [47]. included studies affected the cumulative effect, ‘high-’
Nine studies exclusively analyzed football players [35, and ‘poor-quality’ studies were compared. The cumu-
37, 39, 40, 48, 50, 52–54], and four further studies included lated RR of ‘high-quality’ studies (0.59 [95 % CI
football together with other types of sport [36, 38, 41, 58]. 0.46–0.76]) and ‘poor-quality’ studies (0.47 [95 % CI
Two studies focused on handball [42, 59] and three on 0.33–0.67]) was not significantly different (p = 0.29).
basketball [49, 51, 56]. Ten studies aimed at prevention of Studies with a randomized design (0.54 [95 % CI
all injuries [35, 37, 42, 47–49, 51, 54, 55, 57], and 11 0.42–0.70]) did not significantly differ from non-ran-
aimed at injuries in specific body parts or specific diagnosis domized studies (0.54 [95 % CI 0.37–0.78], p = 0.99).
(lower extremity, knee, or ankle injuries) [36, 38–41, 50, Studies reporting exposure based on hours or number of
52, 53, 56, 58, 59]. Three studies investigated the effect of sessions (RR 0.55 [95 % CI 0.44–0.68]) showed a
pre-season conditioning on injury incidence during the similar (p = 0.83) effect as studies with an exposure
subsequent season [35, 36, 55], 15 analyzed the effects of measurement based on athlete seasons (RR 0.51 [95 %
an intervention that was conducted during the competitive CI 0.30–0.89]).
season [37–42, 47–49, 51–53, 56, 57, 59], and three did
both [50, 54, 58]. Thirteen programs [35, 36, 38, 40–42, 47,
48, 50–53, 59] contained jumping/plyometric exercises, 3.5 Quantitative Data Synthesis
and eight [37, 39, 49, 54–58] contained no such exercises.
Fourteen programs [38, 39, 42, 48–54, 56–59] consisted of The cumulative analysis showed a significant overall effect
or included balance exercises, while seven studies [35–37, of injury prevention programs in children and adolescents
40, 41, 47, 55] did not. Eighteen studies used an exposure (RR 0.54 [95 % CI 0.45–0.67]; Fig. 2).
measure based on hours or the count of training sessions/ Studies showed significant beneficial prevention effects
games [36–38, 40–42, 47–56, 58, 59], and three used the (p \ 0.001) for minor (RR 0.75 [95 % CI 0.63–0.88]),
number of athletes or moderate (RR 0.58 [95 % CI 0.44–0.78]) and severe
athlete seasons [35, 39, 57]. Twelve studies reported (RR 0.68 [95 % CI 0.51–0.90]) injuries, with no significant
injury severity data [37, 39, 42, 48–51, 53–55, 58, 59]. difference (p = 0.36) between the three degrees of injury
severity (minor B1 week of absence, moderate 1–2/3/
3.3 Quality of the Studies 4 weeks of absence, severe C2/3/4 weeks of absence).
There was similar effectiveness of programs in reducing
Thirteen studies used a (cluster-) randomized design [35, ‘all’ (RR 0.62 [95 % CI 0.48–0.81]), ‘lower extremity’
38, 42, 47–49, 51–54, 57–59], and eight studies investi- (RR 0.57 [95 % CI 0.44–0.72]), and ‘ankle’ (RR 0.51
gated effects compared to a control group in a non-ran- [95 % CI 0.31–0.81]) injuries (Fig. 3).
domized setting [36, 37, 39–41, 50, 55, 56]. By trend (p = 0.10), injury prevention of ‘knee’ injuries
On average, the quality score of the studies was 11.8 (RR 0.32 [95 % CI 0.15–0.68]) was more effective com-
(standard deviation [SD] 3.3), ranging from 6 to 16. The pared with the subgroup of studies focusing on ‘all’
mean score of the 11 ‘high-quality’ studies was 14.6 (SD injuries.
1.2) [38, 47–49, 51–54, 57–59], and of the 10 ‘poor-qual- Injury prevention programs were significantly more
ity’ studies, mean score was 8.6 (SD 1.6) [35–37, 39–42, effective when exclusively girls were targeted (RR 0.44
50, 55, 56]. The most obvious differences between these [95 % CI 0.28–0.68]) than when only boys were included
studies were definition of inclusion and exclusion criteria; in the study (RR 0.71 [95 % CI 0.60–0.85], p = 0.05).
description of dropouts, including dropped-out participants, Studies on the sub-elite level (RR 0.51 [95 % CI
in the analysis; blinding of injury assessors; and randomi- 0.39–0.67]) tended to show greater injury reduction than
zation of participants. There were nearly no differences studies on elite athletes (RR 0.67 [95 % CI 0.55–0.80],
between ‘high-’ and ‘poor-quality’ studies concerning the p = 0.11). Studies on programs that included jumping/
definition of outcome measure, active surveillance/appro- plyometric exercises showed a significantly greater injury
priate duration of the study period, and description of the preventive effect (RR 0.45 [95 % CI 0.35–0.57]) than
applied intervention program (ESM S5). studies without such exercises (RR 0.74 [95 % CI
0.61–0.90], p = 0.003).
3.4 Risk of Bias No significant differences were observed between
studies on football, handball, and basketball (Fig. 4); pre-
The funnel plot (ESM S4) showed neither a perfect funnel- season conditioning, programs during season and pre-sea-
shape nor an obvious publication bias, although it seems son- plus in-season-conditioning (p = 0.93); and programs
that small-sized studies with indifferent effects are missing. with and without balance exercises (p = 0.76).

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1742 R. Rössler et al.

Fig. 2 Overall effect of exercise-based sport injury prevention programs (sorted by weight). SE standard error, IV inverse-variance, CI
confidence interval, df degrees of freedom

4 Discussion concluded that programs are effective in reducing injury

risk and recommend age-appropriate strength and neuro-
4.1 Comparison with Other (Systematic) Reviews muscular balance exercises. Gagnier et al. [60] also focused
on ACL injuries. They conducted a systematic review and
To date, no meta-analysis was available that specifically meta-analysis of ACL prevention programs in adolescents
examines the effects of injury prevention programs in and adults and found a significant reduction of injuries
children and adolescents. Ten years ago, Emery wrote a (RR 0.49 [95 % CI 0.30–0.79]). Myer et al. [61] conducted
systematic review on risk factors in child and adolescent a meta-analysis to investigate whether the effectiveness of
sport [12]. Mainly based on the evidence presented in case- ACL injury prevention programs in female athletes is age
control and cross-sectional studies, she concluded that dependent. They found an age-related association between
injury prevention programs targeting potentially modifiable the application of injury prevention programs and reduction
risk factors are warranted and proprioceptive training is of ACL incidence, and recommended the implementation of
recommended. She noted that there is only limited evi- ACL prevention during early adolescence. Herman et al.
dence from high-quality studies, especially RCTs. [62] systematically reviewed neuromuscular warm-up pro-
In 2007, a systematic review of Abernethy and Bleakley grams, which require no additional equipment, for pre-
which included seven studies, reported beneficial effects of venting lower-limb injuries. They found beneficial effects
sports injury prevention programs in adolescent sport in five different prevention programs. Six of the studies they
(without providing a quantitative synthesis) [30]. Cur- included comprised youth athletes. Thus, we also consid-
rently, sports injury prevention is a trending topic, and ered these studies.
within the last 6 years, since the review by Abernethy and Van Beijsterveldt et al. [63] conducted a systematic
Bleakley, ten studies have been published, of which eight review on exercise-based injury prevention programs with
were high-quality studies. Consequently, we included these a specific focus on football players. Although the focus of
in our systematic review and meta-analysis. In 2009, Frisch their review was not specifically set to youth athletes, five
et al. [32] systematically reviewed the effects of exercise- of six studies investigated youth football. Consequently, we
based injury prevention programs in youth sports. Without also included these five studies in our review.
providing a quantitative synthesis, they concluded that Nauta and colleagues [64] recently reviewed the effec-
injury prevention is effective when compliance to the tiveness of school- and community-based injury prevention
program is high. Our systematic review updates their programs on risk behavior and injury risk in 8- to 12-year-
findings as, since then, six new studies have been pub- old children. They concluded that the results with regard to
lished, of which five are high-quality studies. active prevention were inconclusive. This is probably due
Ladenhauf et al. [29] reviewed anterior cruciate ligament to the small number of exercise-based injury prevention
(ACL) injury prevention programs in young athletes. They studies in the school- and community-based setting.

123
Exercise-Based Injury Prevention in Child and Adolescent Sport 1743

Fig. 3 Effects of exercise-based sport injury prevention programs focusing on all (global), knee, ankle, and lower-extremity injuries. SE
standard error, IV inverse-variance, CI confidence interval, df degrees of freedom

The present systematic review is the first meta-analysis costs [15, 65]. The sensitivity analyses did not reveal sig-
that quantifies the effects of injury prevention programs in nificant differences with respect to study quality and type
children and adolescents in organized sports. It updates and of exposure measurement.
extends the systematic reviews of Frisch et al., as well as of
Abernethy and Bleakley [30, 32], and provides cumulative 4.3 Sex
and detailed analyses to clarify more specific questions in
particular subgroups. Most of the studies involved girls and, thus, boys were
highly underrepresented, accounting for just one-eighth of
all participants. This is in contrast to the higher PA par-
4.2 The Overall Effect of Injury Prevention Programs ticipation rates observed in boys compared with girls [66–
68]. The risk of sports injuries is similar for both sexes,
The cumulated overall effect size indicates an injury except for some specific types of injuries (e.g. ACL inju-
reduction of 46 %. This value is slightly reduced to 41 % ries, concussions) [69–72].
when only ‘high-quality’ studies are taken into account. The present meta-analysis revealed that girls profited
However, even a moderate reduction of all sports injuries is significantly more from injury prevention than boys. Based
of acute significance for young people’s health and could on the present data, it is speculative to assume that girls
have a short- and long-term economic impact on healthcare have a greater potential to respond to exercise-based injury

123
1744 R. Rössler et al.

Fig. 4 Effects of exercise-based injury prevention programs in football (outdoor only), basketball, and handball (sorted by weight). SE standard
error, IV inverse-variance, CI confidence interval, df degrees of freedom

prevention. As data for boys are underrepresented, further at least in team sports, the injury reduction effect seems to
research is required to clarify underlying reasons. be independent of the sports performed.

4.4 Level of Competition 4.7 Balance Exercises/Jumping or Plyometric

Exercises
Both elite and sub-elite athletes profited significantly from
prevention programs. The slightly lower effect in elite than Basically, balance exercises and plyometric/jumping
sub-elite athletes could be due to a ceiling effect, meaning exercises are two different approaches as one focuses on
that better trained athletes have less potential for further proprioception and the other one on lower-leg strength/
improvements (e.g. neuromuscular performance). To min- power. Therefore, these two concepts are compared with
imize the probability of ceiling effects, programs should regard to their effects on injury reduction [12, 36]. While
enable the possibility of variation and progression [32]. programs that incorporated balance exercises did not result
in an increased injury reduction, programs including
4.5 Timing of Implementation plyometric and jumping exercises showed a significantly
greater preventive effect than programs that did not apply
The comparison between programs that implemented ‘pre- such exercises. A possible explanation could be the fact
season only’, ‘in-season only’ or ‘pre-season and in-sea- that injuries are often related to high-impact situations
son’ revealed very similar effects. Based on this finding, (landing, change in moving direction, opponent contact)
injury prevention programs can be recommended regard- [53, 73], and that the neuromuscular system is best pre-
less of timing of their implementation. pared to resist these influences through high-intensity
exercises such as jumps and landings [36].
4.6 Type of Sport
4.8 Global Versus Specific Prevention Programs
No statistically significant difference was found between
studies on football, handball, and basketball. All three Although not significant (p = 0.10), a tendency towards
subgroups showed significant preventive effects and, thus, greater preventive effects of programs focusing on knee

123
Exercise-Based Injury Prevention in Child and Adolescent Sport 1745

injuries was observed. However, it has to be considered of the specific setting in which preventive measures are
that a certain amount of injuries is not preventable through applied. As the development of various different preven-
exercise-based programs (e.g. head injuries as a result of a tion programs seems to not be efficient, and current pro-
collision). This basic amount of injuries is not considered grams show similar effects, the current evidence may be
in studies with a ‘specific’ focus, whereas studies with a used to establish a blueprint for effective injury prevention
‘global’ focus include these non-preventable injuries in in children and adolescents.
their analysis. Thus, greater preventive effects are to be Injury prevention trials in children under the age of 14
expected in studies with a ‘specific’ focus. years are almost completely missing to date. Only one
study focused solely on primary-school children, and a few
4.9 Recommendations others included children younger than 14 years of age.
Thus, an analysis of the effectiveness of injury prevention
While it is of special importance to prevent severe injuries programs in different age groups was not possible.
such as ACL ruptures or severe ankle sprains, it can also be
argued that prevention programs should focus on the most 4.11 Directions for Future Research
frequent injuries. It is therefore recommended that injury
prevention targets the reduction of injuries in the broadest This meta-analysis shows promising beneficial effects of
possible way without losing its specificity to tackle the injury prevention programs in organized child and ado-
most severe injuries. It would seem reasonable to call for lescent sport, but more high-quality studies are required to
multimodal approaches that consist of different exercises, clarify the effect of specific exercises and the influence of
each one of which has a specific aim. We also have to be compliance. Studies on sports injury prevention in children
aware of the fact that some injuries will not be preventable under the age of 14 years, and in individual sports athletes,
through a modification of intrinsic risk factors. are desirable for the future.
Consistency with regard to injury definition and severity
4.10 Strengths and Limitations classification are key features to consolidate the evidence
in the future. The success of an injury prevention program
This systematic review was conducted according to the is not only based on a quantitative reduction of injuries but
PRISMA statement [74]. To the best of our knowledge, it is also on a reduction in severity of injury. Therefore, an
the first meta-analysis which cumulates the effects of injury intervention can be beneficial, even without an absolute
prevention programs in organized child and adolescent reduction of injury incidence, if the severity of injuries is
sport. It gives a comprehensive overview of current sci- reduced. Kiani et al. [50] explicitly reported such an effect;
entific evidence. As recommended by Impellizzeri and however, this needs to be substantiated by further research.
Bizzini [75], no cut-off in quality score was used, first to To increase the quality of future studies, authors should
avoid an influence of subjective study rating and, second, report the definition of inclusion and exclusion criteria, use
to get the broadest possible perspective. All subgroup an intention-to-treat analysis, and assure blinding of injury
analyses, except two, were planned a priori. The analyses assessors. As recently shown, the success of a sports injury
which compared mild, moderate, and severe injuries, and prevention program depends essentially on compliance
the analysis that focused on elite and sub-elite level, were [76]. A dose-response relationship of adherence to the
defined a posteriori. Therefore, the findings of these two program and injury reduction effect was found [52, 76, 77].
analyses are exploratory and hence preliminary in nature, Therefore, it is of particular importance to assess and report
and should be carefully interpreted. A sensitivity analysis compliance with the intervention. To clarify the net effect,
was undertaken to check for a potential bias due to study compliance and dose-response analyses are recommended
quality. The 21 studies included in the meta-analysis pro- for all future injury prevention studies. The development
vided a large enough data pool for specific analysis of and application of a consensus statement on how to con-
subgroups with different characteristics in relation to study duct studies on injury prevention programs in child and
population, characteristics of the injury prevention pro- adolescent sports would be warranted, since homogeneity
gram, and outcome variables. The available studies on the with respect to study design will enable a clearer inter-
topic vary considerably in characteristics of the study pretation of results.
population, type of intervention (content, dose, and dura- The prevention of severe sports injuries is a major
tion), injury definition, severity classification (e.g. ‘severe’ challenge of the future. Thereby, the 6- to 18-year-old age
is defined as ‘more than 2 weeks’ or ‘more than 4 weeks’ group is of particular interest as the proportion of sport-
of absence), exposure measurements, and research design. related injuries of all life-threatening injuries is much
However, it can be argued that although different in nature, higher in children and adolescents (32 %) compared with
all programs do seem to have beneficial effects regardless adults (9 %) [78].

123
1746 R. Rössler et al.

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Acknowledgments Oliver Faude and Roland Rössler designed the pediatric sport-related injuries. Clin J Sport Med.
study protocol. Roland Rössler and Thomas Schweizer searched the 2006;16(6):500–13. doi:10.1097/01.jsm.0000251181.36582.a0.
databases and checked the obtained studies regarding inclusion and 14. Collard DC, Verhagen EA, Mechelen W, et al. Economic burden
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the eligibility of the studies for inclusion. Roland Rössler and Thomas 082545.
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