Sustained 50% reduction in ACL injury risk in Norwegian handball ~ Roald Bahr, MD

Great news from female handball in a new study published in the BJSM. The risk of ACL injury has remained low through a nationwide campaign, focusing on the coach as the key partner.

Researchers from the Oslo Sport Trauma Research Center has followed all teams in the three upper divisions from the 1998-99 season through the 2010-2011 season. In the period 1998-2001, the ACL Injury Prevention study was performed among female handball players in the top three divisions in Norway.

The intervention consisted of a neuromuscular training program with exercises on a wobble board, a balance mat and handball-specific exercises made to improve knee control in cutting and landing situations. The message to the players was to avoid “kissing knees”, maintaining the “knee-over-toe” position in all landing and cutting tasks, to perform a more narrow cutting movement and to land on two legs instead of one.

A 40 percent reduction of ACL injuries among the players was achieved during year three of the study, after the intervention program had been adopted by the teams.

Photo by “West Point Public Affairs.” Used with permission. All rights reserved. Source:
Photo by “West Point Public Affairs.” Used with permission. All rights reserved. Source:

After the ACL Injury Prevention Study was terminated at the end of the 2000-01 season, the continuation of prevention exercises depended on each team.

Disappointingly, the results showed that few teams and players continued using the preventive program and the number of ACL injuries increased during subsequent years.

These were the data the researchers at the Oslo Sport Trauma Research Center could not live with; as a consequence they held seminars in Norway’s five largest cities attended by approximately 500 coaches and managers. At the end of the two-hour seminar, every attendee received a DVD including video clips of all the prevention exercises. Reminding the coaches about the importance of balance and strength training with focus on the “knee-over-toe” position produced results with a reduction of ACL injuries registered in 2005-2006 season.

To more easily reach out with information to the coaches, managers and players about how you can reduce the number of injuries in your club, the Oslo Sport Trauma Research Center launched the website in May 2008. It provides information on injury prevention program in a format targeting coaches and athletes, and includes videos of exercises and posters from various prevention programs.

The researchers behind this study, Grethe Myklebust, Arnhild Skjølberg, and Roald Bahr continued to follow the teams for five new seasons and the ACL injury risk remained low. When they started the ACL surveillance in 1998-99 they found 0.5 ACL injuries per team per season, in 2010- 2011 they had 0.25 ACL injuries, a 50% reduction. Great news!

“The coach is a key partner,” says first author Grethe Myklebust at the Oslo Sports Trauma Research Center. “The coach is the one who can include balance and strength exercises with knee control as a natural part of every warm-up. Our results indicate that coaches have taken our messages seriously and continue to include this program in their daily training.”

To learn more about the principles of injury prevention turn to Chapter 9 in Clinical Sports Medicine. The chapter includes a systemic overview, as well as key information on the warm up, principles and types of stretching, taping, and equipment, among other topics.

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Prof Roald Bahr MD PhD joined Aspetar as the Head of the Aspetar Sports Injury & Illness Prevention Programme in October 2012. He is also Professor of Sports Medicine and Chair of the Oslo Sports Trauma Research Center at the Norwegian School of Sports Sciences. In addition, Dr. Bahr is the Chief Medical Officer and Department Chair for Olympiatoppen and the Department of Sports Medicine at the Norwegian Olympic Training Center in Oslo.

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