Attacking the Goal of Netball Injury Prevention: A Review of the Literature

Monash University Accident Research Centre - Report #130 - 1998

Authors: A.C. McGrath & J. Ozanne-Smith

Full report in .pdf format [960KB]

Abstract:

Netball is the most popular team based sport in Australia, played predominantly by females of all ages and skill levels although male and mixed competitions are becoming increasingly popular. Netball has been described as a game reliant on rapid acceleration to "break free" from an opponent, sudden and rapid changes in direction in combination with leaps to receive a pass, intercept a ball or rebound after attempting to goal . Taking these characteristics into consideration, injuries can result in a number of ways. Despite the large participation numbers and the controversy surrounding netball which is often defined as "a game prone to ankle and knee injuries" (Steele, 1990), there is a notable lack of formal, controlled evaluations of the effectiveness of injury prevention countermeasures. The overall aim of this report is to critically review both the formal literature and informal sources that describe injury prevention measures, or countermeasures, for netball. In doing so, it provides an evaluation of the extent to which these countermeasures have been demonstrated to be effective. This report discusses a range of countermeasures for preventing netball injuries including: warm-up and stretching, correction of training errors, attention to the netball environment, correction of netball technique, footwear, use of orthotics, adequate treatment and rehabilitation. Specific factors associated with children's netball injuries are also discussed. Recommendations for further countermeasure research, development and implementation include additional research into the biomechanics of netball and the mechanisms of injury; improved epidemiological studies to identify risk factors; further controlled evaluation of the effectiveness of countermeasures; professional fitting of shoes; professional testing for biomechanical abnormalities and the fitting of orthotic devices.

Executive Summary

Netball is the most popular team based sport in Australia, played predominantly by females of all ages and skill levels, although male and mixed competitions are becoming increasingly popular. Netball has been described as a game reliant on rapid acceleration to "break free" from an opponent, sudden and rapid changes in direction in combination with leaps to receive a pass, intercept a ball or rebound after attempting to goal .

Taking these characteristics into consideration, injuries can result in numerous ways. Despite the large participation numbers and the controversy surrounding netball, which is often defined as "a game prone to ankle and knee injuries" (Steele, 1990), there is a notable lack of formal, controlled evaluations of the effectiveness of injury prevention countermeasures. Studies to date have tended to focus on the incidence and nature of injuries occurring in netball in an attempt to identify causative mechanisms .

Injury prevention is of prime importance because, as well as affecting a player's sporting capabilities, it can also affect their work resulting in forced absenteeism and consequent socioeconomic problems in the home . The benefits of participating in sport need to be weighed up against the risk of incurring a moderate to severe injury . Nevertheless, sport as a behavioural past time is more likely to be beneficial than the absence of physical activity (Togt, 1988; Finch et al., 1995). Consequently, ways need to be found to manage the risk of injury, which is inherent to physical activity .

The aim of this report is to move towards prevention of injuries in netball, through critical review of both the formal literature and informal sources that describe injury prevention measures for netball. Unlike other reports of netball injuries, this report does not focus specifically on the epidemiology of these injuries. Rather, it presents a detailed examination of the range of countermeasures promoted to prevent such injuries. Nevertheless, a brief overview of the epidemiology of netball injuries, particularly from an Australian perspective, is given to set the scene for the subsequent discussion of countermeasures.

Countermeasures for preventing netball injuries can be primary secondary or tertiary and include: factors associated with landing; safe playing environments; stretching; conditioning and technique programs before commencing play; education and training; footwear; mouthguards; taping and bracing; adequate rehabilitation; prompt treatment of injuries and enforced codes of conduct.

This report reviews a range of activities for preventing netball injuries. Recommendations for further countermeasure research, development and implementation have been based on the review as well as discussions with experts acknowledged in this report. Many of the recommended countermeasures have yet to be proven to be effective and more attention to controlled studies "in the field" are needed. More effort directed to basic scientific studies to better understand the biomechanics of netball, the mechanisms of injury and the role of various risk factors in causation are also required. Indeed, the evidence for the effectiveness of certain countermeasures such as warm-up, taping and bracing and landing technique remains equivocal.

INJURY DATA

In a 1997 Australian Bureau of Statistics (ABS) report, netball was rated the fourth most popular sports activity in Australia after aerobics, golf and tennis for persons aged 15 years and over, with 2.4% of total participation or 328,600 participants. Netball was the third most common sporting activity for children aged 5-14 years, in both school and club organised activities. This followed swimming and basketball. It was estimated that 10.2% of children participated in netball. Similarly, in Victoria, netball was the fourth most popular sport with 2.5% of the population participating (ABS, 1997). Netball Victoria reported that in 1997 there were 112,000 registered members allocated to 22 regions throughout Victoria and 275 affiliated Associations and Associates. The proportion of total female sporting participation represented by netball would be considerably higher than for the whole population.

Emergency department presentation data collected by the Victorian Injury Surveillance System (VISS) indicates that netball injuries amongst both adults (15+) and children (<15) who present to emergency departments in Victoria, account for 9% of all sporting injury cases. Eighty three percent of adult and 70% of child netball injuries occurred during formal competition. Of total formal match presentations 3% of child and 4% of adult cases were sufficiently severe to require hospital admission, similar results also occurred in informal netball.

Adults in formal play were predominantly injured as a result of a collision (26%), while children were injured due to falling (23%). Sprains and strains were the dominant injury for both child and adult injury in formal play (42% and 56%, respectively). Lower limbs were the main body region injured in formal adult netball (62%). A higher frequency of upper limb injuries were reported in formal child netball (58%). This is likely to be a result of incorrect technique and a lack of coordination, in which the child falls and uses their outstretched hands to stop them from falling heavily onto their body.

The incidence of injury in terms of body region and nature of injury reported from VISS data correlates to a large extent with the literature reviewed. Although, one notable factor, is the high proportion of fractures and less sprains and strains in children. This is likely to be attributable to emergency department injuries being more severe than those that occur in other population studies. Comparison of the data must be made with caution, given the presentation of data gathered with different study populations, data collection methods and injury definitions.

RECOMMENDATIONS FOR FURTHER COUNTERMEASURE IMPLEMENTATION, RESEARCH AND DEVELOPMENT

Landing and associated factors in relation to netball injuries

  • Given the inconclusive results, to date, of the complex inter-relationship between playing surface, footwear and injury it is recommended that controlled epidemiological studies be undertaken to identify risk or protective factors.
  • Further biomechanical and EMG studies of landing need to take into account age, skill, gender, anthropometric characteristics and other factors known to affect landing and should be conducted within normal playing conditions.
  • Adequately trained controls are required for future studies of the stepping rule.

Warm-up, stretching and cool-down

  • More netball specific research into the effectiveness of warm-up, stretching and cool-down as an injury prevention measure is needed, including the benefits of different types of warm-up, cooling-down and stretching practices and optimal duration, frequency and intensity of each component.
  • The specific needs of the injured netballer, versus the non-injured netballer, should be considered when setting up a warm-up program. Injured netball players should seek professional advice (eg. a physiotherapist) about appropriate exercises.
  • Information about warm-up, cool-down and stretching techniques should continue to be developed and widely promoted to improve specific knowledge of techniques.
  • Research into the maintenance and effectiveness of warm-up during the start-stop nature of netball games and tournament competitions should be conducted.

Correction of training errors

  • Simple fitness testing should be conducted prior to competition to ensure fitness.
  • Players should undergo graduated netball skills and fitness progression, guided by initial fitness testing results.
  • More research is needed to determine the threshold levels of the various training factors under which netball players are likely to remain injury free.
  • A campaign aimed at increasing netball players' awareness of the injury consequences of training errors should be developed and promoted.
  • Appropriate fitness programmes should be undertaken to develop strength, co-ordination, and flexibility, especially of muscles involving the ankle and foot (Steele, 1990a).
  • Proprioceptive and skill training should be implemented, focussing particularly on activities to enhance body balance and control in landing, moving forwards, and catching passes (Steele, 1990a).
  • Players should participate in physical training programmes specific to netball on a regular basis prior to competing in all-day tournaments (Steele, 1990a).
  • Evaluation studies should be conducted to determine the effectiveness of the above 'best practice' recommendations on injury prevention and control.

Anthropometrics and injury

  • Further anthropometric research is required on a wide range of netball players (age and skill variation) to establish a screening and intervention system.

Education and training

  • Coaches, Umpires and Trainers should undertake appropriate training courses specific to the requirements of netball players.
  • All netball teams should have at least one qualified Trainer or Coach on hand at both training and competition to aid in injury prevention and treatment of injury.
  • Coaches and Trainers should regularly update their qualifications.
  • Systematic evaluations of the effectiveness of education and training programs should be conducted.

Correction of netball styles

  • Research is required to identify the relationship between netball style imperfections and injury risk.
  • Correction of netball style needs to be evaluated in terms of injury reduction.
  • Sporting organisations should continue to promote and teach correct netball techniques.
  • Coaches should be guided by current Netball Victoria and Netball Australia recommendations until further evaluation is conducted.

Preventing overuse injuries

  • Further research is necessary to gain a greater understanding of biomechanics of netball play and the associated overuse injuries.
  • Players with potential biomechanical abnormalities (eg. leg length discrepancies) should have these assessed by a professional who can recommend corrective actions.
  • Players should be educated about the risk and the severity of the consequences of overuse injuries.

Netball environment

  • More research into the role of netball playing surfaces is required to assess the impact on injury risk.
  • Netball surfaces should be regularly checked for hazards such as potholes, rubbish etc. and frequently maintained.
  • Netball should not be played on slippery surfaces.
  • Netball events should not be planned for times when there is a likelihood of extreme weather conditions. Whenever possible, such events should be postponed if such weather conditions eventuate.
  • If netball players are planning to play in events likely to be conducted when it is hot or humid, they should undergo a process of acclimatisation and should monitor their fluid loss and replace as needed.
  • Broad spectrum sunscreen should be provided at netball events, where appropriate.
  • Drinking water should be provided at all netball events.
  • Investigations should be conducted on the use of specialised materials for elite level players, which allow evaporating cooling.
  • Biomechanical studies of optimal goal post padding need to be conducted.
  • Goal posts should be firmly fixed into the ground with no parts of the post base protruding onto the court surface or providing a trip.
  • Consistent surface types should be provided within a tournament for a given level of play.
  • Surrounding equipment or advertising should be kept away from the court boundaries.

Netball footwear

  • Netball players should choose their shoes carefully, preferably with professional advice.
  • Future research must account for confounding factors such as previous injury when looking at the relationship between shoe design and injury.
  • Development of shoes to overcome the relatively short life of their impact absorption and sole, should be investigated.
  • Further research should be conducted on the design and benefits of high versus low top shoes.
  • Further development and refinement of orthotic devices specific to the demands of netball is required.
  • The effectiveness of orthoses in netball should be determined by well designed controlled studies of sufficient sample size to provide definitive results.

Mouthguards

  • Research should be conducted to determine the incidence of dental injuries in netball and the protective effort of mouthguards.
  • The use of mouthguards in netball should be strongly promoted until further evidence of effectiveness is available.

Personal hygiene

  • Players should maintain an appropriate level of nutrition (if possible).
  • Players should use individual drink bottles.
  • Players should not share personal items.
  • Blood rules should be implemented to minimise the risk of blood borne infections.

Treatment and rehabilitation

  • Organisers should ensure that there are qualified first aid personnel at all events.
  • Netball players should seek prompt attention to their netball injuries from a person with appropriate medical qualifications for the level of injury.
  • Injured netball players should undertake adequate rehabilitation before returning to their pre-injury level of activity.
  • Pre-screening testing should be undertaken prior to play and after an injury before recommencing play.
  • Taping or bracing of joints should be considered by professionals in their management of injuries.
  • Wobble board exercises and similar rehabilitation exercises should be considered in the rehabilitation of injured ankles and as a preventative measure.
  • Evaluation of rehabilitation programs for netball players is required.
  • Controlled research into the effectiveness of prophylactic and rehabilitative ankle and knee bracing specifically for the repetitive, fast turning and landing actions of the netballer should be undertaken.

Substitutions/rules

  • Rules should be strictly observed by players and enforced by umpires.
  • Modified rules should be utilised for appropriate participants ie. juniors, masters, disabled

Blood

  • Clubs/organisations and facility management should develop and enforce Hepatitis B vaccination regulations.
  • Information on the risks and precautions relevant to bloodborne pathogens should be provided.
  • First aid personnel should be aware of bloodborne pathogens and therefore take precautions when treating an injured player (ie. use of gloves).
  • The blood rules should be strictly adhered to.

Risk management

  • Clubs/organisations should be guided by established risk management plans.
  • Performance indicators should be established and progress reviewed.
  • Clubs/organisations should ensure they take out adequate insurance.

Standards

  • Netball clubs/organisations and facility managers should seek information regarding standards and ensure their facilities meet the requirements.

Children

  • Safety regulations and adequate training programs specifically for children need to be supported and widely implemented.
  • Fun Net and Netta netball should be supported and widely implemented
  • School netball programs should include more information about injury prevention.

Masters

  • Masters participants should be educated about appropriate age related training and competitive practices from available literature.
  • Older players should be aware of their body's capabilities
  • Older players should undertake appropriate training prior to competing in social and other competitions

Women

  • More research into the role of menstrual disturbances and the risk of overuse injuries needs to be undertaken. In particular, the exact relationship between menstrual health, bone health and stress fractures is yet to be elucidated.
  • The impact of dietary behaviours and habits on the incidence of injuries, particularly in women, needs to be determined.

Pregnancy

  • Pregnant women should be provided with educational material regarding physical wellbeing, pregnancy and sport.
  • Further research findings on the effects of sports participation and training on pregnancy should be monitored and relevant findings incorporated into risk management plans.

Netball injury prevention program

  • A program based on the New Zealand model should be developed, implemented and evaluated in Australia.
  • Further investigate how to encourage players to adopt injury prevention strategies

Variations of traditional netball

  • Research should be conducted into the incidence and cause of injuries in mixed games and netball played in indoor cricket centers in comparison to traditional forms of netball.

Other

  • Improved standardised data collection for netball injuries and their associated factors needs to be developed and maintained for both formal and recreational play.
  • Data collections should conform to national guidelines for sports injury surveillance.
  • Ideally, data should be maintained on all players at least at senior levels, including participation details in competition and training and a record kept of all injuries.
  • Information about preventing netball injuries should be disseminated widely through points of sale (eg. shoes), netball magazines and more general magazines.
  • Guidelines for minimum safety requirements for netball events (including the need for mobile phones, telephone contacts, first aid kits, etc) should be further developed and more widely disseminated.
  • Guidelines for netball specific risk management plans should be made available to netball clubs and associations at all levels and to schools and facility managers.
  • Data about netball policy compliance should be collected and evaluated.
  • Data collected on children's injuries should include the type of program they are participant in at the time of injury ie. FunNet, Netta, Competitive.
  • A cost of sports injury study is required to determine overall and relative costs of sports injuries in order to attract commensurate levels of research and prevention funds.

Sponsoring Organisation: Sport and Recreation Victoria