WHO STAYS FIT?
Incidence, aetiology and prevention of sport injuries
in physical education teacher education students
WHO STAYS FIT? Incidence, aetiology and prevention of
sport injuries in physical education teacher education students
voor het bijwonen van de
openbare verdediging van
prevention of sport
injuries in physical
op dinsdag 21 september 2021
om 13:45 uur in de
aula van de universiteit,
De Boelelaan 1105
Na aﬂoop bent u van harte
uitgenodigd om te proosten
bij de receptie.
WHO STAYS FIT?
Incidence, aetiology and prevention of sport injuries
in physical education teacher education students
The research in this thesis was embedded in Amsterdam Movement Sciences Research
Institute, at the department of Public and Occupational Health, Amsterdam UMC,
location Vrije Universiteit Amsterdam, Netherlands
Studies presented in this thesis were supported by funding from:
• SIA-RAAK (2013-15-12P, RAAK.PRO02.022, SPR.VG01.007)
• NWO-NRO (40518865231)
Financial support for printing this thesis has kindly been provided by BLIEKENDAAL B.V.
Cover Ilse Modder | www.ilsemodder.nl
Lay-out Ilse Modder | www.ilsemodder.nl
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© S. Bliekendaal, the Netherlands
All rights reserved. No part of this book may be reproduced or transmitted in any
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appropriate, the publishers of the paper.
Who stays fit?
Incidence, aetiology and prevention of sport injuries
in physical education teacher education students
ter verkrijging van de graad Doctor of Philosophy aan
de Vrije Universiteit Amsterdam,
op gezag van de rector magnificus
prof.dr. V. Subramaniam,
in het openbaar te verdedigen
ten overstaan van de promotiecommissie
van Faculteit der Geneeskunde
op dinsdag 21 september 2021 om 13.45 uur
in de aula van de universiteit,
De Boelelaan 1105
geboren te Breukelen
promotor: prof.dr. E.A.L.M. Verhagen
copromotor: dr. J.H. Stubbe
“My body could stand the crutches,
but my mind couldn’t stand the side-line”
– Michael Jordan –
TABLE OF CONTENTS
CHAPTER 1 General introduction
CHAPTER 2 Incidence and risk factors of injuries and their impact on
academic success: a prospective study in PETE students
CHAPTER 3 Incidence and risk factors of Medial Tibial Stress Syndrome:
a prospective study in PETE students
CHAPTER 4 Dynamic balance and ankle injury odds:
a prospective study in 196 PETE students
CHAPTER 5 Mechanisms of sport-related injuries in physical education
teacher education students: a descriptive analysis of 896
CHAPTER 6 Sports injury prevention practices and directions for
improvement: a multi-centre qualitative study in PETE
CHAPTER 7 General discussion
List of contributors
About the author
PHYSICAL ACTIVITY AND INJURY
Physical activity (e.g., sports participation) is considered an essential pillar of a healthy
lifestyle which has various beneﬁcial eects on overall health [1-3]. Physical activity and
health have a dose-response relationship where even little physical activity can lead to
substantial beneﬁts on multiple health-related outcomes, such as all-cause mortality,
cancer, coronary heart disease and mental health [2, 4]. Despite that the beneﬁts greatly
outweigh any potential adverse eects , physical activity also provides health risks,
such as injury [4, 5]. Consequences of injuries include the inability to proﬁt from the
health beneﬁts due to reduced physical activity , the risk of long term health issues [7,
8], and increased medical costs . Besides these consequences at the personal level,
injuries involve an economic problem as well. For example, in the Netherlands, the direct
costs of acute sports injuries alone were estimated at 360 million euros in 2018 .
PHYSICAL EDUCATION TEACHER EDUCATION PETE STUDENTS
To facilitate safe participation in physical activities and sports and prevent injuries,
professionals in physical activity and sports need to be competent in implementing
preventive strategies. Physical Education (PE) teachers are among the main groups of
professionals involved in physical activities (i.e., PE class) in children and adolescents.
As such, they are responsible for preventing pupils’ injuries during these. The bachelor
degree program for PETE prepares future PE teachers for these responsibilities. In the
Netherlands, six PETE programmes include approximately 4.350 PETE students .
These PETE programs are based on the national qualiﬁcation criteria for the Bachelor
PETE degree , but curricular activities may vary in practice. In general, the PETE
program consists of a 4-year curriculum that includes developing a high skill level in
various sports, such as athletics, climbing, dance, ﬁeld sports (e.g., basketball, hockey,
soccer, softball), gymnastics, martial arts, racket sports, and swimming. Hence, the
student’s academic success depends largely on learning new skills in various sports
over a short period. However, because of the intense PETE program, injuries are
lurking. A unique aspect of the injury problem in PETE students is that they can cause
students to be unable to participate in sports classes and, therefore, negatively impact
the academic success (e.g., delay, exit, lower grades) and professional development.
Hence, injury prevention is not only relevant for their future role as a teacher; it is
also essential for themselves as a PETE student. Additionally, the PETE’s teachers and
curriculum managers are responsible for the PETE program and its injury prevention
policy. They need to know the speciﬁc features of the PETE students’ injuries to make
well-informed decisions about injury prevention.
INJURY PREVENTION RESEARCH
To address the injury problem and work towards prevention, van Mechelen et al. (1992)
 published the prevention sequence in the early 1990s. This model describes a
four-step process towards preventing injury (ﬁgure 1.1). In step 1, the injury problem’s
extent and characteristics are described. In step 2, risk factors and injury mechanisms
are identiﬁed. Preventive measures are introduced in step 3. Subsequently, the
eectivity of the preventive measures is evaluated in step 4. This model’s essence
is that before preventive measures are implemented, evidence-based knowledge is
needed regarding injury and injury aetiology.
Although numerous preventive strategies are described in the literature and tested
under controlled circumstances, they have limited eects in practice [13-15]. This can
be considered as a gap between science and practice. To address this gap and work
forward on the sequence of prevention, Finch  proposed in 2006 the Translating
Research Into Injury Prevention Practice (TRIPP) framework (ﬁgure 1.2). Finch argued
that in step 4 of the sequence of prevention, preventive measures are evaluated under
ideal conditions, and two additional steps are needed to obtain real-world changes.
In step 5 of the TRIPP-framework, the implementation context is described to inform
implementation strategies. This facilitates the development of more context-driven
injury prevention strategies. Such strategies may connect better with the target
population’s everyday practices, supporting implementation and intervention uptake
[17-19]. In step 6, the eectiveness of preventive measures is evaluated. Per these
injury prevention frameworks, the following paragraphs address the injury problem,
injury aetiology, and injury prevention within the PETE population.
Establish the extent of
repeating step 1
Figure 1.1 The four-step sequence of prevention for sports injury prevention research. Reproduced
from Mechelen et al. (1992) 
THE INJURY PROBLEM IN PETE STUDENTS
The literature indicates that PETE students have relatively high injury risks, as injury
rates ranging from 0.85 to 2.1 injuries per year are found [20-26]. Previous studies
indicated that most injuries are acute (52% - 74%), involve the lower extremities (52% -
74%), are often recurrent (20% - 30%), occur frequently during curricular activities (35%
- 59%) and often need medical aid (68% - 84%) [23-26]. However, only one of these
studies included Dutch PETE students, which was published in 1996. These results
may be outdated since curricula have been evolved and modernised over the past two
decades. Additionally, a unique aspect of the injury problem in PETE students is the
potential eect on academic success. However, this eect’s nature and extent have
not been investigated yet. This indicates that there is insucient knowledge regarding
the injury problem. Therefore, to work towards prevention, this thesis addresses
incidence, severity, characteristics, and impact on the academic success of injuries in
Dutch PETE students.
Stage 1 Injury surveillance
Stage 2 Establish aetiology and mechanisms of injury
Stage 4 “Ideal conditions” / scientific evaluation
Stage 3 Devellop preventive measures
Stage 5 Describe interventions context to inform implementation strategies
Stage 6 Evaluate effectiviness of preventive measures in implementation context
Figure 1.2 The six-stage Translating Research Into Injury Prevention Practice framework. Adapted
from Finch (2006) 
Internal risk factors:
Age (maturation, aging)
Body composition (e.g., body weight, fat
mass, BMD, antropometry)
Health (e.g., history of previous injury,
Physical fitness (e.g., muscle
strength/power, maximal O2 uptake, joint
Anatomy (e.g., alignment, intercondylar
Skill level (e.g., sport specific technique,
Psychological factors (e.g.,
competitiveness, motivation, perception
Exposure to external risk factors:
Sports factors (e.g., co aching, rules,
Protective equipment (e.g., helmet,
Sports equipment (e.g., shoes, skis)
Environment (e.g., weather, snow and
ice conditions, floor and turf type,
Player/ opponent behavior
Gross biomechanical description
Detailed biomechanical description
Risk factors for injury
(distant from outcome)
Mechanism of injury
(proximal to outcome)
Figure 1.3 Multifactorial model for injury causation by Bahr and Krosshaug , based on the
model of Meeuwisse (1994) 
BMD, body mass density. ROM, range of motion
AETIOLOGY OF INJURY IN PETE STUDENTS
As the injury prevention frameworks describe, an essential aspect of prevention is
understanding the causation of injuries [12, 27, 29, 30]. Hence, a theoretical framework
for sports injury’s aetiology was developed [28, 31] (ﬁgure 1.3). This framework illustrates
the interactions between internal and external factors that contribute to an event
leading to an injury [27, 29]. The event that precedes injury occurrence is considered
the injury mechanism . Etiological research aims to identify, preferably modiﬁable,
factors associated with the cause of injury. The rationale to use this knowledge is that
targeting such factors can reduce injury risk. For example, if reduced leg strength is
associated with a knee injury, strengthening the leg muscles may have a protective
eect. Non-modiﬁable risk factors are, at best, useful to target preventive measures.
For example, when female athletes have a higher risk of developing a particular injury,
they may be advised to apply a targeted preventative strategy to prevent injury.
Factors that have been shown to increase injury odds in PETE students are sex (female),
previous injury, muscle weakness, decreased hip abduction, decreased ankle plantar
ﬂexion, increased subtalar inversion, and impaired dynamic joint stability [23, 24, 32-
34]. However, these studies, except one, were conducted outside the Netherlands.
The single study that included Dutch PETE students only addressed factors associated
with medial tibial stress syndrome (MTSS) and was conducted using a cross-sectional
design. No literature was found that presented detailed information in PETE students
regarding injury mechanisms. Thus, there are no recent prospective studies on risk
factors of injuries nor injury mechanisms in Dutch PETE students available in the
literature. Thus, this thesis also addresses the aetiology of injury to work towards injury
INJURY PREVENTION IN PETE STUDENTS
When insight into the injury problem, injury aetiology, and the implementation context
is obtained, a preventive strategy can be developed and implemented. In the literature,
ﬁve main sports injury prevention targets are identiﬁed , which are:
1. improve the athlete (e.g., neuromuscular training),
2. new or modiﬁed rules and regulations (e.g., level of physical contact allowed),
3. new or modiﬁed equipment (e.g., protective gear),
4. change in sport setting or context (e.g. physical, sociocultural or policy),
5. multiple components (combinations of intervention targets).
Preventive strategies can also be targeted to four dierent time-frames of which injury
occurs. These time frames are pre-event (aiming to prevent injury to occur in the ﬁrst
place), event (aiming to be eective at the time of the injury event) and post-event (aiming
to minimize the consequence of injury) . Combining the ﬁve preventive targets and
the four time-frames provides 20 dierent strategies. Two of these preventive strategies,
which are dominant in the scientiﬁc literature, aim to prevent injury occurrence by
interventions at the athlete level (e.g., education, neuromuscular training) and at the
time of the injury event (e.g., by applying a change in equipment) .
Although numerous sports injury prevention strategies have been described within the
literature , the PETE population’s literature on injury prevention is very scarce. One
systematic review is available in the scientiﬁc literature with lessons from sports to
develop preventive strategies in the PETE population . This study recommended a
multifactorial intervention including an awareness programme and functional training
(three times per week: strength, stretching, warm-up, core stability, dynamic stability
exercises of the lower limbs) with a gradual build-up and simple materials. However,
there are some shortcomings in this study. First, it was designed to identify injury
prevention strategies concerning intrinsic risk factors. Considering the previously
discussed multifactorial framework for injury aetiology, this is a substantial limitation.
Also, the review study assumed the transferability of preventive methods from sports
to the PETE context. This may be a somewhat optimistic assumption since dierences
between the implementation contexts limit such strategies’ transferability [37, 38]. For
example, sporting routines within the PETE program are, to a large extent, dierent from
those in sports. Athletes focus on a particular sport and have carefully planned training
and match days to facilitate recovery in between sessions. In contrast, PETE students
are confronted with various weekly sports classes, which have a train-the-trainer
character and are not necessarily well distributed over the week. Additionally, PETE
students are most often involved in extra-curricular sports, indicating heterogeneity
in sports participation.
To date, only one study is available in the literature that described and evaluated an
injury prevention program with PETE students as the target population . This so-
called “No Gain With Pain” (NGWP) intervention consisted of an injury awareness
program (theoretical and practical workshop for sports teachers and students) and
the implementation of neuromuscular training in the sport classes (warming-up,
stretching, stability training, strength training, core-stability, technical training). This
study provided a feasible preventive strategy tailored to Belgium PETE students.
However, since this intervention was designed following the previously discussed
review study, there may be some shortcomings in the design of this preventive strategy.
Furthermore, although this study provided promising results (i.e., reducing acute, ﬁrst-
time and extra-curricular injuries), the intervention did not signiﬁcantly reduce the
overall incidence rate. The fact that literature on the PETE implementation context
(step 5 of the TRIPP-framework) is lacking helps explain this result. It also indicates
that critical knowledge is missing. Qualitative research may be helpful to work forward
on this because it provides understanding about the implementation context and the
subjective perspectives from a target population. Therefore, this thesis also addresses
injury prevention from the subjective perspective of PETE students.
THESIS OBJECTIVES AND OUTLINE
The previous paragraphs illustrate the inadequate body of knowledge of Dutch PETE
students’ injuries. To recapitulate, the knowledge of the injury problem’s extent is
minimal and outdated. Additionally, there are no recent prospective studies on risk
factors of injuries nor injury mechanisms in Dutch PETE students. Finally, studies on
injury prevention’s subjective perspectives are non-existent in the literature. This
knowledge needs to be established to work towards prevention. Therefore, this thesis
aims to develop knowledge on incidence, aetiology, and prevention of injury in Dutch
The following research questions guide the studies within this thesis:
1. What is the incidence of injuries in PETE students?
2. What are the characteristics and mechanisms of injuries in PETE students?
3. Which factors are associated with the development of injuries in PETE students?
4. What measures could be introduced for injury prevention in PETE students?
This thesis is outlined in seven chapters. After the general introduction in chapter
1, the incidence and characteristics of injury are presented in chapter 2. Chapter 2
also describes several risk factors and the association between injury and academic
success. The following two chapters address the incidence and risk factors of the
most common injury types; Medial Tibial Stress Syndrome (MTSS) (chapter 3) and
acute ankle injuries (chapter 4). Chapter 5 provides an overview of the mechanisms of
sport-related injuries. Chapter 6 presents the ﬁnal study in this thesis which addressed
injury prevention from the students’ perspectives, including their suggestions for
improvements. This thesis ﬁnishes with chapter 7, where all the results are discussed,
and the main research questions are answered.
Incidence and risk factors of injuries
and their impact on academic success:
a prospective study in PETE students
Bliekendaal, S., Goossens, L., & Stubbe, J. H. (2017).
Scandinavian journal of medicine & science in sports,27(12), 1978-1985.
Injuries can have a major impact on the physical performance and academic career of
Physical Education Teacher Education (PETE) students.
To investigate the injury problem, risk factors and the impact of injuries on academic
success, 252 PETE students were followed during their ﬁrst semester. Risk factor
analysis was conducted by means of logistic regression analysis with a dierentiation
for upper body, lower body, acute, overuse and severe injuries.
An incidence of 1.26 injuries/student/semester was found. Most injuries involved the
lower body (61%), were new injuries (76%), occurred acutely (66%) and were sustained
during curricular gymnastics (25%) or extracurricular soccer (28%). Signiﬁcant risk
factors for lower body acute injuries were age (OR = 2.14; p = .01), previous injury
(OR = 2.23; p = .01) and an injury at the start of the year (OR = 2.56; p = .02). For
lower body overuse injuries gender (OR = 2.85; p = .02) and the Interval Shuttle
Run Test score (OR = 2.44; p = .04) were signiﬁcant risk factors. Previous injury
(OR = 2.59; p = .04) and injury at the start of the year (upper body: OR = 4.57; p = .02;
lower body: OR = 3.75; p < .01) were risk factors for severe injuries. Injury related time-
loss was positively related with total academic success (r = .20; p = .02) and success
in theoretical courses (r = .24; p = <.01). No association was found between time-loss
and academic success for sport courses.
Injuries can be highly disadvantageous. They can lead to reduced physical performance
, high medical costs  and in extreme cases they can be career-ending [23, 41,
Physical Education Teacher Education (PETE) students are professionally involved in
sports and therefore injuries in PETE students need special attention. Several studies
have described the injury problem in PETE students in the past decades [20-26].
Injury incidence in PETE students ranges from 0.85 to 2.1 injuries/year [20-26]. This
is relatively high compared to the general active population, which has an injury
incidence of 0.36 injuries/year .
The cause of injuries is multifactorial . Several risk factors have been found to
apply in sport active populations, for instance, previous injury [23, 44], female gender
[45, 46], higher age , high exposure to sports [47, 48], high fat percentage  and
a lower endurance capacity [45, 49]. Recent literature shows that risk factors can be
dierentiated for acute and overuse injuries  and for severe injuries . There is
little up-to-date literature on risk factors in PETE students and the available studies
do not dierentiate between acute and overuse injuries and the severity of injuries.
Furthermore, to our knowledge, the impact of these injuries on the academic career
of PETE students is unknown.
The main goal of this study was to describe the injury problem in PETE students in terms
of incidence, circumstance, mechanism, type, localization, and severity. Secondly,
this study aimed to investigate contributions of risk factors including previous injury,
gender, age, exposure to sports, fat percentage and endurance capacity for acute,
overuse and severe injuries. A third aim of this study was to investigate the impact of
injuries on academic success.
The study sample consisted of ﬁrst-year bachelor degree PETE students from the
Amsterdam University of Applied Sciences. The ﬁrst year PETE program consisted,
apart from the theoretical courses, of courses in six dierent sports (gymnastics, ﬁeld
sports, martial arts, dance, athletics, swimming) with a scheduled exposure of 11.5
hours/week. In total, 292 students were followed during the ﬁrst semester, September
to February, in the academic year 2014-2015.
INCIDENCE AND RISK FACTORS
A prospective cohort study design was used. Prior to the start of the academic year,
all students underwent a compulsory Pre-Participating Examination where height,
weight, and fat percentage by 4-point skin thickness  were measured by a sports
At the start of the academic year, all students were informed about the study and
invited to provide written informed consent and complete a baseline questionnaire if
they wished to participate. The baseline questionnaire included questions about sports
participation before the start of the academic year (sport discipline and exposure
time), current injuries and injuries in the past year. Injuries had to be speciﬁed in terms
of localization, type and duration of time-loss. In addition, all students performed an
Interval Shuttle Run Test (ISRT)  to assess endurance capacity. All students were
instructed to perform the test with maximal eort. Heart rate frequency was measured
(Polar Team2, Polar, Sweden) during the test and directly after the test, the Rating of
Perceived Exertion (RPE)  was collected. The heart rate measures and the RPE
were used to determine whether the test was performed with maximal eort, using
the following criteria: 1) the RPE had to be higher than 15/20 and 2) the dierence
between the highest reached heart rate during the last two completed intervals had
to be equal to or lower than three beats/minute. Compliance with these criteria was
assessed concurrently by two researchers and agreed by consensus. Submaximal tests
were excluded from the analysis.
An online injury registration form was completed on four occasions (every ﬁve curricular
weeks) during the semester. The injury registration form included questions about
extracurricular sport exposure and, if applicable, speciﬁcations of a sustained injury. The
injury was speciﬁed by the following items: date of occurrence, circumstances of the
inciting event (sustained during intra- or extracurricular activities and the speciﬁc (sport)
activity), injury mechanism (acute or overuse injury), new or recurrent injury, date of
recovery, localization and type. An injury was deﬁned as any physical complaint that
resulted in a student being unable to fully take part in sporting activities for at least 1 day,
also referred to as a time-loss injury . The injury registration form was used in previous
studies [41, 42] and adjusted for a PETE population. When a student did not complete a
questionnaire within ﬁve days an automatically generated reminder was sent by e-mail.
To improve data quality, students were contacted by e-mail when incomplete data were
entered in the questionnaire. Injury severity was determined in terms of duration of time-
loss. Data regarding duration of time-loss were not normally distributed and therefore
categorized as follows: minimal (1-3 days), mild (4-7 days), moderate (8-28 days) and
severe (>28 days) . For completing a theoretical and sports course students could
obtain one to three European Credit Transfer and accumulation System (ECTS) credits. A
total of 24 ECTS-credits (15 ECTS-credits for theoretical courses and nine ECTS-credits
for sports courses) could be obtained during the semester. Only the ECTS-credits from
newly entering students were used for analysis because students who re-entered the
ﬁrst year may have had ECTS-credits from a previous year or certain exemptions. The
protocol of this study was approved by the ethics committee of the Academic Medical
Centre in Amsterdam (reference number W14_222 # 14.17.0285).
The continuous variables were categorized as follows. Firstly, fat percentage and ISRT-
score were categorized as below or above average for men and woman separately.
Secondly, students were divided into the age groups above and below the average
age (19.5 ± 2.0). Thirdly, values for sport exposure before the start of the year and
extracurricular sport exposure were categorized into two categories by using the
median as a cut-o point. Finally, the localization of the injuries was categorized as
upper (head, neck, hand/ﬁngers, wrist, lower arm, elbow, upper arm, shoulder, clavicle,
chest, ribs, belly, upper back, lower back) or lower body (hip, groin, buttocks, upper
leg, knee, lower leg, Achilles tendon, ankle, heel, foot, toe). Risk factor analysis was
conducted according to injury categories based on localization (upper- or lower body)
and mechanism (acute or overuse) of the ﬁrst sustained injury. All injuries sustained
after the ﬁrst injury were excluded from the risk factor analysis.
DATA ANALYSIS AND STATISTICS
Compliance was determined by dividing the number of completed injury registration
forms by the total number of forms that should have been completed (four for each
student). Injury incidence was calculated by dividing the total number of injuries
recorded across the semester by the number of students. To investigate associations
between risk factors and injuries a univariate Pearson chi-square test was used. Only
the variables associated with injuries with a p-value lower than 0.2 were entered into
a stepwise multivariate logistic regression analysis. For assessing the relationship
between injury duration and ECTS-credits the Pearson correlation coecient was
determined. P values lower than .05 were considered signiﬁcant. All statistical tests
were conducted with IBM SPSS statistics 22 (SPSS Inc., Chicago, Illinois, USA).
SUBJECTS AND COMPLIANCE
During the study, 40 students ended their education or did not respond to any of the
questionnaires and were excluded from the study. The causes of ending education
were not recorded. The remaining 252 students were included in the study. Subject
INCIDENCE AND RISK FACTORS
characteristics can be found in table 2.1. In total 18 students re-entered the ﬁrst year
and were excluded from the analysis of the impact of injury-related time-loss on
academic success. Furthermore, 16 students were excluded from the analysis of ISRT
score as a risk factor because their score was rated as a submaximal score. At the start
of the year, the students reported an average extracurricular sport exposure of 410
minutes/week (standard deviation: 238 minutes/week; median: 360 minutes/week)
and during the year they reported an average extracurricular sport exposure of 265
minutes/week (standard deviation 175 minutes/week; median: 262 minutes/week). In
total 815 completed questionnaires were received, giving an overall compliance of
81%. In total 142 (56%) students completed four questionnaires, 50 (20%) students
completed three questionnaires, 31 (12%) students completed two questionnaires and
29 (12%) students completed only one questionnaire. From 231 (73%) injuries the date
of recovery was obtained. In 87 (27%) cases no information about the date of recovery
Table 2.1 Subject characteristics (mean ± SD)
N 169 83
Age 19.9 ± 2.2 18.8 ± 1.2
Height (m) 1.82 ± 0.07 1.69 ± 0.06
Weight (kg) 73.3 ± 8.0 61.2 ± 7.1
Fat (%) 13.4 ± 3.5 26.2 ± 4.2
ISRT score 96 ± 18 63 ± 18
ISRT: Interval Shuttle Run Test
A total of 318 injuries were registered by 252 students. This equates to a total injury
incidence of 1.26 injuries/student/semester. During the semester, 164 (65%) students
registered one or more injuries of which 80 (32%) students sustained one injury, 42
(17%) students sustained two injuries, 24 (10%) students sustained three injuries, 11 (4%)
students sustained four injuries, ﬁve (2%) students sustained ﬁve injuries and two (1%)
students sustained six injuries. Most injuries were new injuries (76%) and acute (66%).
Most of the acute injuries occurred during curricular sports activities (53%). Curricular
gymnastics (25%) and extracurricular soccer (28%) were the disciplines with the
highest injury incidence (ﬁgure 2.1). Most injuries were located at the lower extremities
(61%) and involved the knee (16%), the ankle (14%) and the anterior side of the lower
leg (14%). The lower back (9%) and the shoulder (7%) were the most common injury
locations in the upper body. The most common injury locations are presented in ﬁgure
2.2. Most injuries were muscle strains (18%), contusions (12%), ligament strains (11%),
tendonitis (7%) or sore muscles (5%). In some cases, students were unable to deﬁne an
injury type (7%). The time-loss duration was determined for 231 injuries. Most injuries
were severe (43%), followed by moderate (26%), mild (18%) and minimal (14%) injuries.
Most overuse injuries (N = 43) were found in the severe injury category, and this is
illustrated in ﬁgure 2.3.
Figure 2.1 Most common activities where acute injuries (N = 210) were sustained
Figure 2.2 Most common injury locations
INCIDENCE AND RISK FACTORS
Figure 2.3 Injury duration (time-loss) for acute and overuse injuries (N = 231)
RISK FACTOR ANALYSIS
The results from the risk factor analysis are displayed in table 2.2. Gender was a
signiﬁcant risk factor for injuries. Women had a higher risk than men of sustaining an
overuse injury in the lower body. The higher age category had an increased risk of
sustaining a lower-body acute injury. An upper-body injury in the previous year was a
signiﬁcant risk factor for sustaining a severe injury. A lower-body injury in the previous
year was a signiﬁcant risk factor for sustaining a lower-body acute injury. An upper-
body injury at the start of the academic year was a signiﬁcant risk factor for sustaining
a severe injury. A lower-body injury at the start of the academic year was a signiﬁcant
risk factor for sustaining a lower-body acute injury and a severe injury. The students
with a relatively high ISRT score were less likely to sustain an upper-body acute injury
and more likely to sustain a lower-body overuse injury compared to students with a
relatively low ISRT score. Fat percentage, sport exposure before the start of the year
and extracurricular sport exposure were not signiﬁcant risk factors for any of the injury
RELATIONSHIP BETWEEN INJURY AND ACADEMIC SUCCESS
The total time-loss due to injury correlated positively with total obtained ECTS credits
(r = .20; p = .02) and ECTS credits obtained for theoretical courses (r = .24; p < .01).
Total time loss was not signiﬁcantly correlated with obtained ECTS credits for sporting
courses (r = -.01; p = .95).
Table 2.2 Risk factors for upper and lower body acute injuries, upper and lower body overuse injuries and severe injuries for PETE students (N=252). P
values for univariate chi-square and multivariate logistic regression analysis are displayed
Acute injury (N = 114) Overuse injury (N = 47) Severe injury (N = 68)
Upper body (N = 41) Lower body (N = 73) Upper body (N = 11) Lower body (N = 36)
UV MVLR UV MVLR UV MVLR UV MVLR UV MVLR
Variables p OR (95% CI) p p OR (95% CI) p p OR (95% CI) p p OR (95% CI) p p OR (95% CI) p
Gender (female) .86 .55 .81 .05* 2.85 (1.23-6.64) .02* .17 1.50 (0.80-2.83) .21
Fat% (>mean) .87 .94 .64 .55 .86
Age (>mean) .98 .02* 2.14 (1.18-3.86) .01* .77 .07 0.60 (0.26-1.39) .23 .54
(>median) .95 .16 0.62 (0.35-1.11) .11 .29 .04* 2.19 (0.95-5.06) .07 .33
(>median) .57 .74 .74 .76 .10 0.53 (0.28-1.00) .05
Upper body .15 2.75 (0.95-7.96) .06 -.86 -<.01** 2.59 (1.06-6.34) .04*
Lower body - <.01** 2.23 (1.21-4.10) .01* - .29 .02* 1.75 (0.92-3.32) .09
Injury at start
Upper body .16 0.51 (0.06-4.45) .54 - .05* 4.65 (0.90-24.13) .07 -<.01** 4.57 (1.29-16.15) .02*
Lower body - <.01** 2.56 (1.17-5.61) .02* -.14 2.55 (0.86-7.60) .09 <.01** 3.75 (1.69-8.34) <.01**
(>mean) .06 0.44 (0.20-0.97) .04* .74 .61 .04* 2.44 (1.04-5.71) .04* .31
UV: univariate analysis; MVLR: multivariate logistic regression analysis; OR: odds ratio; CI: conﬁdence interval
* signiﬁcant at p < 0.05
** signiﬁcant at p < 0.01
INCIDENCE AND RISK FACTORS
The main ﬁndings of this study are ﬁrst that with an incidence of 1.26 injuries/semester
PETE students have a high risk for sustaining a time-loss injury. Injuries were mainly
sustained during curricular gymnastics and extracurricular soccer. Secondly, the
following risk factors apply to PETE students: female gender, higher age, previous
injuries, injuries at the start of the year and ISRT score. Thirdly, injury-related time-loss
has a weak positive relationship with academic success.
With an incidence of 1.26 injuries/semester (2.52 injuries/year) PETE students have a
signiﬁcantly higher injury incidence than the 0.36 injuries/year of the general Dutch
sport-active population . Compared to previous studies in PETE students we
found the highest incidence. Previous studies by Lysens et al. (1989) , Twellaar et
al. (1996) , Ehrendorfer (1998) , Flicinski (2008) , Goossens et al. (2014) 
and Mukerhjee (2015)  found an injury incidence of 1.7, 0.97, 1.37, 2.1, 1.5 and 1.0
injuries/year, respectively. The most important reasons for the dierences between
the studies are the use of dierent deﬁnitions and methodologies. Several studies used
a retrospective approach and found a lower incidence of 1.37  and 2.1  injuries/
year. Retrospective study designs are associated with recall errors  and can lead
to a lower count of injuries when compared to prospective studies [26, 55]. All studies
used dierent injury deﬁnitions which makes it dicult to compare the results with our
study. In some studies, it is unclear which deﬁnition is used [20, 21]. Goossens et al.
(2014)  used a deﬁnition based on the consequences: “… the student having to stop
the activity and/or suering from pain during sports participation and/or not being
able to (fully) participate in the next planned sports class, training session or match”
. Mukherjee (2014)  used 6 criteria as an injury deﬁnition, which are: “1) Injury
occurred as a result of the PE curriculum sports participation; 2) Injury occurred as a
result of training/practice related to the PE curriculum; 3) Injury occurred as a result
of participation in the other forms of organized sport (e.g. leisure, inter-hall games,
varsity sports etc.); 4) The injury may or may not aect academic commitment in any
form for any length of time; 5) The injury may or may not require medical attention; 6)
Any dental injury regardless of time loss”. Twellaar et al. (1996)  used the following
deﬁnition; “A physical discomfort sustained during physical activity that hindered the
subject practising sport lessons at the institute”. Lysens et al. (1989)  deﬁned an
injury as any injury “that occurred during the sports workout sessions, and causing
at least a 3-day absence from sports”. Our deﬁnition is any physical complaint, not
necessarily acute injuries, sustained during sports activities, that results in a student
being unable to fully take part in sporting activities for at least 1 day. Our deﬁnition
may be interpreted as less delimited than the deﬁnitions of Lysens et al. (1989) ,
Goossens et al. (2014)  and Mukherjee (2015)  which helps to explain the
higher injury incidence found in our study. This is supported by the fact that we found
more injuries with a short time-loss duration compared to the study of Goossens et
al. (2014) . However, we also found substantially more injuries with a time-loss
duration of more than four weeks. This cannot be explained by dierences in deﬁnition
use alone. This might indicate that the PETE students in our study actually sustain
more and more severe injuries. Dierences between the study of Twellaar et al. (1996)
 and our study may be explained by dierences in the follow-up period. Twellaar
et al. (1996)  prospectively followed 136 Dutch PETE students during their 4-year
education and found an overall incidence of 0.97 injuries/student/year. Our study only
included the ﬁrst semester of the ﬁrst year. Previous research shows that most injuries
are sustained during the ﬁrst semester (54%) of the ﬁrst academic year . A longer
follow-up period might lead to a lower incidence. Observations from practice support
the hypothesis that injury incidence decreases in the following academic years.
The results in the literature are dicult to compare also due to dierences between
the PETE programs. For instance, curricular exposure time varies from 6.8 hours/
week in Singapore  to up to 15 hours/week in Austria . The students in
the current study had an exposure time of 11.5 hours/week for curricular sports.
curricular skiing and ice skating are only seen in the PETE curriculum in Austria .
Curricular incidence rates range from 1.96 injuries/1000 hours in Belgium  to 2.83
injuries/1000 hours in Singapore  indicating potential dierences in the physical
demands of the curriculum. Furthermore, the average age of the PETE populations
varies from 18.4 years in Belgium  to 25.9 years in Singapore  indicating
potential signiﬁcant dierences in population characteristics. To conclude, our higher
observed injury incidence can be attributed to the following factors: 1) in our study all
physical complaints leading to time-loss were included; 2) we used prospective data
acquisition procedures; 3) the follow-up period was only the ﬁrst semester, generally
the semester where most injuries occur; 4) possibly, the exposure time and physical
demands of the curriculum in our study were higher than in most studies (unfortunately
we cannot support this hypothesis because we lack detailed data on the exposure time
and intensity of the sports courses); and 5) dierences in population characteristics
may play an important role.
Regarding injury localization in PETE students, our results show that 61% of all injuries
were located in the lower extremities. This is in agreement with results of Twellaar et al.
(1996) , Flicinski (2008) , Goossens et al. (2014) , Mukherjee (2014)  and
Goossens et al (2015) . They found a proportion of lower extremity injuries of 66%,
69%, 74%, 52% and 72% respectively. Like our study, most studies found that the knee,
ankle and lower leg were most frequently injured [20, 21, 23, 25, 26]. Our study found
that 67% of the injuries were non-recurrent. This is lower, but in line with ﬁndings of
INCIDENCE AND RISK FACTORS
Lysens et al. (1989) , Goossens et al. (2014) , Goossens et al. (2015)  and
Mukherjee (2014)  who report respectively 80%, 70%, 72%, 74% new injuries. The
proportion of acute injuries (66%) in our study agrees with earlier ﬁndings of 71%, 65%
and 70% found by respectively Twellaar et al. (1996) , Goossens et al. (2014) 
and Goossens et al. (2015) . That the majority (53%) of all injuries were sustained
during curricular activities also corresponds with the literature [23, 25, 26]. In general,
the injury characteristics found in our study correspond to a large extent with earlier
ﬁndings in PETE students.
Previous injury is the main risk factor for an injury identiﬁed in our study. This
corresponds with the results of multiple other studies [23, 44, 45]. Our study adds
that this risk factor can be speciﬁc. Previous injury was a speciﬁc risk factor for acute
lower-body injuries and severe injuries. Incomplete recovery of previously injured body
parts probably increases the likelihood of a recurrent injury. In our study women had a
signiﬁcantly higher risk of sustaining a lower-body overuse injury when compared to
men. This result is not in line with a previous study on PETE students . The study
by Goossens et al. (2014)  indicated that gender was not a risk factor for knee,
ankle, lower leg injuries and injuries in general. However, no analysis was executed
for overuse injuries in particular. In military personnel, it has been shown that women
have an increased risk of sustaining an overuse injury  and an injury in the lower
extremities . A review on risk factors shows that conﬂicting literature can be found
on the relationship between gender and lower extremity injury risk . Our ﬁndings
support the literature that indicates that women have an increased risk of sustaining
lower body overuse injuries.
In our study, higher age was found to be a risk factor for lower body acute injuries.
Conﬂicting results have been found in the literature regarding age as a risk factor,
with most studies ﬁnding an increased injury incidence in higher age categories
. Therefore our ﬁnding regarding lower body acute injuries corresponds with the
majority of the literature on this topic.
A relatively high ISRT score was found to be associated with a lower risk for upper body
acute injuries and a higher risk for lower body overuse injuries. This does not correspond
with earlier ﬁndings of Verstappen et al. (1998)  who found no relationship between
aerobic ﬁtness and injury risk in PETE students. However, they did not control the
analysis for the type and localization of the injuries. Our ﬁndings suggest that students
with a high aerobic ﬁtness have a reduced risk of sustaining an upper-body acute injury,
and this corresponds with most studies of the relationship between aerobic ﬁtness and
injury risk . Our ﬁndings also suggest that higher aerobic ﬁtness is associated with
an increased risk for sustaining a lower-body injury, and this does not correspond with
the literature. However, we hypothesize that the students with a relatively high aerobic
ﬁtness were also the students with a large extracurricular sport exposure and therefore
are more likely to sustain a lower-body overuse injury. The rationale that a high level
of sport exposure increases the risk for sustaining lower body overuse injuries is in line
with the literature . To test the hypothesis we performed additional analysis and
found a signiﬁcant association between a high ISRT score and a high extracurricular
sport exposure (p < .01).
Fat percentage was not a signiﬁcant risk factor in our study. Conﬂicting results can be
found in the literature for body composition as a risk factor . An increased risk of
overuse injuries has been found for under- and overweight young conscripts . The
study by Taanila et al. (2015)  demonstrates a U-shaped relationship between body
composition and injury risk. This U-shaped relationship might be the reason that in our
dichotomous analysis no relationship was found.
No relationship was found between total injury-related time-loss and academic
success for sports courses. Total time-loss had a weak positive correlation with total
academic success and with results of theoretical courses. This might be explained
by our observations that injured students used their injured period to prepare for
theoretical classes and exams. Besides, the curriculum in our study provided occasions
to catch up with missed sports courses and their examinations at a later time. This
appeared to be sucient for injured students to catch up with the uninjured students,
in their work.
This study has some limitations that need to be addressed. The details of the injuries
were registered by the students by means of self-evaluation, and there were no
professional diagnoses of the injuries. This means that the injury characteristics should
be interpreted with caution. Besides, it is important to point out that our study did
not focus on acute sports injuries but on physical complaints leading to time-loss,
regardless of their origin. This partially explains the high numbers of injuries in our
study and explains in particular the injuries caused in an activity other than regular
sports activities (table 2.2) and suggests that our ﬁndings apply to injuries in general.
Only data from one semester is included and no complete view over the full academic
year was obtained. Besides, in total 110 students did not complete all questionnaires
and in 27% of all injuries, no time-loss duration was determined. This may have biased
our results. Furthermore, a rule of thumb is that 10 injuries are needed per risk factor
included in the analysis. Not all injury categories had a sucient number of injuries
with respect to the number of risk factors. The results from the risk factor analysis
should therefore also be interpreted with caution.
INCIDENCE AND RISK FACTORS
We conclude that PETE students have a substantial injury problem. Curricular
gymnastics and extracurricular soccer are the main causes of acute injuries. Important
risk factors are female gender, greater age, injuries in the previous year, injuries at the
start of the year and ISRT score. Despite the high incidence of injuries, injuries had
no negative eect on academic success with regard to the sports courses. Oering
occasions to catch up with the missed sport lessons or examinations is probably
sucient to compensate for the injury-related time-loss. Future studies should aim
to realize a longer inclusion period than in our study and gather more data on the
duration of time-loss due to injury, in order to make a more comprehensive analysis of
the long term impact of injuries on academic success in PE students.
PETE students have a relatively high risk of sustaining an injury. Curricular gymnastics
and extracurricular soccer are major causes of injuries. These activities may be
prioritized when applying preventive measures. The previous injury seems to be the
most robust risk factor in PETE students. Furthermore greater age, female gender
and ISRT score are relevant risk factors. This knowledge can be used for improving
screening methods for upcoming students by selecting students with high injury
risk and oering them additional advice or support. Injury-related time-loss in PETE
students should not necessarily be regarded as an academic eciency problem.
Of course, much eort is needed in the area of injury prevention for the purpose
of ensuring optimal academic development of the students, but oering alternative
training and examination occasions seems sucient to enable students to catch up
with the uninjured students after recovery from an injury.
INCIDENCE AND RISK FACTORS
Incidence and risk factors of Medial Tibial Stress
Syndrome: a prospective study in PETE students
Bliekendaal, S., Moen, M., Fokker, Y., Stubbe, J. H., Twisk, J., & Verhagen, E. (2018).
BMJ open sport & exercise medicine,4(1).
Medial Tibial Stress Syndrome (MTSS) is a common lower extremity overuse injury often
causing long-term reduction of sports participation. This study aimed to investigate
the incidence and risk factors of MTSS in ﬁrst-year Dutch Physical Education Teacher
Education (PETE) students.
This prospective study consisted of physical measures at baseline (height, weight, fat
percentage, 3,000 meters run test, navicular drop test, hip internal and external ROM,
hip adduction and abduction strength, single-leg squat, and shin palpation), an intake
questionnaire at baseline (age, sports participation, presence of MTSS, MTSS history,
insole use, and the use of supportive shoes) and a MTSS registration procedure during
the academic year of 2016-2017 (10-months) using a validated questionnaire. In total
221 ﬁrst-year PETE students were included, of which 170 (77%) were males and 51
(23%) females. The evaluation of risk factors was conducted with uni- and multivariable
logistic Generalized Estimating Equations analysis.
In total 55 (25%) subjects, 35 (21%) males and 20 (39%) females, developed MTSS
during the follow-up period. Associated risk factors were the female sex (OR = 3.14,
95% CI: 1.39 - 7.11), above average age (OR = 0.31, 95% CI: 0.13 - 0.76), above average
body mass index (OR = 2.29, 95% CI: 1.02 - 5.16), and history of MTSS (OR = 5.03, 95%
CI: 1.90 - 13.30).
The incidence of MTSS is high in PETE students. Several risk factors were identiﬁed.
These results demonstrate the need for prevention and may provide direction to
preventive intervention design.
Medial Tibial Stress Syndrome (MTSS) is one of the most common lower extremity
injuries . It is induced by weight-bearing activities, like running or jumping and
characterised by pain on the posteromedial border of the tibia . Incidence rates
of 7% to 35% are reported in military personnel [46, 61, 62], 14% to 20% in runners
 and 20% in female Physical Education Teacher Education (PETE) students .
Usually, MTSS leads to a prolonged period of physical complaints and a reduced ability
to participate in sports activities [63, 64]. To design preventive measures a profound
insight into, preferably modiﬁable, factors that are associated with an increased risk of
developing MTSS is needed .
Several intrinsic risk factors for MTSS have been identiﬁed in review studies. The most
signiﬁcant risk factors are the female sex [60, 65, 66], a history of MTSS , and a
higher navicular drop [60, 65-68]. Other signiﬁcant risk factors are a high Body Mass
Index (BMI) [60, 66-68], increased weight , high plantarﬂexion Range of Motion
(ROM) [67, 68], high hip external ROM [60, 65-68], lower internal rotation ROM ,
lower calf girth , previous running injury , running experience , and orthotic
use . Numerous other potentially relevant factors have been investigated for their
association with MTSS, including shin pain at palpation, shin oedema, knee varus-
valgus, running performance, and sports participation . However, the literature is
not consistent on the signiﬁcance of the above risk factors .
For a more in-depth exploration of the risk factors, there is a need for more prospective
studies . The primary goal of this study was to investigate the incidence of MTSS
in PETE students. Secondary goals investigated the signiﬁcance of factors associated
with an increased risk for developing MTSS, including sex, BMI, length, weight, fat
percentage, age, MTSS history, shin pain at palpation, shin oedema, navicular drop, hip
ROM, hip strength, knee varus-valgus, running performance, and sport participation.
All subjects were ﬁrst-year bachelor degree Physical Education Teacher Education
(PETE) students at the Amsterdam University of Applied Sciences. Apart from theoretical
courses, the PETE program consists of six dierent sports courses (gymnastics, ﬁeld
sports, martial arts, dance, athletics, and swimming) with a weekly curricular exposition
of approximately 11.5 hours. In total 285 students were invited to participate in the
study during the academic year of 2016-2017.
INCIDENCE AND RISK FACTORS OF MTSS
A prospective study design was used with baseline measures (April-June 2016) and
a 10-month follow-up period during the academic year of 2016-2017. Before the
baseline measures, subjects were informed about the study procedures and were
asked to complete an intake questionnaire and informed consent. Information was
obtained about sex, age, the presence of MTSS, MTSS history, insole use, shoe type,
and participation in sports with high running and jump loads.
Baseline measures consisted of a necessary selection procedure and medical screening
and an additional physical screening regarding this study. The selection procedure
included a 3,000-meter running test supervised by teachers of the PETE program.
The medical screening included measurements of length (cm), weight (kg), BMI, fat
percentage (%) and was conducted by sports physicians. The additional physical
screening on the potential factors associated with MTSS was performed by bachelor
degree Physical Therapy (PT) students who were trained by an experienced physical
therapist (YF). This screening consisted of the following tests.
A navicular drop test was conducted after marking the navicular prominence in a
seated (non-weight-baring) position with the feet in shoulder width. The distance
between the ﬂoor and the marked navicular prominence was measured in millimetres.
After standing up (weight-bearing), without moving the feet, the measurement of the
distance between the navicular prominence and the ﬂoor was repeated. The amount
of drop for both feet was calculated by subtracting the seated score from the elevated
Hip internal and external ROM measurements were conducted in a supine position with
the hip and knee ﬂexed to 90 degrees. Each hip was internally and externally rotated
to a ﬁrm feel. Angles were measured by using a goniometer . The procedure was
executed twice, and the scores were averaged per hip.
Hip adduction and abduction strength were measured in a side-lying position using a
hand-held dynamometer (HHD) (JTech PowerTrack Commander I) using a 5 seconds
break-test procedure . Before the test, the placing for the HHD was determined
by marking 8 centimetres above the lateral and medial malleolus. The tested leg was
held at a 0 degrees angle, the other leg was held at a 90 degrees angle. Subjects
were instructed to hold on to the side of the examination bed with their hands for
stabilisation and to perform the test with maximal eort. The procedure was executed
twice, and the scores were averaged per hip. An adduction - abduction ratio was
calculated by dividing the average adduction score by the average abduction score.
A single leg Squat test was conducted to determine varus or valgus angles. White
markers (6) were placed at the Spina iliaca anterior superior (SIAS), the greater
trochanter, the lateral and medial femoral condyle, and the lateral and medial malleoli.
Subjects were instructed to execute the single-leg squat with their arms crossed in
front of their chest with their hands on the shoulder, remain their knees in parallel
and their vision forwards. To provoke a natural execution of the squat no technical
instructions were given. After a series of practice squats the squat test was executed
twice for both legs and recorded on video (Ipad Mini, Apple Inc., CA, USA) in the frontal
and sagittal plane. Videos were synchronised (Dartﬁsh 7, Alpharetta, GA, USA) and the
knee angle (varus-valgus) and the squat angle were determined (Kinovea 0.8.15) at the
lowest squat position or the lowest position that the SIAS marker was visible. Results
from the two consecutive squats were averaged per knee. Two-dimensional evaluation
of the single-leg squat knee angles has good reliability .
Shin palpation for pain and oedema was conducted with the subject supine and the
knee ﬂexed in 90 degrees and the foot on the examination bed. The place of palpation
was determined by marking 2/3 of the distal medial surface of the tibiae. Pain presence
was assessed by palpating the posteromedial border of the tibia and the presence of
pitting oedema was assessed by a 5 seconds hold of the medial tibial surface .
During the follow-up period, subjects were asked to complete a MTSS registration
form every ﬁve curricular weeks, in total on seven occasions. MTSS was deﬁned
as exercise-induced pain at the medial side of de tibia . The registration form
included the Dutch version of the MTSS-score questionnaire, designed and validated
by Winters et al. (2015). The questionnaire contained an entry question regarding the
presence of MTSS at the left leg, the right leg or both legs. When MTSS was indicated,
the nature of the complaints had to be speciﬁed in four questions with four answer
options regarding; (1) limitations for participating in sporting activities (no limitations
- no participation); (2) pain while performing sporting activities (no pain - unable to
exercise); (3) pain during walking (no pain - unable to walk); and (4) pain at rest (no
pain - very painful). Based on the answers a MTSS severity score (scale: 0-10, with 0
indicating no complaints and 10 indicating maximal complaints) was calculated .
DATA ANALYSIS AND STATISTICS
Subjects were included in the study when 1) at least three follow-up questionnaires
were completed, and 2) only one or two questionnaires were completed, but with the
indication of MTSS in at least one questionnaire. Legs with a MTSS severity score equal
to or higher than one in one or more of the follow-up questionnaires were considered
as MTSS legs. Baseline test results were presented in means and standard deviation
INCIDENCE AND RISK FACTORS OF MTSS
for continuous variables and numbers and percentages in dichotomous variables.
Continuous data from males and females were combined after dichotomising the data
as higher and lower than average for males and females separately. The association
between the potential risk factors and MTSS was analysed at the leg level using logistic
General Estimating Equation (GEE) analysis. GEE was used to take into account the
dependency of the observations of the two legs within the subject. Both univariable
and multivariable logistic GEE analyses were performed. Only variables with a P-value
lower than .20 in the univariable analysis were included in the multivariable analysis.
P-values smaller than .05 were considered signiﬁcant. All statistical tests were
performed with IBM SPSS 24 (SPSS Inc, Chicago, IL, USA).
In total 285 subjects enrolled in the study. All of these subjects volunteered to
participate in the study. Several subjects had MTSS at the time of administrating the
intake questionnaire. This lead to the exclusion of 16 subjects. The fact that some
subjects completed less than three injury registration questionnaires and did not
develop MTSS, lead to the exclusion of 48 other subjects. Therefore, a total of 221
subjects, 170 (77%) males and 51 (23%) females, were included in the data analysis.
The 221 included subjects returned 1,344 ﬁlled in questionnaires indicating a response
of 87%. In 130 (10%) questionnaires, a MTSS score equal to or higher than 1 was found.
These MTSS complaints had a mean severity score of 2.7 (median = 2.0, interquartile
range = 2). Table 3.1 presents the results from the MTSS score questionnaires. These
results indicate that in 35% of the cases sports participation was reduced, in 88%
pain during sports participation was present, in 51% pain while walking was present,
and in 56% pain at rest was present. Unilateral or bilateral complaints were found in
respectively 27% (12% only left and 15% only right) and 73% of the cases.
During the follow-up period 55 (25%) subjects, 35 (21%) males and 20 (39%) females
suered from MTSS. Figure 3.1 shows the development of MTSS during the follow-
up period, indicating a substantial increase of MTSS after the ﬁrst weeks of the PE
program and a ﬂuctuating incidence (range: 0-12%) and prevalence (range: 5-15%)
during the follow-up period. The subjects indicated MTSS on one to seven occasions
in respectively 40%, 26%, 13%, 9%, 7%, 4%, and 1% of the cases.
Baseline characteristics of legs with and without MTSS are shown in Table 3.2 for males
and females separately. In univariable analysis, the following factors were signiﬁcantly
associated with the development of MTSS: the female sex, a history with MTSS, an
above-average hip exorotation ROM, the use of supportive shoes, and shin oedema
(Table 3). In multivariable regression analysis, the following variables were found to be
associated with the development of MTSS: the female sex, a below-average age, an
above-average BMI, and history with MTSS (Table 3).
Table 3.1 Answer distribution of the MTSS registration form (N = 130)
Answer option, n (%)
Item number Item name 1 2 3 4
1 Current sporting activities 84 (65) 36 (28) 6 (5) 4 (3)
2 Pain during sporting activities 16 (12) 95 (73) 15 (12) 4 (3)
3 Pain while walking 64 (49) 58 (45) 8 (6) 0 (0)
4 Pain at rest 57 (44) 67 (52) 4 (3) 2 (2)
Answer option number 1 corresponds to no limitations, and option number 4 corresponds to
Figure 3.1 Incidence (New cases) and prevalence (Total cases) of MTSS before the start of the year
(T0) and during the follow-up period (T1 - T7)
INCIDENCE AND RISK FACTORS OF MTSS
Table 3.2 Descriptives for baseline measures for control legs and MTSS legs
Male legs (N = 340) Female legs (N = 102)
(N = 280)
(N = 60)
(N = 62)
(N = 40)
Age (years, SD) 19.8 (2.4) 19.1 (1.8) 18.8 (1.3) 18.4 (1.5)
Height (cm, SD) 183.7 (6.8) 183.0 (6.1) 171.8 (6.4) 170.9 (7.1)
Weight (kg, SD) 74.6 (9.9) 73.5 (7.7) 63.5 (9.1) 64.3 (6.1)
BMI (kg/height2, SD) 22.1 (4.5) 21.9 (1.9) 21.4 (2.7) 22.6 (2.2)
Fat (%, SD) 13.6 (4.4) 12.9 (3.8) 25.2 (3.5) 26.4 (4.7)
3000-meter run (min:sec, SD) 13:20 (1:22) 13:47 (1:44) 16:24 (1:40) 16:42 (1:44)
Hip exorotation ROM (degrees, SD) 61.6 (9.7) 62.9 (12.1) 64.4 (8.6) 65.5 (10.3)
Hip endorotation ROM (degrees, SD) 25.7 (9.2) 26.1 (9.1) 32.5 (9.9) 30.7 (8.5)
Hip strength adduction (N, SD) 182.9 (37.7) 184.6 (36.9) 134.3 (29.0) 136.5 (26.9)
Hip strength abduction (N, SD) 188.0 (41.8) 182.1 (36.9) 144.6 (25.1) 152.4 (28.3)
Hip adduction/abduction ratio (SD) 0.99 (0.16) 1.03 (0.20) 0.93 (0.12) 0.91 (0.14)
Navicular drop (mm, SD) 6.6 (3.1) 7.0 (3.1) 6.4 (2.8) 7.8 (3.5)
Squat knee angle (degrees, SD) 167.1 (10.1) 167.2 (9.7) 164.0 (8.4) 165.5 (11.3)
High jump/run sport (no, %) 37 (13) 13 (22) 8 (13) 8 (20)
MTSS history (yes, %) 20 (7) 14 (23) 6 (10) 10 (25)
Insole use (yes, %) 27 (10) 9 (15) 18 (29) 6 (15)
Supportive shoes (yes, %) 17 (6) 7 (12) 2 (3) 8 (20)
Shin pain (yes, %) 83 (33) 21 (38) 25 (43) 19 (48)
Shin oedema (yes, %) 42 (17) 14 (26) 15 (26) 11 (28)
BMI, body mass index; MTSS, medial tibial stress syndrome; ROM, range of motion
Table 3.3 Results from uni- and multivariable GEE analysis
Variable OR (CI 95%) p OR (CI 95%) p
Sex (female) 3.01 (1.53-5.91) <.01** 3.14 (1.39-7.11) <.01**
Age (>mean) 0.54 (0.27-1.04) .07 0.31 (0.13-0.76) .01*
Height (>mean) 0.93 (0.49-1.79) .83
Weight (>mean) 0.96 (0.51-1.83) .91
BMI (>mean) 1.68 (0.89-3.23) .12 2.29 (1.02-5.16) .05*
Fat (>mean) 1.21 (0.63-2.35) .57
3000-meter run (>mean) 1.58 (0.79-3.18) .20
High jump/run sport (no) 0.57 (0.26-1.26) .17 0.47 (0.17-1.29) .14
MTSS history (yes) 3.72 (1.63-8.50) <.01** 5.03 (1.90-13.30) <.01**
Insole use (yes) 1.15 (0.48-2.75) .76
Supportive shoes (yes) 2.98 (1.11-7.98) .03* 2.65 (0.62-11.24) .19
Hip exorotation ROM (>mean) 2.01 (1.06-3.81) .03* 1.89 (0.86-4.14) .11
Hip endorotation ROM (>mean) 1.22 (0.65-2.29) .54
Hip strength adduction (>mean) 1.34 (0.71-2.52) .37
Hip strength abduction (>mean) 1.06 (0.56-1.99) .86
Hip adduction-abduction ratio (>mean) 0.96 (0.72-1.28) .79
Navicular drop (>mean) 0.99 (0.65-1.50) .95
Squat knee angle (>mean) 1.22 (0.93-1.59) .15 1.33 (0.93-1.91) .12
Shin pain (yes) 1.24 (0.66-2.33) .51
Shin oedema (yes) 2.08 (1.08-4.01) .03* 1.92 (0.87-4.23) .11
* signiﬁcant at p<.05. ** signiﬁcant at p<.01
BMI, body mass index; GEE, general estimating equation; MTSS, medial tibial stress syndrome;
ROM, range of motion
The main ﬁndings of this study are ﬁrst that we found a high incidence of MTSS in our
PETE students, in particular in female students. Secondly, that female sex, a below-
average age, an above-average BMI, and a history with MTSS are associated with an
increased risk for the development of MTSS.
COMPARISONS WITH LITERATURE
With a MTSS incidence of 25%, in speciﬁc 21% in men and 39% in women, we found
relatively high results compared to other studies. Verrelst et al. (2014) found a MTSS
incidence of 20% in female PETE students (N = 81) during a follow-up period of 29
weeks . Sharma et al. (2011) found an incidence of 8% in male recruits (N = 468)
during a 26 week training period . Rauh et al. (2010) found an incidence of 7% in
female Marine Corps recruits during a 13 week training period . Yates et al. (2004)
found an incidence of 35% in 124 naval recruits, 26% for men (N = 84) and 45% for
women (N = 40), during a 10 week basis training program . In runners incidence
rates between 14% and 20% are reported during follow-up periods of 12 months [76-
79]. Bennet et al. (2001) included 125 high school cross-country runners and fond an
incidence of 12% during an 8-week training program . All the above-mentioned
studies used a clinical diagnosis of MTSS. Except for the study of Yates et al. (2004), all
studies found a lower incidence compared to our study .
There are three major dierences between these studies and our study. Firstly, our
study used self-evaluation of MTSS complaints, which may also be sensitive to several
other injuries in the lower extremities (e.g. tibial stress fracture, chronic exertional
compartment syndrome, and muscle and tendon injuries) . Most studies in MTSS
used clinical diagnosis of the MTSS, this methodological dierence helps to explain
the lower incidence of MTSS in the literature compared to our study. We attempted
to minimise self-evaluation errors by using a validated questionnaire  and a clear
deﬁnition . Nevertheless, the self-evaluation procedure of MTSS complaints may
be the primary explanation for the higher MTSS incidence in our study. Secondly, our
study consists of a 10-month follow-up period, which is substantially longer than most
of the previous studies. A longer follow-up period may be associated with a higher
incidence of MTSS. Thirdly, most studies involve a dierent population (runners or
militaries) compared to our study. The training regimes of these populations may be
very dierent regarding training frequency, volume and type compared to the training
regimes of PETE students.
Only one study, in militaries, found a higher incidence compared to our study . The
authors report a weekly physical activity of 16 hours and explain that this is relatively
INCIDENCE AND RISK FACTORS OF MTSS
high for militaries. Also, that study is unique in the conﬁdentially of the diagnosis of
MTSS, meaning that the subjects were probably more comfortable in coming forward
with any complaints because there were no consequences of reporting this injury.
The high weekly physical activity and conﬁdentiality may explain the higher incidence
found in that study compared to other studies in militaries and our study.
Winters et al. (2016) is the single study in the literature that reports responses per
item of the MTSS-score questionnaire . That study shows that in MTSS diagnosed
patients (N = 133) in 78% sports participation was reduced due to MTSS related pain.
Furthermore, the study shows that 97% of the patients reported pain during sporting
activities, 69% reported pain while walking, and 64% reported pain at rest. Our results
are respectively 35%, 78%, 51%, and 56%. This indicates that Winters et al. (2016) found
a substantial higher severity of MTSS compared to our study. This can be explained
by the fact that we used the MTSS-score questionnaire to monitor complaints in a
non-patient group. This logically leads to the inclusion of cases with mild MTSS. This
principle is well documented in the literature .
No studies regarding risk factors of MTSS speciﬁcally in PETE students were found.
A history with MTSS, with an odds ratio of 5.03 (95% Conﬁdence Interval [CI]: 1.90
- 13.30), is the most relevant risk factor in our study. Injury history is, in general, a
robust risk factor for injuries in the literature [31, 81]. This is also the case for MTSS
[65, 66]. Based on ﬁve prospective studies Newman et al. (2014) report an overall
odds ratio of 3.74 (95% CI: 1.17 - 11.91) for subjects with a history of MTSS to repeat
occurrence of MTSS . Compared to this review study our study found a relatively
strong association between MTSS history and the reoccurrence of MTSS. However,
odds ratios up to 18.3 , 20.0  and 30.0  can be found in literature. Therefore,
our results are still in agreement with the literature.
Review studies report that females (athletes, runners and militaries) are more likely to
develop MTSS compared to men by 2.35 (95% CI: 1.58 - 3.50)  and 1.71 (95% CI:
1.15 - 2.54)  times. Our study found a relative risk of 3.14 (95% CI: 1.39 - 7.11) for the
female sex, which is slightly higher but in agreement with the literature. It is unknown
why females are more predisposed to develop MTSS. Newman et al. (2013) suggest
that dierences in running kinematics between males and females may attribute to the
increased risk for females.
Most review studies on the risk factors of MTSS report a signiﬁcant relationship
between a higher BMI and MTSS risk [65-68]. Our study found an odds ratio of 2.29
(95% CI: 1.02 - 5.16) for the group with an above-average BMI, which is consistent with
the literature. An explanation for this ﬁnding is that higher body weight relative to body
height causes a relatively high mechanical loading to the tibia during weight-bearing
activities . When this frequently occurs during a prolonged period, the body is
unable to recover appropriately producing bony overload and adhering complications
Our study found conﬂicting results with the literature regarding age as a risk factor for
developing MTSS. The literature consistently reports that age is not associated with
an increased risk . Our study found an odds ratio of 0.31 (95% CI: 0.13 - 0.76) for
the above-average age group. Observations from practice are in line with this result.
Therefore, this might be a speciﬁc risk factor in our PETE population. A rationale
for this ﬁnding is that the older students are more likely to sustain an acute lower
extremity injury compared to the younger students . The older and injured students
may be less actively involved in the sports program and therefore less susceptible to
developing MTSS. However, we lack data to support this rationale.
All the other risk factors in our study did not have a signiﬁcant relationship with
the development of MTSS in our PETE students. This includes height, weight, fat
percentage, running performance, sports participation, insole use, use of supportive
shoes, hip exorotation ROM, hip endorotation ROM, hip adduction and abduction
strength, hip adduction-abduction strength ratio, navicular drop, squat knee angle,
shin pain at palpation, and shin oedema.
STRENGTHS AND LIMITATIONS
Our study has some limitations that need to be addressed. Firstly, our study used a
self-evaluation injury registration. This method may overestimate the actual incidence
of MTSS. We attempted to minimise this eect by using a validated questionnaire and
a precise deﬁnition. Secondly, our study managed to reach a response of 87%. The
13% missing’s may bias the results underestimating the incidence of MTSS and the
signiﬁcance of the risk factors. Thirdly, we did not control for sports exposition. Fourth,
the physical screening test results may have limited reliability. Most of the conducted
tests are well documented in the literature and have good reliability. However, we did
not analyse interrater reliability during the training sessions. Thus, the results should
be treated with care.
This study also had some strengths. Firstly, we used a relatively large population
compared to previous prospective studies, and we included both males and females.
Secondly, we used a relatively extended follow-up period in comparison to most
previous studies on MTSS.
INCIDENCE AND RISK FACTORS OF MTSS
We conclude that MTSS is a substantial problem in our PETE population. The most
relevant risk factors are the female sex, a below-average age, an above averaged BMI,
and history of MTSS. These results can be used for targeting preventive measures.
Future studies should aim to investigate the validity of the MTSS-score questionnaire
regarding the detection of MTSS or incorporate clinical diagnosis of MTSS in the study.
Furthermore, we suggest investigating the relation between sport exposition changes
and the development of MTSS.
INCIDENCE AND RISK FACTORS OF MTSS
Dynamic balance and ankle injury odds:
a prospective study in 196 PETE students
Bliekendaal, S., Stubbe, J., & Verhagen, E. (2019).
BMJ open,9(12), e032155.
The aim of this study was to investigate whether dynamic balance, measured with the
anterior component of the Star Excursion Balance Test (SEBT-ANT), is a risk factor for
ankle injuries in physical education teacher education (PETE) students.
DESIGN AND SETTING
A prospective mono-centre study in ﬁrst-year PETE students.
A total of 196 subjects, of which 137 men (70%) and 59 women (30%).
This study consisted of measures of the anterior component of the SEBT at baseline
(September 2015) and an injury registration procedure during a follow-up period
(September 2015 – June 2016). The association between the SEBT-ANT score and
subsequent ankle injury was analyzed with Generalized Estimating Equations analysis
at the leg level.
Men and women had an average SEBT-ANT score of respectively 65.1% and 67.7% of
leg length. In 20 (15%) subjects the ﬁrst injured body site involved the ankle. Across
all participants, a below-average SEBT-ANT score was not associated with increased
ankle injury odds (odds ratio [OR] = 2.43, 95% conﬁdence interval [CI]: 0.94 – 6.29,
p = .07). In men, a below-average SEBT-ANT score indicated 7-fold increased odds for
ankle injury (OR = 7.06, 95% CI: 1.43 – 34.92, p = .02). In women, this relationship was
not signiﬁcant (OR = 0.72, 95% CI: 0.19 – 2.71, p = .62).
Below average normalized SEBT-ANT scores were associated with a 7-fold likelihood
for ankle injuries in men. In contrast, no relationship was found between the SEBT-
ANT score and ankle injuries in women. These results may provide directions for the
implementation of screening tools, as part of an injury prevention program, to identify
male PETE students with an increased likelihood for ankle injuries.
Physical activity and sport participation are essential for maintaining and improving
health [1, 86]. The downside of physical activity and sport participation is, however, the
risk of sustaining an injury . physical education teacher education (PETE) students
participate, as part of the PETE curriculum, in a wide range of physical activities which
puts them at risk for sustaining an injury . Injured students are limited to participate
in the educational program which can cause suboptimal professional development,
higher study costs and, in extreme cases, exclusion from the PETE program. Therefore,
the prevention of injuries in this population is needed.
According to the ‘sequence of prevention’ model by van Mechelen et al. (1992) 
knowledge about the injury problem and associated risk factors are needed before
preventive measures can be developed. Several studies have described the injury
problem in PETE students and indicate that the ankle is in the top three of injury
localizations in this population [23, 25, 57, 85, 87]. In the literature, one of the most
signiﬁcant risk factors for ankle injuries is the dynamic balance of the ankle [45, 88,
89]. A common and practical method to assess the dynamic balance of the ankle is
the Star Excursion Balance Test (SEBT) [90-97]. The literature shows that, in athletic
populations, low scores on the anterior component of the SEBT (SEBT-ANT) are
associated with an increased risk for lower extremity injuries in general [90, 94, 95]
and ankle injuries in particular [93, 97].
However, no studies are found in the literature regarding dynamic balance as a
risk factor for ankle injuries in PETE students. In addition, because of dierences in
characteristics between the PETE and sport-speciﬁc population the existing literature
on this topic has limited transferability to the PETE population. Therefore, the aim of
this study was to investigate whether dynamic balance, measured with the anterior
component of the SEBT, is a risk factor for ankle injuries in PETE students. Based on the
literature, it was hypothesized that dynamic balance would be a risk factor for an ankle
injury. Identifying signiﬁcant risk factors for ankle injuries can be of importance in the
development of an injury prevention program in the PETE population.
The study population consisted of ﬁrst-year PETE students of the Amsterdam
University of Applied Sciences. The ﬁrst-year PETE curriculum consisted of, apart
from theoretical courses, an average weekly sports exposition of approximately 10.5
DYNAMIC BALANCE AND ANKLE INJURY
hours in six dierent sports (athletics, dance, ﬁeld sports, gymnastics, martial arts, and
swimming). In total 229 students enrolled the academic year 2015-2016. Exclusion
criteria for subjects were: 1) No participation in the physical test/inability to perform
the physical test. 2) No response in injury surveillance.
A prospective study design was used. At the start of the academic year, all subjects
were informed about the study design and procedures during a plenary presentation
and were asked to complete informed consent. A baseline questionnaire, which was
completed by the subjects after the plenary presentation, was used to obtain data
regarding sport participation, gender, age and ankle injury history in the past 12 months
(yes/no). During the ﬁrst week of the study, subjects underwent a pre-participation
examination by a sports physician, including measures of length and body weight,
and a physical screening including the SEBT-ANT as a measure for dynamic balance
of the ankle (anterior reach relative to leg length). An injury surveillance procedure
was conducted during the following academic year to obtain data regarding sport
participation (average hours/week) and subsequent injuries. The study procedures were
approved by the ethical committee of the Academic Medical Centre in Amsterdam.
Star Excursion Balance Test
The SEBT was used as a measure for the dynamic balance of the ankle . Dierent
applications of this protocol, mainly regarding foot placement and pass/fail criteria,
can be found in the literature . We conducted the SEBT in accordance with the
study of Gribble et al. (2016) . The SEBT was executed only in the anterior direction
(SEBT-ANT) as the literature shows that this component of the SEBT has the strongest
association with subsequent injury [93, 94]. The subjects received plenary instruction
about the execution of the test. In accordance with the literature, they had to perform
six practising trials for each leg [98, 99]. To execute the SEBT-ANT, subjects had to
stand on one foot with the most distal aspect of the weight-bearing foot at a starting
line. With their free leg subjects had to reach slowly as far as possible in the anterior
direction, slightly above a measuring tape on the ﬂoor, while maintaining the hands
placed on their hips and their standing foot ﬂat on the ﬂoor. The maximal reach was
determined, by way of visual evaluation, at the point of maximal reach and administered
with the nearest 0.5 centimetres. The trial was rejected, and repeated when the subject:
1) failed to maintain a one-legged stance with their foot ﬂat on the ﬂoor, 2) failed to
maintain balance during or directly after the test, 3) touched down with the reaching
foot. The test was repeated three times successfully for each leg. The measurements
were conducted by a team of ﬁve trained fourth-year PETE students.
Leg length was determined for the purpose to normalize the SEBT-ANT score. Subjects
lay on a mat table in a supine position while a physical therapist measured, with a
cloth tape, the distance between the most inferior aspect of the anterior superior iliac
spine and the most distal portion of the lateral malleolus of the right and left leg. All
measurements were conducted by the same therapist.
During the academic year (September 2015 – June 2016) subjects registered newly
sustained injuries on seven occasions. For practical purposes and to obtain a high
response rate, the injury registrations were completed during plenary coaching meetings.
This led to injury registration intervals of ﬁve curricular weeks for injury registrations
one to six, the ﬁnal injury registration covered seven curricular weeks. Injuries had to be
speciﬁed in terms of localization, injury mechanism (acute or overuse), circumstances
of the inciting event, contributing factors, type and duration. An injury was deﬁned
as any physical complaint that resulted in a subject being unable to fully take part in
sporting activities for at least 1 day, also referred to as a time-loss injury . This data
acquisition method has been used in previous studies . Ankle injuries were identiﬁed
using the localization (ankle), as no further diagnoses of the injuries were done and the
literature shows that the type of the self-evaluated injuries is not accurate .
DATA ANALYSIS AND STATISTICS
The SEBT-ANT scores from the three trials were averaged and normalized for leg
length for each leg . Data from the injury surveillance was used to categorize legs
in the ankle injury (the ﬁrst injury involved the ankle) or no ankle injury (no injury or ﬁrst
injury did not involve the ankle) group.
To analyze the relationship between SEBT-ANT scores and subsequent ankle injury
independent-samples t-tests were used to analyze dierences in SEBT-ANT scores
between men and women.
Second, the relationship between normalized SEBT-ANT and subsequent ankle
injury was assessed at the leg level using Generalized Estimating Equations (GEEs)
with gender and ankle injury history in the model as confounders and controlled for
intrasubject relations (2 limbs per subject). This analysis was also conducted for men
and women separately, without gender in the model as a confounder, because women
had higher normalized SEBT-ANT scores than men (table 4.1). In addition, a secondary
analysis was performed with the exclusion of subjects where the ﬁrst injury did not
involve the ankle.
Third, the normalized SEBT-ANT scores were dichotomized using the average as the
cut-o point. Finally, odds ratios were calculated using GEE analysis (with >mean
DYNAMIC BALANCE AND ANKLE INJURY
as the reference group) with ankle injury history and gender as a confounder in the
model. The average score of the study sample was used as a cut-o point to exclude
the possibility that a pre-deﬁned cut-o point from the literature introduced a bias
in the study, as the literature shows that the SEBT protocol is often conducted in
dierent ways  and dierent optimal cut-o points are found in dierent athletic
populations (e.g. 84% of leg length in basketball players  and 64% of leg length in
soccer players ). Again, a secondary analysis was conducted with the exclusion of
subjects where the ﬁrst injury did not involve the ankle.
An alpha level of p < .05 was used to assess signiﬁcance. The analysis was conducted
using SPSS V.24.
PATIENT AND PUBLIC INVOLVEMENT
The study participants were not involved in the design of this study. No patient
Table 4.1 Subject characteristics
Male Female Total
Subjects (N, %) 137 (70) 59 (30) 196
Age (year, SD) 19.5 (2.4) 18.6 (1.3) 19.3 (2.2)
Length (cm, SD) 182 (7) 170 (6) 178 (8)
Weight (kg, SD) 71.6 (8.7) 61.9 (5.1) 68.7 (8.9)
BMI (SD) 21.7 (2.2) 21.5 (1.8) 21.6 (2.1)
Ankle injury in past 12 months (N, %) 21 (15) 8 (14) 29 (15)
Extra-curricular sport participation
Exposure (hours/week, SD) 5.5 (3.5) 5.7 (5.3) 5.6 (4.1)
Sports top 5 (N, %) Soccer (57, 42)
Fitness (53, 39)
Running (29, 21)
Martial arts (10, 7)
Cycling (8, 6)
Fitness (11, 19)
Running (10, 17)
Hockey (9, 15)
Soccer (9, 15)
Gymnastics (7, 12)
Soccer (66, 34)
Fitness (64, 33)
Running (39, 20)
Hockey (12, 6)
Martial arts (12, 6)
BMI, body mass index
In total 196 subjects were included in the analysis (ﬁgure 4.1) of which 137 men (70%)
and 59 women (30%). Subject characteristics are presented in table 4.1. Results from
the SEBT-ANT test are presented in table 4.2.
Table 4.2 SEBT-ANT scores (mean, SD) and p-values regarding dierences in men and women
SEBT-ANT score Total (N = 196) Men (N = 137) Women (N = 59) p
Average 64.02 (5.79) 64.63 (6.12) 62.60 (4.68) <.02*
Left 64.15 (6.15) 64.86 (6.35) 62.50 (5.36) .01*
Right 63.89 (5.89) 64.40 (6.28) 62.71 (4.72) .07
Normalized (%leg length)
Average 65.88 (5.52) 65.11 (5.54) 67.67 (3.96) <.01**
Left 66.01 (5.64) 65.34 (5.86) 67.55 (4.82) .01*
Right 65.76 (5.40) 64.88 (5.67) 67.79 (4.06) <.01**
* signiﬁcant at p <. 05, ** signiﬁcant at p < .01
SEBT-ANT: Starr Excursion Balance Test Anterior Reach
During the follow-up period, the researchers received 1,111 of the 1,372 expected
injury registration forms. This indicates an overall response rate of 81%, where the
majority (51%) of the subjects had a response rate of 100%. In total 137 (70%) subjects
sustained 1 or more injuries, of which 20 (15%) cases involved the ankle as the ﬁrst
injury (unilateral: N = 19, bilateral: N = 1). All the ankle injuries occurred acutely. Further
details of the ankle injuries are presented in table 4.3.
The relationship between normalized SEBT-ANT score and subsequent ankle injury
was signiﬁcant in the total group (OR = 1.11, 95% CI: 1.02 - 1.22, p = .02) and in men
(OR = 1.14, 95% CI: 1.04 - 1.26, p < .01), where lower SEBT-ANT scores indicated
increased ankle injury odds. This relationship was not signiﬁcant in women (OR = 1.05,
95% CI: 0.86 – 1.28, p = .66) (table 4.4). The secondary analysis, only including legs
for subjects where the ﬁrst injury involved the ankle and subjects without any injury
during the follow-up period, produced comparable results (total: OR = 1.10, 95% CI:
1.02 – 1.19, p = .01; men: OR = 1.11, 95% CI: 1.02 – 1.22, p = .02; women: OR = 1.09,
95% CI: 0.94 – 1.26, p = .26).
For the total group, a below-average SEBT-ANT score was not statistically signiﬁcantly
associated with increased ankle injury odds (OR = 2.43, 95% CI: 0.94 – 6.29, p = .07).
In men, legs with a below-average normalized SEBT-ANT score had 7-fold increased
odds to sustain a subsequent ankle injury compared to legs with an above-average
score (OR = 7.06, 95% CI: 1.43 – 34.92, p = .02). A below-average SEBT-ANT was not
associated with increased ankle injury odds in women (OR = 0.72, 95% CI: 0.19 – 2.71,
p = .62) (table 4.5).
The secondary analysis, only including legs for subjects where the ﬁrst injury involved
the ankle and subjects without any injury during the follow-up period, produced
comparable results (total: OR = 2.58, 95% CI: 1.03 – 6.50, p = .04; men: OR = 6.49,
95% CI: 1.33 – 31.82, p = .02; women: OR = 0.93, 95% CI: 0.23 – 3.71, p = .92).
DYNAMIC BALANCE AND ANKLE INJURY
Table 4.3 Speciﬁcations of the self-evaluated ankle injuries
Subject Recurrence Mechanism Activity Contact Contributing factors Side Type Duration (days)
1 First time Acute Gymnastics Indirect contact Bad landing L Sprain 90
2 First time Acute Gymnastics Non-contact Bad landing L Sprain 1
3 First time Acute Soccer Contact with person Bad landing, distortion R Sprain 4
4 First time Acute Soccer Indirect contact Distortion R Sprain 45
5 First time Acute Soccer Non-contact Distortion R Sprain 2
6 First time Acute Gymnastics Non-contact Distortion, bad coordination L Sprain 21
7 First time Acute Martial arts Contact with person Fall, bad landing R Sprain N.A.
8 First time Acute Martial arts Indirect contact Bad landing R N.A. 120
9 First time Acute Soccer Non-contact Bad landing R Sprain 25
10 First time Acute Soccer Indirect contact N.A. L Bruise, wound 5
11 First time Acute Else Unknown N.A. R Sprain N.A.
12 First time Acute Basketball Indirect contact Sudden turn/stop, distortion L Sprain N.A.
13 First time Acute Soccer Contact with person Sudden turn/stop, distortion L Sprain 3
14 First time Acute Else Unknown Sudden turn/stop, explosive movement L N.A. N.A.
15 Recurrent Acute Gymnastics Indirect contact Bad landing L N.A. 90
16 Recurrent Acute Volleyball Non-contact Bad landing L N.A. 1
17 Recurrent Acute Else Contact with object Fall R Fracture 50
18 Recurrent Acute Soccer Indirect contact Fall, bad landing, incomplete recovery
L + R Fracture 50
19 Recurrent Acute Gymnastics Contact with object Underground L N.A. N.A.
20 Recurrent Acute Soccer Contact with person Sudden turn/stop, distortion, underground L N.A. 32
L, left; N.A., not available; R, right
Table 4.4 Normalized SEBT-ANT scores (mean, SD) for non-injured and injured male legs (non-
injury: N = 262, injury: N = 12) and female legs (non-injury: N = 109, injury: N = 9) and the results
from the GEE analysis
Normalized SEBT-ANT score GEE analysis
Non-injury Injury OR (95% CI) p
Men 65.30 (5.66) 61.00 (6.54) 1.14 (1.04-1.26) <.01**
Women 67.76 (4.21) 66.64 (6.93) 1.05 (0.86-1.28) .66
Total 66.02 (5.39) 63.42 (7.13) 1.11 (1.02-1.22) .02*
* Signiﬁcant at p < .05, ** Signiﬁcant at p < .01
SEBT-ANT: Starr Excursion Balance Test Anterior Reach
Enrolled academic year
(N = 229)
(N = 201)
No participation in injury registration
(N = 5)
No SEBT performed
(N = 11)
Participation in injury registration
(N = 196)
(N = 137)
(N = 20)
Signed informed consent
(N = 212)
Declined / no response invitation
(N = 17)
Figure 4.1 Flowchart of the inclusion of subjects (N = 196)
SEBT, Star Excursion Balance Test
DYNAMIC BALANCE AND ANKLE INJURY
Table 4.5 Number of ankle injuries (N, %) per group and results from the GEE analysis
Non-injury Injury OR (95% CI) p
< mean 113 (41) 10 (4) 7.06 (1.43-34.92) .02*
> mean 149 (54) 2 (1) -
< mean 54 (46) 4 (3) 0.72 (0.19-2.71) .62
> mean 55 (47) 5 (4) -
< mean 167 (43) 14 (4) 2.43 (0.94-6.29) .07
> mean 204 (52) 7 (2) -
* Signiﬁcant at p < .05.
The purpose of this study was to investigate whether the dynamic balance of the
ankle, measured with the SEBT-ANT, is a risk factor for ankle injuries in PETE students.
The main ﬁnding is that below average normalized SEBT-ANT scores were associated
with a 7-fold odds for subsequent ankle injuries in men. In contrast, no association
between SEBT-ANT scores and ankle injury was found in women. This indicates that
gender was an eect modiﬁer in the relationship between dynamic balance and ankle
COMPARISONS WITH LITERATURE
Our study shows that the ankle is involved in 15% of the ﬁrst injuries, which is in
accordance with the literature. Previous studies in male and female ﬁrst-year PETE
students report ankle injury rates between 12% and 17% [23, 25, 85, 87]. Furthermore,
a review study by Fong et al. (2007) showed that in 11.2%-20.8% of all the injuries the
ankle is the involved body site . Because ankle injuries mostly consist of ankle
sprains  our results can also be compared to results from studies that focused on
ankle sprains. Hootman et al. (2007) conducted an analysis on data from 16 years of
injury surveillance in male and female college athletes in 15 dierent sport, covering
182.000 injuries, and showed that in 14.9% of the cases the injury involved a sprain of
the ankle .
In our study, an average anterior reach of 65.1% and 67.7% of leg length was found
for men and women respectively. In the literature, mean values of 65.6% to 84.1% are
found for men and 70.3% to 81.4% for women [91-94, 98, 104, 105]. This indicates that
our results are relatively low compared to the literature. A study by Plisky et al. (2009)
showed that the application of the SEBT protocol is often used in dierent ways, which
inﬂuences the results . The most observed dierences are: a) the extent to which
that subject is allowed to touch down with the reaching foot, b) the extent that stance
foot movement is allowed, c) stance foot positioning . In our study, subjects were
instructed not to touch down with the reaching foot and place their stance foot against
the starting line. Besides, we instructed subjects to maintain their hands placed on the
hip. The extent that arm movement is allowed is often unspeciﬁed in literature. These
three factors may explain the lower scores in our study. Gribble et al. (2016) conducted
the SEBT-ANT in a similar way as in our study and found an average score of 69.0% in
male high school and collegiate football players, which is 3.9% higher than the men
in our study. An explanation for this dierence may be that high-level football players
probably have higher physical performance, include dynamic balance, compared to
our heterogeneous sports population of PETE students.
Our study showed a 7-fold increased ankles injury odds for legs with below-average
normalized SEBT-ANT scores in men. Our study found higher odds compared to the
study by Gribble et al. (2016). Gribble et al. (2015) used a normalized SEBT-ANT cut-
o score of 67.2% and found a signiﬁcant odds ratio of 2.84 for lateral ankle sprain
injuries in male football players (N = 539) . The fact that Gribble et al. (2016) had
approximately twice the sample size and injury cases compared to our study, included
only male soccer players and determined the cut-o score using ROC analysis may
help to explain the dierences in results.
Ko, Rosen and Brown (2018) investigated dynamic balance as a risk factor for ankle
injuries in adolescent male and female soccer players and found, an almost signiﬁcant,
4-fold increased odds for an ankle injury in subjects with lower SEBT-ANT scores
(<64%). This is in agreement with the overall results of our study. Dierences in subjects
age, type of sport participation, the used cut-o score and the proportion of males
and females in the study may help to explain the dierence in observed odds for the
subgroups. Attenborough et al. (2017) found no relationship between the SEBT-ANT
score and subsequent ankle injury in female netball players , which corresponds
with the ﬁndings in female PETE students in our study.
Other studies that used the SEBT-ANT as a risk factor for injuries are conducted by
Plisky et al. (2006)  and De Noronha et al. (2015) . Plisky et al. (2006) used a
normalized SEBT-ANT cut-o score of 84.3% in male and females basketball players
(N = 235) and found odds ratios in the range of 1.8 to 4.1 for lower extremity injuries
 in women. In this study, no signiﬁcant relationship was found in men, which is the
opposite of the result in our study. However, Plisky et al. (2006) analyzed the SEBT-
DYNAMIC BALANCE AND ANKLE INJURY
ANT score as a risk factor for lower extremity injuries in general, not as a risk factor
for ankle injuries. This is a major dierence, which helps to explain the dierences in
results. De Noronha et al. (2013) conducted a study on active university students and
did not ﬁnd a relationship between normalized SEBT-ANT and subsequent ankle injury
. However, it is dicult to compare this study with our study because regular
university students are probably less physically active than PETE students.
In summary, in accordance with several studies, our study indicated that lower scores
on the SEBT-ANT indicated increased odds for a subsequent ankle injury in males,
not in females. In our study, this indicates that gender is an eect modiﬁer in this
relationship. An explanation for this ﬁnding may be as following. The SEBT incorporates
components of coordination, ﬂexibility and strength of the lower extremities [94,
107]. These are all important intrinsic factors related to injury risk , where better
coordination, ﬂexibility and strength represents a lower injury risk. Several studies
indicate that, in general, males and females have similar SEBT-ANT scores [94, 104,
106]. Our study presents higher SEBT-ANT scores in female subjects. This may point
out that female subjects in our study had a relative ‘better’ dynamic balance than male
subjects and therefore were less prone to an ankle injury.
STRENGTH AND LIMITATIONS
The strength of our study is that we used a prospective study design with a relatively
long follow-up period. Furthermore, our study used a more sophisticated analysis (GEE
analysis at the leg level and controlled the model by the person and previous ankle
injury) compared to other studies on the same topic. Another strength of this study is
that, with an overall response rate of 81% and 51 subjects with a 100% response rate,
our study managed to reach a relatively high response rate.
This study also has some limitations that need to be addressed. First, we used a self-
evaluation registration of injuries. To minimize this limitation, we used a clear injury
deﬁnition and a relatively short recall period. Furthermore, we used localization for the
identiﬁcation of self-reported ankle injuries as these are more reliable parameters than
other detailed characteristics of self-reported injuries (e.g. type) . Second, we
did not determine the interrater reliability of our SEBT test group. The SEBT has good
inter-rater reliability but is also often used in dierent manners . This indicates
that our results from the SEBT have limitations for comparisons with other studies.
Third, the overall response rate of 81% can be considered as good. Nevertheless, 19%
of non-response might bias our results. Fourth, in accordance with common injury
research methodology, we used linear regression analysis to evaluate the signiﬁcance
of risk factors . However, recent literature pointed-out the importance of non-
linear analysis for risk factors and addressed the complex inter-relations between
factors [47, 108, 109]. Fifth, we had a relatively low number of ankle injury cases in
the two subgroups (men and women). This indicates a limited statistical power of the
risk factor analysis for the subgroups. Sixth, we determined cut-o scores with the
average SEBT-ANT scores. These cut-o scores have limited clinical relevance as they
are based on a single sample of PETE students. Seventh, the analysis in this study was
not controlled for body mass index (BMI). Several subjects (14%) had missing values for
BMI. BMI was unsuitable to use as a confounder in the analysis as a sensitivity analysis
indicated that analysis with BMI as a confounder demonstrated decreased robustness
of the results due to the number of missing values. Finally, in our analysis, we did
not discriminate between types or severity of the ankle injury. In the literature, the
dynamic balance of the ankle is considered a risk factor for speciﬁcally ankle sprains.
Our study may have included other types of ankle injuries and underestimated the true
relationship between SEBT-ANT and subsequent ankle injury. These limitations should
be kept in mind when interpreting the results from this study.
Future studies are advised to: 1) determine normative values for the SEBT-ANT in
PETE students and determine optimal cut-o scores to identify students at risk for
an ankle injury, 2) investigate which (combination of) balance tests have the strongest
relation with ankle injury risk, 3) use more precise data regarding the ankle injury (e.g.
professional diagnosis of injuries, speciﬁc injury type), 4) investigate whether non-
linear relations exist in the relations between ankle balance and ankle injury risk, or 5)
assess whether preventive measures (e.g. a neuromuscular training program or the use
of bracing) reduces ankle injury likelihood in PETE students.
This study indicates that lower scores on the normalized SEBT-ANT, as a measure for
dynamic balance, are associated with increased odds for a subsequent ankle injury in
male PETE students. Therefore, the SEBT-ANT has potential as a screening tool for
ankle injury risk in male PETE students. However, before the implementation of the
SEBT-ANT as a screening tool normative values and optimal cut-o scores should
be determined. By doing so preventive measures can be targeted eciently and
eectively. For instance, male students with a positive outcome for the SEBT-ANT can
be advised to participate in a neuromuscular training program  or to use ankle
bracing during sports participation [111, 112].
DYNAMIC BALANCE AND ANKLE INJURY
Mechanisms of sport-related injuries in physical
education teacher education students:
a descriptive analysis of 896 injuries
Bliekendaal, S., Barendrecht, M., Stubbe, J. H., & Verhagen, E. (2021).
Translational Sports Medicine. 00:1–10.
The aim of this study was to determine sport-related injury mechanisms in Physical
Education Teacher Education (PETE) students.
This prospective cohort study (40-weeks) in ﬁrst-year PETE students obtained self-
reported characteristics of injuries (body part, injury setting, injury mechanism and
movements related to the cause of injury). Students (N = 759) from the academic years
of 2015-2016, 2016-2017 and 2017-2018 participated in this study. Descriptive data
analysis was conducted on the injury characteristics.
In total 896 injuries were registered by 489 (64%) students. Large proportions of the
injuries resulted from both non-contact (N = 496, 56%) and contact (N = 381, 42%)
mechanisms. The most common injury mechanism was gradual onset non-contact
(N = 275, 31%). High proportions of non-contact injuries were found in curricular
practices (N =120, 44%) and extra-curricular practices (N = 30, 38%). Injuries during
extra-curricular games were mainly contact related (N = 133, 81%). Furthermore, injury
onset was most commonly associated with a landing (N = 179, 29%), a fall (N = 158,
25%), an explosive movement (N = 114, 18%).
The most common injury mechanism was gradual onset non-contact. For practices
(curricular and extra-curricular) and extra-curricular games, the most common injury
mechanism were respectively non-contact and contact with a person. Furthermore,
injuries were most commonly associated with landings, falls and explosive movements.
Students from the Physical Education Teacher Education (PETE) program participate
in multiple weekly sports classes in various sports (e.g. athletics, climbing, dance,
ﬁeld sports, gymnastics, martial arts, and swimming) [23, 25, 85, 113]. In addition,
the literature indicates that PETE students are involved in extra-curricular sports
participation, mostly in soccer (34%), ﬁtness (33%), running (20%), hockey (6%), and
martial arts (6%) . Such an intense program puts the PETE students at high risk for
sport-related injuries [23, 85]. These injuries can have severe consequences, as they
can lead to long term physical problems [7, 8], increased medical costs , and drop
out from the curriculum. This indicates the need for injury prevention in the PETE
population. In the literature, however, only one study evaluated an injury prevention
method in the PETE population . Despite that this study presented a promising
and feasible strategy to prevent injuries, no signiﬁcant reduction in the injury rates
was found. Therefore, the search for solutions for the injury problem in the PETE
population is still ongoing.
The ‘sequence of prevention’ describes the process from the systematic collection
of information on the cause of injury towards the development and evaluation of
preventive methods . One key step towards injury prevention is to understand
the aetiology of injury in terms of risk factors and injury mechanisms, while these
insights form the basis of preventive methods [12, 27]. Grasping the injury mechanisms
provides insight into what actually happens at the time of the inciting event. These
insights play a crucial role in the development of preventive measures. For example,
an ankle sprain due to a kick to the lower leg during a soccer game is not necessarily
prevented by balance training. Instead, a multifaceted approach may be more eective
in such a case.
Injuries can have either a clear acute or repetitive mechanism or they can have
components of these two mechanisms [27, 114]. Both mechanisms can lead to an injury
with a sudden onset presentation. On the other hand, injuries with a gradual onset
presentation can only result from a repetitive injury mechanism. The International
Olympic Committee (IOC) consensus statement provides the following classiﬁcation
of injury mechanisms : (1) direct contact; (2) indirect contact; and (3) non-contact.
Gradual onset injuries are, by their nature, non-contact. Additionally, a more precise
description of the injury mechanism can be made by analyzing various elements of
the injury mechanism. Such a description can take elements of the athlete situation,
athlete behaviour as well as whole body and joint biomechanics leading up to the
injury into account .
MECHANISMS OF SPORT INJURIES
Several studies have already described the injury problem [23, 25, 85, 87] and
various risk factors [32, 115] in the PETE population. However, the literature on injury
mechanisms in this population is missing. Thus, for the development of preventive
methods in the PETE population, knowledge is lacking. Therefore, the aim of this
study was to determine the mechanisms of sport-related injuries sustained during the
academic year in PETE students. The results of this study may provide directions for
the development of preventive methods.
MATERIALS AND METHODS
DESIGN & SUBJECTS
During this prospective observational cohort study, an injury monitoring system was
implemented for the ﬁrst-year PETE cohorts. In the ﬁrst week of the academic year
(September) all subjects were informed about the goals and procedures of the study
and were invited to participate. After informed consent was signed, information about
sex and age was obtained from the University. During the following 40 weeks of the
freshman year (September – June) a self-report injury registration procedure was used
to obtain detailed information of injuries. The study procedure was approved by the
ethical committee of the Academic Medical Centre in Amsterdam.
Subjects were ﬁrst-year PETE students from the Amsterdam University of Applied
Sciences from the cohorts of 2015-2016 (N = 229), 2016-2017 (N = 285) and 2017-
2018 (N = 283). The PETE program, besides theoretical courses, consists of sports
classes in dierent sports (e.g. athletics, climbing, dance, ﬁeld sports, gymnastics,
martial arts, practical didactics, swimming), which corresponds with a curricular sports
participation of approximately 10.5 hours per week. Additionally, PETE students are
involved in an average of 5 hours of weekly extra-curricular sports participation .
During this study, no injury prevention method was present in the PETE program.
The time-loss deﬁnition for injury was used, deﬁning injury as any physical complaint
that resulted in a student being unable to fully take part in sporting activities for at least
1 day . Characteristics of the injury included body part, setting, injury mechanism
and movements at the time of injury. Body part was categorized into head/neck,
trunk/back, upper extremity and lower extremity [103, 116]. Setting referred to the
activity where the injury occurred and was categorized as follows. The various PETE
sports classes were categorized as curricular practices. Sport settings outside the PETE
program were categorized as extra-curricular practices or extra-curricular games.
Other settings were categorized as other. All injuries were considered as sport-related,
except the injuries where the setting other was indicated.
In our study, mechanisms of injury were deﬁned as following: 1. direct contact with
an object (e.g. a hockey stick, ball, wall); 2. direct contact with a person (e.g. tackle,
kick, collision, landing on someone’s foot); 3. indirect contact with a person or object
(e.g. fall or sprain after a push or pull); 4. non-contact (sudden onset); 5. non-contact
(gradual onset); 6. unknown injury mechanism. In addition, particular movements
related to the cause of injury could be indicated as an element of the injury mechanism,
which included: fall, landing, sudden turn or stop, misstep or distortion, and explosive
movement (multiple options possible).
During the 40-week follow-up period of each academic year, subjects completed a
standardized injury registration questionnaire [42, 85] on seven occasions. To obtain
a high response rate and for practical reasons, the planning of the questionnaires was
synchronized with periodic coaching classes. This resulted in recall periods of 5 weeks
(questionnaire numbers 1-3, 5, 6), 7 weeks (questionnaire number 4) and 8 weeks
(questionnaire number 7). As this study focusses on the details of unique injuries, the
dierences in recall periods are unlikely to aect the results.
In case that subjects sustained an injury during the recall period, characteristics of
that injury (body part, setting, mechanism, movements) were registered. Data was
collected using hard-copy questionnaires (2015-2016 and 2016-2017) or an online
questionnaire (2017-2018). Hard-copy questionaries were delivered by PETE lecturers
during the coaching classes and were digitized afterwards. To ﬁll in the online
questionnaire, students received an e-mail with a link to the questionnaire. Absent or
non-responding subjects were contacted (personal contact or a weekly reminder by
e-mail) to obtain their questionnaire during the two following weeks. Each year, injury
surveillance was coordinated by the same researcher throughout the study (SB).
DATA ANALYSIS AND STATISTICS
Response rates were calculated by dividing the total number of received injury
registrations by the number of maximally expected injury registrations. The period
prevalence was calculated by dividing the number of injured students by the total
number of participating students per recall period. Descriptive analyses were used
to describe baseline characteristics, body part, injury setting, injury mechanism and
movements using means and SD, or number and percentages. Descriptive analyses
were conducted with IBM SPSS 25 (SPSS Inc, Chicago, IL, USA).
MECHANISMS OF SPORT INJURIES
In total 759 (95%) of the 797 eligible students participated in the study, of which 208
(27%) women and 551 (73%) men, with a mean age at baseline of 19.4 years (SD ±2.1).
The researchers received a total of 4,038 completed injury registration questionnaires
including details of 896 injuries. These injuries were sustained by 489 (64%) students.
Most injuries involved the lower extremity (N = 520, 58%) (table 5.1). The development
of response rates and period prevalence of injury during the year is presented in ﬁgure
5.1. The overall response rate was 76%.
Table 5.1 Numbers and proportions (N, %) of injury mechanisms by body part
Head/neck 8 (25) 10 (31) 2 (6) 9 (28) 3 (9) 0 (0) 32 (4)
Trunk/back 8 (9) 9 (10) 12 (13) 23 (25) 38 (41) 3 (3) 93 (10)
Upper extremity 41 (25) 20 (12) 18 (11) 39 (23) 44 (27) 4 (2) 166 (19)
Lower extremity 55 (11) 93 (18) 70 (13) 132 (25) 163 (31) 7 (1) 520 (58)
Other 1 (17) 0 (0) 1 (17) 0 (0) 4 (67) 0 (0) 6 (1)
Missing 13 (16) 12 (15) 8 (10) 18 (23) 23 (29) 5 (6) 79 (9)
Total 126 (14) 144 (16) 111 (12) 221 (25) 275 (31) 19 (2) 896 (100)
Figure 5.1 Development of response rate and period prevalence of injury during the follow-up
period (September – June) for the three cohorts
In total 56% (N = 496) of the injuries resulted from a non-contact mechanism and 42%
(N = 381) resulted from a contact mechanism. The most mentioned injury mechanisms
were gradual onset non-contact (N = 275, 31%), sudden onset non-contact (N = 221,
25%) and contact with a person (N = 144, 16%) (table 5.1). The development of injury
mechanisms during the year is presented in ﬁgure 5.2.
Figure 5.2 Development of injury mechanism proportions during the follow-up period (September
– June) for the three cohorts combined
Regarding sudden onset mechanisms, proportions of the mechanisms varied between
curricular and extra-curricular sport participation (table 5.2). In curricular practices,
extra-curricular practices and extra-curricular games injuries resulted from a contact
mechanism in respectively 54% (N = 149), 61% (N = 49) and 81% (N = 133) of the
cases. Moreover, in extra-curricular games, the most common injury mechanism was
contact with a person (N = 76, 48%). Additionally, higher proportions of non-contact
mechanisms were found in curricular practices (N = 120, 44%) and extra-curricular
practices (N = 30, 38%) compared with extra-curricular games (N = 29, 18%).
MECHANISMS OF SPORT INJURIES
Table 5.2 Injury mechanisms (N, %) per setting of sudden onset injuries (N = 621)
Curricular practices 64 (23) 36 (13) 49 (18) 120 (44) 4 (1) 273 (44)
Extra-curricular 38 (16) 96 (40) 48 (20) 59 (24) 2 (1) 243 (39)
Games 21 (13) 79 (48) 33 (20) 29 (18) 1 (1) 163 (26)
Practices 17 (21) 17 (21) 15 (19) 30 (38) 1 (1) 80 (13)
Other 22 (31) 8 (11) 11 (15) 27 (38) 3 (4) 71 (11)
Missing 2 (6) 4 (12) 3 (9) 15 (44) 10 (29) 34 (5)
Total 126 (20) 144 (23) 111 (18) 221 (36) 19 (3) 621 (100)
Movements related to the cause of injury were indicated in 73% (N = 456) of the sudden
onset injuries. The most common mechanisms involved a landing (N = 179, 29%), a fall
(N = 158, 25%), an explosive movement (N = 114, 18%), a misstep or distortion (N =
98, 16%) and a sudden turn or stop (N = 85, 14%). Figure 5.3 presents the movements
related to the cause of injury per setting. Landing and falling are the main movements
related to the cause of injury in all settings. Furthermore, explosive movements (N =
65, 24%) are also often related to the cause of injury in curricular practices. Figure 5.4
presents the movements related to the cause of injury per injury mechanism. Contact
mechanisms are most commonly associated with a fall or landing. Non-contact
injuries are most commonly associated with explosive movements.
Figure 5.3 Proportions of movements related to the cause of sport-related injury per setting
Figure 5.4 Proportions of movements related to the cause of sport-related injury per injury
This study was conducted to determine the sport-related injury mechanisms in PETE
students. The results indicated that the most common injury mechanism was gradual
onset non-contact. For practices (curricular and extra-curricular) and extra-curricular
games, the most common injury mechanisms were respectively non-contact (sudden
onset) and contact with a person. Additionally, the onset of sport-related injury was
most commonly associated with a landing, a fall or explosive movement.
The found proportions of respectively 69% and 31% for sudden and gradual onset
injuries are in agreement with the 65-66% sudden and 34-35% gradual onset injuries
found in other studies on PETE students [22, 23, 85]. This may indicate that the
proportions of sudden and gradual onset injuries are quite consistent in the PETE
Overall, our study indicated that injuries resulted to a large extent from both non-
contact and contact mechanisms. The high percentage of non-contact injuries found
in our study is mostly due to gradual onset injuries. Curricular and extra-curricular
practices were characterized by relatively high proportions of non-contact injuries.
Additionally, non-contact injuries were mostly associated with explosive movements.
MECHANISMS OF SPORT INJURIES
The found proportions of non-contact injuries during extra-curricular practices were
in accordance with results in college athletes (37%) . However, curricular practices
had somewhat more sudden onset non-contact injuries and somewhat fewer injuries
due to contact with another person in comparison with extracurricular practices. This
may be explained by the fact that the PETE program includes several individual sports
with a relatively low amount of physical contact (e.g. athletics , gymnastics 
and swimming ).
Extra-curricular games had a relatively high proportion of injuries due to contact
with another person compared to practices (curricular and extra-curricular). A similar
dierence in injury mechanisms between practices and games is observed in multiple
sports [103, 120, 121]. Additionally, the literature indicates that soccer games are
characterized by a large proportion of injuries due to contact with another person
. Therefore, the high rate of participation in soccer in PETE students may help
to explain the high proportion of injuries due to contact with another person during
Landing and falling were the main movements related to the cause of injuries in all
settings. Interestingly, landing and falling were in particular associated with contact
injuries. The literature shows that landing and falling are most often associated with
injuries in various sports, such as ﬁeld sports (e.g. basketball, volleyball) , martial
arts , and gymnastics . An explanation for the fact that most curricular
injuries were related to a landing or fall, is that a previous study in Dutch PETE students
indicated that most curricular injuries are sustained during gymnastics .
This study has several limitations that should be kept in mind when interpreting the
results of this study. First, we used a self-report injury registration procedure. Since an
expert evaluation of the injury mechanism was missing this method is limited to more
generic data about injuries. Considering user-friendliness, feasibility and the study aim
we decided to restrict to the self-report method. Nevertheless, self-evaluation of injury
characteristics has demonstrated acceptable to good reliability [23, 100, 124, 125]. On
the other hand, especially in the case of longer recall periods (e.g. 12 months) self-
report of injury characteristics has limited validity [26, 100]. To minimize this limitation,
we used a clear injury deﬁnition, a standardized questionnaire and relatively short
recall periods. Therefore, we consider our results as a reliable reﬂection of reality.
Second, our study used the time-loss deﬁnition of injury. Therefore, the results of
this study only apply to time-loss injuries. Third, we used a single research approach
to investigate injury mechanisms. Krosshaug et al. (2005) discussed eight dierent
research approaches regarding mechanisms of injuries . The authors elaborated
that dierent approaches should be combined to obtain a complete description of
injury mechanisms. Because of the single research approach in our study, the results
provide a generic overview of injury mechanisms. Additionally, a precise description
of the athletes’ situation, athletes’ behaviour and biomechanics of the inciting event
are lacking. Therefore, results from this study are not suitable in the development of
preventive methods that target particular injury types (e.g. ACL injuries).
The aim of this study was to determine the sport-related injury mechanisms in the PETE
population. This study indicated that: 1) The main sport-related injury mechanism was
gradual onset non-contact. 2) For practices (curricular and extracurricular) and games,
the most common injury mechanisms were respectively non-contact (sudden onset)
and contact with a person. 3) Onset of sport-related injuries was most commonly
associated with a landing, a fall or explosive movement. Therefore, prevention in the
PETE population needs to target injuries accordingly.
The PETE population may beneﬁt from introducing an injury prevention program,
as meta-analyses of injury prevention programs in other athletic populations have
demonstrated substantial reductions in injury rates [126-129]. To date, only 1 study is
found in the literature that described an injury prevention program with PETE students
as the target population . This so-called “No Gain With Pain” (NPWG) intervention
consisted of an injury awareness program (theoretical and practical workshop for sports
teachers and students) and the implementation of neuromuscular training in the sport
classes (warming-up, stretching, stability training, strength training, core-stability,
technical training). Arguably, these components are essential in injury prevention.
However, additional preventive strategies may be needed to improve eectiveness.
Our study indicated speciﬁc aspects of injury mechanisms in PETE students that may
support further development of the NPWG intervention as following:
1) Prevention should target both contact and non-contact related injuries to
about a similar degree. For this purpose, contextual modiﬁcations  to
improve safety aspects in sport classes (e.g. physical contact regulations,
material handling regulations, supervision) and improving the management
of intra- and extra-curricular load [47, 130, 131] are suggested additions to
2) Prevention should particularly target landing and fall-related injuries, for
MECHANISMS OF SPORT INJURIES
instance by improving landing skills (with and without contact) in PETE
students [132, 133]. Improving landing skills is already a part of the NPWG
interventions, thus our study suggests that this part is essential and may need
to be emphasized;
3) Since many injuries are sustained during extra-curricular practices and games,
prevention should also teach PETE students to apply preventive strategies
within their extra-curricular sports routines.
Future research in the PETE population may aim to evaluate the eectivity of a tailored
injury prevention method based on the available literature on injury characteristics, risk
factors, injury mechanisms and preventive methods in this population. In addition, it
may be relevant to investigate subjective opinions and suggestions on opportunities
for prevention in the PETE population. Also, future research on injury mechanisms may
aim to combine several research approaches as proposed by Krosshaug et al. (2005)
. For example, video analysis may be incorporated into the research approach. To
obtain a better understanding of the speciﬁc features of injury mechanisms, it would
also be relevant to work towards a more detailed subclassiﬁcation of injury mechanisms
. For instance, the subclassiﬁcation of injury mechanisms can be enriched with
details of contact with a person (e.g. collision, kick, tackle, landing on foot), contact
with an object (e.g. ball, net, stick, bat, gate, wall), indirect contact (e.g. push, pull) and
movements related to the cause of injury (e.g. deceleration, fall, landing, sprint, jump,
pivoting, cutting, throw). Furthermore, as self-report of injury is often used method in
research and practice, it is advisable to conduct a validation study for self-reported
injury mechanisms. Finally, it may be hypothesized that severe injuries have dierent
injury mechanisms than minor injuries. Therefore, the relationship between injury
mechanism and injury severity may be an interesting target of research.
MECHANISMS OF SPORT INJURIES
Sports injury prevention practices
and directions for improvement:
a multi-centre qualitative study in PETE students
Bliekendaal, S., Barendrecht, M., Stubbe, J., Bolling, C., & Verhagen, E.
To describe sports injury prevention practices from Physical Education Teacher
Education (PETE) students’ perspective and map their suggestions for improvement.
In this qualitative study, we conducted 21 semi-structured interviews with PETE
students from four dierent PETE schools in the Netherlands, which were transcribed
verbatim and analysed using the thematic analysis method.
Most participants considered sports injuries a threat to academic success and
embraced the need for injury prevention. The participants believed that injuries are
an inherent part of sports and the PETE program. However, participants felt that they
could prevent speciﬁc injuries (e.g., recurrent injuries, muscle injuries). They all applied
various preventive measures and described injury prevention as a standard part of daily
life and approached it in a multi-faceted and dynamic way. The critical factors to apply
injury prevention successfully mentioned were: communication, learning what works,
self-management, shared responsibilities, and social support. The main motives for
injury prevention were to care for the body and perform well (e.g., academic success,
sports). Given the participants, injury prevention could be improved in various ways,
but mostly by enhancing the PETE program’s load management (e.g., schedules) and
oering injury prevention education (e.g., theory, practical skills).
This study provided insight into how injury prevention is shaped in practice, identiﬁed
critical factors for successful injury prevention and motives for injury prevention,
and mapped recommendations for its improvement from the target population. The
ﬁndings support the development of context-driven preventive strategies in the PETE
Physical Education Teacher Education (PETE) students follow a curricular program
with various weekly sports classes and, also, many participate in extra-curricular sports
activities [20, 23, 25, 85, 134]. This high physical workload puts the PETE students at
increased risk for sustaining injuries. Incidence rates range from 1.0 to 2.1 injuries per
academic year [23, 32, 85, 87, 115]. Consequently, injuries can lead to increased medical
costs , long term physical complaints [7, 8] and may negatively aect their academic
development and future career (e.g., drop-out; delay). Therefore, injury prevention
in this population is of paramount importance. Despite the numerous sports injury
prevention strategies described in the literature [35, 126], only one study on injury
prevention includes PETE students as a target population . Since this study was
limited in reducing injury rates, there remains an ongoing challenge for developing
and implementing successful preventive strategies in the PETE population.
The Translating Research into Injury Prevention Practice (TRIPP) framework described
that it is critical to understand the implementation context (e.g. social factors, personal
factors) to work towards successful preventive strategies [16-19, 135-138]. In this
process, the use of qualitative research methods is deemed necessary [135, 139]. By
gathering information about a population’s perspectives, qualitative research methods
provide an understanding of the ‘what’, ‘how’ and ‘why’ of injury prevention .
Learning about these aspects supports developing more context-driven preventive
strategies and supports successful implementation and intervention uptake .
However, no previous study explored injury prevention from the PETE population’s
perspective. Therefore, this qualitative study aimed to describe injury prevention
practices from PETE students’ perspective and map their recommendations for
We conducted an exploratory qualitative study using semi-structured interviews.
Because activities of the PETE programs within the Netherlands may vary, we chose
to use a multi-centred approach to decrease selection bias. The Ethical Committee
of the Amsterdam University Medical Centre (location VUmc, reference number:
2019.317) approved the study procedures.
Participants were current PETE students and were recruited at four dierent PETE
SPORTS INJURY PREVENTION PRACTICES
programs at Dutch Universities of Applied Sciences. These four locations represented
67% of the PETE programs in the Netherlands and were chosen because the authors
had collaborations with colleagues from these schools. All the PETE programs have
a curriculum designed following national qualiﬁcation criteria for a Bachelor PETE
degree , but curricular activities may vary in practice.
Participant recruitment took place via convenience sampling . Students were
invited to participate by e-mail. Participants were informed about the study’s goals
and procedures and completed informed consent and a baseline questionnaire before
the interview. The baseline questionnaire included age (years), sports participation,
and injury history. Inclusion criteria for participants were: 1) completed the ﬁrst three
years of the PETE program; 2) understanding of the Dutch language at the native level
because of the language used during the interviews.
Semi-structured interviews were conducted using an interview guide based on a
topic list. The following topics were discussed: experiences with combining extra-
curricular sports participation and the PETE program; injury deﬁnition; experiences
with injury; risk factors and injury mechanisms; injury prevention. The main questions
from the interview guide are presented in table 6.1. The course of the interview did
not necessarily follow a particular order. Follow-up questions were added to enhance
clarity and understanding. Nevertheless, all interviews covered the same topics. This
paper covers only the data related to the injury prevention topic.
Table 6.1 Main questions that guided the interviews
1. Can you tell about how you experienced the PETE program’s physical load, potentially in
combinations with your extra-curricular sport participation?
2. What do you consider a sports injury?
3. Have you had any injuries during the PETE program?
4. Can you indicate why these injuries occurred?
5. Can injuries be prevented? How? Do you do this?
6. Imagine you are the PETE program manager; what would you implement ﬁrst to prevent injuries in
7. Are there any other preventive measures you would recommend?
8. Is there something else you would like to mention?
Before the actual interviews, the two researchers conducted a test interview. Twenty-
one interviews were conducted in Dutch by telephone (without video) between March
and May 2020. Interviews lasted between 28 and 49 minutes (mean: 36 min., SD: 6
min.), were audio-recorded (Olympus VN-541PC) and transcribed verbatim (in Dutch)
by the researchers to ensure accuracy in the data. The interviews were conducted
by one of the researchers (MB [N = 9] and SB [N = 12]). During the data collection
process, the two researchers (SB, MB) frequently discussed the progress to share
experiences and new insights. In the last four interviews, no new insights emerged
from the interviews, and data saturation was reached.
An inductive thematic analysis approach was used . We chose to follow a highly
collaborative and iterative approach to support reﬂection on the process and obtain
consensus on the analysis. The coding was conducted by two researchers (SB, MB).
A third researcher (CB) provided feedback at all the coding process stages. The steps
were as follows. The ﬁrst ﬁve transcripts were read closely and open-coded by two
researchers (SB and MB) together as a ﬁrst step. These transcripts were discussed in
detail, and codes were assigned to text fragments after joint agreement. Subsequently,
a preliminary code-list was created in a consensus meeting with SB, MB and CB. As
a second step, the sixth transcript was open-coded independently by SB and MB.
Subsequently, the two researchers discussed and reﬁned the codes until consensus
was achieved on all the codes in this transcript. The remaining transcripts were divided
and open-coded by SB and MB separately as a third step. Discussion between the
two researchers followed until consensus was achieved on these transcripts’ codes.
As a fourth step, the three researchers analysed the relationships between the codes,
categories, and sub-categories to identify the main themes. Similar codes were
merged. A ﬁnal code-list was created after consensus was achieved between the
researchers. ATLAS.ti was used to organise, code, and select the transcripts’ data. The
most suitable quotes were selected to illustrate the results. Only the presented quotes
were translated into English (SB), reviewed (MB) and revised if needed.
Participants’ (N = 21) characteristics (e.g., sex, age, sports, and sports level) are
presented at the group level to ensure anonymity in table 6.2. All participants had
experienced one or more injuries as a PETE student. The participants typically
perceived injuries as physical complaints that hampered participation or performance.
Moreover, injuries were considered a threat to academic success. Regarding injury
prevention, four main themes emerged from the data. Three themes were related
SPORTS INJURY PREVENTION PRACTICES
to injury prevention practices: 1) applied preventive strategies, 2) critical factors
for successful injury prevention, 3) motives for injury prevention. The fourth theme
involved recommendations for improvement. Figure 6.1 summarises these themes and
the related main codes, elaborated on within the following paragraphs.
Table 6.2 Participants characteristics
N Gender (N) Age (mean, range) Year Main sport (N) Sports level (N)
M F 3 4
1 11 9 2 22 (19-25) 7 4 soccer (4), skateboarding (1),
korfball (1), skiing (1), gymnastics
(1), ﬁtness (2), trail running (1)
elite (1), club (6),
2 5 1 4 21 (19-25) 5 - handball (1), swimming (1),
athletics (1), judo (2)
elite (4), club (1)
3 4 1 3 21 (19-23) 3 1 hockey (1), soccer (3) elite (2), club (2)
4 1 1 - 21 1 - judo (1) club (1)
M, Male. F, Female.
THEME: APPLIED PREVENTIVE STRATEGIES
All participants mentioned having applied various preventive strategies (table 6.3).
They described focussing on preventing recurrence or worsening of injuries. Using
protective and supportive gear (e.g., proper shoes, shin guards, taping) was mentioned
as a common preventive strategy. Maintaining a healthy lifestyle (e.g., nutrition; sleep)
and balancing load and recovery were consistently described as essential injury
prevention strategies. The participants mentioned that they maintained participation
as long as possible when tired or having sores. To achieve this, they adjusted physical
load (e.g., reduced intensity; changed exercises) and described resting during the
weekends. Nevertheless, they explained that extra-curricular sports participation
limited proper recovery and sometimes skipped extra-curricular training sessions.
They also mentioned that elite athletes had ﬂexible schedules to combine their sports
career with the PETE educational program. However, they said that particularly semi-
professional athletes, who are not eligible for ﬂexible schedules, faced diculties
balancing load and recovery due to combining the PETE program with sports. Along
that line, quitting extra-curricular sports participation was also mentioned several
The participants explained, when injured, researching (e.g., internet searches, ask
peers) what they could do to resolve the injury. Other frequently mentioned preventive
strategies were doing exercises (e.g., strength training) and proper warm-ups. Warm-
ups were often given extra attention to reduce their physical complaints (e.g., longer
warm-ups, speciﬁc exercises). When their approach did not resolve the injury,
participants described seeking for professional help (e.g., physiotherapist).
Applied preventive strategies
A Healthy lifestyle
Adjust load when with pain
Balance load and recovery
Get professional help when injured
Study what you can do
Use of protective and supportive gear
Critical factors for successful injury prevention
Communication with stakeholders
Learning what works
Motives for injury prevention
Accessibility of (para)medical care
Care for the body
Inability to participate
It matches with personality
Perception and experiences of what works
Performing well (e.g., academic success)
Rules and regulations
The need to know the injury type
The perception that injuries can be prevented
Recommendations for improvement
Create more awareness in students
Improve access to (para)medical care
Improve individual coaching
Improve load of the PETE program
Improve preparation for the start at PETE program
Improve the use of protective gear
Make injuries more discussable
More attention for prevention by PETE teachers
More theoretical training on injury prevention
Screening and monitoring
Figure 6.1 Main codes related to the ‘injury prevention’ theme
SPORTS INJURY PREVENTION PRACTICES
Table 6.3 Main codes and typical quotes related to the theme ‘Applied preventive strategies’
A healthy lifestyle “It sounds a bit wishy-washy, but I think to shape your life well, eat healthily, eat well,
sleep a lot, anyhow just get enough sleep.” (participant 8)
“In daily life, consider that if I have to do a lot of physical exercises, then I will not
make it a late night. Or to pay attention to food or alcohol consumption, which I
reduce. To give my body more recovery.” (participant 16)
Adjust load when with
“So yes, then I just participated in everything. But for example, in a game of basketball,
I will put in less energy, and I will be less likely to sprint because I am aware that it can
worsen the injury or that I will have extra problems.” (participant 15)
“I noticed that if I took a little bit of rest or when I have problems with my knees, then I
sit down and let them rest for a day, and then it will be ﬁne again. I noticed that I could
stay in the running that way.” (participant 9)
Balance load and
“And I think if you look for a balance between, okay what can I handle and how far am
I already energised.” (participant 5)
Get professional help
“The ﬁrst time I didn’t do anything with it. I took a rest, but I did not go to the doctor
or a physiotherapist. The second, third and fourth time I did go to a physiotherapist to
strengthen the muscle and the tendon, which tore repeatedly.” (participant 3)
Study what you can
“I looked up a few things for myself, which in addition to starting slowly, I can
incorporate to make it [the hamstrings] stronger. Or so to speak. To prevent it from
happening again.” (participant 17)
I always try to research a bit myself. Like, what it is and what can I do about it before I
go to a physio?” (participant 7)
Supportive exercises “I just really got into it, in the gym and at home, with some of the exercises that I had
been given.” (participant 9)
“I think it is mainly about preparation. Rather before that injury occurs again in winter,
so before then, extra training.” (participant 15)
Use of protective and
“Make sure I wear good shoes, instead of ﬂat sneakers with too little cushioning.”
“From then onwards, I started doing everything with a brace. And because of the brace,
my arm did not stretch, so neither did it overstretch, and that makes a big dierence”
Warm-up “Doing a warm-up. Super important to prevent injuries, is to ensure that you are
warmed-up” (participant 16)
“For example, in athletics, we indicated that he [PETE lecturer] really should not make
us run two or 3 kilometres without any warm-up. Eventually, not much had been done
with that. So, the next time we came to class earlier to do a warm-up.” (participant 20)
THEME: CRITICAL FACTORS FOR SUCCESSFUL INJURY PREVENTION
The participants described several critical factors for successful injury prevention (table
6.4). They considered themselves the main responsible person for injury prevention and
consistently explained the importance of self-management accordingly. Nevertheless,
they also mentioned responsibilities for PETE teachers (e.g., taking care that students
do not exceed their limits, demanding proper shoes), PETE managers (e.g., appropriate
schedules), and sports trainers (e.g., adequate training). Therefore, the participants
also described the importance of communication. They mentioned discussing training
content and participation level with PETE teachers and sports trainers when injured.
Also, they noted that getting social support (e.g., advise) from their stakeholders (e.g.,
parents, classmates, teammates, PETE lecturers) helped to make decisions regarding
injury prevention (e.g., reducing extra-curricular sports, going to the physiotherapist).
Furthermore, the participants frequently mentioned that applying preventive strategies
was part of the learning process. The participants said they learned from previous
injuries and mentioned that theoretical knowledge is essential, which both helped
them implementing preventive strategies within their daily routines.
Table 6.4 Main codes and typical quotes related to the theme ‘Critical factors for successful injury
“Mainly because you raise the alarm on time. You do not come to class and ask, like, hi
[name] I am injured and what can I do. But send an e-mail in advance like well, this is
happening, this is the advice of the therapist.” (participant 11)
“I sent an e-mail to all the relevant sports class teachers, and they were very nice to deal
with. And it was very easy for them. Because at that time, I could not participate so for
each sports class we looked at what the easiest option was to conclude the exams as
soon as possible.” (participant 15)
“I did not play in the selection of my club for a while, and that meant that I only trained
once a week. So that was a bit more balanced in terms of intensity. In the second year,
I combined it [playing in the selection]. I indicated to my trainer; ‘I have already had so
many lessons today or already did these speciﬁc classes. I just participate when I can.
When I am tired, I just take it easy’, and that worked ﬁne so far” (participant 5)
Learning what works “I have done a lot of individual sports from an early age. So, because of that, I think I am
used to knowing how far I can commit and how far I cannot.” (participant 3)
“I did learn a lot about that [injury prevention] within the course and during the internship
at the physio. You learn a lot about it, and that gave me a lot of knowledge. It also gave
me the idea to do something with it [the injury].” (participant 10)
“Then I kicked and tore it [hamstrings] immediately. Since that moment, I have started to
be a bit more careful with jumping right into it.” (participant 12)
“With the jumpers-knee, I knew that I had to put in a lot of eort at school to stand up
for myself, to take good care of myself when we had sports classes. I also really needed
some time to warm-up. You had to stand up for yourself in class. That is one of those
things, and if I want to keep everything going as I do now, I must take the space to take
good care of myself in the form of a warm-up. So if that was not possible in class, then
I noticed that I went all out, then I immediately noticed it in my injuries. It ached extra.”
Self-management “When I did not feel ﬁt enough, I just said, let me put it this way, I just decided for
myself I will not participate in this class. I do make those kinds of choices.” (participant
“Just by having a polite and friendly attitude towards teachers and giving the impression
that you need each other to make things work. I think you can achieve a lot with that. It
is not just asking a teacher, and it is also giving and take.” (participant 11)
“What I did about it was a lot of stretching, a lot of stretching and a lot more focus on
the knees within the warming-up. So, making sure that my legs were warm, and my
ankles and that other things were warm. So, the knees would not get a beating, or so
they were warmer to endure the beating at least. I bought straps, straps to go around
my knee tendon and put pressure on the knee-tendon to relieve that nagging pain. And
I went to the doctor again. To check what is useful to do because of the physical load I
have at the PETE.” (participant 21)
“But I still think that in injury prevention there is mainly a responsibility for the student
himself.” (participant 11)
“You also have to be able to protect your students from themselves as a teacher, or as an
outside coach.” (participant 5)
“I think it is important that if, due to the PETE itself or the education itself, many injuries
occur. That the school, as it is, because of the schools itself. So that the school itself
does something about it, they should oer something for it. I think that’s important.”
SPORTS INJURY PREVENTION PRACTICES
Table 6.4 Continued
Social support “When you talk about it with your fellow students, well like; ‘I don’t want to get injured.’.
You talk about it a bit with your fellow students and, at least in my class; there arose a
bit of an atmosphere of, then it stops [extra-curricular sport participation]. But fellow
students were also … entering into a conversation with fellow students were also a
reason for me to make that choice easier.” (participant 6)
“And when injured, they [PETE lecturers] ask about it and whether you do something with
it. Or whether they can help. I really like that.” (participant 13)
“I could hardly do anything at school. I could not even open my computer, or I already
got a headache. In the sport classes, when a ball bounced, the headache started again,
and so my parents had sent me to the physiotherapist.”
THEME: MOTIVES FOR INJURY PREVENTION
Given the participants, particularly recurrent and muscle injuries, could be prevented
and, therefore, they applied preventive strategies targeting these injuries. Preventing
injury was not their primary goal, but it was considered necessary. Maintaining
participation and performing well (e.g., academic success; sports) were mentioned
as priorities, so injury prevention was more a mean than a goal. Moreover, the
participants considered injuries an inherent part of sports and the PETE program
and, correspondingly, explained accepting injury risks (e.g., in contact sports).
Several students mentioned that speciﬁc injuries (e.g., ankle injuries) did not hamper
performances and, therefore, were accepted as trivial. Nevertheless, they consistently
described care for the body as a motive for injury prevention.
The participants described that they were more likely to apply preventive strategies
when injury hampered participation. In contrast, they also expressed the inability to
participate as failing or abandoning the class- or teammates, and they maintained
participation if possible. When injured, participants mentioned that they were more
likely to seek professional help (e.g., physiotherapist, general practitioner) at an early
stage of an injury when access was easy or uncertain about the injury diagnosis. The
participants also explained that motivation for prevention depended on personality,
experiences of beneﬁts (e.g., reduced pain after strengthening exercises) and harms
(e.g., decreased ankle strength due to taping), and rules and regulations.
Table 6.5 Main codes and typical quotes related to the theme ‘Motives for injury prevention’
Accessibility of (para)
“I heard from some classmates who went to the, I never went there myself, went to
the physiotherapist at the PETE, and he was always dicult to reach.” (participant 3)
“That was pure because, at the time, I was living in rooms in [name location]. And the
other time, I lived an hour away from school, so it was more convenient to go to the
physiotherapist at home.” (participant 17)
Care for the body “My body becomes my profession, and I really have to look after myself” (participant
“But yes, the larger muscle groups are a bit dierent, for example, when you have
back pain. I would take that a bit more seriously and go to a physiotherapist sooner to
see if something is really wrong.” (participant 20)
Inability to participate “You are side-lined, but that is dicult. Especially for the average PETE student,
they just do not like that at all. I did not like that at all. So, you will still participate
wherever you can.” (participant 2)
“Well the idea that I could not lean on my arms while I am physically very ﬁt made it
clear to me that I had to go there [physio].” (participant 8)
It matches with
“That’s my character, I think. Now I chose to commit to PETE and even quitted
elite sports. And then you want to achieve, and I wanted to get my P [propaedeutic
diploma] in 1 year. And I just want to graduate in 4 years, so I also want to put in the
“Because a lot of people are still young, some are 17 years old, under 18. They are
still developing themselves very much. They do not yet know what they can and
cannot do and what they should be doing.” (participant 9)
experiences of what
“You constantly get hits on the wrists. Without dealing with it by taking good care of
it, at some point, it all goes bad. I noticed that at the time, and I noticed it afterwards.
I looked at it together with the physiotherapist and did some exercises. I did some
stretching and strengthening exercises. It went better afterwards. Suppose I would
do it now, I would really need those exercises.” (participant 10)
“I also work in a sports shop where we get a lot of similar stories. And we know quite
a bit about it [hamstring injuries], so I already knew some things about it. So, when
I tore mine, I thought, okay, this [compression short] is probably a good option to
use.” (participant 14)
“Because I am afraid that my ankle will become weak, and that it will get used to it
[taping]. So, I want to tape as little as possible, so it doesn’t get lazy.” (participant 21)
Performing well (e.g.,
“The drive to get educational credits and the realisation that I would not pass if I
could not pass my sports classes. For me, the idea was to put my studies before
my recreational sport, which was an important reason to make a choice very easily.
Then I will quit my sports, and then I will prioritise my studies, because I just like to,
well, my studies have priority over my sport.” (participant 6)
“I did see in my environment that people, for example, tore their knee ligaments
because of soccer and therefore either stopped the PETE completely or were
delayed for a year and a half. And I think that fear of such a serious injury also plays a
role in the back of your mind.” (participant 15)
Rules and regulations “Because at the beginning of the ﬁrst-year, it is said [by PETE lecturers] that you
[when injured] must present some proof, but after the ﬁrst block, you have realised
that it is not taken that seriously at all.” (participant 11)
“I am missing some guidance. There is no consequence when you do not participate
because you do not want to or because you do not participate because of an injury.”
“Because I think that students don’t like that much [individually performing warming-
up]. And if you [PETE lecturer] schedule 10 minutes in class for a warm-up, it will
happen” (participant 19)
SPORTS INJURY PREVENTION PRACTICES
Table 6.5 Continued
The need to know the
“Because we had a lot of exercises for a high jump. We were jumping on benches
and other assignments. And I just noticed that my knees did not work anymore
because my knees were hurting. I had a lot of problems with my knees, and I was
not quite sure what it was. So, I then asked other people; ‘Hey, did you ever suer
from that?’.” (participant 4)
“Yes, because at the time it [injury] was something I have not had before. So, I should
have it looked at to see what it could be.” (participant 17)
that injuries can be
“I think it [injuries] is just a bit part of it when I consider my sport, soccer. It is a
contact sport.” (participant 1)
“You can hardly prevent it. It is part of sports. I think that every athlete has
experienced running into an injury or that he could not fully participate. So yes,
I also think that every athlete already considers risks when he gets on the mat or
something” (participant 2)
“I think mainly muscle injuries because they are lurking. I have experienced that
often enough when I am not warmed-up and start exercising. And overuse injuries.
That also comes from my own experience with, well yes, shin splits. That knee. That
is why I pay attention to whether I do a little extra on certain days. To relieve my legs
a bit.” (participant 16)
THEME: RECOMMENDATIONS FOR IMPROVEMENT
All participants provided recommendations on how PETE students, PETE teachers,
or PETE managers could improve injury prevention (table 6.6). The most consistent
mentioned recommendation was to improve the PETE curriculum load. Many
participants noted that a proper warm-up at the start of sports classes should be
standard, which they missed sometimes. They consistently mentioned that the
schedules should be improved, for example, by oering more and longer breaks
between sports classes and a better distribution of sports classes during the week. The
participants also mentioned missing education on sports injury and injury prevention
and recommended implementing such education, preferably at the beginning of the
PETE curriculum. Additionally, participants suggested oering more screening and
monitoring, for example, by repeating medical examinations at a later stage in the
education or monitoring load capacity during the academic year. The participants
also recommended improving accessibility (e.g., opening hours, promotion) of the in-
house (para)medical consultation hours (e.g., physiotherapist, sports physician).
A few recommendations referred to the role of PETE students. The participants
mentioned that increasing PETE students’ awareness of sports injuries and injury
prevention could be beneﬁcial. For example, by making injuries more discussable
among students. They also mentioned that future ﬁrst-year PETE students could
beneﬁt from better preparation. They said that PETE students should be well informed
about the PETE program’s demands before the start of the education to make well-
informed decisions about the level of extra-curricular sport participation. Additionally,
they said that some students might need to improve their ﬁtness before starting their
Several recommendations referred to the role of the PETE teachers. The participants
suggested that they should be more open about injuries during sports classes and
pay more attention to injury prevention. For example, ensuring that the students do
not exceed their limits, providing more individual coaching during sports classes, or
discussing injury prevention more frequently during consultations with their study
coach. Another suggestion for improvement was making better use of protective and
supportive gear. For example, PETE lecturers should demand proper shoes during
PETE sports classes.
Table 6.6 Main codes and typical quotes related to the theme ‘Recommendations for improvement’
Create more awareness
“I think it is very important to see if there is perhaps a little more that can be done to
make students a bit more aware of injuries in sport.” (participant 4)
“I would perhaps give it [information on injury prevention] sooner in the ﬁrst-year.
Because it is not only about your students, it is about yourself as well. For example,
take a critical look at your shoes, or take a critical look at how much you move and
how much energy you spend, how full your agenda is.” (participant 5)
Improve access to
“So, I think if it is made clear before the start of education, there is a physio who has
a consultation hour, and you can just walk in. I think you can beneﬁt a lot from that.”
“Of course, you cannot inﬂuence what happens outside the PETE that much, except
for having a conversation with students. Like; ‘What else do you do besides the PETE
and can you handle it all?’.” (participant 5)
“I would ask for more lifestyle management. So, what can I do best with my life?
Literally. Thus management, but also something about having a healthy life or a
more vital life. And ask what do I do with sports outside of the PETE?” (participant 9)
Improve load of the
“Maybe spend a bit more time on doing warm-ups. Because that does not happen
enough.” (participant 12)
“For example, what I might also think is the good idea is to spread it out over 4 years
because I noticed in the third and fourth year, I have had very few sports classes.”
“The divisions during the week. That could certainly be better.” (participant 16)
for the start at the PETE
“I can imagine if you, well, if you are not physically ﬁt, then you’ll do some training
before you begin.” (participant 19)
“Perhaps some information would be good. To be aware of it anyway. Like; ‘Hey,
the ﬁrst year is pretty tough. Remember, because your health is central of course.’.”
Improve the use of
“You can of course, do a little bit of prevention by demanding good shoes.”
“Yes, then you should take a preventive measure by taping your ankle or use those
new supports that keep your foot ﬁrmly in your shoe.” (participant 1)
Make injuries more
“For me, a helping hand or even a consultation hour with fellow students in which
others tell about what they are doing would help a lot.” (participant 9)
“I do know that some teachers say beforehand; ‘Is anyone suering from
something? Let me know.’. But a lot of teachers do not ask this. And I think that if
this is a bit more discussable, then you will go a long way.” (participant 14)
More attention to
prevention by PETE
“Yes, providing information or teach a course about it. But not only for students but
also for teachers. To pay extra attention to it in class.” (participant 16)
SPORTS INJURY PREVENTION PRACTICES
Table 6.6 Continued
training on injury
“Because now, there is a lot of focus on your way of sports and the techniques
of sports and how you can get the children to work with it. But I think that if, for
example, a course is focusing on sports injuries and sports injury prevention that
could be a very nice addition.” (participant 4)
“As part of the education, I missed the bit about injury and injury prevention, because
I didn’t hear much about it in my studies.” (participant 21)
“A more personal medical examination would be in order. But not quite at the
beginning, but just halfway through. At the beginning and halfway through you
should say.” (participant 9)
“There is one more point that I can think of to make students more aware. That
could be monitoring students’ load capacity. I think that it is also an extra, that it
would also make a good point.” (participant 16)
This paper focused on sports injury prevention from the PETE students’ perspectives
by describing the applied preventive strategies, critical factors for successful injury
prevention, motives for injury prevention, and recommendations for injury prevention
THE MULTIFACETED AND DYNAMIC APPROACH TO INJURY PREVENTION
Consistent with literature in other athletic populations [143-145], our ﬁndings
revealed that PETE students used various preventive strategies and highlighted their
multi-faceted and dynamic approach to injury prevention. Similar to results in circus
artists and elite athletes [143, 144], PETE students described injury prevention as a
standard part of daily life (e.g., healthy lifestyle, balance load and recovery) and sport
participation (e.g., warm-up, protective gear usage). Additionally, they explained that
their preventive behaviour is related to their needs at a particular moment. For example,
the pacing of activities forms an integral part of their injury prevention approach.
They described to adjust physical load (e.g., type, intensity) or skip training when they
were tired or had sores to allow the body to recuperate. This behaviour is labelled as
self-monitored activity pacing in the literature and was also previously described in
competitive runners . However, the participants noted that PETE students with
demanding extra-curricular sport participation (e.g., semi-professional athletes) faced
diculties pacing their activities. In that sense, they may need more support in ﬁnding
a balance between sports and their education.
CRITICAL FACTORS FOR SUCCESSFUL USE OF INJURY PREVENTION
The ﬁndings highlighted that to apply injury prevention successfully, PETE students
depend on others but need to do it themselves. The importance of self-management
can be explained by the fact that PETE students are involved in various sports activities
(e.g., curricular sports classes, extra-curricular sport participation). They may be
best capable of balancing these activities themselves. Consistent with the literature
[29, 31], PETE students considered themselves the main responsible person in injury
prevention. They also mentioned sharing responsibilities with other stakeholders (e.g.,
PETE teachers, PETE managers, sports trainers). Along those lines, they described the
importance of communication and social support. Notably, the PETE context calls for
communication with various stakeholders (e.g., sport class teachers; sports trainers).
This may be challenging for the less experienced students who may need more
Another important ﬁnding is that PETE students described that successful preventive
strategies needs to be learned, following other athletic populations’ results [143, 144,
146]. The participants described developing preventive strategies for themselves
according to experiences with injuries and knowledge about injury prevention. In
that sense, one might argue that this learning process’s guidance is crucial in injury
MOTIVES FOR INJURY PREVENTION
The ﬁndings indicated that participants believed they could prevent speciﬁc injuries
(e.g., recurrent injuries, muscle injuries). However, more than preventing injuries to
happen in the ﬁrst place, participants described focussing on preventing recurrence
or worsening of injuries. Additionally, preventing injuries was not described as their
primary goal. Maintaining participation and performing well (e.g., academic success,
sports) were mentioned as priorities, and therefore they needed to avoid injury.
Such performance-driven motives for injury prevention were also found in other
athletic populations [143, 147]. When injured, not fully participating was associated
with negative emotions such as failing or abandoning the class- or teammates. They
wanted to be part of the social process. Therefore, participation is maintained as much
as possible, causing participation with pain or injury. This dilemma was also described
in other athletic populations [148-150] and can be considered a barrier for injury
prevention. As proposed by Eduard, Alonso and Branco (2016) , promoting that
participating with injury or pain should not be considered the norm may help to tackle
this dilemma in PETE students.
In line with the ﬁndings of Gabriel, Hoch and Cramer (2019) , the present study
indicated that willingness for injury prevention is related to perceived beneﬁts. For
example, participants described implementing speciﬁc exercises in their warm-
up routines based on their experiences; it reduces soreness during the training.
Correspondingly, the participants mentioned care for the body as an essential motive
for injury prevention, followings ﬁndings in elite athletes , circus artists  and
SPORTS INJURY PREVENTION PRACTICES
secondary school students . However, injuries were also described as an inherent
part of sports and, therefore, injury risks are sometimes accepted. Fuller and Drawer
(2004)  previously described the phenomenon of sports injury risk acceptance
as a complex issue within the risk management framework. The authors stressed that
communication about injury risks is helpful in such cases.
Several circumstantial factors, such as adherence to rules and regulations and easy
access to (para)medical care, were also mentioned as injury prevention motives.
The importance of such circumstantial factors in injury prevention motives was also
described by Lee, Standage, Hagger and Chan (2019) in secondary school students
STUDENTS’ RECOMMENDATIONS TO IMPROVE INJURY PREVENTION
The present study gave voice to the target population and mapped their
recommendations to improve injury prevention. The participants provided various
recommendations, encouraging multi-factorial preventive strategies . Many
suggestions were process-oriented, highlighting the need for injury prevention
as a continuous process. A consistently mentioned recommendation was the
improvement of the PETE schedules. For example, more and longer breaks in between
sports classes on the same day and improving sports classes distribution during the
week. Such improvements were deemed to support balancing load and recovery,
following other athletic populations’ ﬁndings [143, 145, 147]. The participants also
suggested a more tailored approach, including more individual coaching, repeated
screenings, monitoring, improved preparation, and more attention to injury prevention
by PETE teachers. Furthermore, the participants consistently suggested oering injury
prevention education from the beginning of PETE curriculum’s. Such education
could enable them to become ‘better’ in applying injury prevention earlier. This result
corresponds well with the literature, as education is considered a common part of
injury prevention .
The particular strengths of this study were as follows. The study had a multi-centre
design and obtained a wide range of participant (e.g., sex, age, sport, sport level),
which reduced selection bias and strengthened credibility. The collaborative and
reﬂective analysis process with three independent researchers strengthened this
study’s credibility and dependability.
This study also had several limitations. First, PETE students are a speciﬁc population
because of the heterogeneity in extra-curricular sport participation (e.g., type, level)
and the educational nature of the PETE sports classes. Therefore, our ﬁndings should
not be transferred to other athletic populations. Second, as we only included third- and
fourth-year students in this study, this study only reﬂects these students’ perspectives.
The ﬁndings provide directions for the development of preventive strategies. The
PETE students’ preventive behaviour suggests that injury prevention calls for a multi-
factorial strategy and a continues process. Given the results, preventive strategies need
to facilitate students’ communication with stakeholders, learning what works, self-
management, shared responsibilities, and social support. Injury prevention strategies
should also relate to PETE students’ motives; caring for the body and performing
well (e.g., academic success, sports). Given PETE students, injury prevention can be
improved in various ways, mainly by improving load management (e.g., breaks, weekly
distribution of sports classes) and injury prevention education (e.g., theory, practical
skills). The less experienced students and students with demanding extra-curricular
sports participation may need extra guidance in applying injury prevention strategies.
SPORTS INJURY PREVENTION PRACTICES
This thesis’ goal was to develop knowledge on the incidence, aetiology, and prevention
of sports injuries in Dutch PETE students. Such knowledge is essential to the PETE
community (e.g., students, teachers, curriculum managers) for several reasons. First,
because of the physically intense PETE program, students are at high risk for injuries
and need to learn how to prevent injuries during their education. Second, because
of future professional involvement in sports, PETE students will have responsibilities
to prevent pupils’ injuries. Third, the PETE’s teachers and curriculum managers are
responsible for the PETE program and its injury prevention policy. They need to know
the speciﬁc features of the PETE students’ injuries to make well-informed decisions
about injury prevention. However, little is known about injuries and injury prevention
in PETE students, as only one PETE injury prevention intervention is described and
evaluated in the literature. Although this study provided a feasible preventive strategy
for Belgium PETE students, this intervention was limited in reducing the overall
incidence rate . Thus, there remains an ongoing challenge for developing and
implementing successful preventive strategies in the PETE population.
To work towards injury prevention, the TRIPP-framework suggests following a six-stage
approach. In short, these stages are as follows: 1) Injury surveillance; 2) Establish aetiology
and mechanisms of injury; 3) Develop preventive measures; 4) Scientiﬁc evaluation of
preventive measures under ideal conditions; 5) Describe interventions context to inform
implementation strategies; 6) Evaluate the eectiveness of preventive measures in the
implementation context (ﬁgure 1.2). In light of this injury prevention framework and the
thesis’ goal, the following research questions were formulated: 1) What is the incidence
of injuries in PETE students?; 2) What are the characteristics and mechanisms of injuries
in PETE students?; 3) Which factors are associated with the development of injuries in
PETE students?; 4) What measures could be introduced for injury prevention in PETE
students? A longitudinal study, including multiple cohorts, and a qualitative study were
conducted to answer these research questions. The ﬁndings from these studies are
presented in chapters 2 to 6. In this chapter, the overall ﬁndings are discussed.
WHAT IS THE INCIDENCE OF INJURY IN PETE STUDENTS?
This thesis illustrates the high injury risk in PETE students. The ﬁndings in chapter 2
indicated that PETE students have, on average, 2.52 injuries per academic year, which
is substantially higher than the 0.36 injuries per year found in the general Dutch sport-
active population . Compared to previous studies, reporting incidence ranging
between 0.9 and 2.1 injuries per academic year in PETE students [20-26], we found
a relatively high incidence. Although comparison with the literature was limited due
to dierences in injury deﬁnitions and injury surveillance methodologies, potential
dierences in PETE programs’ physical demands may explain the higher injury rate.
The literature indicated MTSS as a common injury in sport-active populations (e.g.,
runners, militaries) [67, 68] and PETE students . Our ﬁndings in chapter 2 also
indicated the lower leg (anterior) (e.g., MTSS) as a typical injury localisation in our study
sample. Therefore, a follow-up study investigated the incidence of MTSS more in-
depth (chapter 3). Students were monitored during the academic year (i.e., 40-weeks)
using the Dutch version of the MTSS-score questionnaire . In total, 25% of the
students developed MTSS during follow-up, where women (39%) were more likely
to develop MTSS then men (21%). The ﬁndings are consistent with the literature in
female Belgium PETE students . Moreover, a comparable dierence in MTSS rates
between men and women is found in army recruits .
Apart from the expected consequences of injury (e.g., medical costs, risk of long-
term health issues), it was hypothesised that PETE students’ injuries could also harm
academic success. We analysed the relationship between cumulative injury-related
time-loss and the number of obtained ECTS (chapter 2) to investigate this hypothesis.
There was no relationship between time-loss and ECTS obtained from sports classes.
However, injury-related time-loss was positively related to ECTS scores in theoretical
courses. Thus, the results suggested an overall beneﬁcial eect. It appeared that
injured students could compensate for the injury-related time-loss by catching up
with missed lessons and sports-skills exams.
However, the relationship between cumulative time-loss and obtained ECTS scores
may not tell the whole story. For example, the ﬁndings in chapter 6 illustrated that
students described injuries as a signiﬁcant problem and a threat to academic success.
Thus, this may involve hampered sports skills development rather than failing sport
skill exams. However, whether this is the case remains to be determined.
To conclude, the ﬁndings indicated high incidence rates of injuries in general and in
particular MTSS and highlighted the need for prevention (chapters 2 and 3). Regarding
its consequences, the injury could not be considered a problem for curriculum
progress because injury-related time loss was not associated with reduced academic
success (chapter 2).
WHAT ARE THE CHARACTERISTICS AND MECHANISMS OF INJURIES IN PETE
Characteristics of injuries (e.g., localisation, setting, severity) were addressed in chapter
2. In total, 61% of the injuries involved the lower body, 76% were new injuries, 66%
occurred acutely, and 43% were severe (i.e., >28 days of time loss). The top-3 injury
localisations involved the knee (16%), the lower leg (anterior) (14%), and the ankle (14%).
The injury localisations found in our study correspond well with previous ﬁndings in
PETE students [20, 21, 23-26]. A speciﬁc aspect of this injury problem in PETE students
is that injuries are sustained in various settings (e.g., curricular sports classes, extra-
curricular sports), which is also observed in previous studies [22, 23]. Acute injuries were
most sustained during curricular gymnastics (25%) or extra-curricular soccer (28%).
An overview of MTSS injuries’ characteristics is provided in chapter 3. MTSS injuries
were predominantly bilateral (73%). With a mean severity score (range: 0-10, with 0
indicating no complaints and 10 indicating maximal complaints) of 2.7, the severity
of MTSS was relatively low. In 88% of the cases, pain during sports participation was
present, and sports participation was reduced in 55% of the cases. Nevertheless, 60%
of the students reported MTSS injuries on multiple occasions (>2 out of 7) during the
academic year, indicating long-lasting consequences.
Chapter 5 addresses the mechanisms of sport-related injury. Mechanisms of injury are
classiﬁed as direct contact, indirect contact, or non-contact . A more in-depth
analysis of the injury mechanism can be made by addressing aspects of the situation,
behaviour, and whole-body and joint biomechanics leading to the injury . Insight
in injury mechanisms supports the development of preventive measures as it provides
direction for targeting inciting events. No studies on injury mechanisms in the PETE
population were found in the literature. This study’s ﬁndings indicated that the primary
injury mechanism was gradual onset non-contact (31%). For practices (curricular and
extra-curricular) and extra-curricular games, the most common injury mechanisms
were respectively sudden onset non-contact (38%-44%) and contact with a person
(48%). Ìn general, injury onset was most associated with landings (29%), falls (25%), and
explosive movements (18%).
To conclude, injuries most involved the lower extremity and developed gradually
(chapter 2). Acute injuries most occurred during curricular activities (e.g., gymnastics)
and extra-curricular soccer (chapter 2 and 5). Injury onset was most associated with
landings, falls and explosive movements (chapter 5). The ﬁndings also illustrated that
MTSS leads to long-lasting functional consequences (chapter 3). Thus, targeting these
injuries should be prioritised in injury prevention.
WHICH FACTORS ARE ASSOCIATED WITH THE DEVELOPMENT OF INJURY IN PETE
Aetiology of injury was addressed in chapters 2, 3, and 4. Multiple generic risk factors
for injury were identiﬁed in chapter 2. A previous injury seemed to be a strong risk
factor. Furthermore, higher age, female sex, and a higher ISRT score were signiﬁcant
risk factors for sustaining an injury. Female students had a more gradual onset of
lower extremity injuries. Older students had more acute lower extremity injures. A
higher ISRT score was also associated with higher injury odds. However, it is illogical to
assume that a lower running performance has protective potential. This ﬁnding could
be explained by the fact that students with higher ISRT scores were, on average, more
involved in extra-curricular sport participation and exposed to injury risks. The ﬁndings
regarding previous injury and the female sex correspond well with the literature, as
they have been identiﬁed as risk factors by multiple studies [23, 44, 154].
Subsequently, we investigated risk factors for MTSS in chapter 3. This study included
various factors at the person (i.e., BMI, fat percentage, 3000-meter run test) and leg
level (i.e., hip ROM test, hip strength test, squat test, navicular drop test). The results
indicated that the female sex, a below-average age, an above-average BMI, and history
of MTSS were associated with a higher likelihood of developing MTSS. The results
regarding history with MTSS, the female sex, and increased BMI mirror ﬁndings in the
Risk factors for ankle injuries were investigated in chapter 4. Based on the literature,
we focussed on dynamic balance, measured with the SEBT test. In total, 15% of the
study sample obtained an acute ankle injury as a ﬁrst injury during the year. This result
follows the literature, as previous studies in PETE students reported ankle injury rates
between 12% and 17% [23, 25, 87]. Moreover, between 11.2% to 20.8% of all the injuries
involve the ankle in general sports . Below average normalised SEBT-ANT scores
were associated with a sevenfold increased likelihood for ankle injuries in men. In
contrast, in women, no such relationship was found. While a few studies also reported
increased odds for an ankle injury in men with lower dynamic balance scores [93,
97], conﬂicting results are found in the literature regarding the relationship between
dynamic balance and subsequent injury risk [96, 106, 155].
To conclude, several signiﬁcant risk factors were identiﬁed. The results suggested that
preventive strategies particularly need to target previously injured students, students
with a higher BMI, and female students (chapter 2 and 3). The previous injury was a
consistent risk factor, as this was found in chapters 2 and 3. The results regarding age
as a risk factor were divers, as a lower age was associated with the development of
MTSS (chapter 3), and a higher age was associated with acute lower extremity injuries
(chapter 2). Although our ﬁndings suggest that the SEBT is a promising screening tool
to identify male PETE students with an increased risk of an ankle injury (chapter 4), the
literature’s inconsistency may indicate a need for more research on this topic.
WHAT MEASURES COULD BE INTRODUCED FOR INJURY PREVENTION IN PETE
To date, only one PETE injury prevention intervention is described and evaluated within
the literature . This intervention, called ‘No Gain With Pain’ (NGWP), consisted of
an injury awareness program and neuromuscular training. Although this intervention
provided promising results (i.e., reducing acute, ﬁrst-time and extra-curricular injuries),
it can be improved as it did not signiﬁcantly reduce the overall incidence rate. The
fact that literature on the PETE context is lacking indicates that critical knowledge is
missing and helps explain this result. Insight in the implementation context is needed, as
preventive strategies need to connect with the target population’s everyday practices
[13, 139, 156]. Therefore, chapter 6 addressed the implementation context by describing
injury prevention practices from the students’ perspective and their suggestions for
improvement. PETE students considered injuries a substantial problem and a threat
to academic success. They also believed that some injuries (e.g., recurrent injuries,
muscle injuries) could be prevented and embraced the need for prevention. They
mainly focused on preventing recurrence or worsening of injuries. Injury prevention
was considered a part of daily life (e.g., healthy lifestyle) and is approached in a multi-
faceted and dynamic way, suggesting that injury prevention calls for a multi-factorial
strategy and a continuous process. Balancing load and recovery were considered
primary preventive strategies. To successfully apply preventive strategies, PETE
students communicate with stakeholders, learn what works, apply self-management,
share responsibilities, and acquire social support. Therefore, preventive strategies need
to facilitate students in these aspects. The described approach to injury prevention
resembles other athletic populations’ ﬁndings [143-145].
The main motives for injury prevention were to protect the body and to perform well
(e.g., academic success). In the students’ view, injury prevention could be improved
in various ways. The most consistently mentioned suggestions were improving load
management (e.g., schedules) and providing injury prevention education. Injury
prevention education is preferably implemented at the beginning of the PETE program
and is proposed to address various topics: beneﬁts of injury prevention, injury risks,
dealing with physical problems and injury, and practical skills (e.g., injury prevention
exercises, warm-ups). In particular, the less experienced students and students with
demanding extra-curricular sports participation may need extra guidance in applying
injury prevention strategies.
To conclude, PETE students described applying various preventive strategies within
their daily sporting routines and approaching injury prevention in a multi-faceted and
dynamic way (chapter 6). Their primary strategy was to balance load and recovery. The
results highlighted the importance of communication, learning, self-management,
responsibilities, and social support in injury prevention. Given the students, injury
prevention could be improved by better load management (e.g., schedules) and injury
All studies in this thesis were conducted according to high methodological standards.
Issues of methodological rigour are discussed in detail in each separate chapter.
Nevertheless, some methodological factors strengthened or limited the study’s
internal validity and needed to be kept in mind when interpreting this thesis’s results.
This thesis is built-up from a longitudinal study, including multiple cohorts (chapters
2-5) and one qualitative study (chapter 6). The applied methodological strategies
strengthened the studies. Prospective cohort studies are considered a high-quality
epidemiological study approach . We investigated associations between potential
risk factors and the ﬁrst consecutive injury event during follow-up, in correspondence
with standard methodology for sports injury research . While chapter 2 addresses
risk factors at the person level, chapter 3 and 4 also addresses risk factors at the leg
level. In all these studies, we used univariate and multivariate regression techniques.
Leg level factor analysis was conducted with more advanced statistical methods
(general estimating equation) to correct the analysis for correlations within the cases.
The applied methodology strengthened the qualitative study within this thesis (chapter
6). Qualitative studies can provide understanding perspectives of target populations.
We conducted semi-structured interviews, transcribed verbatim, and used thematic
analysis. We frequently reﬁned the coding during the research process, which improved
this study’s dependability.
BIAS, SAMPLING AND COMPLIANCE
Information bias may have inﬂuenced the results presented in chapters 2 to 5. First,
injury data were collected using self-report methods. This method was chosen because
of its feasibility. As an expert evaluation of the injuries was missing, the studies were
limited to more generic data about injuries. Although self-report methods are widely
used in injury research and have demonstrated good reliability [23, 100, 124, 125],
it is also associated with underreporting and misclassiﬁcation after more extended
recall periods (e.g., 12-months) [25, 26]. We used a precise deﬁnition, well-structured
injury surveillance, and relatively short recall periods to increase the results’ reliability.
Nevertheless, the ﬁndings may underestimate the actual injury incidence, and we
cannot guarantee complete accuracy of the injury details (e.g., localisations, setting,
Second, the time-loss deﬁnition of injury was used in chapter 2, 4 and 5. This time-
loss deﬁnition is deemed to underestimate the health problems that limit performance
and participation . For example, as described in chapters 3 and 6, PETE students
participated in sports with symptoms. Such symptoms may hamper performance and
participation but are not registered as time-loss injuries. Thus, the data in chapters 2,
3, and 4 only relates to time-loss and may underestimate the health problems that
limit performance and participation.
Third, we implemented changes in injury reporting methods for studies in chapters
3 and 5. The MTSS-score questionnaire was added to the injury surveillance to
investigate the incidence and risk factors of MTSS (chapter 3). Furthermore, after
ﬁnishing the study in chapter 4, we decided to implement online injury reporting.
Therefore, chapter 5 consists of data obtained from hard-copy forms and online
forms. Although they included the same content and data acquisition procedures were
maintained (e.g., recall periods), the methodological changes may have inﬂuenced the
results. However, we considered this inﬂuence as small as response rate and period
prevalence of injury were similar during these years (ﬁgure 5.1).
Fourth, in chapter 2, 3, and 4, we did not determine the inter-observer reliability (ICC)
of the research assistants’ ratings. Therefore, we are uncertain about the measurement
error level in the physical performance tests data. However, we consider the data
reliable because most of the used tests have been demonstrated to have high ICC’s
(e.g., BMI, 4-point skinfold thickness, SEBT-ANT, navicular drop test, hip ROM, hip
strength) within the literature, and we followed the standard protocols.
Finally, some analyses in chapter 2 and 5 were overﬁtted as they do not all meet the
rule of thumb of at least 10 cases per studied risk factor. In these cases, the results
should be interpreted with care.
The risk of selection bias is considered low in chapter 2, 3, 4, and 5 since we obtained
high response rates ranging between 73% and 87%. Selection bias may have inﬂuenced
the results from chapter 6. This chapter described the subjective perspectives on injury
prevention of PETE students. Although we obtained a diverse sample (e.g., multi-centre
approach, ages, sex, sports, sport level), they voluntarily responded to the invitation to
participate in the study. Therefore, the participants may be more consciously engaged
in injury prevention than others who did not respond to the invitations. However, we
cannot estimate how this may have aected the ﬁndings.
Although this thesis provided valuable insight into sports injury and injury prevention
within the Dutch PETE population, some factors limited external validity. The ﬁndings
should not be generalised to other populations because the PETE population is unique.
For example, PETE students are heterogeneous in terms of background (e.g., sports
participation, sport level) and sports activities (e.g., curricular sports classes; extra-
curricular sports). Besides, while sports involve a recreational or performance-driven
context, the PETE sports classes have an educational character. These particularities
of the PETE program and the PETE population limit generalising the results to general
or elite sports contexts. The multi-centre approach in chapter 6 improved external
validity to other Dutch PETE programs.
Additionally, the results in chapters 2-5 apply to ﬁrst-year students. However, they
may help inform injury prevention in second-, third-year students because of the
curriculums’ similarities. The results may also help inform the development of injury
prevention in other educational programs in the Netherlands, such as secondary
vocational education in sports, because of similarities in sports classes’ physical
demands and educational character.
Caution is recommended for translating the results to PETE programs in other
countries. Depending on which sports are involved in the curricular program, the
results may or may not be helpful. The results may be relevant to the Belgium PETE
population because of similarities in the sports classes . Applying the results to PETE
programs in countries with dierent climates and sports cultures is considered limited.
For example, the PETE program in Austria includes skiing , limiting translating the
results from our study.
IMPLICATIONS FOR FUTURE RESEARCH
This thesis developed knowledge regarding injury and injury prevention in Dutch
PETE students. Future research is needed because an injury prevention protocol
is still missing. Hence, there are ample opportunities for future research. Speciﬁc
recommendations for future research are provided within the previous chapters.
General recommendations for future research are as follows.
1. Chapters 2 to 5 described the injury problem based on the time-loss injury
deﬁnition, which may underestimate injuries’ total burden and functional
consequences. Therefore, it is advised to implement the Oslo Sports Trauma
Research Centre questionnaire on health problems , which also captures
the functional consequences of injury and symptoms below the time-loss
injuries threshold. This method supports a more comprehensive analysis of
the injury problem and its functional consequences.
2. Although the ﬁndings indicated that injuries did not hamper academic
success (chapter 2), students themselves described injuries as a threat to
academic success (chapter 6). Thus, this may involve hampered sports skills
development instead of failing sport skill exams. However, this remains to be
investigated. Therefore, future research may investigate associations between
injury and sport skill exam results and how many students drop-out from the
program due to injuries.
3. The ﬁndings in chapter 3 indicated a high incidence of MTSS. The development
of MTSS is thought to be caused by overload . As the association between
load and the development of MTSS was not investigated, future research is
4. As stated above, this thesis did not provide an injury prevention protocol or
tested preventive strategies in a real-life setting, which is needed to improve
practice. Therefore, future research may aim to synthesise the currently
available literature, develop a preventive strategy, and test its eectiveness.
IMPLICATIONS FOR PRACTICE
Following this thesis’ results, recommendations can be given to PETE teachers and
curriculum managers about injury prevention priorities and preventive strategies. It
should be noted that these recommendations do not aim to provide a one-size-ﬁts-all
approach. More than that, they are guidelines for further development of preventive
strategies. Given the results, the preventive strategy needs to address the following:
1. The preventive strategy should target a variety of injuries. Contact related
injuries should be targeted by improving safety aspects in sport classes (e.g.,
physical contact regulations, material handling regulations, supervision,
warm-up). Non-contact related injuries (e.g., MTSS) should be targeted by
improving intra- and extra-curricular load management. For example, by
improving schedules and provide students with more guidance on adjusting
extra-curricular activities. Younger students and female students may need
more guidance on this, as they were more prone to developing MTSS.
2. Implement injury prevention education (theoretical and practical), which is
best oered from the PETE program’s start. Complementary to this education,
it is suggested to implement neuromuscular training to improve strength
 and balance  of the lower extremities. Such training should also
emphasise the improvement of landing skills (with and without contact) to
target landing-, and fall-related injuries. Also, PETE students should be taught
to apply preventive strategies (e.g., proper warming-up, balancing load and
recovery) to extra-curricular activities.
3. Screenings may help to identity PETE students who are more prone to injuries.
They could be oered a tailored injury prevention approach. Previously injured
students are advised to participate in neuromuscular training to prevent
recurrent injuries . Male students with reduced dynamic balance may
be advised to improve balance  through neuromuscular training or ankle
bracing during sports participation [111, 112]. Students with relatively high BMI
may beneﬁt from lifestyle advise (e.g., nutrition) to reduce BMI.
4. Flexibility in attending sports classes and sport skill exams was deemed to
limit injuries’ impact on academic success (chapter 2). These measures were
considered beneﬁcial and should be intensiﬁed as students still view injuries
as a threat to academic success (chapter 6).
The main goal was to develop knowledge on incidence, characteristics, aetiology,
mechanisms, and prevention of injury in PETE students. The ﬁndings indicated
relatively high injury incidence rates. Most injuries involved the lower extremities
and most commonly occur during curricular practices (i.e., gymnastics) and extra-
curricular games (i.e., soccer). The most common injuries involved the ankle, lower leg
(e.g., MTSS), and knee. The primary injury mechanism was gradual onset non-contact,
but the main mechanisms of acute injuries diered between practices (i.e., sudden
onset non-contact) and games (i.e., contact with a person). Acute injuries were most
associated with landings, falls, and explosive movements. Factors associated with
increased likelihood for injury were decreased dynamic balance (males only), increased
BMI, injury history, and sex (female).
Given the students, injuries were a threat to academic success. Hence, they embraced
the need for prevention. They approached injury prevention in a multi-faceted and
dynamic way and mainly aimed at preventing recurrence or worsening of injuries. Their
primary strategy was to balance load and recovery. To successfully apply preventive
strategies, PETE students needed to communicate with their stakeholders (e.g., PETE
teachers, sports trainers), learn what works, be good at self-management, share
responsibilities, and acquire social support. Performing well (e.g., academic success,
sports) and care for the body were the main motives to stay ﬁt and prevent injuries.
Preventive strategies need to consider these factors and motives to support successful
implementation and uptake. The students themselves suggested that injury prevention
could be improved, mainly by improving load management (e.g., schedules) and injury
prevention education. It is recommended to work towards a multi-factorial preventive
strategy, including enhancing load management (e.g., schedules), safety aspects in
sport classes, screening, injury prevention education, and neuromuscular training.
The results highlighted many dimensions to the injury problem, and there is no simple
solution. Therefore, injury prevention calls for a continues process of learning and
improving. This thesis encourages further research and further development of injury
prevention in PETE students.
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List of contributors
About the author
Sports injury prevention is essential to the Physical Education Teacher Education
(PETE) community because students are at high risk for injury and need to learn how to
prevent injury during their education. Also, because of future professional involvement
in sports, PETE students have responsibilities to prevent pupils’ injuries. PETE’s teachers
and curriculum managers need to know the speciﬁc features of the PETE students’
injuries to make well-informed decisions about injury prevention. However, little is
known about injuries and injury prevention in PETE students. Therefore, this thesis’
goal was to develop knowledge on incidence, aetiology and prevention of injury in
PETE students. A longitudinal study, including multiple cohorts, and a qualitative study
were conducted to establish this knowledge.
INCIDENCE OF SPORT INJURIES
The injury risk in PETE students is high, as the results indicated an injury incidence
of 2.52 injuries per academic year. This incidence is higher than the 0.36 injuries per
year found in the general sport-active population. Additionally, the ﬁndings indicated
that 25% of the students developed Medial Tibial Stress Syndrome (MTSS) during the
academic year, where women (39%) were more likely to develop MTSS then men (21%).
Hence, the results highlight the need for prevention in PETE students.
We also analysed the impact of injuries on academic success. The ﬁndings indicated
that injury-related time-loss was positively related to ECTS scores in theoretical
courses. However, there was no relationship between injury-related time-loss and
ECTS obtained from sports classes. These results suggest an overall beneﬁcial eect
and that injured students could compensate for the injury-related time-loss and
catch-up with uninjured students.
CHARACTERISTICS AND MECHANISMS OF SPORT INJURIES
The most common characteristics and mechanisms of injuries were identiﬁed, which
should be targeted accordingly in prevention strategies. The ﬁndings indicated that
61% of the injuries involved the lower body, 76% were new injuries, 66% occurred
acutely, and 43% were severe (i.e., >28 days of time loss). Most injuries involved the
knee (16%), the lower leg (anterior) (14%), and the ankle (14%). Acute injuries were
most sustained during curricular gymnastics (25%) or extra-curricular soccer (28%).
The primary injury mechanism was gradual onset non-contact (31%). For practices
(curricular and extra-curricular) and extra-curricular games, the most common injury
mechanisms were respectively sudden onset non-contact (38%-44%) and contact
with a person (48%). Injury onset was most commonly associated with landings (29%),
falls (25%), and explosive movements (18%).
Notwithstanding the high incidence rate of MTTS, the severity of MTSS was relatively
low. In 88% of the cases, pain during sports participation was present, and sports
participation was reduced in 55% of the cases. Nevertheless, 60% of the students
reported MTSS injuries multiple reporting occasions (≥2 out of 7) during the academic
year, indicating long-lasting consequences.
Multiple risk factors for injury were identiﬁed within this thesis’ studies. A previous injury
was a consistent risk factor, as this was found in two separate studies. Furthermore,
higher age and sex (female) were signiﬁcant risk factors related to an injury. Female
students had a more gradual onset of lower extremity injuries. Older students had
more acute lower extremity injures. The female sex, a below-average age, an above-
average BMI, and history of MTSS were factors associated with a higher likelihood
of developing MTSS. Below average normalised SEBT-ANT scores were associated
with a sevenfold increased likelihood for ankle injuries in men. In contrast, in women,
no such relationship was found. The results suggested that preventive strategies
particularly need to target previously injured students, students with higher BMI, and
female students, as they were identiﬁed as more prone to injury.
SPORTS INJURY PREVENTION
Preventive strategies need to connect with the target population’s everyday practices to
support successful implementation and uptake. Therefore, we conducted a qualitative
study to describe injury prevention from the students’ perspective. The ﬁndings
indicated that PETE students believed that speciﬁc injuries could be prevented, and they
mainly focussed on preventing recurrence or worsening of injuries. Injury prevention
was seen as a part of daily life (e.g., healthy lifestyle) and was approached in a multi-
faceted and dynamic way. Balancing load and recovery was considered as a primary
preventive strategy. Several factors were deemed essential to apply preventive strategies
successfully: communication with stakeholders, learning what works, applying self-
management, sharing responsibilities, and acquiring social support. The main motives for
injury prevention were caring for the body and performing well (e.g., academic success,
sports). The ﬁndings suggest that injury prevention calls for a multi-factorial strategy and
a continues process. Also, preventive strategies need to support critical factors and relate
to their motives. In the students’ view, injury prevention could be improved in various
ways. The most consistently mentioned suggestions were improving load management
(e.g., schedules) and providing injury prevention education. A
This thesis’ results provide guidelines for further development of preventive strategies.
First, contact-related injuries should be targeted by improving safety aspects (e.g.,
supervision, warm-up) in sport classes, and non-contact related injuries (e.g., MTSS)
should be targeted by improving load management (e.g., schedules). Younger students
and female students may need more guidance on this, as they were more prone to
injury. Second, implement injury prevention education and neuromuscular training
(e.g., dynamic balance, landing skills, strength). PETE students should also be taught
to apply preventive strategies extra-curricular. Third, screenings may help to provide
tailored preventive measures to PETE students more prone to injuries. Previously
injured students are advised to participate in neuromuscular training to prevent
recurrent injuries. Male students with reduced dynamic balance may be advised to
improve balance through neuromuscular training or use ankle bracing during sports
participation. Students with relatively high BMI may beneﬁt from lifestyle advise (e.g.,
nutrition) to reduce BMI. Finally, ﬂexibility in attending sports classes and sport skill
exams enables injured students to catch-up with uninjured students and should be
The main goal was to develop knowledge on incidence, aetiology, and prevention of
injury in PETE students. The ﬁndings indicated relatively high injury incidence rates. The
majority of injuries involved the lower extremities and most commonly occur during
curricular practices (i.e., gymnastics) and extra-curricular games (i.e., soccer). The most
common injuries involved the ankle, lower leg (e.g., MTSS), and knee. The primary injury
mechanism was gradual onset non-contact, but the main mechanisms diered between
practices (i.e., sudden onset non-contact) and games (i.e., contact with a person). Acute
injuries were most commonly associated with landings, falls, and explosive movements.
Factors associated with increased likelihood for injury were: decreased dynamic balance
(males only), increased BMI, injury history, and sex (female).
Given the students, injuries were a threat to academic success. Hence, they embraced the
need for prevention. They approached injury prevention in a multi-faceted and dynamic
way and mainly aimed at preventing recurrence or worsening of injuries. Their primary
strategy was to balance load and recovery. To successfully apply preventive strategies,
PETE students needed to communicate with their stakeholders (e.g., PETE teachers,
sports trainers), learn what works, be good at self-management, share responsibilities,
and acquire social support. Performing well (e.g., academic success, sports) and care
for the body were the main motives to stay ﬁt and prevent injuries. Preventive strategies
need to consider these factors and motives to support successful implementation and
uptake. The students themselves suggested that injury prevention could be improved,
mainly by improving load management (e.g., schedules) and injury prevention education.
It is recommended to work forward on developing a multi-factorial preventive strategy,
including enhancing load management (e.g., schedules), safety aspects in sport classes,
screening, injury prevention education, and neuromuscular training.
Preventie van sportblessures is essentieel voor de Academies voor Lichamelijke
Opvoeding (ALO), omdat ALO studenten risico lopen om geblesseerd te raken tijden
hun opleiding. Zij moeten leren om blessures te voorkomen. Daarnaast krijgen zij als
toekomstig sportprofessional de taak om blessures bij leerlingen te voorkomen. Het
is ook van belang dat docenten en managers aan de ALO’s de eigenschappen van
het blessureprobleem weten om weloverwogen keuzes te maken ten aanzien van
blessurepreventie. Echter, er is weinig bekent over sportblessures en blessurepreventie
bij ALO studenten. Daarom is het doel van deze thesis om kennis te ontwikkelen ten
aanzien van incidentie, etiologie en preventie van sportblessures bij ALO studenten. Om
deze kennis te ontwikkelen hebben we een longitudinaal onderzoek, met meerdere
cohorten, en een kwalitatief onderzoek uitgevoerd.
INCIDENTIE VAN BLESSURES
Het risico op sportblessures is groot bij ALO studenten, gezien de gevonden incidentie
van 2.52 blessures per schooljaar. Dat is hoger dan de incidentie (0.36 per jaar) van
de regulier actieve populatie in Nederland. Bovendien gaven de resultaten aan dat
25% van de studenten mediaal tibiaal stresssyndroom (MTSS) ontwikkelde tijdens het
academische jaar, waarbij vrouwen (39%) meer kans hadden om MTSS te ontwikkelen
dan mannen (21%). Deze resultaten benadrukken de noodzaak van blessurepreventie
bij ALO studenten.
We analyseerden ook de impact van blessures op studiesucces. De bevindingen
gaven aan dat blessures, in positieve zin, gerelateerd waren aan het aantal behaalde
studiepunten bij theoretische cursussen. Er was echter geen verband tussen blessures
en ECTS behaald bij sportlessen. Deze resultaten suggereren een algemeen gunstig
eect en dat geblesseerde studenten hun blessuretijd later in het jaar konden
KENMERKEN EN MECHANISMEN VAN BLESSURES
In dit onderzoek zijn de meest voorkomende kenmerken en mechanismen
geïdentiﬁceerd, wat aangeeft waar preventieve strategieën zich op moeten richten.
De resultaten gaven aan dat 61% van de blessures betrekking had op het onderlichaam,
76% betrof nieuwe blessures, 66% trad acuut op en 43% was ernstig (>28 dagen). De
meeste blessures betroen de knie (16%), het onderbeen (voorzijde) (14%) en de enkel
(14%). Acute blessures werden het vaakst opgelopen tijdens curriculaire turnlessen
(25%) of extra-curriculair voetbal (28%). De meeste blessures ontstonden geleidelijk
(31%). Voor trainingen (curriculaire en extra-curriculair) en wedstrijden (extra-
curriculair) waren de meest voorkomende blessuremechanismen respectievelijk
geleidelijk (38% - 44%) en contact met een persoon (48%). Acute blessures werden het
meest geassocieerd met landen (29%), vallen (25%) en explosieve bewegingen (18%).
Ondanks de hoge incidentie van MTTS was de ernst van MTSS relatief laag. In 88%
van de gevallen ervaarde men pijn tijdens sportdeelname, echter sportdeelname werd
maar verminderd in 55% van de gevallen. Desalniettemin, 60% van de studenten met
MTSS meldde klachten op meerdere momenten tijdens het academiejaar (≥2 van de
7), wat duidt op langdurige klachten.
Preventieve strategieën moeten aansluiten bij de dagelijkse praktijk van de doelgroep
ten behoeve van een succesvolle implementatie en naleving. Daarom hebben we een
kwalitatief onderzoek uitgevoerd en blessurepreventie vanuit het perspectief van de
studenten beschreven. De bevindingen gaven aan dat de studenten van mening waren
dat sommige blessures voorkomen konden worden, en dat ze zich vooral richten op het
voorkomen van herhaling of verergering van blessures. Blessurepreventie werd gezien
als een onderdeel van het dagelijks leven (b.v. een gezonde leefstijl) en wordt op een
veelzijdige en dynamische manier benaderd. Het balanceren van belasting en herstel
werd beschouwd als een primaire preventieve strategie. De volgende factoren bleken
van belang om preventieve strategieën met succes toe te passen: communiceren met
stakeholders, leren wat werkt, zelfmanagement, delen van verantwoordelijkheden en
ontvangen van sociale steun. De belangrijkste motieven voor blessurepreventie waren
zorg voor het lichaam en goed kunnen presteren (b.v. studiesucces, sportprestaties).
De resultaten suggereren dat blessurepreventie een multifactoriële strategie en
een continu proces vereist. Preventieve strategieën moeten de succesfactoren
ondersteunen en in verband staan met de motieven van de studenten. Volgens de
studenten kan blessurepreventie op verschillende manieren worden verbeterd. De
meest genoemde suggesties waren het verbeteren van de belasting van de ALO (b.v.
roosters) en het aanbieden van blessurepreventielessen.
De resultaten van dit proefschrift bieden richtlijnen voor de verdere ontwikkeling van
preventieve strategieën. Ten eerste moeten contact gerelateerde blessures worden
aangepakt door veiligheidsaspecten in de sportlessen te verbeteren (b.v. toezicht,
warming-up). Niet-contact gerelateerde blessures (b.v. MTSS) kunnen worden
aangepakt door de belasting van het ALO-programma (b.v. roosters) te verbeteren.
Jongere studenten en vrouwelijke studenten hebben hier mogelijk meer begeleiding
bij nodig, omdat ze vatbaarder waren voor blessures. Ten tweede, implementeer
sportblessurepreventie lessen en neuromusculaire training (b.v. dynamische balans
van de onderste extremiteiten, landingsvaardigheden, kracht). ALO studenten moeten
ook worden geleerd om preventieve strategieën buitenschools toe te passen. Ten
derde, screenings kunnen helpen om op maat gemaakte preventieve maatregelen aan
te bieden aan ALO studenten die vatbaarder zijn voor blessures. Eerder geblesseerde
studenten wordt geadviseerd om deel te nemen aan neuromusculaire training om
recidiverende blessures te voorkomen. Mannelijke studenten met een verminderd
dynamische balans kunnen worden geadviseerd om de balans te verbeteren door
middel van neuromusculaire training, of om een enkelbrace te gebruiken tijdens
sportdeelname. Studenten met een relatief hoge BMI kunnen baat hebben bij
leefstijladvies (b.v. voeding) om de BMI te verlagen. Tot slot, het wordt geadviseerd om
ﬂexibiliteit in het bijwonen van sportlessen en het afsluiten van sportvaardigheden te
intensiveren, aangezien dit geblesseerde studenten in staat stelt om hun achterstanden
in te halen.
Het doel was om kennis te ontwikkelen over incidentie, etiologie en preventie van
sportblessures bij ALO studenten. De bevindingen wezen op een relatief hoge incidentie
van sportblessures. De meeste blessures betroen de onderste extremiteiten en
worden opgelopen tijdens curriculaire sportlessen (m.n. turnen) en extra curriculaire
wedstrijden (m.n. voetbal). De meest voorkomende blessures betroen de enkel,
het onderbeen (b.v. MTSS) en de knie. De meeste blessures ontstonden geleidelijk,
maar de belangrijkste mechanismen verschilden tussen trainingen (m.n. non-contact)
en wedstrijden (m.n. contact met een persoon). Acute blessures werden het meest
geassocieerd met landingen, vallen en explosieve bewegingen. Factoren die verband
hielden met een verhoogde kans op blessures waren: verminderde dynamische balans
(alleen mannen), verhoogde BMI, blessuregeschiedenis en geslacht (vrouwen).
Volgens de studenten vormen blessures een bedreiging voor hun studiesucces en
herkennen zij de noodzaak van blessurepreventie. Ze benaderden blessurepreventie op
een veelzijdige en dynamische manier, en waren vooral gericht op het voorkomen van
herhaling of verergering van blessures. Hun belangrijkste strategie was het balanceren
van belasting en herstel. Om preventieve strategieën met succes toe te passen, moeten
ALO studenten communiceren met hun belanghebbenden (b.v. ALO docenten,
sporttrainers), leren wat werkt, goed zijn in zelfmanagement, verantwoordelijkheden
delen en sociale steun verwerven. Goed presteren (b.v. studiesucces, sportprestaties)
en zorg voor het lichaam waren de belangrijkste motieven om ﬁt te blijven en blessures
te voorkomen. Om een succesvolle implementatie en opvolging te ondersteunen,
moeten preventieve strategieën rekening houden met deze factoren en motieven. De
studenten zijn van mening dat blessurepreventie kan worden verbeterd, voornamelijk
door het verbeteren van de belasting van het ALO-programma (b.v. roosters) en het
aanbieden van blessurepreventielessen. Het wordt aanbevolen om verder te werken
aan de ontwikkeling van een multifactoriële blessurepreventiestrategie, inclusief
het verbeteren van de belasting (b.v. roosters), veiligheidsaspecten in sportlessen,
screening, blessurepreventielessen en neuromusculaire training.
LIST OF CONTRIBUTORS
The following persons (alphabetical order of surnames) contributed greatly to this
Mijn Fysio en Adviespunt, Den Haag, The Netherlands
Avans+, Breda, The Netherlands
Amsterdam Collaboration on Health and Safety in Sports, Department of Public and
Occupational Health, Amsterdam Movement Science, Amsterdam UMC, Amsterdam,
Amsterdam University of Applied Sciences, Centre for Applied Research in Sports and
Nutrition, Amsterdam, The Netherlands
Department for Movement and Sports Sciences, Ghent University, Ghent, Belgium
Amsterdam UMC, Univ of Amsterdam, Department of Orthopaedic Surgery, Amsterdam
Movement Sciences,Amsterdam, The Netherlands
Department of Sports Medicine,Bergman Clinics,Naarden, The Netherlands
The Sports Physician Group, Onze Lieve Vrouwe Gasthuis West, Amsterdam, The
Codarts University of the Arts,Rotterdam, The Netherlands
PErforming artist and Athlete Research Lab (PEARL), Rotterdam, The Netherlands
Rotterdam Arts and Science Lab (RASL), Rotterdam, The Netherlands
Department of General Practice, Erasmus MC University Medical Center, Rotterdam,
Department of Epidemiology and Biostatistics, VU University Medical Center,
Amsterdam, The Netherlands
Amsterdam Collaboration on Health and Safety in Sports, Department of Public and
Occupational Health, Amsterdam Movement Science, Amsterdam UMC, Amsterdam,
UCT/MRC Research Unit for Exercise Science and Sports Medicine (ESSM), Department
of Human Biology, Faculty of Health Sciences, University of Capetown, Capetown,
School of Physical Education, Faculty of Physical Therapy & Occupational Therapy,
Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
LIST OF CONTRIBUTORS
De aanleiding om een promotietraject te starten was mijn ‘drive’ voor inhoudelijk
verdieping in een onderwerp dat ik heel interessant vind, namelijk de theorie en praktijk
van de sportblessurepreventie. Wat mij betreft heb ik dit persoonlijke doel behaald. Ik
kijk terug op het promotietraject als het beklimmen van een mooie berg. Ondanks
zorgvuldige voorbereiding kom je onverwachte obstakels tegen en is de bestemming
een stuk verder weg dan het steeds lijkt. Maar je komt ook prachtige vergezichten
tegen en is het avontuur belangrijker dan de bestemming.
Uiteraard heb ik het niet alleen kunnen doen en wil ik hieronder iedereen bedanken die
een belangrijke bijdrage heeft geleverd aan mijn promotietraject.
PROMOTOR EN COPROMOTOR
Allereerst wil ik mijn promotor en co-promotor bedanken.
Evert, veel dank voor de wijze waarop jij mij in dit promotietraject van begeleiding hebt
voorzien. Je stond altijd klaar voor advies en hebt op een prettige wijze het onderzoek
naar een hoger niveau geduwd. Veel dank daarvoor.
Janine, bedankt voor jouw tomeloze support en enthousiasme in onze samenwerking.
Jij stond aan de basis van dit onderzoek en was, tot en met de afronding van dit
promotieonderzoek, een rots in de branding. Veel dank daarvoor.
Mijn dank aan alle coauteurs. Met jullie inbreng hebben de publicaties meer diepgang
gekregen. Veel dank!
Over de jaren heen hebben honderden deelnemers meegewerkt aan dit onderzoek.
Zonder hun vrijwillige deelname was dit onderzoek niet mogelijk. Daarom, veel dank
aan iedereen die heeft deelgenomen aan dit onderzoek!
Wat heb ik ook veel ﬁjne collega’s gehad. Een aantal collega’s hebben in raad en daad
een belangrijke rol gespeeld. Sander, je was een cruciale partner en een ﬁjn maatje
tijdens alle activiteiten. Maarten, ik beschouwde jou als mijn onderzoeksmaatje.
Young, het MTSS-onderzoek stond als een huis door jouw inzet. Huib, dank voor je
geweldige collegialiteit en de goede gesprekken. Grethil, dank voor je faciliterende
bijdrage. Veel andere collega’s hebben meegeholpen, te weten: Angelo, Caroline,
Jacqueline, Heleen, Jeroen, Michiel, Douwe, Ramon, Chris, Stephanie, Marc en Linda.
Het thuisfront was voor mij de belangrijkste factor. Allereerst, dank aan mijn familie
dat jullie mij altijd gestimuleerd hebben om mij verder te ontwikkelen en geholpen
koersvast te blijven. Els, René, Joris, Erik en Lukas, bedankt! Maaike, je bent een topper.
Wat enorm ﬁjn dat je er altijd voor mij was en mij hebt geholpen een nuchtere blik te
houden. En altijd als prioriteit, mijn zoons Liam en Owen. Makkelijker konden jullie het
niet maken, wel leuker!
Sander Bliekendaal (Breukelen, 1984) holds a bachelor’s degree
in Physical Education (2006) and a master’s degree in Human
Movement Sciences (2011). He worked as a sports trainer,
physical education teacher, and PETE lecturer. Since 2012
Sander was involved in sports injury prevention research, where
his interest in this topic of research increased over the years
and ﬁnally evolved into this PhD thesis. For the years to come,
Sander will continue his mission to promote health and safety in
physical activity and sports.
ABOUT THE AUTHOR
ABOUT THE AUTHOR
WHO STAYS FIT?
Incidence, risk factors and prevention of sports injuries
in physical education teacher education students
WHO STAYS FIT? Incidence, risk factors and prevention of
sports injuries in physical education teacher education students
voor het bijwonen van de
openbare verdediging van
prevention of sports
injuries in physical
op dinsdag 21 september 2021
om 13:45 uur in de
aula van de universiteit,
De Boelelaan 1105
Na aﬂoop bent u van harte
uitgenodigd om te proosten
bij de receptie.