Netball & ACL Injuries
Netball is the most popular team sport played by children and adolescent girls in Australia. Netball involves acceleration, deceleration, change of direction (agility) and landing. Ankle sprains are the most common injury in netball, however anterior cruciate ligament (ACL) injuries account for up to a third of all netball injuries. ACL reconstruction rates are rising in 5 – 14 year-olds and are 2-3 times more common in females compared to males. Landing characteristics associated with ACL injury include landing with stiff knees or knees dropping in as shown in the picture below (image credit Stuelcken et al 2016).
Injury Prevention Programs
Over the last two decades, injury rates in sport have received a lot of attention. Injury prevention programs have been developed with the aim to improve strength, movement patterns and balance. They are typically used as a warm-up prior to training or games.
Research into the effectiveness of the FIFA 11+ (an injury prevention program for soccer) has shown the program reduced ACL injuries by up to 74%.
Based on the success of other injury prevention programs, Netball Australia developed the Netball KNEE program. The KNEE program is a netball-specific injury prevention program aimed to correct movement patterns in take-off, landing, deceleration and direction changes. The KNEE program is tailored to junior (11-14 years), recreational (14+ years) and elite players (state and national representatives).
There are four components to the Netball KNEE program: warmup/footwork, balance/landing, strength, and agility. All exercises in the warmup/footwork section should be performed and coaches can pick 4 exercises each from the balance/landing, strength and agility sections to perform. An example of the junior netball KNEE program is shown below.
Despite the proven effectiveness of injury prevention programs, research has shown that implementation of injury prevention programs in sport is poor. Many coaches modify or do not perform exercises, and do not provide feedback to correct exercise performance when it is required.
However, we don’t know if the netball KNEE program is implemented in community netball.
What we did
We observed one netball training session for 67 teams ranging from net-set-go (7–10-year-olds) to open players (aged 18 years and over). We documented whether teams performed activities from the netball KNEE program at any time during the training session. We recorded if exercises were performed as intended (exactly as instructed in the KNEE program) or they performed a modified version of the exercise (for example, jogging forwards only instead of jogging forwards and backwards).
We also recorded whether feedback was provided to players on performance of the exercises if it was required.
What we found
Most of the time, the netball coach delivered the netball KNEE program.
None of the teams observed performed the full program or even half of the netball KNEE program as intended. Five teams didn’t perform any netball KNEE program exercises (all 5 teams had players aged under 11 years).
When we included modified versions of the exercises, none of the teams performed the full netball KNEE program. Two teams performed at least half of the recommended number of knee program exercises (both teams had players aged over 14 years).
We found that warmup/footwork exercises were consistently performed more frequently across all teams. Balance/landing and agility exercises were performed least frequently across all teams.
We also found that feedback was required in 66% of exercises observed, but 56% of the time, feedback was not provided when it was required.
Things to keep in mind
We observed only four netball teams from one region, so these results may not apply to other netball clubs in other regions. We erred on the side of recording exercises performed modified rather than not performed which may have led to over-estimation of KNEE programme exercises performed. We do not know why feedback was not given when it was required (e.g. lack of knowledge of correct movement patterns vs. trying not to overload players with too many corrections).
How this impacts clinical practice
Implementation of the netball KNEE program in community netball is low. Balance/landing and agility exercises are least frequently performed, and feedback is not often given when it required. These findings are concerning as the aim of injury prevention programmes is to correct movement patterns that lead to increased risk of ACL injury.
Given coaches are the primary deliverer of netball KNEE exercises, we need to better understand from coaches what is limiting implementation of the netball KNEE programme.
Saad T, Davies L, Smith M. Implementation of an injury prevention programme in community netball: An observational study. J Sports Sci. 2021 Oct;39(19):2180-2188. doi: 10.1080/02640414.2021.1923932. Epub 2021 May 18. PMID: 34000967.
Netball Insurance Data 2011 – 2016
Stuelcken, M. C., Mellifont, D. B., Gorman, A. D., & Sayers, M. G. (2016). Mechanisms of anterior cruciate ligament injuries in elite women’s netball: A systematic video analysis. Journal of Sports Sciences, 34(16), 1516–1522. https://doi.org/10.1080/02640414.2015.1121285
Zbrojkiewicz, D., Vertullo, C., & Grayson, J. E. (2018). Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000–2015. The Medical Journal of Australia, 208(8), 354–358. https:// doi.org/10.5694/mja17.00974