Category: Contributor’s corner
Running and Patellofemoral Pain Syndrome: What makes you weak at the knees?
Patellofemoral Pain Syndrome (PFPS) is a knee condition associated with anterior knee pain when loading the knee in movements like squatting, stair climbing, running and jumping (Ferber et al., 2015). Due to its high prevalence and running becoming an increasingly common form of exercise, it is important that high quality evidence regarding treatment and preventative strategies are made accessible to the public.
Like most soft tissue injuries, PFPS is also a multifactorial condition involving structural, sensorimotor, somatosensory, psychological, and nociceptive processing changes (Powers et al., 2017). Consequently, a consensus paper was written which outlined the current evidence-based understanding of the complex aetiology of this condition. Figure 1 shows the varied levels of scientific knowledge on the proposed mechanisms of the pathophysiology in PFPS.
To understand how best to deal with PFPS we are going to look at a question posed by Ferber et al.: what is the best form of exercise when treating PFPS? According to the most recent consensus statement on treatment regarding PFPS, there is an understanding that exercise and multimodal treatment involving knee, hip and core training is the most evidence-based approach when treating PFPS (Crossley et al., 2016). However, until 2015, there had not been research into whether, in isolation, a hip and core or knee protocol is more efficient (Feber et al., 2015).
Feber et al. (2015) included 199 individuals suffering from PFPS in the USA in a randomised control trial comparing a 6-week knee protocol (Figure 3) to a 6-week hip and core protocol (Figure 2). These programs used functional exercises to progressively overload the participants throughout the 6-weeks. Both protocols produced similar statistically significant increases in maximum isometric knee extension strength (Hip/Core – 8.04% (p<0.05); Knee – 6.37% (p<0.05)) and functional capacity measured by the Anterior Knee Pain Score (Hip/Core – 12.58% (p<0.05); Knee – 12.90% (p<0.05)) post treatment . However, the hip and core protocol had a greater reduction in VAS pain scores after 3-weeks (p<0.05) even though pain scores were equal at 6 weeks. The hip and core also produced greater hip extension (Hip/Core – 11.34%; Knee – 7.13%; p<0.05) and abduction (Hip/Core – 11.46%; Knee – 8.21%; p<0.05) maximal isometric strength post treatment (Feber et al., 2015). Both of these variables are shown to be possible risk factors for PFPS (Figure 1). Therefore, the hip and core protocol may have a greater efficiency when treating PFPS as it targets more risk factors than the knee protocol.
Therefore, this hip and core exercise protocol, which is time efficient and uses a shotgun approach against the risk factors relating to PFPS, may be a much sort after injury prevention program for runners wanting to avoid future anterior knee pain.
Crossley, K. M. et al. (2016) ‘2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: Recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions)’, British Journal of Sports Medicine, 50(14), pp. 844–852. doi: 10.1136/bjsports-2016-096268.
Ferber, R. et al. (2015) ‘Strengthening of the hip and core versus knee muscles for the treatment of patellofemoral pain: A multicenter randomized controlled trial’, Journal of Athletic Training, 50(4), pp. 366–377. doi: 10.4085/1062-6050-49.3.70.
Powers, C. M. et al. (2017) ‘Evidence-based framework for a pathomechanical model of patellofemoral pain: 2017 patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester, UK: Part 3’, British Journal of Sports Medicine, 51(24), pp. 1713–1723. doi: 10.1136/bjsports-2017-098717.
Overuse injuries in basketball: A dribble of sprains and pains
by Tumelo Lethule
Basketball has become one of the most popular sports in the world and has given us the pleasure of gushing over NBA stars such as O’neal, James, Curry and of course, the legendary Jordan. As a non-contact sport, basketball remained one of the safest sports ever played. However, as the sport seems to increase its popularity status; so did the injuries associated with the sport. Injuries most common to basketball are ankle sprains, knee injuries, lower back pains, facial and finger injuries as well as anterior cruciate ligament injuries.
In comparison with contact and other non-contact sports, basketball has been classified as one of the sports with a higher injury risk of injury and injury incidence . Because basketball is a sport that requires speed, strength and power to accomplish movements such as rebounds and jump-shots, one can presume that players are likely to suffer some injuries when performing these highly dynamic movements .
Weiss, KJ et. al  used the Oslo Sports Trauma Research Questionnaire (OSTRQ) to record the onset of overuse injuries for the ankle, knee and lower back in professional male basketball players. The author assessed the prevalence and severity of overuse injuries and also determined the efficacy of the questionnaire over one season. The authors found that severe knee overuse injuries were reported more than ankle and lower back injuries , suggesting injury prevention strategies may need to focus on the knee.
Another study showed the prevalence of injuries in female basketball players (19.5% ankle injuries, 20.6% knee injuries) and in male basketball players (28.4% ankle, 17.5 knee injury)  suggesting a higher injury risk in women than men. Zuckerman and his team  found that during practice, males had a higher rate of ankle injury compared to females while females have higher rate of overuse knee injuries curing practice. From these findings, one can assume that females are more at risk to knee injuries and male’s ankle injuries.
While the underlying causes of injuries are yet to be fully understood, some research has emerged to understand how these injuries occur. Ankle sprains may occur as an athlete lands on an opponent’s foot. Overuse knee injuries seem to be caused by overloading and previous injury. Interestingly, knee injuries are seen mostly in centre players than any other positions, suggesting that playing positions may be a risk factor .
The cause of overuse knee injuries and ankle sprains is still a puzzle that seems to have little pieces, at least for now. With that said, through injury surveillance and the identification of injury risk factors and further understanding how injuries occur, better injury prevention strategies can be formulated and implemented. Until then, sprains and pains remain a concern in basketball.
 Weiss, K.J., McGuiren, MR, Besier, T.F., Whatman, CS, 2017. Application of Simple Surveillance Method for Detecting the Prevalence and Impact of Overuse Injuries in Professional Men’s Basketball. The Journal of Strength and Condition Research, 31(10), p2734-2739.
 Cumps, E., Verhagen, E., and Meeusen, R. 2007. Prospective epidemiological study of basketball injuries during one competitive season: Ankle sprains and overuse knee injuries. Journal of Sports Science and Medicine, 6, p204-211.
 Andreoli, C.V., Chiaramonti, B.C., Biruel, E., Pochini, Andre de Castro, Ejnisman, B., Cohen, M., 2018. Epidemiology of sports injuries in basketball: integrative systematic review. BMJ Open Sport Exerc Med
 Zuckerman, SL, Wegner, AM, Roos, KG, et. al. 2018. Injuries sustained in National Collegiate Athletic Association men’s and women’s basketball, 2009/2010-2014/2015. British Journal Sports Medicine, 52: 261-268
FIFA 11+: An effective way to reduce injuries in amateur soccer players?
by Aminah Emeran
Soccer is arguably the most popular sport globally, with an estimated 200 million players worldwide (1). There are many health benefits of playing soccer, including reducing the risk of type 2 diabetes and hypertension (2). Despite its health benefits, soccer also poses a significant risk of injury (3), particularly to areas such as the knee, ankle and thigh (4). These injuries are largely attributed to insufficient warm-ups, muscle fatigue and imbalance (5). A study conducted on the incidence of soccer injuries, showed that 15-20 injuries occurred per 1000 hours of match play, in players above 15 years old (6).
Because of the high incidence of soccer injuries worldwide, an injury prevention strategy for amateur players was developed in 2006, called the FIFA 11+. The FIFA 11+ comprises of a simple warm-up routine consisting of 15 exercises, that soccer players are to perform for a minimum of 2 times per week. The warmup requires minimal equipment, is available online and can be performed within 10-15 minutes (7).
Does the warmup reduce injury risk?
This question was answered by conducting trials that implemented the FIFA 11+ intervention into real life practice. These trials were then analysed in systematic reviews. The studies selected for review were implemented in a range of locations including North America, Europe, Asia and Africa, and tested male and female amateur players, with ages ranging from 15-45 years (7–10).
Overall results showed that implementing the FIFA 11+ warm-up for about 2 months, reduced the number of injuries in male and female amateur players between 13 and 25 years, by 30-39%. Studies also showed an improvement in motor and neuromuscular performance such as improved balance, increased quadriceps and muscle strength, speed and agility (7,8,10). The largest reduction in injury risk occurred when players adhered to performing the warm-up correctly. This was achieved with the help of supervision from coaches. Studies where little reduction in injury was seen, could be due to lack of compliance to the intervention and lack of guidance from coaches (7).
These results sound very promising. However, there are some limitations in the studies analysed. These include a risk of outcome bias that could result from the participants knowing that they were receiving the 11+ intervention, and the researcher knowing what group did and did not perform the intervention (9). Some studies also used different injury definitions, with some not even defining the type of injury analysed (8).
Despite these limitations, the warm-up has been successfully utilised in other sporting fields, such as basketball. It has also been endorsed by 20 FIFA Member Associations. Thus, given the high prevalence of soccer injuries sustained by amateur players, the FIFA 11+ intervention is recommended to reduce injury risk (7)(9).
- FIFA C. FIFA Big Count 2006: 270 million people active in football. FIFA Commun Div Inf Serv. 2007;31:1–12.
- Krustrup P, Bangsbo J. Recreational football is effective in the treatment of non-communicable diseases. Br J Sports Med. 2015;49(22):1426–7.
- Rahnama N, Reilly T. Injury risk associated with playing actions during competitive soccer. Br J Sport Med [Internet]. 2002;36:354–9. Available from: http://bjsm.bmj.com/
- Price RJ, Hawkins RD, Hulse MA, Hodson A. The Football Association medical research programme: An audit of injuries in academy youth football. Br J Sports Med. 2004;38(4):466–71.
- Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury patterns in professional football: The UEFA injury study. Br J Sports Med. 2011;45(7):553–8.
- Faude O, Rößler R, Junge A. Football injuries in children and adolescent players: Are there clues for prevention? Sport Med. 2013;43(9):819–37.
- Barengo NC, Meneses-Echávez F, Ramírez-Vélez R, Cohen DD, Tovar G, Correa Bautista JE, et al. The Impact of the FIFA 11+ Training Program on Injury Prevention in Football Players: A Systematic Review. Int J Environ Res Public Heal [Internet]. 2014;11:11. Available from: http://www.mdpi.com/journal/ijerph
- Thorborg K, Krommes KK, Esteve E, Clausen MB, Bartels EM, Rathleff MS. Effect of specific exercise-based football injury prevention programmes on the overall injury rate in football: A systematic review and meta-analysis of the FIFA 11 and 11+ programmes. Br J Sports Med. 2017;51(7):562–71.
- Sadigursky D, Braid JA, De Lira DNL, Machado BAB, Carneiro RJF, Colavolpe PO. The FIFA 11+ injury prevention program for soccer players: A systematic review. BMC Sports Sci Med Rehabil. 2017;9(1):1–8.
- Bizzini M, Dvorak J. FIFA 11+: An effective programme to prevent football injuries in various player groups worldwide – A narrative review. Br J Sports Med. 2015;49(9):577–9.