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Published ahead of Print
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A Multi-station Proprioceptive Exercise Program Prevents Ankle
Injuries in Basketball
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Eric Eils1,2, Ralf Schröter1, Marc Schröder1, Joachim Gerss3, and Dieter Rosenbaum1
1
Funktionsbereich Bewegungsanalytik (Movement Analysis Lab), Orthopaedic Department,
University Hospital Muenster, Muenster, Germany
2
Institute of Sport Science, Motion Science, University of Muenster, Muenster, Germany
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3
Department of Medical Informatics and Biomathematics, University Hospital Munster,
Muenster Germany
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Accepted for Publication: 28 March 2010
Medicine & Science in Sports & Exercise® Published ahead of Print contains articles in unedited
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Please note that during the production process errors may be discovered that could affect the content.
Copyright © 2010 American College of Sports Medicine

Medicine & Science in Sports & Exercise, Publish Ahead of Print
DOI: 10.1249/MSS.0b013e3181e03667
A Multi-Station Proprioceptive Exercise Program Prevents Ankle Injuries in Basketball
Eric Eils1,2 PhD, Ralf Schröter1 MD, Marc Schröder1, Joachim Gerss3 PhD, Dieter
Rosenbaum1 Prof.,
1
Funktionsbereich Bewegungsanalytik (Movement Analysis Lab), Orthopaedic Department,
University Hospital Muenster, Domagkstrasse 3, 48149 Muenster, Germany
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2
Institute of Sport Science, Motion Science, University of Muenster, Horstmarer Landweg
62b, 48149 Muenster, Germany

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Department of Medical Informatics and Biomathematics, University Hospital Munster,
Domagkstrasse 9, 48149 Muenster Germany

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Correspondence to:
Priv. Doz. Dr. Eric Eils,
Institute of Sport Science, Motion Science
University of Muenster,
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Horstmarer Landweg 62b,

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48149 Muenster, Germany
Phone: ++49-251-8334866; Fax: ++49-251-8334872

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Email: eils@uni-muenster.de
Running title: Exercise program to prevent ankle injuries
This study was funded by a research grant of the Bundesinstitut für Sportwissenschaft
(Federal Institute of Sports Science). Grant number: VF 0407(01/68/2004).
Copyright © 2010 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Abstract
Purpose: To investigate the effectiveness of a multi-station proprioceptive exercise program
for the prevention of ankle injuries in basketball players using a prospective randomized
controlled trial in combination with biomechanical tests of neuromuscular performance.
Methods: 232 players participated in the study and were randomly assigned to a training or
control group following the CONSORT-statement. The training group performed a multi-
station proprioceptive exercise program and the control group continued with their normal
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work-out routines. During one competitive basketball season the number of ankle injuries
was counted and related to the number of sports participation sessions using logistic
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regression. Additional biomechanical pre-post tests (angle reproduction, postural sway) were
performed in both groups to investigate the effects on neuromuscular performance.
Results: In the control group 21 injuries occurred, while in the training group 7 injuries
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occurred. The risk for sustaining an ankle injury was significantly reduced in the training
group by approximately 35%. The corresponding numbers-needed-to-treat (NNT) was 7.
Additional biomechanical tests revealed significant improvements in joint position sense and
single limb stance in the training group.

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Conclusion: The multi-station proprioceptive exercise program effectively prevented ankle

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injuries in basketball players. NNT-analysis clearly showed the relatively low prevention
effort that is necessary to avoid an ankle injury. Additional biomechanical tests confirmed the
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neuromuscular effect, and confirm a relationship between injury prevention and altered
neuromuscular performance. With this knowledge, proprioceptive training may be optimized
to specifically address the demands in various athletic activities.
Key Words: Proprioceptive training, Prospective randomized controlled trial, Prevention and
rehabilitation, Biomechanical tests; neuromuscular performance
Introduction
Paragraph Number 1 Sporting activities like basketball, soccer, team handball and
volleyball are high-risk activities especially for lateral ligament injuries of the ankle joint
complex (8). In basketball, every other injury that occurs affects the ankle joint (21, 27).
These injuries often result in a considerable amount of time off for the injured players;
typically one or more weeks (16) or five to six sessions (18). Players may be unavailable for
their team in important phases during the season thus causing a serious problem particularly
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for professional or semi-professional teams.
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Paragraph Number 2 Different intervention methods have been recommended for the
prevention of ankle injuries (17). There is evidence that ankle braces are effective in the
prevention of acute, as well as recurrent, ankle sprains but there is still controversy
concerning the effectiveness of special training procedures (8). It was reported that
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proprioceptive training is not effective as a primary prevention in healthy subjects (4);
however, recent results seem promising in underlining its effect as secondary prevention in
subjects with recurrent ankle injuries (3, 11).

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Paragraph Number 3 The effectiveness of specific training programs has been evaluated
using prospective randomized controlled trials or laboratory based studies (5-7, 9, 11, 24,
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26). In prospective randomized intervention trials, a training group and a control group are
monitored during a season and differences in the number of injuries at the end of one season
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are indicative for the effectiveness of the training program. In laboratory-based studies,
different test procedures are performed before and after a training period. Differences in
neuromuscular performance are indicative of the effectiveness of the training program.
However, both approaches are insufficient for a thorough understanding of ankle injury
prevention. For example, when investigating the effectiveness of training programs, the
reasons for possibly reduced injury rates might remain unclear. On the other hand,
investigating the effects of a pre-post test design does not implicate that changes in
neuromuscular parameters are effective with respect to injury reduction. A combination of
both approaches may help to improve our understanding of the relationship of ankle injury
prevention and neuromuscular performance in athletes.
Paragraph Number 4 Therefore, the aim of the present investigation was to simultaneously
evaluate the effectiveness of an intervention program for the prevention of ankle injuries as
well as the effects of laboratory-based trials on neuromuscular performance during a
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basketball game season. The intervention trial was conducted as prospective randomized
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controlled trial, with a laboratory-based aspect involving neuromuscular measurements in a
subgroup before and after the training period. The underlying hypothesis was that there will
be a significant reduction in the number of ankle sprains in the training group and, in
addition, neuromuscular performance changes related to the specific multi-station

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proprioceptive exercise program will be found in the training group.
Methods
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Subjects
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Paragraph Number 5 The CONSORT statement was followed in the design of the study (1).
The study contained a prospective randomized controlled trial and a pre-post laboratory-
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based test of a selected subgroup. The respective number of athletes recruited and
investigated in the course of the trial is shown in Fig. 1.
Paragraph Number 6 In total, 232 players on 35 teams in the vicinity of Muenster,
Germany, participated in the study (Tab. 1). All players played basketball on a regular basis
and the performance level of the players varied between the seventh highest (Kreisliga) and
the highest league (Bundesliga) in Germany. Prior to participation, all subjects signed an
informed consent form. The tests were approved by the local human ethics committee and all
procedures were performed in accordance to the principles of the Declaration of Helsinki.
Subjects were free of injuries at the start of the study. To evaluate the effect of the multi-
station proprioceptive exercise program on injury incidence, all subjects who wore external
stabilizing devices (braces, tape) or who had previously performed proprioceptive exercises
were excluded from the study. The remaining 198 subjects were randomly assigned to the
control or the training group using a stratified randomization design with the strata defined
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by performance (high, middle, low) and sex (male, female). It has to be noted that subjects
were allocated to the groups as teams because the balance training program had to be
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integrated in the normal training process. Teams were assigned using random numbers (0
and 1) that were generated by a computer program. The randomization list was established
in advance and strictly maintained. This finally resulted in two randomized groups that were
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comparable in terms of performance and sex.
Training program
Paragraph Number 7 The control group consisted of 102 players who continued with their
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normal work-out routines. The training group consisted of 96 players who performed a multi-
station proprioceptive exercise program that was designed in cooperation with the School of
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Physiotherapy of the University Hospital. The program was integrated within the regular
training routines and was especially designed for basketball work-outs. At the beginning of
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the season, each coach obtained an eight-page training manual which contained a detailed
description of the set-up, all exercises (including the different difficulty levels) and additional
background information concerning posture corrections and proprioception. In addition, a
physiotherapist introduced this program to all players and coaches on site and gave detailed
instructions for correct execution. This was repeated for each difficulty level. During the
season, the coaches were encouraged to contact us and were contacted by us on a regular
basis to keep them motivated and to help with questions or problems.
Paragraph Number 8 The multi-station program was adapted from a program presented by
Eils and Rosenbaum (5). It was performed once a week and consisted of six stations that were
performed twice (barefoot) at the beginning of the normal training routine (Fig. 2). The
exercise period took 20 minutes (including set-up and removal). The exercises were
performed for 45 s followed by a 30 s break where subjects transferred to the next station.
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The correct posture of the lower leg of the subjects was controlled (slight external rotation of
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the foot, slightly flexed knee and the patella over the metatarsophalangeal joint) during the
exercise. The intensity and difficulty of the exercises were increased during the season twice
by minor modifications for each station.
Injuries:
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Paragraph Number 9 From the beginning of the season, all injuries of the players in a team
were registered by a person in charge of the team (coach, physiotherapist, player) using a
specific injury questionnaire that was filled out and returned in case of an injury. To reduce
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reporter’s bias to an acceptable degree, we contacted the coach and the player to obtain
further information about the circumstances, the severity and the medical diagnosis. All
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injuries were reported but the contact to the coaches and players was only arranged in case
of ankle injuries. An injury was defined as an event that forced the subject to terminate the
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ongoing basketball activity and, in addition, prevented further participation in the next
scheduled basketball activity.
Biomechanical tests:
Paragraph Number 10 Additional biomechanical tests were performed in a subgroup of
both, the control and the training group in order to investigate the influence of the training
program on neuromuscular performance. The subgroup was randomly selected using a
stratified randomization design as mentioned above. Subsequently, players within these
teams were randomly selected and asked for participation in the study. Finally 24 subjects
(11 in the control group, 13 in the training group) were enrolled and performed the pre-tests
in angle reproduction and postural sway. During the season, 8 players of this group (3
control group, 5 training group) were lost due to different reasons (see Fig. 1). Finally, data
of 16 players (8 of each group) who performed both pre- and post tests could be analysed.
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Paragraph Number 11 A pressure distribution platform (Emed ST4, Novel GmbH, Munich,
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Germany) was used to measure postural sway in single-limb stance (Fig. 3). No instructions
concerning the posture were given to the subjects except to avoid contact of the legs and to
focus on a point on the wall directly ahead. Individual posture was noted and subjects were
informed to use the same style as in the pre-test when it deviated in the post-test. For each
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foot, three trials of single limb stance (10 sec. each) were performed. For analysis, the sway
variation and the sway amplitude of the center of pressure (CoP) in medio-lateral and
anterior-posterior direction as well as the total sway distance (total length of the CoP-line)
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were determined and averaged.
Paragraph Number 12 A custom-built device was used for testing joint position sense in a
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passive angle reproduction test. It consisted of a footplate in combination with a Penny &
Gilles goniometer (Biometrics Ltd, Gwent, UK). Subjects sat in front of the measuring device
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and placed the foot on the horizontal footplate (Fig. 4). The rotation axis of the device was
aligned with the medial malleolus. The knee joint was placed over the ankle. This position
was defined as the neutral position (0°). Subjects were unable to see their feet throughout the
examination and had their eyes closed to concentrate on the measurements. For the passive
angle reproduction test, the foot was brought into one of the two testing positions (10°
dorsiflexion, 15° plantarflexion) and was held for two seconds. Then it was brought back to
the neutral position and back towards the testing position until the subjects indicated that they
felt to have reached the same position. The foot was returned to the neutral position and the
next angle was chosen. Angles were tested in random order and each angle was tested three
times. All joint position tests were performed by the same investigator. The differences
between predefined and reproduced angles were saved for analysis. Lower leg strength was
not tested in this study because it was shown that deficits in ankle strength are not related to
chronic ankle instability or subjects who previously sustained sprains without instability as a
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complaint (12, 19, 28).
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Statistics:
Paragraph Number 13 To calculate the injury incidence of the groups, the number of
injuries was related to the number of sports participation sessions (game and practice
sessions combined). The data was then analyzed by logistic regression. The results were
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presented as odds ratios of injury as well as the numbers needed to treat (NNT). Pre- post-
test-analysis was performed using the dependent non-parametric Wilcoxon signed-rank test.
Differences between groups (training, control) were tested using the independent Student’s t-
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test (whole group) and the independent Mann-Whitney U-Test (biomechanical subgroup).
Prediction intervals based on the data of the total study population were used to test the
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representativeness of the biomechanical subgroup. In all statistical procedures, p-values
below 0.05 were regarded as significant. The statistical analyses were performed by means of
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SPSS17 (SPSS Inc., Chicago, Illinois).
Results
Paragraph Number 14 During the season, 21 ankle injuries occurred in the control group
and 7 injuries in the training group. Significant differences were found when focusing on the
preventive effect of the multi-station proprioceptive exercise program (Tab. 2). The logistic
regression revealed a significantly reduced odds ratio of 0.355 for training vs. control group
(95% CI: 0.151 - 0.835, p=0.018). The NNT-analysis revealed a value of 360 for the training
group. Due to the fact that the observation unit is not the player but the single participation in
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sports, the NNT-values have to be reconsidered. Therefore, with an average of 55 sports
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participation sessions in our investigation (average of both groups), NNT-values have to be
corrected to 360/55 = 6.5. This indicates that 7 basketball players (NNT-values are rounded
to the next number to avoid underestimation) have to perform the multi-station proprioceptive
exercise program to prevent one ankle injury during 55 sports participation sessions, i.e. in a
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time period of 18 weeks for recreational (assuming 2 work-outs per week, 1 game per week)
or nine weeks for professional players (assuming 5 work-outs per week, 1 game per week).
Paragraph Number 15 Analysis of players who had previously sustained an ankle injury
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revealed an odds ratio of 1.6 (95% CI: 0.755-3.553, p=0.212) indicating an increased but
non-significant risk (factor 1.6) of sustaining an ankle injury.

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Paragraph Number 16 Players of the training group showed a significantly more stable
single limb stance concerning medio-lateral and overall sway parameters (Tab. 3). Sway in
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antero-posterior direction was also decreased in the post-test but not found to be significant.
Players in the control group also showed slightly decreased values in the post-test but none of
the differences were significant.
Paragraph Number 17 A clear effect of the training program is apparent for the angle
reproduction test. The degree of error for 10° dorsiflexion, 15° plantarflexion and the mean
was significantly reduced for the post-test in the training but not in the control group (Tab. 4).
Discussion
Paragraph Number 18 The present investigation evaluated the effectiveness of a multi-
station proprioceptive exercise program for prevention of ankle injuries using a prospective
randomized controlled trial in combination with a laboratory based pre-post test. The results
suggest that the training program is effective in reducing the incidence of ankle injuries in
basketball players and also leads to specific changes in neuromuscular performance;
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specifically in terms of proprioception and postural sway. In summary, these findings
indicate that improvements in these neuromuscular parameters may be a key factor for an
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effective reduction in ankle injury risk.
Paragraph Number 19 The multi-station proprioceptive exercise program led to a
significant reduction of ankle injuries in basketball players. The risk of sustaining an ankle
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injury was reduced by 35.5% and the NNT-analysis revealed that 7 players have to be treated
with this training program to prevent one ankle injury during 55 sports participation sessions.
This underlines the potential benefit of an active injury prevention protocol, especially in
professional sport. Results for risk reduction and NNT calculation are comparable to results
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in the literature. For example, Hupperets et al. recently reported a similar NNT value of 9 and
a relative risk reduction of 35% in the training group compared to the control group in a
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randomized controlled trial using home based proprioceptive training on recurrences of
ankle sprains (11). In the present study, a frequency of 4.31 injuries per 1000 sports
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participation sessions was comparable to results of McKay et al. who reported 3.85 ankle
injuries per 1000 sports participation sessions in Australian basketball players (16).
Paragraph Number 20 Neuromuscular training programs consisting mainly of exercises on
an ankle disk, performed several times per week, were found to be effective in the reduction
of ankle injury incidence (6, 9, 20, 23), although Handoll and colleagues questioned the
efficacy in an evidence-based review of the literature due to a limited amount of high quality
studies (8). Preliminary evidence was only given for those with previous ankle injuries. Eils
and Rosenbaum speculated that specific training on an ankle disk probably generated only
single stimulation and therefore introduced a six-week multi-station proprioceptive exercise
program that addressed strength and coordination in multiple ways and was performed only
once a week (5). The authors showed that this program led to significant improvements
within the neuromuscular system in the training group but not in the control group. However,
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it still remained unclear whether the measured effects of this ‘low-frequency and high
stimuli’ program would lead to a reduction in the number of ankle injuries. The results of the
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present study underlined the effectiveness of such a program and suggest that training-
induced changes within the neuromuscular system may be related to the reduced incidence of
ankle injuries. It must be noted that a direct one-to-one relationship cannot be established
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since only a subgroup of the entire cohort was evaluated in the lab due to organizational
concerns. However, although the sample was small, it was randomly drawn and
representative. A post-hoc analysis using prediction intervals based on data of the total study
population revealed that the sample is proven to be representative of the total study
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population except for the rate of high performance players. Furthermore, significant
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differences were found between pre- and post-tests. The study design involving a randomized
controlled trial combined with laboratory based testing is important in more appropriately
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identifying the relationship between ankle injury prevention and neuromuscular
performance, compared to independent randomized controlled trials and laboratory based
testing. This relationship will help to better understand the complex interaction between
injury prevention and neuromuscular performance.
Paragraph Number 21 Recently, the importance and efficacy of complex intervention
programs consisting of a variety of exercises, have also been reported for volleyball players
(26) and in athletes with acute ankle sprains (10-11). Therefore, there is new evidence that
proprioceptive training programs with challenging exercises to create multiple stimuli may be
recommended for the prevention of ankle injuries. The effects of proprioceptive training have
been well documented in the past and laboratory-based studies concerning alterations in joint
position sense, sway regulation in single limb stance, muscle strength or peroneal reaction
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times have been performed (5-7, 9, 12-15, 24-25). Despite differing findings (22), there
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appears to be a trend of characteristic neuromuscular performance adaptations due to
specific training programs.
Paragraph Number 23 In the present investigation, the results of the angle reproduction test
show a significant improvement in neuromuscular performance. The results for the sway
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regulation are similar but not all improvements in the training group were significant. The
training program seems to be more effective in improving sway reduction in medio-lateral
direction. This is comprehensible because movement in medio-lateral direction is mainly

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controlled in the subtalar joint whereas the movement in antero-posterior direction is more
regulated in the tibiotalar joint. A similar result was reported by Eils and Rosenbaum (2001)
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when evaluating the effects of a multi-station proprioceptive exercise programs in patients
with ankle instability (5).

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Paragraph Number 24 In previous studies, the relationship between training-related
changes within the neuromuscular system and effectiveness of injury prevention was vague.
In the present investigation, this relationship was evaluated for the first time with parallel
biomechanical testing in a smaller subgroup, including angle reproduction and postural
sway testing. Although we analyzed only a small subgroup and are aware of the fact that
other factors may play a role in this context, we believe that the results of the present study
underline a more direct relationship between measured alterations within the neuromuscular
system and effectiveness of injury prevention than shown in previous studies due to the fact
that the sample was randomly selected and representative. The results of the postural sway
analysis in single-limb stance and angle reproduction showed significant differences within
the training group but not in the control group for selected parameters. Therefore, an
improved ability to detect a predetermined angle (improved joint position sense) and the
ability to regulate sway in single-limb stance appear to be related to a reduction of lateral
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ankle injuries. These improvements may help athletes to prevent ankle injuries in potentially
dangerous circumstances, e.g. in cutting and landing movements, due to an improved joint
position sense of the foot and ankle complex.
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Paragraph Number 25 At this point, it will be of interest how exercises have to be designed
to be most effective. For example, what are the effects of a typical ankle disk training
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compared to a more complex exercise on a neurophysiologic basis? Is it possible to derive
some typical characteristics or ‘key aspects’ that make an exercise more suitable for
proprioceptive training? However, this remains speculative and has to be addressed in

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additional biomechanical studies.
Paragraph Number 26 One aspect that needs clarification in the present investigation is the
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influence of proprioceptive training on subjects with and without previous ankle injuries. It
has been stated that a beneficial effect is most pronounced for athletes with previous ankle
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injuries and that there is only a small or no effect of training in healthy subjects (4, 8). We
found an increased chance (factor 1.6) of obtaining an ankle injury in subjects with previous
injuries. However, this increase was not significant. Only players who never performed
proprioceptive exercises or wore ankle stabilizing devices before were included in the present
investigation. Therefore, a high percentage of players with previously injured ankles have
probably been excluded resulting in a similar percentage of players (about 50% each) with
and without previous injuries. This explains why the effect for players with previous injuries
is not as pronounced as in other investigations (2, 16, 26).
Paragraph Number 27 Significant differences between players’ age and sports activity were
initially found between the training and control group. The players in the training group were
significantly younger (22.6 vs. 25.5 years) and more active (3.5 vs. 2.8 times per week) than
the controls. These group differences actually emphasize the findings because it can be
argued that younger and more active individuals would have a greater risk of injury due to
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increased exposure.
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Paragraph Number 28 The results of the present investigation show that the number of
ankle injuries was reduced but there was no information concerning other injuries. This
might be a limitation in the present study because it would be of interest to know whether
ankle injuries may be replaced by injuries in other areas. We were not able to derive this
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information from our data because coaches and players were only contacted in case of ankle
injuries. However, a systematic Cochrane review focusing on interventions for preventing
ankle ligament injuries did not report an apparent effect on the incidence of other leg
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injuries (8). This leads us to trust that there is no significant shift of injuries to other body
areas.
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Conclusion
Paragraph Number 29 The results of the present investigation show that a specific multi-
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station proprioceptive exercise program performed only once a week significantly reduced
the frequency of ankle injuries in a population of basketball players. In addition,
characteristic and significant improvements in neuromuscular performance were found in
biomechanical tests of proprioception and postural sway that may be directly related to the
risk of ankle injury. This is the first study to directly underline a relationship between injury
incidence and alterations in neuromuscular performance. The evaluation of injury incidence
as well as objective parameters from biomechanical tests warrants the recommendation of
such exercises for the prevention of ankle injuries.
Paragraph Number 30 Although the population were basketball players, it may be safe to
assume that the program is also applicable to other sports or high-risk activities like team
handball, volleyball or soccer.
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Acknowledgement
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Paragraph Number 31 The authors wish to thank M. Overbeck and colleagues for their help
in setting up the exercise program. This study was funded by a research grant of the
Bundesinstitut für Sportwissenschaft (Federal Institute of Sports Science). Grant number: VF

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0407(01/68/2004). None of the authors of this article have any conflicts of interest or
financial conflicts to disclose. The results of the present study do not constitute endorsement by
American College of Sports Medicine.

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Mechelen W. The effect of a balance training programme on centre of pressure excursion in
one-leg stance. Clin Biomech (Bristol, Avon). 2005; 20(10):1094-100.
26. Verhagen EA, van der Beek A, Twisk J, Bouter L, Bahr R, and van Mechelen W. The
Effect of a Proprioceptive Balance Board Training Program for the Prevention of Ankle
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Sprains. A Prospective Controlled Trial. Am J Sports Med. 2004; 32(6):1385-93.

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27. Wang HK, Chen CH, Shiang TY, Jan MH, and Lin KH. Risk-factor analysis of high
school basketball-player ankle injuries: a prospective controlled cohort study evaluating

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postural sway, ankle strength, and flexibility. Arch Phys Med Rehabil. 2006; 87(6):821-5.
28. Willems T, Witvrouw E, Verstuyft J, Vaes P, and De Clercq D. Proprioception and
Muscle Strength in Subjects With a History of Ankle Sprains and Chronic Instability. J Athl
Train. 2002; 37(4):487-93.
List of Figures
FIGURE 1: Flowchart of number of athletes participating in this study.
FIGURE 2: Exercises and variations of the multi-station proprioceptive exercise program.
Please note that this is only a short description of the program and the exercises.
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FIGURE 3: Measurement of postural sway in single-limb stance on the pressure distribution
platform and an example of the derived parameters (excursions of the center of pressure CoP
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in medio-lateral and antero-posterior directions as well as total sway distance).
FIGURE 4: Joint position sense testing in a custom-built device in combination with an

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electrogoniometer. The foot of the subjects was passively moved into 10° of dorsiflexion and
15° of plantarflexion. Deviations between predefined and reproduced angles were derived for
analysis.
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Figure 1
Players assessed for

eligibility (n=232)
Excluded (n=34)
Previous use of braces (13 players)
Previous performing proprioceptive / neuromuscular
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training programs (9 players)
Did not return questionnaire (7)
Other reasons (11 players)
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198 Players were enrolled and agreed to
participate in the study.
Allocated to control Allocated to

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group training group
(n=102) (n=96)
Biomechanical pre-
post subgroup
analysis (n=24)
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Lost to follow-up: Lost to follow-up: Lost to follow-up:

(n=11) (n=8) (n=15)
Reasons: Reasons: Reasons:
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Did not return questionnaire of Did not participate in Did not return questionnaire of
participations in sports post-test (2 players) participations in sports
(6 players) Erroneous data (1 (9 players)
Sustained other injuries (2 player) Sustained other injuries (3
players) Unknown reasons (5 players)
Unknown reasons (3 players) players) Unknown reasons (3 players)
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Analyzed
(n=16)
Analyzed Analyzed
(n=91) (n=81)
Figure 2
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Exercise 1 Exercise 2 Exercise 3 Exercise 4 Exercise 5 Exercise 6
Basic Exercise: Basic Exercise: Basic Exercise: Basic Exercise: Basic Exercise: Basic Exercise:
W alking slow ly back Single leg stance on Jump from one leg to W alk up and dow n an Maintain balance in Maintain balance in
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and forth on a balance exercise mat with the the other on an exercise inclined surface and single-leg stance single-leg stance on
beam (1 step=3 contralateral leg flexed. mat and control landing dribble the ball. elevating the inversion-eversion tilt
seconds). The Lower and raise the for 4 seconds. R aise the contralateral leg against board. The contralateral
contralateral leg sw ings body. D istribute load on contralateral leg Variation 1: resistance of an elastic leg is rested on an
through and nearly the foot. Only small W alk on inclined surface strap. inclined surface nearly
touches the ground knee movements to the Variation 1: up and dow n and without being loaded.
left and right are Jump from one leg to dribble the ball. In Variation 1:
Variation 1: allowed. the other (exercise mat) addition, an elastic strap Maintain balance in Variation 1:
W alking faster than with a partner. D isturb is wrapped around the single-leg stance (eyes The same as above w ith
before on the balance Variation 1: each other during the knees. W alk forwards closed) elevating the a partner. Pass the ball
beam. W ay back: slowly Single limb stance as flight phase (hand and backwards. Focus contralateral leg against and control stance after
with same execution as above opposite to a contact) and control the on wide steps. resistance of an elastic catching the ball.
above. partner. A basketball is landing and stance for 4 strap.
passed to the partner. seconds. Variation 2: Variation 2:
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Variation 2: After catching the ball, W alk up and dow n an Variation 2: Maintain balance in
Stance on a balance the position is controlled Variation 2: inclined surface. An Maintain balance in single-leg stance on
beam. The contralateral for 2 seconds. Pass the As before, but on a soft opposite partner is single-leg stance inversion-eversion
leg moves a basketball ball back and forth. mat. doing the same. Pass moving the contralateral board. The contralateral
that lies on the ground the ball betw een leg sideways against leg is elevated.
in circles. Focus on the Variation 2: partners and move up resistance of an elastic
supporting leg. Single leg stance on a and down with only the strap. Evert the lateral
soft mat. Balance a ball forefoot in ground edge of the contralateral
(tennis ball, basketball) contact. foot.
on the dorsum of the
elevated contralateral
Cfoot.
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Figure 3
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Figure 4
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TABLE 1. Anthropometric data of the whole (upper part) and the biomechanical subgroup
(lower part)
Whole group Training group (n=81) Control group (n=91) P-level

Mean ± SD Range Mean ± SD Range
Age (years) 22.6 ± 6.3 14-43 25.5 ± 7.2 15-43 p<0.01.
Weight (kg) 77.2 ± 15.3 50-117 77.8 ± 14.6 53-115 n.s.
Height (cm) 184.1 ± 11.0 163-207 183.6 ± 10.4 161-211 n.s.
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Gender (m/f) 49/32 54/37
Sports activity (per week) 3.5±1,1 1-7 2.8±0.9 1-7 p<0.01
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Previous injuries (y/n) in % 48/52 46/54
Subgroup Training group (n=8) Control group (n=8) P-level

Mean ± SD Range Mean ± SD Range
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Age (years) 24.3 ± 2.9 22-30 25.9 ± 8.2 17-38 n.s.
Weight (kg) 75.8 ± 12.4 57-90 80.6 ± 18.6 65-115 n.s.
Height (cm) 182.1 ± 6.9 175-196 184.4 ± 7,8 174-196 n.s.
Gender (m/f) 4/4 4/4

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Sports activity (per week) 2.9±0.4 2-3 3.5±1.8 2-7 n.s.
Previous injuries (y/n) in % 63/37 75/25

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Differences between groups (training, control) were tested using the independent Student’s t-test (whole group)
and the independent Mann-Whitney U-Test (biomechanical subgroup).
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TABLE 2. Number of ankle injuries, participations in sports, injury frequency related to 1000
participations in sports, odds ratio and number needed to treat (NNT).
Training group Control group

Absolute number of injuries 7 21
Total number of participations 4565 4876
in sports
Injury frequency per 1000 sport 1.53 4.31
participations
Odds ratio (95% CI); p-value 0,355 (0.151-0.835); p=0.018 1
Number needed to treat (NNT) 7 /
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TABLE 3. Postural sway parameters (mean ± standard deviation).

Pre test Post test Pre test Post test
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Postural sway [mm] Mean ± SD Mean ± SD P level Mean ± SD Mean ± SD P level
Standard deviation medio-lateral 5.8 ± 0.7 5.1 ± 0.8 <.05 5.4 ± 1.3 5.3 ± 1.1 n.s.
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Standard deviation antero-posterior 6.7 ± 0.9 6.6 ± 1.3 n.s. 7.4 ± 1.8 7.4 ± 1.0 n.s.
Maximum sway medio-lateral 26.9 ± 3.9 23.1 ± 3.5 <.01 25.3 ± 4.9 23.9 ± 3.9 n.s.
Maximum sway antero-posterior 33.1 ± 4.5 28-9 ± 3.9 n.s. 34.1 ± 8.7 31.6 ± 4.7 n.s.
Total sway distance 425.2 ± 47.5 359.2 ± 57.7 <.05 351.2 ± 73.8 336.2 ± 87.1 n.s.
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TABLE 4. Angular errors in the joint position test from predetermined angles (mean ± standard deviation).

Pre test Post test Pre test Post test
Degrees of error [°] Mean ± SD Mean ± SD P level Mean ± SD Mean ± SD P level
10° dorsiflexion 2.0 ± 0.5 1.2 ± 0.5 <.05 2.5 ± 1.3 1.9 ± 0.8 n.s.
15° plantarflexion 3.7 ± 1.4 2.1 ± 1.2 <.05 2.3 ± 0.8 2.8 ± 1.1 n.s.
Mean error 2.9 ± 0.6 1.7 ± 0.6 <.05 2.4 ± 0.8 2.4 ± 0.9 n.s.
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Published ahead of Print

Accepted for Publication: 28 March 2010

Copyright © 2010 American College of Sports Medicine

A Multi-Station Proprioceptive Exercise Program Prevents Ankle Injuries in Basketball

University Hospital Muenster, Domagkstrasse 3, 48149 Muenster, Germany

62b, 48149 Muenster, Germany

Domagkstrasse 9, 48149 Muenster Germany

Priv. Doz. Dr. Eric Eils,

Institute of Sport Science, Motion Science

Horstmarer Landweg 62b,

48149 Muenster, Germany

Phone: ++49-251-8334866; Fax: ++49-251-8334872

Running title: Exercise program to prevent ankle injuries

(Federal Institute of Sports Science). Grant number: VF 0407(01/68/2004).

Purpose: To investigate the effectiveness of a multi-station proprioceptive exercise program

controlled trial in combination with biomechanical tests of neuromuscular performance.

performed in both groups to investigate the effects on neuromuscular performance.

group by approximately 35%. The corresponding numbers-needed-to-treat (NNT) was 7.

single limb stance in the training group.

Conclusion: The multi-station proprioceptive exercise program effectively prevented ankle

neuromuscular performance. With this knowledge, proprioceptive training may be optimized

to specifically address the demands in various athletic activities.

rehabilitation, Biomechanical tests; neuromuscular performance

subjects with recurrent ankle injuries (3, 11).

neuromuscular performance are indicative of the effectiveness of the training program.

neuromuscular parameters are effective with respect to injury reduction. A combination of

prevention and neuromuscular performance in athletes.

well as the effects of laboratory-based trials on neuromuscular performance during a

addition, neuromuscular performance changes related to the specific multi-station

investigated in the course of the trial is shown in Fig. 1.

Paragraph Number 6 In total, 232 players on 35 teams in the vicinity of Muenster,

procedures were performed in accordance to the principles of the Declaration of Helsinki.

background information concerning posture corrections and proprioception. In addition, a

basis to keep them motivated and to help with questions or problems.

by minor modifications for each station.

scheduled basketball activity.

Paragraph Number 10 Additional biomechanical tests were performed in a subgroup of

stratified randomization design as mentioned above. Subsequently, players within these

were determined and averaged.

representativeness of the biomechanical subgroup. In all statistical procedures, p-values

SPSS17 (SPSS Inc., Chicago, Illinois).

non-significant risk (factor 1.6) of sustaining an ankle injury.

the differences were significant.

Paragraph Number 18 The present investigation evaluated the effectiveness of a multi-

basketball players and also leads to specific changes in neuromuscular performance;

Paragraph Number 19 The multi-station proprioceptive exercise program led to a

randomized controlled trial using home based proprioceptive training on recurrences of

Paragraph Number 20 Neuromuscular training programs consisting mainly of exercises on

single stimulation and therefore introduced a six-week multi-station proprioceptive exercise

identifying the relationship between ankle injury prevention and neuromuscular

performance, compared to independent randomized controlled trials and laboratory based

injury prevention and neuromuscular performance.

specific training programs.

training program seems to be more effective in improving sway reduction in medio-lateral

direction. This is comprehensible because movement in medio-lateral direction is mainly

when evaluating the effects of a multi-station proprioceptive exercise programs in patients

with ankle instability (5).

Paragraph Number 24 In previous studies, the relationship between training-related

biomechanical testing in a smaller subgroup, including angle reproduction and postural

ability to regulate sway in single-limb stance appear to be related to a reduction of lateral

position sense of the foot and ankle complex.

proprioceptive training? However, this remains speculative and has to be addressed in