Ankle Injury Prevention

by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.Copyright @ 2010

Multistation Proprioceptive Exercise ProgramPrevents Ankle Injuries in Basketball

ERIC EILS1,2, RALF SCHROTER1, MARC SCHRODER1, JOACHIM GERSS3, and DIETER ROSENBAUM1

1Funktionsbereich Bewegungsanalytik (Movement Analysis Lab), Orthopaedic Department, University Hospital Muenster,Muenster, GERMANY; 2Institute of Sport Science, Motion Science, University of Muenster, Muenster, GERMANY; and3Department of Medical Informatics and Biomathematics, University Hospital Muenster, Muenster, GERMANY

ABSTRACT

EILS, E., R. SCHROTER, M. SCHRODER, J. GERSS, and D. ROSENBAUM. Multistation Proprioceptive Exercise Program

Prevents Ankle Injuries in Basketball. Med. Sci. Sports Exerc., Vol. 42, No. 11, pp. 2098–2105, 2010. Purpose: To investigate the

effectiveness of a multistation proprioceptive exercise program for the prevention of ankle injuries in basketball players using a

prospective randomized controlled trial in combination with biomechanical tests of neuromuscular performance. Methods: A total of

232 players participated in the study and were randomly assigned to a training or control group following the CONSORT statement.

The training group performed a multistation proprioceptive exercise program, and the control group continued with their normal

workout routines. During one competitive basketball season, the number of ankle injuries was counted and related to the number of

sports participation sessions using logistic regression. Additional biomechanical pre–post tests (angle reproduction and postural sway)

were performed in both groups to investigate the effects on neuromuscular performance. Results: In the control group, 21 injuries

occurred, whereas in the training group, 7 injuries occurred. The risk for sustaining an ankle injury was significantly reduced in the

training group by approximately 35%. The corresponding number needed to treat was 7. Additional biomechanical tests revealed

significant improvements in joint position sense and single-limb stance in the training group. Conclusions: The multistation pro-

prioceptive exercise program effectively prevented ankle injuries in basketball players. Analysis of number needed to treat clearly showed

the relatively low prevention effort that is necessary to avoid an ankle injury. Additional biomechanical tests confirmed the neuromuscular

effect and confirmed a relationship between injury prevention and altered neuromuscular performance. With this knowledge, proprioceptive

training may be optimized to specifically address the demands in various athletic activities. Key Words: PROPRIOCEPTIVE TRAINING,

PROSPECTIVE RANDOMIZED CONTROLLED TRIAL, PREVENTION AND REHABILITATION, BIOMECHANICAL TESTS,

NEUROMUSCULAR PERFORMANCE

Sporting activities such as basketball, soccer, teamhandball, and volleyball are high-risk activitiesespecially for lateral ligament injuries of the ankle

joint complex (8). In basketball, every other injury thatoccurs affects the ankle joint (21,27). These injuries oftenresult in a considerable amount of time off for the injuredplayers, typically 1 wk or more (16) or five to six sessions(18). Players may be unavailable for their team in importantphases during the season, thus causing a serious problemparticularly for professional or semiprofessional teams.

Different intervention methods have been recommendedfor the prevention of ankle injuries (17). There is evidencethat ankle braces are effective in the prevention of acute, as

well as recurrent, ankle sprains, but there is still controversyconcerning the effectiveness of special training procedures(8). It was reported that proprioceptive training is noteffective as a primary prevention in healthy subjects (4);however, recent results seem promising in underlining itseffect as a secondary prevention in subjects with recurrentankle injuries (3,11).

The effectiveness of specific training programs has beenevaluated using prospective randomized controlled trials orlaboratory-based studies (5–7,9,11,24,26). In prospectiverandomized intervention trials, a training group and acontrol group are monitored during a season, and differ-ences in the number of injuries at the end of one season areindicative for the effectiveness of the training program. Inlaboratory-based studies, different test procedures areperformed before and after a training period. Differencesin neuromuscular performance are indicative of the effec-tiveness of the training program. However, both approachesare insufficient for a thorough understanding of ankle injuryprevention. For example, when investigating the effective-ness of training programs, the reasons for possibly reducedinjury rates might remain unclear. On the other hand,investigating the effects of a pre–post test design does notimplicate that changes in neuromuscular parameters are

Address for correspondence: Eric Eils, Ph.D., Institute of Sport Science,Motion Science, University of Muenster, Horstmarer Landweg 62b, 48149Muenster, Germany; E-mail: [email protected] for publication December 2009.Accepted for publication March 2010.

0195-9131/10/4211-2098/0MEDICINE & SCIENCE IN SPORTS & EXERCISE�

Copyright � 2010 by the American College of Sports Medicine

DOI: 10.1249/MSS.0b013e3181e03667

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effective with respect to injury reduction. A combination ofboth approaches may help to improve our understanding ofthe relationship of ankle injury prevention and neuromus-cular performance in athletes.

Therefore, the aim of the present investigation was tosimultaneously evaluate the effectiveness of an interventionprogram for the prevention of ankle injuries as well as theeffects of laboratory-based trials on neuromuscular perfor-mance during a basketball game season. The interventiontrial was conducted as a prospective randomized controlledtrial, with a laboratory-based aspect involving neuromuscu-lar measurements in a subgroup before and after the trainingperiod. The underlying hypothesis was that there will be asignificant reduction in the number of ankle sprains in thetraining group, and in addition, neuromuscular performance

changes related to the specific multistation proprioceptiveexercise program will be found in the training group.

METHODS

Subjects. The CONSORT statement was followed inthe design of the study (1). The study contained aprospective randomized controlled trial and a pre–postlaboratory-based test of a selected subgroup. The respectivenumber of athletes recruited and investigated during thetrial is shown in Figure 1.

In total, 232 players on 35 teams near Muenster,Germany, participated in the study (Table 1). All playersplayed basketball on a regular basis, and the performancelevel of the players varied between the seventh highest

FIGURE 1—Flowchart of the number of athletes participating in this study.

EXERCISE PROGRAM TO PREVENT ANKLE INJURIES Medicine & Science in Sports & Exercised 2099

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(Kreisliga) and the highest league (Bundesliga) in Germany.Before participation, all subjects signed an informedconsent form. The tests were approved by the local humanethics committee, and all procedures were performed inaccordance to the principles of the Declaration of Helsinki.Subjects were free of injuries at the start of the study. Toevaluate the effect of the multistation proprioceptive

exercise program on injury incidence, all subjects whowore external stabilizing devices (braces or tape) or whohad previously performed proprioceptive exercises wereexcluded from the study. The remaining 198 subjects wererandomly assigned to the control or the training group usinga stratified randomization design, with the strata defined byperformance (high, middle, or low) and sex (male or

TABLE 1. Anthropometric data of the whole (upper part) and the biomechanical subgroup (lower part).

Training Group (n = 81) Control Group (n = 91)

Whole Group Mean T SD Range Mean T SD Range P

Age (yr) 22.6 T 6.3 14–43 25.5 T 7.2 15–43 G0.01Weight (kg) 77.2 T 15.3 50–117 77.8 T 14.6 53–115 NSHeight (cm) 184.1 T 11.0 163–207 183.6 T 10.4 161–211 NSSex, M/F 49:32 54:37Sports activity (per week) 3.5 T 1.1 1–7 2.8 T 0.9 1–7 G0.01Previous injuries (%), Y/N 48:52 46:54

Training Group (n = 8) Control Group (n = 8)

Subgroup Mean T SD Range Mean T SD Range P

Age (yr) 24.3 T 2.9 22–30 25.9 T 8.2 17–38 NSWeight (kg) 75.8 T 12.4 57–90 80.6 T 18.6 65–115 NSHeight (cm) 182.1 T 6.9 175–196 184.4 T 7.8 174–196 NSSex, M/F 4:4 4:4Sports activity (per week) 2.9T0.4 2–3 3.5 T 1.8 2–7 NSPrevious injuries (%), Y/N 63:37 75:25

Differences between groups (training and control) were tested using the independent Student’s t-test (whole group) and the independent Mann–Whitney U test (biomechanicalsubgroup).NS, not significant.

FIGURE 2—Exercises and variations of the multistation proprioceptive exercise program. Please note that this is only a short description of theprogram and the exercises.

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female). It has to be noted that subjects were allocated to thegroups as teams because the balanced training program hadto be integrated in the normal training process. Teams wereassigned using random numbers (0 and 1) that weregenerated by a computer program. The randomization listwas established in advance and was strictly maintained.This finally resulted in two randomized groups that werecomparable in performance and sex.

Training program. The control group consisted of 102players who continued with their normal workout routines.The training group consisted of 96 players who performed amultistation proprioceptive exercise program that wasdesigned in cooperation with the School of Physiotherapyof the University Hospital Muenster. The program was in-tegrated within the regular training routines and was es-pecially designed for basketball workouts. At the beginningof the season, each coach obtained an eight-page trainingmanual that contained a detailed description of the setup,all exercises (including the different difficulty levels), andadditional background information concerning posture cor-rections and proprioception. In addition, a physiotherapistintroduced this program to all players and coaches on siteand gave detailed instructions for correct execution. Thiswas repeated for each difficulty level. During the season,the coaches were encouraged to contact us and were con-tacted by us on a regular basis to keep them motivated andto help with questions or problems.

The multistation program was adopted from a programpresented by Eils and Rosenbaum (5). It was performedonce a week and consisted of six stations that wereperformed twice (barefoot) at the beginning of the normaltraining routine (Fig. 2). The exercise period took 20 min(including setup and removal). The exercises were per-formed for 45 s followed by a 30-s break when subjectstransferred to the next station. The correct posture of thesubject’s lower leg was controlled (slight external rotationof the foot, slightly flexed knee and the patella over the

metatarsophalangeal joint) during the exercise. The inten-sity and difficulty of the exercises were increased during theseason twice by minor modifications for each station.

Injuries. From the beginning of the season, all injuriesof the players in a team were registered by a person incharge of the team (coach, physiotherapist, or player) usinga specific injury questionnaire that was filled-out andreturned in case of an injury. To reduce reporter’s bias toan acceptable degree, we contacted the coach and the playerto obtain further information about the circumstances, theseverity, and the medical diagnosis. All injuries werereported, but the contact to the coaches and players wasonly arranged in case of ankle injuries. An injury wasdefined as an event that forced the subject to terminate theongoing basketball activity and, in addition, preventedfurther participation in the next scheduled basketball activity.

Biomechanical tests. Additional biomechanical testswere performed in a subgroup of both the control and thetraining groups to investigate the influence of the trainingprogram on neuromuscular performance. The subgroup wasrandomly selected using a stratified randomization design asmentioned previously. Subsequently, players within theseteams were randomly selected and asked for participation inthe study. Finally, 24 subjects (11 in the control group and13 in the training group) were enrolled and performed thepretests in angle reproduction and postural sway. During theseason, eight players of this group (three from the controlgroup and five from the training group) were lost because ofdifferent reasons (Fig. 1). Finally, data of 16 players (eightfrom each group) who performed both pretest and posttestcould be analyzed.

A pressure distribution platform (Emed ST4; Novel GmbH,Munich, Germany) was used to measure postural sway insingle-limb stance (Fig. 3). No instructions concerning theposture were given to the subjects except to avoid contact ofthe legs and to focus on a point on the wall directly ahead.Individual posture was noted, and subjects were informed to

FIGURE 3—Measurement of postural sway in single-limb stance on the pressure distribution platform and an example of the derived parameters(excursions of the CoP in mediolateral and anteroposterior directions as well as total sway distance).


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use the same style as in the pretest when it deviated in theposttest. For each foot, three trials of single-limb stance (10 seach) were performed. For analysis, the sway variation andthe sway amplitude of the center of pressure (CoP) inmediolateral and anteroposterior directions as well as thetotal sway distance (total length of the CoP-line) weredetermined and averaged.

A custom-built device was used for testing joint positionsense in a passive angle reproduction test. It consisted of afootplate in combination with a Penny and Gilles goniom-eter (Biometrics Ltd., Gwent, UK). Subjects sat in front ofthe measuring device and placed the foot on the horizontalfootplate (Fig. 4). The rotation axis of the device wasaligned with the medial malleolus. The knee joint wasplaced over the ankle. This position was defined as theneutral position (0-). Subjects were unable to see their feetthroughout the examination and had their eyes closed toconcentrate on the measurements. For the passive anglereproduction test, the foot was brought into one of the twotesting positions (10- dorsiflexion or 15- plantarflexion)and was held for 2 s. Then it was brought back to theneutral position and back toward the testing position untilthe subjects indicated that they felt they had reached thesame position. The foot was returned to the neutral position,and the next angle was chosen. Angles were tested inrandom order, and each angle was tested three times. Alljoint position tests were performed by the same investigator.The differences between predefined and reproduced angleswere saved for analysis. Lower leg strength was not testedin this study because it was shown that deficits in anklestrength are not related to chronic ankle instability orsubjects who previously sustained sprains without instabil-ity as a complaint (12,19,28).

Statistics. To calculate the injury incidence of thegroups, the number of injuries was related to the numberof sports participation sessions (game and practice sessionscombined). Data were then analyzed by logistic regression.The results were presented as odds ratios of injury as wellas the numbers needed to treat (NNT). Pre–post testanalysis was performed using the dependent nonparametricWilcoxon signed-rank test. Differences between groups(training and control) were tested using the independentStudent’s t-test (whole group) and the independent Mann–Whitney U test (biomechanical subgroup). Prediction in-tervals on the basis of the data of the total study populationwere used to test the representativeness of the biomechan-ical subgroup. In all statistical procedures, P G 0.05 wasregarded as significant. Statistical analyses were performedusing SPSS v.17 (SPSS, Inc., Chicago, IL).

RESULTS

During the season, 21 ankle injuries occurred in thecontrol group and 7 injuries in the training group. Signif-icant differences were found when focusing on the pre-ventive effect of the multistation proprioceptive exerciseprogram (Table 2). The logistic regression revealed a sig-nificantly reduced odds ratio of 0.355 for training versuscontrol group (95% CI = 0.151–0.835, P = 0.018). TheNNT analysis revealed a value of 360 for the traininggroup. Because the observation unit is not the player but thesingle participation in sports, the NNT values have to bereconsidered. Therefore, with a mean of 55 sports partici-pation sessions in our investigation (mean of both groups),NNT values have to be corrected to 360/55 = 6.5. Thisindicates that seven basketball players (NNT values arerounded to the next number to avoid underestimation) haveto perform the multistation proprioceptive exercise programto prevent one ankle injury during 55 sports participationsessions, i.e., in a period of 18 wk for recreational players(assuming two workouts per week, one game per week) or9 wk for professional players (assuming five workouts perweek, one game per week).

Analysis of players who had previously sustained anankle injury revealed an odds ratio of 1.6 (95% CI = 0.755–3.553, P = 0.212), indicating an increased but nonsignifi-cant risk (factor = 1.6) of sustaining an ankle injury.

Players of the training group showed a significantly morestable single-limb stance concerning mediolateral and overall

FIGURE 4—Joint position sense testing in a custom-built device incombination with an electrogoniometer. The foot of the subjects waspassively moved into 10- of dorsiflexion and 15- of plantarflexion.Deviations between predefined and reproduced angles were derivedfor analysis.

TABLE 2. Number of ankle injuries, participation in sports, injury frequency related to1000 participations in sports, odds ratios, and NNT.

Training GroupControlGroup

Absolute No. of injuries 7 21Total No. of participations in sports 4565 4876Injury frequency per 1000 sport

participations1.53 4.31

Odds ratio (95% CI), P 0.355 (0.151–0.835),0.018

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sway parameters (Table 3). Sway in the anteroposteriordirection was also decreased in the posttest, but this wasfound not to be significant. Players in the control group alsoshowed slightly decreased values in the posttest, but none ofthe differences was significant.

A clear effect of the training program is apparent for theangle reproduction test. The degree of error for 10-dorsiflexion and 15- plantarflexion and the mean weresignificantly reduced for the posttest in the training groupbut not in the control group (Table 4).

DISCUSSION

The present investigation evaluated the effectiveness ofa multistation proprioceptive exercise program for the pre-vention of ankle injuries using a prospective randomizedcontrolled trial in combination with a laboratory-based pre–post test. The results suggest that the training program iseffective in reducing the incidence of ankle injuries in bas-ketball players and also leads to specific changes in neu-romuscular performance, specifically, in proprioception andpostural sway. In summary, these findings indicate that im-provements in these neuromuscular parameters may be a keyfactor for an effective reduction in ankle injury risk.

The multistation proprioceptive exercise program led to asignificant reduction of ankle injuries in basketball players.The risk of sustaining an ankle injury was reduced by 35.5%,and the NNT analysis revealed that seven players have to betreated with this training program to prevent one ankle injuryduring 55 sports participation sessions. This underlines thepotential benefit of an active injury prevention protocol,especially in professional sport. Results for risk reduction andNNT calculation are comparable to results in the literature.For example, Hupperets et al. (11) recently reported a similarNNT value of 9 and a relative risk reduction of 35% in thetraining group compared with the control group in arandomized controlled trial using home-based proprioceptivetraining on recurrences of ankle sprains. In the present study,a frequency of 4.31 injuries per 1000 sports participationsessions was comparable to the results of McKay et al. (16)who reported 3.85 ankle injuries per 1000 sports participationsessions in Australian basketball players.

Neuromuscular training programs consisting mainly ofexercises on an ankle disk, performed several times perweek, were found to be effective in the reduction of ankleinjury incidence (6,9,20,23), although Handoll et al. (8)questioned the efficacy in an evidence-based review of theliterature because of a limited amount of high-qualitystudies. Preliminary evidence was given only for those withprevious ankle injuries. Eils and Rosenbaum (5) speculatedthat specific training on an ankle disk probably generatedonly single stimulation and, therefore, introduced a 6-wkmultistation proprioceptive exercise program that addressedstrength and coordination in multiple ways and wasperformed only once a week. The authors showed that thisprogram led to significant improvements within the neuro-muscular system in the training group but not in the controlgroup. However, it remains unclear whether the measuredeffects of this ‘‘low-frequency and high-stimuli’’ programwould lead to a reduction in the number of ankle injuries.The results of the present study underlined the effectivenessof such a program and suggested that training-inducedchanges within the neuromuscular system may be related tothe reduced incidence of ankle injuries. It must be noted thata direct one-to-one relationship cannot be establishedbecause only a subgroup of the entire cohort was evaluatedin the laboratory because of organizational concerns.However, although the sample was small, it was randomlydrawn and was representative. A post hoc analysis usingprediction intervals on the basis of data of the total studypopulation revealed that the sample is proven to berepresentative of the total study population except for therate of high-performance players. Furthermore, significantdifferences were found between pretest and posttest. Thestudy design involving a randomized controlled trialcombined with laboratory-based testing is important inmore appropriately identifying the relationship betweenankle injury prevention and neuromuscular performancecompared with independent randomized controlled trialsand laboratory-based testing. This relationship will help tounderstand better the complex interaction between injuryprevention and neuromuscular performance.

Recently, the importance and efficacy of complex inter-vention programs consisting of a variety of exercises have

TABLE 3. Postural sway parameters (mean T SD).

Training Group Control Group

Postural Sway (mm) Pretest Posttest P Pretest Posttest P

SD mediolateral 5.8 T 0.7 5.1 T 0.8 G0.05 5.4 T 1.3 5.3 T 1.1 NSSD anteroposterior 6.7 T 0.9 6.6 T 1.3 NS 7.4 T 1.8 7.4 T 1.0 NSMaximum sway mediolateral 26.9 T 3.9 23.1 T 3.5 G0.01 25.3 T 4.9 23.9 T 3.9 NSMaximum sway anteroposterior 33.1 T 4.5 28-9 T 3.9 NS 34.1 T 8.7 31.6 T 4.7 NSTotal sway distance 425.2 T 47.5 359.2 T 57.7 G0.05 351.2 T 73.8 336.2 T 87.1 NS

TABLE 4. Angular errors in the joint position test from predetermined angles (mean T SD).

Training Group Control Group

Degrees of Error (-) Pretest Posttest P Pretest Posttest P

10- dorsiflexion 2.0 T 0.5 1.2 T 0.5 G0.05 2.5 T 1.3 1.9 T 0.8 NS15- plantarflexion 3.7 T 1.4 2.1 T 1.2 G0.05 2.3 T 0.8 2.8 T 1.1 NSMean error 2.9 T 0.6 1.7 T 0.6 G0.05 2.4 T 0.8 2.4 T 0.9 NS


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also been reported for volleyball players (26) and in ath-letes with acute ankle sprains (10,11). Therefore, there isnew evidence that proprioceptive training programs withchallenging exercises to create multiple stimuli may be rec-ommended for the prevention of ankle injuries. The effectsof proprioceptive training have been well documented inthe past, and laboratory-based studies concerning altera-tions in joint position sense, sway regulation in single-limbstance, muscle strength, or peroneal reaction times havebeen performed (5–7,9,12–15,24,25). Despite differingfindings (22), there seems to be a trend of characteristicneuromuscular performance adaptations because of specifictraining programs.

In the present investigation, the results of the anglereproduction test show a significant improvement inneuromuscular performance. The results of the swayregulation are similar, but not all improvements in thetraining group were significant. The training program seemsto be more effective in improving sway reduction in themediolateral direction. This is comprehensible becausemovement in the mediolateral direction is mainly controlledin the subtalar joint, whereas the movement in theanteroposterior direction is more regulated in the tibiotalarjoint. A similar result was reported by Eils and Rosenbaum(5) when evaluating the effects of a multistation proprio-ceptive exercise programs in patients with ankle instability.

In previous studies, the relationship between training-related changes within the neuromuscular system and theeffectiveness of injury prevention was vague. In the presentinvestigation, this relationship was evaluated for the first timewith parallel biomechanical testing in a smaller subgroup,including angle reproduction and postural sway testing.Although we analyzed only a small subgroup and we areaware of the fact that other factors may play a role in thiscontext, we believe that the results of the present studyunderline a more direct relationship between measuredalterations within the neuromuscular system and the effec-tiveness of injury prevention than shown in previous studiesbecause the sample was randomly selected and representa-tive. Results of the postural sway analysis in single-limbstance and angle reproduction showed significant differenceswithin the training group but not in the control group forselected parameters. Therefore, an improved ability to detecta predetermined angle (improved joint position sense) andthe ability to regulate sway in single-limb stance seem to berelated to a reduction of lateral ankle injuries. Theseimprovements may help athletes to prevent ankle injuries inpotentially dangerous circumstances, e.g., in cutting andlanding movements, because of an improved joint positionsense of the foot and ankle complex.

At this point, it will be of interest how exercises have tobe designed to be most effective. For example, what arethe effects of a typical ankle disk training compared with amore complex exercise on a neurophysiologic basis? Is itpossible to derive some typical characteristics or ‘‘keyaspects’’ that make an exercise more suitable for propri-

oceptive training? However, this remains speculative andhas to be addressed in additional biomechanical studies.

One aspect that needs clarification in the presentinvestigation is the influence of proprioceptive trainingon subjects with and without previous ankle injuries. It hasbeen stated that a beneficial effect is most pronounced forathletes with previous ankle injuries and that there is onlya small or no effect of training in healthy subjects (4,8).We found an increased chance (factor = 1.6) of obtainingan ankle injury in subjects with previous injuries.However, this increase was not significant. Only playerswho never performed proprioceptive exercises or woreankle-stabilizing devices before were included in thepresent investigation. Therefore, a high percentage ofplayers with previously injured ankles have probably beenexcluded, resulting in a similar percentage of players(approximately 50% each) with and without previousinjuries. This explains why the effect for players withprevious injuries is not as pronounced as that in otherinvestigations (2,16,26).

Significant differences between players’ age and sportsactivity were initially found between the training andcontrol groups. The players in the training group weresignificantly younger (22.6 vs 25.5 yr) and more active (3.5vs 2.8 times per week) than the controls. These groupdifferences actually emphasize the findings because it canbe argued that younger and more active individuals wouldhave a greater risk of injury because of increased exposure.

The results of the present investigation show that thenumber of ankle injuries was reduced, but there wasno information concerning other injuries. This might be alimitation in the present study because it would be ofinterest to know whether ankle injuries may be replaced byinjuries in other areas. We were not able to derive thisinformation from our data because coaches and playerswere contacted only in case of ankle injuries. However, asystematic Cochrane review focusing on interventions forpreventing ankle ligament injuries did not report anapparent effect on the incidence of other leg injuries (8).This leads us to trust that there is no significant shift ofinjuries to other body areas.

CONCLUSIONS

The results of the present investigation show that aspecific multistation proprioceptive exercise program per-formed only once a week significantly reduced thefrequency of ankle injuries in a population of basketballplayers. In addition, characteristic and significant improve-ments in neuromuscular performance were found inbiomechanical tests of proprioception and postural swaythat may be directly related to the risk of ankle injury. Thisis the first study to underline directly a relationship betweeninjury incidence and alterations in neuromuscular perfor-mance. The evaluation of injury incidence as well as


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objective parameters from biomechanical tests warrants therecommendation of such exercises for the prevention ofankle injuries.

Although the population were basketball players, it maybe safe to assume that the program is also applicable toother sports or high-risk activities such as team handball,volleyball, or soccer.

This study was funded by a research grant of the Bundesinstitutfur Sportwissenschaft (Federal Institute of Sports Science, grant No.VF 0407(01/68/2004)).

None of the authors of this article has any conflicts of interest orfinancial conflicts to disclose.

The authors thank M. Overbeck and colleagues for their help insetting up the exercise program.

The results of the present study do not constitute endorsementby the American College of Sports Medicine.

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