Despite published evidence that bracing and targeted exercises can prevent ankle injuries in high school basketball players, surprisingly few teams have adopted these practices. Barriers to implementation include a lack of awareness and expertise as well as time and money.
By P.K. Daniel
Ankle injuries are the most common sports injury suffered by high school athletes, with more than 325,000 occurring in the US each year. Basketball is the biggest culprit. Boys high school basketball players experience the highest rate (7.74 per 10,000 athlete exposures), followed by girls basketball players (6.93).1 Most (83%) of those injuries are ankle sprains.1
Ankle injury occurrence can be reduced, however, with neuromuscular training (primarily balance exercises)2 and external ankle supports (taping or bracing)3—the two practices most supported by published evidence on ankle injury prevention—and yet a surprisingly low number of high school coaches are advocates of either intervention.4
“We know now that bracing’s effective, these exercise programs are effective, so what are [the coaches] doing, because when I go out to schools I’m not seeing this being done,” said Tim McGuine, PhD, ATC, a senior scientist in the Department of Orthopedics and Rehabilitation at the University of Wisconsin in Madison.
Wisconsin and beyond
In a study published in the June 2013 issue of Sports Health, McGuine and colleagues surveyed Wisconsin high school basketball coaches to determine if they used either method, and if not, why not.4 The survey was distributed to 873 coaches; 480 completed the survey. They found just 37% of respondents promoted the use of prophylactic ankle bracing, and only one-half utilized an ankle injury prevention exercise program. School size, team gender, coaching experience, and education level did not affect the respondents’ position on the use of injury prevention strategies.
The reasons why more coaches don’t opt for injury prevention are multifold. Some of the barriers cited by coaches, athletic trainers, and researchers included lack of awareness and expertise, attitude, time, and money. The findings also raise the question of whether reported trends are different in other parts of the country.
The study didn’t specifically control for coaches’ access to a certified athletic trainer, but some experts thought that would be helpful. It’s unknown what percentage of high schools in Wisconsin have access to certified athletic trainers, but larger school districts tend to have greater access, according to the Wisconsin Athletic Trainers Association. The trainers are not directly employed by the schools but are retained on a contracted basis through a healthcare facility.
“For schools that do not have access, student-athletes rely heavily on guidance from coaches who have very little training in sport injury prevention and, quite frankly, do not have the time to stay informed—surprising given the instant information age we live in today,” said Thomas W. Kaminski, PhD, ATC, director of athletic training education and professor in the Department of Kinesiology and Applied Physiology at the University of Delaware in Newark. “Access to quality sports healthcare coverage via a certified athletic trainer is a key element in the ‘buy-in’ process. In my opinion, the biggest reasons coaches don’t get involved is, one, lack of knowledge and, two, they are more concerned with Xs and Os, despite the fact that an ounce of prevention is worth a pound of cure.”
Jay Hertel, PhD, ATC, professor of sports medicine in the University of Virginia’s Curry School of Education in Charlottesville, agreed that attitude is an issue.
“I do think that athletic trainers can have a role in enacting injury prevention initiatives at schools, but the biggest issue for coaches is whether they see ankle sprains as a problem or not,” Hertel said. “In some sports, like basketball, there is a culture that considers ankle sprains as being part of the game. If coaches don’t feel it is a serious problem, they won’t invest time or resources into prevention efforts.”
Connie Martinez, MA, ATC, works directly with the boys and girls basketball teams at Coronado High School in Coronado, CA, in her role as athletic trainer.
“I’m not sure if basketball coaches ‘accept’ ankle injuries as part of the game, but some may not take the time, or make extra time, for injury prevention, or they may not see it as a need,” Martinez said.
Part of the problem is that sometimes, as McGuine noted, information about injury prevention isn’t always reaching the coaches or the powers that be. John Labeta is the assistant commissioner for the California Interscholastic Federation San Diego Section and a former longtime girls high school basketball coach. And yet, he wasn’t aware of the clinical information.
“I have not really seen any specific reports stating taping or bracing is required for ankles,” Labeta said. “We all hate to lose players to a sprain. It happens with tape and braces also though.”
Evidence for intervention
No intervention is foolproof, but high school basketball players who wore lace-up ankle braces had 68% fewer ankle injuries than those who did not, according to a 2011 study by McGuine and colleagues.3 That effect was consistent across both male and female high school players, and those with and without a previous history of ankle injury. The rate of acute ankle injury (per 1000 exposures) was .47 in the braced group and 1.41 in the control group of unbraced athletes. However, the study also found that, though braces were associated with a lower incidence of ankle injuries, bracing did not have an effect on injury severity.
In a study of 765 high school soccer and basketball players published in the July 2006 issue of the American Journal of Sports Medicine, McGuine and colleagues found a significantly lower rate of ankle sprains in athletes who participated in a balance training program than those in a control group that performed standard conditioning exercises.2 In athletes with a history of ankle sprain, the risk of recurrent sprain was decreased by one-half in those who participated in the intervention; the sprain rate in those without a history of sprain was also lower in the intervention group than the control group, but that difference was not statistically significant.
Joe Szczerba Jr, PhD, head athletic trainer at the Salesianum School, a private boy’s Catholic school in Wilmington, DE, also cited a lack of awareness and time as contributing factors in situations in which injury prevention exercises are not implemented.
“Not everybody knows of the different exercises,” Szczerba said. “I know that when people get into coaching, that’s specifically what they want to do. They don’t necessarily want to get into the strength and conditioning aspect of it or the injury prevention aspect of it. A lot of times they rely on others to do that. I also think there are coaches out there who haven’t even thought that much about it.”
Having access to a certified athletic trainer increases coaches’ awareness. But relying on the school’s athletic trainer to educate everyone is not practical. Very rarely is there more than one trainer at a high school. In fact, a 2010 special report by Scripps Howard News Service found that fewer than one-third of US high schools with a sports program have even one full-time professional athletic trainer.5
“That’s asking a lot of one person when they have to service three basketball teams, three wrestling teams, three ice hockey teams, a winter track team,” Szczerba said.
However, the idea that athletic trainers could teach others, such as team captains, to lead their teams in preventive exercises was something Szczerba said he and others would embrace.
A matter of time
The question of how many minutes a day, how many days a week, or how many weeks of exercise will lead to the greatest protective effect hasn’t been examined in ankles. However, McGuine noted that a 2010 literature review by Dutch researchers,6 as well as the prevailing opinion of experts at the Fifth International Ankle Symposium held in October 2012 in Lexington, KY, suggest it takes eight to 10 weeks to gain the greatest protective effect from exercise programs.
Ideally, that would mean these programs would have to start before the playing season. But, because different state associations have various no-contact rules, that can be a challenge.
Some states have more lenient contact rules than Wisconsin, where access to student-athletes before the season starts is restricted by the state athletic association. McGuine said it’s therefore hard to know if his findings apply to coaches in other parts of the country.
“In Wisconsin, the coaches are pretty limited,” McGuine said. “They can’t have a lot of contact with their basketball team in the spring or the summer, so they may not be implementing these programs.”
In the balance training study, the preventive exercises took only 10 minutes per day, three times per week, during the season. But coaches still may see that additional time as cutting into practices.
“Coaches have two hours to get their practice in and they don’t want to waste time or put time into their practice plan to be doing it,” Szczerba said. “They would have to rely on the kids doing it by themselves after practice.”
While Kaminski said it would not be difficult for coaches to incorporate these programs, he also echoed the suggestion to get the players more involved in the process.
“Coaches could easily build in a balance training program to their existing warm-up period that would take about 10 minutes,” he said. “This alone could prove beneficial. Getting the student-athletes themselves to buy into such a routine would be difficult, but they could certainly perform exercises on their own time that would prove beneficial.”
Martinez said that, though she considers ankle taping to be expensive and impractical, an athletic trainer can educate coaches and athletes on proper injury prevention exercises.
“It wouldn’t be too time consuming if coaches understand how to incorporate it into their regular strength and conditioning sessions, warm-ups, or practice,” she said.
Others also noted the challenges involved in taping at the high school level. Salesianum fields freshman, junior varsity, and varsity basketball teams that practice each day at 3 pm. Classes end at 2:40 pm.
“It would be impossible to tape the 48 to 50 basketball players that we have,” Szczerba said.
Labata said San Diego high school coaches are aware of ankle injury risks and many do implement exercises to strengthen that area, but he cited cost as the primary obstacle to external ankle braces or taping.
“Part of it is costs for taping all athletes, and not everyone likes tape or even braces,” Labata said. He noted that braces are usually bought by parents, especially when high schools do not have budgets to purchase those.
Szczerba, like Labata, said cost could be a hardship for some students and schools at the high school level.
“You usually see prophylactics at the college level,” Szczerba said. “Not every high school has an athletic trainer or the money to be taping everybody for every practice.”
Szczerba noted his school doesn’t use braces because of the expense, which he estimated to be between $20 and $30 per brace. Martinez described high-quality braces as costing between $35 and $50. Yet, in the long run, braces are far more economical and practical than disposable taping. Taping, at about $3 per player per practice or game, can cost one team more than $3000 for the season compared with a one-time outlay of $450 to $650 for bracing.
“The school doesn’t allot for that much money for taping,” Szczerba said. “In a perfect world, it would be great to have everybody taped or everybody braced, and also doing balance-type exercises.”
He said athletes at the high school level seem reluctant to wear braces.
“Psychologically, they feel like it slows them down or it’s uncomfortable,” he said.
And then there’s the invincibility factor.
“Dealing with the high school athlete, they all feel invulnerable; they’re not going to get injured,” Szczerba said.
Interestingly, McGuine said he didn’t find the same disconnect among basketball coaches. They didn’t believe that the braces would slow down kids or prevent them from jumping, but neither did they promote them. Only about one in three coaches advocated for their use. McGuine said the coaches identified having too many choices as an obstacle.
But every situation is different, he said. Some coaches may be inclined to use just an exercise program while others may want to use just bracing. The combination of the two is optimal, but McGuine said he would advocate the balance training program over bracing alone for its positive effect on multiple body parts.
“The advantage of movement-based programs is the injury-protective effect seems to take place for the foot, ankle, the knee, the hip, and other things as well,” McGuine said. “When you put on an ankle brace you’re just protecting the ankle. You’re not protecting other body parts. I think they go together, but I think each situation is different. For example, if I have athletes who have had an injury within the past year, I would brace them as well as put them in a training program. For kids who have never been hurt, I would stick with the training program.”
He noted, however, that in a study epublished in January by the British Journal of Sports Medicine,7 Dutch researchers found bracing was superior to neuromuscular training in reducing the incidence, but not the severity, of recurrent ankle sprains.
“But I have only seen this in patients recovering from ankle injury, not true prophylaxis prior to any injury,” McGuine said.
Although McGuine’s research has looked only at balance exercises, he said that his discussions with other ankle injury experts suggest movement-based strategies are also effective–hopping, jumping, landing drills—and he would encourage their use at the outset of the season. He would also put kids in braces at the beginning of the season and wean them off over time, assuming they were doing preventive exercises concurrently.
McGuine said the first challenge in bracing high school players is getting past the misconception, held by some coaches and even some practitioners, that bracing a healthy athlete can actually weaken the ankle or foot and lead to other injuries. McGuine said that isn’t true.
“There’s no evidence of that,” McGuine said. “There are some misconceptions out there about bracing and what it can do. One of the biggest obstacles is trying to get over that.”
Interviews for this article confirmed the existence of those misconceptions. One very experienced athletic trainer told LER, “Wearing braces, and taping, for long periods of time have also been considered to reduce ankle and foot muscle strength, weakening the ankle.”
McGuine said that thinking is rooted in the heavy, restrictive braces of the distant past.
“If you use really restrictive braces obviously there’s a biomechanical effect,” McGuine said. “Most of the braces now are lighter. They’re more compliant. They actually fit the ankle a lot better. They’re not as big and bulky.”
P.K. Daniel is a freelance sportwriter and editor based in San Diego, CA.
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