ARTICLE IN PRESS

Physical Therapy in Sport 7 (2006) 65–73

www.elsevier.com/locate/yptsp

Original research

Biomechanical outcomes of a knee neuromuscular exercise

programme among adolescent basketball players: A pilot study
Quinette Louwa,, Karen Grimmerb, Christopher L. Vaughanc
a
Department of Physiotherapy, Stellenbosch University, P.O. Box 19063, Tygerberg 7505, South Africa
b
Division of Health Sciences, University of South Australia, Australia
c
Department of Human Biology, University of Cape Town, South Africa
Received 7 April 2005; received in revised form 6 March 2006; accepted 14 March 2006

Abstract

Objective: The objective was to test if a neuromuscular exercise programme would improve jump-shot landing technique of male
adolescent basketball players.
Design: A non-equivalent pre-test–post-test control group experimental design was used.
Setting: Intervention (a 6-week neuromuscular exercise programme) took place at club practise venues and motion analysis at a
biomechanics laboratory.
Participants: Five case and five matched control subjects participated.
Main outcome measures: Six high-speed (120 Hz), Oxford Metrics Vicon 370 cameras (Oxford Metrics, Oxford, UK) and a strain
gauge AMTI force plate (AMTI Inc., Newton, MA, USA) synchronised were used to analyse three-dimensional (3-D) knee kinetics
and kinematics of a jump-shot landing. Vertical ground reaction force, knee joint angles and negative work were calculated.
Results: Repeated ANOVA tests were used to compare the peak vertical ground reaction force, knee flexion, and total negative
work prior to and following the exercise intervention. There was an overall significant difference for time of testing (pre-and-post
intervention) and group allocation (case or control) for peak ground reaction force, knee flexion and negative working when landing
from a jump-shot.
Conclusion: The improvements noted in the performance of case subjects suggest that neuromuscular exercises could aid in the
reduction of injury rate or severity of knee injuries sustained during game play.
r 2006 Elsevier Ltd. All rights reserved.

Keywords: Adolescent knee injury prevention; Neuromuscular exercise; Sports; Basketball; Motion analysis

1. Introduction Epidemiological studies have shown one of the most

Knee injuries are commonly sustained during sporting
activity and the consequences are usually more serious
and costly than injuries to other joints (Louw, Grimmer,
& Vaughan, 2003). Jump sports such as basketball are
arguably associated with a higher prevalence of knee
injuries compared with other sports (Messina, Farney, &
De Lee, 1999).
Corresponding author. Tel.: +27 21 938 9300;
fax: +27 21 931 1252.
E-mail address: qalouw@sun.ac.za (Q. Louw).
common injury mechanisms leading to knee injuries to
be when a player lands from a jump (Hicky, Fricker, &
McDonald, 1997; Louw et al., 2003).
Preventative action is strongly advocated by research-
ers who report on the prevalence of knee injuries
(McKay, Goldie, Payne, Oakes, & Watson, 2001). The
question of whether sports-related knee injuries can
be prevented by enhanced performance programmes,
including exercise rehabilitation strategies, is a com-
plex one. Studies into the effectiveness of preven-
tative interventions for sports-related injuries are
limited (Parkkari, Kujala, & Kannus, 2001). Exercise

1466-853X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ptsp.2006.03.004
 ARTICLE IN PRESS
66 Q. Louw et al. / Physical Therapy in Sport 7 (2006) 65–73
programmes are considered to be a viable option in
combating knee injuries (Caraffa, Cerulli, Projetti, Aisa,
& Rizzo, 1996). Cost effective exercise programmes that
are practical and can complement usual training sessions
have promising outcomes with respect to injury preven-
tion (Caraffa et al., 1996; Hewett, Lindenfeld, Ricco-
bene, & Noyes, 1999).
Most studies aimed at the prevention of injuries are
conducted on adults, leaving a gap in research into the
prevention among adolescents. Electronic databases
from 1960 to 2005 (Medline, SPORTSDicuss, Current
Contents & CINAHL) indicate two studies relating to
adolescents (Hewett et al., 1999; Myer, Ford, Palumbo,
& Hewett, 2005). These two studies validated the
usefulness of accepted current best practise in rehabili-
tation practices. The study by Hewett, Stroupe, Nance,
and Noyes (1996) showed that plyometrics, strengthen-
ing and landing technique training given to adolescent
females, reduced ground reaction forces, knee adduction
and abduction moments, and improved jumping ability.
A follow-up intervention by this research group showed
that plyometric and resistance training exercises lead to
reduced prevalence of serious knee injuries among
young soccer, volleyball and basketball players (Hewett
et al., 1999). A recent publication by this research group
demonstrated that neuromuscular exercise techniques
also improve jumping performance in adolescent female
athletes (Myer et al., 2005).
Review of published knee injury preventative studies
indicated that neuromuscular exercise programmes,
including balance and proprioceptive exercises, cur-
rently provide the highest level of evidence for prevent-
ing knee injuries (Caraffa et al., 1996; Hewett et al.,
1999; Soderman, Werner, Pietila, Engström, & Alfred-
son., 2000). These studies present experimental evidence
(Level 2a and Level 2b as classified by Sackett,
Richardson, Rosenberg, & Haynes, 2000). Neuromus-
cular control refers to the unconscious activation of
dynamic restraints resulting from proprioceptive input
occurring in preparation for, and in response to, joint
motion and loading to restore functional joint stability
(Riemann & Lephart, 2002; Voight & Cook, 2001).
Sound neuromuscular control is particularly important
to players when learning high speed sporting man-
oeuvres.
Many motor control and skilled learning theories
have been presented (Foerster, 1977; Forssberg, Grill-
ner, & Rossignol, 1975; Sherrington, 1947), but very
little is understood about the motor control processes
leading to improvement in performing a movement
(Garret & Kirkendall, 2000). One of these theories
suggests three stages of motor learning, namely the
cognitive stage which refers to understanding how to
perform the task, the associative stage for refinement of
skill and the autonomous stage when skill becomes
automatic (Garret & Kirkendall, 2000). Neuromuscular
training allows for adequate learning opportunities to
practise or refine a complex skill until it becomes
automatic (Lees, 1981). In learning how to land in a safe
manner, the task should be repeated often and
corrective feedback should be given to players.
The process that describes why practising a motor
action improves skill is still unknown (Brooks, 1983).
Theoretically, it is suggested that motor improvements
result from cognitive processes or goal-directed thoughts
and thus it is important to spend sufficient time
practising the technique (Brooks, 1983). Motor learning
theories suggest that an action can result from a motor
programme, stored as a set of motor commands
(Brooks, 1983). The better the motor programme has
been learned by repetition and correction, the fewer
corrections are needed after implementation. The motor
programme related to learning a technique should also
prepare players for typical game play perturbations,
otherwise the motor response time to joint instability
will be longer and injury occurrence virtually inevitable
(Garret & Kirkendall, 2000). Research into landing
techniques also found that appropriate verbal feedback
on technique was effective in reducing ground reaction
forces when landing from a jump (Cowling, Steele, &
McNair, 2003).
Landing from a jump during sporting activities is one
of the common injury mechanisms leading to knee
injuries (Louw et al., 2003). A number of kinetic and
kinematic biomechanical knee injury risk factors during
the landing action are reported in the published
literature (Caster & Bates, 1995; Hewett et al., 1996;
Lephart, Ferris, Riemann, Myers, & Fu, 2002; McNair
& Marshall, 1994). One of the most frequently reported
measures is peak knee flexion angle when the player
lands from a jump (Hewett et al., 1996; Huston,
Greenfield, & Wojtys, 2000). The amount of knee
flexion when landing may be an indication of the
player’s ability to absorb impact forces imposed on the
knee joints during the landing action (Dufek & Bates,
1990). However, the optimal degree of knee flexion, rate
of knee flexion and the critical time-frame for maximum
knee flexion is still unclear. Inadequate knee flexion has
been associated with high vertical ground reaction forces
placing strain on the knee joint structures (Dufek &
Bates, 1990). Ground reaction forces have been studied
extensively by researchers conducting research into
landing from a jump (Decker, Torry, Noonan, Riviere,
& Strerett, 2002; McNair & Marshall, 1994.) Ground
reaction forces during the landing action range between
2 and 4.5 times body weight (Louw, 2004). Published
reports postulate that these high forces may be related to
knee injury occurrence. This may particularly be a factor
to consider in jump sports when such high forces are
repeatedly imposed on the knees of young players who
may also lack adequate dynamic muscle support to
control alignment of the knee joint during the landing
 ARTICLE IN PRESS
Q. Louw et al. / Physical Therapy in Sport 7 (2006) 65–73
action (Louw, 2004). Dynamic muscle support is viewed
to be important in maintaining stability of the knee joint
during dynamic actions such as landing. Muscle work
has thus also been identified as a knee injury risk factor
by researchers in this field (Zhang, Bates, & Dufek,
2000).
This article reports on a research project into knee
injury prevention in adolescent sporting activity. The
study focused on landing from a jump, as it is one injury
mechanism that is found to be common for knees and
that could be addressed from a physiotherapeutic
perspective (Louw et al., 2003). The aim was to test if
a neuromuscular exercise programme would improve
the landing technique of adolescent male basketball
players when they perform a jump-shot. The hypothesis
was that the neuromuscular exercise programme would
reduce the size of impact forces, improve knee flexion
and improve negative muscle work when adolescent
basketball players land from a jump.
2. Methodology
2.1. Study design and recruitment
A non-equivalent pre-test–post-test control group
experimental design was used to test the effects of the
exercise programme. Two conveniently selected clubs in
Cape Town, South Africa participated. The clubs
selected were among the three clubs with the largest
number of adolescent players in Cape Town. The
training venues of the clubs were situated about 20 km
from each other, but they used similar training surfaces.
Two clubs were selected, since an experimental and
control group were included in this study. One of the
two coaches was available to conduct the exercise
session and based on this, his club constituted the
experimental club. The coach at the first club con-
veniently selected five control subjects and the coach at
the second club selected five case subjects (experimental)
to participate in this study. Only male players, aged 14–
16 years, were included. Coaches nominated players
who they considered to be reliable in attending training
and competitions regularly. Coaches were not informed
about the type of biomechanical parameters to be
measured and did not consider players that they
perceived to be more talented in playing basketball.
The mean age of the players in the experimental and
control group was 15.6 years (70.8). The mean weight
of the case subjects was 538 N (792.64) and the mean
height was 1.64 m (70.23). The mean weight of the
control subjects was 542 N (783.13) and the mean
height was 1.62 m (70.63). Neither the case group
subjects nor those of the control group had any history
of lower limb injuries and all were registered with the
67
Western Cape Basketball Association as competitive
league players.
2.2. Ethical approval
Ethical approval to conduct the study was obtained
from the University of South Australia Human Ethics
Committee. Parents and subjects all gave informed
written consent to participate in the study. Consent was
also obtained from the Western Cape Basketball
Association in Cape Town, South Africa.
2.3. Measurement tools
Six high-speed Vicon 370 cameras (120 Hz) (Vicon,
Oxford Metrics, Oxford, UK) and Workstation and
Bodybuilder software by Oxford Metric (Oxford Me-
trics, Oxford, UK) were used to analyse landing
patterns. The six cameras were strategically positioned
in the laboratory to ensure that all markers were
captured throughout the trial. A strain gauge six-
channel force plate (AMTI Inc., Newton, MA, USA)
was used to measure the ground reaction forces. A
standard calibration procedure is used to enable
automatic calibration of the Vicon System (Vicon 370
Users’ Manual, 1997). The Vicon system is calibrated to
determine the exact positions and orientation of the
cameras with respect to the laboratory. Static and
dynamic calibration (using the frame and wand,
respectively) was performed to ensure that the ‘‘calibra-
tion residual’’ values were below 0.1% of the recon-
struction volume (Vicon 370 Users’ Manual, 1997).
2.4. Vicon laboratory testing procedures
2.4.1. Subject preparation
One researcher took all the anthropometric measure-
ments using standard protocols. A Holtain calliper
(Holtain, UK) and tape measure were used for anthro-
pometric measurements. The anthropometric para-
meters were measured in the manner described by
Vaughan, Davis, and O’Conner (1999). The anthropo-
metric measurements included body mass, height,
anterior superior iliac spine breadth, thigh length, mid-
thigh circumference, knee diameter, foot length, mal-
leolus height, malleolus width and foot breadth, as these
measures were required in the analysis for kinetic and
kinematic measures. These measures were standardised
according to the kinanthropometric standards.
2.4.2. Trial capture
All subjects performed a standard 10-min warm-up
session consisting of jogging and stretching upper and
lower limb muscles. During the warm-up, subjects also
practised three jump-shots in preparation for data
capture. The Helen Hays marker set developed for
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68 Q. Louw et al. / Physical Therapy in Sport 7 (2006) 65–73
lower limb testing was used (Vaughan et al., 1999).
Fifteen retro-reflective markers were applied to the
subject’s anterior superior iliac spines, mid-position of
the base of the sacrum, lateral aspect of the mid-thigh,
lateral aspect of the mid-joint line of the knee joint, the
lateral aspect of the mid-leg, mid-position of the lateral
malleoli, base of the second metatarsal and posterior
aspect of the mid-calcaneous.
The subjects performed two practise jump-shots to
familiarise themselves with the laboratory equipment
and testing procedures. Thereafter they performed 10
jump-shots, landing on the force plate five times with
each foot. These 10 trials were captured. All subjects
were barefoot and the choice of landing with the right or
left foot on the force plate first, was determined by the
subject, and no instructions were given by the research-
er. Subjects were also barefoot to aid the reliability of
marker placement and to reduce the effect of differences
in footwear among the players. Subjects were given the
following standard instructions: ‘‘Run forward and land
with one foot on the force plate’’; ‘‘Jump as high as
possible and perform a jump-shot with a light ball.’’
2.4.3. Trial data capture
Trial data were captured with Workstation Biome-
chanical Software (Oxford Metrics, Oxford, UK). Trial
data capture commenced as the subject ran up towards
the force plate, and ended after the subject had landed
on the force plate. Biomechanical activity in both knees
was assessed in all subjects. The trial was deemed
acceptable for analysis if the correct jump was
performed and all the markers were visible on the
computer monitor throughout the trial, especially
during the landing phase. The subject had to maintain
balance when landing on the force plate for about 1–2 s,
i.e. the subject had to avoid falling when landing. If the
subjects were not able to maintain their balance upon
landing, the trial was repeated. If a subject lost his
balance and fell, the trial was discarded and repeated.
The subject was instructed to repeat the trial if it was
deemed inappropriate. Most of the subjects were able to
control their balance after they had performed the
practise jumps. Only two subjects lost their balance
twice and repeated these trials. The unsuccessful trials
were discarded and not recorded or saved on the hard
drive of the computer.
2.4.4. Trial data validation
The trials were checked with the use of Workstation
or Bodybuilder Biomechanical Software to ensure that
all marker labels were correctly applied to bony
segments. Intermittent gaps in the trajectory of a
selected parameter were filled, in Bodybuilder or Work-
station, by linear interpolation from the surrounding
frames. This interpolation provided a reasonable esti-
mate of the position of the marker during the period it
was obscured. If the maximum number of gaps to be
filled was larger than 10 consecutive frames, then the
interpolated points were no longer deemed to be an
accurate estimate and the trial was rejected. Once the
markers were filtered and data gaps filled the trial files
were accepted for analysis.
2.4.5. Trial data processing
Trials were truncated to highlight the landing phase
since this was the major focus of the study. All analysis
was based on measurements from the airborne position
until after the subject had landed on the force plate.
Three-dimensional joint kinematics and force data
were obtained from the Vicon system and Vicon
software. Moment, power and work values were
calculated using well accepted biomechanical techniques
(Vaughan et al., 1999). A kinetic mathematical model
based on the inverse dynamics approach was applied in
Bodybuilder to calculate kinetic values (Vaughan et al.,
1999). The total negative work (eccentric action) was
obtained by using Gaitlab programme by Kiboho
Publishers. Total negative work was calculated from
the trapezoid integration of the area below the negative
portion of the power/time graphs (Devita, Hortobagyi,
& Barrier, 1998; Kowalk, Duncan, McCue, & Vaughan,
1997). All data were exported as text files for analysis in
Excel (Microsoft Corporation).
Data were standardised to facilitate comparison
between subjects of different sizes. The moment and
work data were standardised to body weight and height
and multiplied by 100 for expression as a percentage.
The moment data were normalised to body height and
weight (hence the unit, % body weight
height)
(Hewett et al., 1996). Impact force was expressed as a
component of body weight (hence the unit,
body
weight) (Hewett et al., 1996).
2.5. Data collection
Subjects in the experimental and control groups acted
as their own controls, and data at similar time periods
were compared between matched cases and controls.
The landing technique of subjects in the experimental
group was evaluated on three test occasions during the
6-week intervention period (prior to commencement of
the programme, 3 weeks after and at 6 weeks after the
final session of the intervention programme). The
control subjects were only tested twice, prior to
commencement of the programme and then again after
6 weeks (Fig. 1).
2.6. Implementation of the exercise programme
The intervention exercise programme (provided to the
cases) lasted for 6 weeks. The coach at the experimental
club, assisted by a physiotherapist, conducted the
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Q. Louw et al. / Physical Therapy in Sport 7 (2006) 65–73 69

exercise programme at the training venue of the club.
The programme was conducted during the pre-competi-
tion period. Two sessions per week, each lasting 40 min
each, were conducted for 6 weeks. The sessions took
place before the usual practise sessions of the club. The
duration of the pilot exercise programme was limited to
40 min to allow sufficient time for basketball training.
No placebo intervention was conducted at the control
club and control subjects continued with their usual
basketball training.
Start of intervention
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7
Test 1 for intervention
and control groups
Test 2 for intervention group
Fig. 1. Data collection time line.
The coach at the intervention club received training
from the principal researcher on how to conduct the
exercise sessions. An important component of the
exercise programme was feedback if the exercise
technique was incorrect. Common errors in exercise
technique were also discussed. Video recordings were
made every second week and viewed by the principal
researcher to assess whether the coach and physiothera-
pist conducted the exercise programme appropriately
and to ensure that adequate feedback was given
regarding technique. The researcher then provided
feedback to the coach and research assistant regarding
their performance. Generally, the execution of the
End of intervention exercise programme and feedback provided to the
subjects were adequate.
Week 8
The intervention exercises were designed based on
previous motion analyses of the landing patterns of
injured and uninjured players (Louw, 2004) as well as on a
Test 3 for intervention review of the literature (Caraffa et al., 1996; Guskiewicz,
group and test 2 for
control group 2001; Hewett et al., 1996; Voight & Cook, 2001; Williams,
Chmielewski, Rudolph, Buchanan, & Snyder-Mackler,
2001). The exercises are described in Table 1 and the

Table 1
Exercise descriptions

Exercise 1 Stand on one leg with the knee slightly flexed to about 201 (stand 6 s on each leg). Maintain good sagittal alignment of the hip, knee
and ankle joints while bouncing a ball, interchanging from the left to the right hand.
Exercise 2 Stand on one leg with the knee slightly flexed to about 201 (stand on each leg for 6 s). Maintain good sagittal alignment of the hip,
knee and ankle joints while bouncing a ball to a partner standing four steps away.
Exercise 3 Stand on one leg with the knee slightly flexed to about 201 while bouncing a ball with the coach performing gentle perturbations to
the shoulder of the player (stand on each leg for 6 s).
Exercise 4 Stand holding a ball slightly above the head and feet about 40 cm apart, jump on the spot and land while trunk and lower limb
control is encouraged by the coach.
Exercise 5 Holding a ball slightly above the head, stand with the feet about 40 cm apart. Jump forwards, backwards and diagonally while
trunk and lower limb control is encouraged by the coach.
The coach encourages players: ‘‘Land as softly as possible when landing’’, ‘‘Maintain good alignment of the trunk and lower limb
and keeping the knees over the toes when landing’’ and ‘‘Absorb shock by bending the knees sufficiently.’’
Exercise 6 Stand on one leg with eyes closed and the knee slightly flexed to about 201. Reach forwards, upwards and diagonally with both arms
for 5 s.
Exercise 7 Single-legged hop, landing with good knee control and sufficient knee flexion while catching and throwing a ball to a partner.
Coach or partner should perform perturbations at the shoulder joint when landing.
Exercise 8 Perform a single-leg hop forwards, backwards and diagonally (star-shaped pattern).
Exercise 9 Stand on a 20–30 cm high step; lower one leg slowly down the step for 4 s while knee control is maintained. Return lowered foot
onto step.
Exercise 10 Perform step exercise 9 while bouncing a ball.
Exercise 11 Do single leg stance on airex, with knee slightly flexed to about 201; catch and throw a ball to a partner.
Exercise 12 Single leg squat jumps on airex, landing with sufficient knee flexion and lower limb control.
Exercise 13 Jog towards the airex and land on one leg on the airex, maintaining balance for 3 s (simulate shooting action).
Exercise 14 Two players stand facing away from each other and tie a theraband around their waists. Players should stand away from each other
until tension is taken up in the theraband. They then perform a forward lunge against the theraband and return to the upright
position.
Exercise 15 Two players stand facing in the same direction and tie a theraband around their waists. Then they perform a sideways lunge away
from each other and return to the upright position. Players should stand away from each other until tension is taken up in the
theraband.
Exercise 16 Two players stand facing in same direction and tie a theraband around their waists. Players should stand away from each other
until tension is taken up in the theraband. Then they perform lateral shuffle movements away and slowly back towards each other.
Exercise 17 Run forward for about 5 m and perform 2 single leg hops, maintaining the landing position for 3 s after the second hop (coach
ensures good knee control).
Exercise 18 Run and rotate 901 in midair while catching the ball, landing with good knee control.
 ARTICLE IN PRESS
70 Q. Louw et al. / Physical Therapy in Sport 7 (2006) 65–73

exercise programme is summarised in Table 2. The
programme consists of initial exercises which are pro-
gressed in degree of difficulty and then replaced by more
complex exercises in the later stages of the programme
(the exercises can be viewed online at: http://www.uni-
sa.edu.au/cahe/wkshps/seminarmaterials.asp).
2.7. Data analysis
Repeated ANOVA tests were used to compare the peak
vertical ground reaction force, knee flexion, and total
negative work of the right and left knee prior to and
following the exercise intervention. The independent
variables were group allocation and time of test (i.e. pre-
and post-intervention). Each ANOVA design included two
within factors (group and time of test). The purpose of this
design was to determine whether there were any significant
Table 2
Exercise programme (intervention)
differences in the dependant variables (ground reaction
force, knee flexion and total negative work) as a
consequence of group allocation or test limb. Significance
level was set at po0:05. In the event of a significant main
effect or interaction following ANOVA contrasts, post hoc
comparisons were conducted using the Bonferroni test to
assess for differences within and between group measure-
ments at baseline and post-intervention. All analyses were
performed using Statistica Version 7.
3. Results
A total of 208 trials were deemed sufficiently complete
to be included in the analysis. Ninety-eight trials of the
control and 111 trials of the cases were analysed. One of
the case subjects attended two of three test sessions only
due to family commitments.
The pre- and post-intervention results of the biome-
chanical parameters measured are summarised in Table 3.

Exercises Repetitions/duration 3.1. Ground reaction force

Week 1 Week 2
Statistical analysis revealed that there was an overall
Exercise 1 6 repetitions with each leg 8 repetitions with each leg significant difference for time and group allocation
Exercise 2 6 repetitions with each leg 8 repetitions with each leg (p ¼ 0:017) (Fig. 2). The two groups did not differ
Exercise 3 5 repetitions with each leg 8 repetitions with each leg
Exercise 4 10 repetitions 15 repetitions
significantly at baseline (p ¼ 0:162) and the control
Exercise 5 10 repetitions 15 repetitions group subjects had a lower ground reaction force
compared with the case group subjects. The Bonferroni
Week 3 Week 4
Exercise 1 6 repetitions with each leg
test results also demonstrated that there was a sig-
Exercise 4 10 repetitions 15 repetitions nificant difference between the baseline pre-intervention
Exercise 6 5 repetitions with each leg 8 repetitions with each leg tests and the post-intervention peak ground reaction
Exercise 7 25 s 50 s force (p ¼ 0:007) of the case subjects. The peak ground
Exercise 8 25 s 50 s reaction force of the control subjects did not change
Exercise 9 30 s with each leg 1 min with each leg
Exercise 11 30 s with each leg
between the two test occasions (p ¼ 1).

Week 5 Week 6 3.2. Knee flexion angles

Exercise 10 30 s with each leg
Exercise 12 30 s with each leg 50 s with each leg
Exercise 13 5 repetitions with each leg 8 repetitions with each leg ANOVA test results indicate an overall significant
Exercise 14 50 s difference for time and group allocation (p ¼ 0:0001) in
Exercise 15 50 s peak knee flexion angles (Fig. 3). There was no
Exercise 16 30 s 1 min difference between the mean peak knee flexion angles
Exercise 17 8 repetitions with each leg
Exercise 18 30 s of the two groups at baseline (p ¼ 1). The case group
significantly improved their peak knee flexion angle

Table 3
Mean peak GRF, knee flexion and negative work pre and post the 6-week exercise intervention

Biomechanical measurement Pre Post p-value

Case Control Case Control Group effect Time effect Group
time effect

GRF (
BW) 2.5570.63 1.7170.23 1.6670.20 1.5970.39 0.07 0.004* 0.01*

Knee flexion (1) 52.81710.86 53.48710.75 83.02710.86 54.08713.40 0.06 0.0001* 0.0001*
Total negative work (J/N m) 10.5875.36 11.9478.08 28.6978.86 10.3073.45 0.02* 0.004* 0.001*

*Indicates significant difference po0:05.

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Q. Louw et al. / Physical Therapy in Sport 7 (2006) 65–73 71

3.4 0
3.2
-5
Peak ground reaction force (XBW)

3.0
2.8 -10

Total negative work(J/N.m)

2.6
-15
2.4
2.2 -20
2.0
-25
1.8
1.6 -30
1.4
-35
1.2
1.0 -40
Pre Post Pre Post
TIME TIME

Fig. 2. Peak ground reaction force measured pre- and post-exercise Fig. 4. Total negative work measured pre- and post-exercise interven-
intervention (p ¼ 0:017). Vertical bars denote 0.95 confidence intervals. tion (p ¼ 0:0015). Vertical bars denote 0.95 confidence intervals.

110 biomechanical parameters when a subject lands after

performing a jump shot. The programme tested in this
100
pilot study provides a framework within which future
90 modifications can be made to intervention programmes,
based on sound understanding of what is being
Knee flexion angle

80 attempted, and what could be achieved.

Players who participated in the preventative exercise
70
programme demonstrated significant improvements in
60 knee flexion angles, total negative work (absorption work)
and reduced ground reaction forces when landing from a
50 jump. The effect of the intervention exercise programme
40
on biomechanical parameters when the subjected landed
from a jump thus addressed the potential biomechanical
30 risk factors of knee injury reported in the literature (Caster
Pre Post
& Bates, 1995; Hewett et al., 1996; Lephart et al., 2002;
TIME
McNair, & Marshall, 1994).
Fig. 3. Peak knee flexion angles measured pre- and post-exercise The pre-intervention mean knee flexion among the
intervention (p ¼ 0:00018). Vertical bars denote 0.95 confidence cases and control was less than the amount of knee
intervals.
flexion demonstrated by adolescents in published studies
(Myer et al., 2005). In a recent publication, adolescent
(p ¼ 0:00007) and the control group’s mean knee flexion female athletes demonstrated knee flexion during the
angles did not change (p ¼ 1). landing phase of a box drop to range from 71.91 to
76.91. This may be an indication that the adolescent
3.3. Negative work basketball players who participated in this study can
improve their landing technique and thereby reduce
There was an overall significant difference for time their chances of injury.
and group (p ¼ 0:0015) (Fig. 4). There was no significant It is proposed that landing techniques can be biome-
difference between the case and control groups at chanically safer if players land with the knees in more
baseline (p ¼ 1). The case group improved significantly knee flexion (Hewett et al., 1996). Landing with a
over (p ¼ 0:0017) and the control group players’ relatively straight knee correlates with higher peak vertical
performance did not change significantly with respect ground reaction forces and less energy absorption by the
to total negative work (p ¼ 1). muscular system. High ground reaction forces and
reduced energy absorption place increased strain on the
4. Discussion skeletal structures and will thus increase injury risk
(Decker et al., 2002; Devita & Skelly, 1992; Louw,
The purpose of this pilot study was to test the effect 2004). One prerequisite to adequate knee flexion during
of a neuromuscular exercise programme on the landing may be proprioceptive control (Lephart & Fu,
 ARTICLE IN PRESS
72 Q. Louw et al. / Physical Therapy in Sport 7 (2006) 65–73
1995). Sound proprioception ensures appropriate motor
responses from the dynamic stabilisers and consequent
joint stability (Lephart, 2003). When a player lands from a
jump, absorption of the impact forces by the quadriceps
muscles is believed to provide knee joint stability as the
knee lexes through the available range (Zhang et al.,
2000). Negative work to absorb impact is important in
maintaining balance during activities that requires decel-
eration of body segments such as landing (Zhang et al.,
2000). Sufficient negative work by the quadriceps muscles
is necessary to stabilise the knee joint increase injury risk
(Zhang et al., 2000). However, it remains arguable
whether reduced eccentric muscle activity is not only
related to reduced local muscle strength factors, but also
to impaired neuromuscular control (Lephart, 2003).
Therefore it is plausible that the player may have sufficient
muscle strength, yet may not be able to apply it
appropriately when performing a complex movement
such as landing.
This neuromuscular exercise programme was aimed
towards pre-planning of motor responses to enhance the
feed-forward system of neuromotor control as this is
believed to reduce motor response time (Lephart, 2003).
Anticipation of perturbations is particularly important in
fast movements such as the landing phase after jumping
(determined as 0.03 s) (Louw, 2004). Enhancing the feed-
forward control that allows for anticipatory reactions even
before the detection of disturbances in balances, allows
much quicker motor reactions to restore or maintain joint
stability than during the feedback motor control system
(Lephart, 2003). The aims and experimental methods
employed in this study were not adequate to detect whether
timing of motor responses to sensory disturbances had
improved. However, the findings of this exercise validation
study suggest that the proposed training programme
appears to improve landing technique that could enable
appropriate pre-activation of stabilising muscles via the
feed-forward motor control system to have a protective
effect on the knee joint against forces leading to injuries.
It is most likely that the biomechanical changes
observed among the players who underwent the knee
injury prevention training were brought about by the
effect of the exercise programme and not by usual
basketball training. No improvement in any of these
parameters was observed among the control players. This
observation emphasises the specificity principle of training
and the fact that general basketball training does not
necessarily bring about changes that would improve
landing skill, although it contributes towards general
conditioning and fitness. It is also important to note that
none of the case players who participated in the knee
injury prevention training programme suffered from
adverse effects such as knee or other lower limb injuries.
This training programme can thus be recommended in
health promotion programmes as having few negative
outcomes and many positive ones.
4.1. Limitations
The case players were tested on three occasions: pre-
intervention, mid-intervention and post-intervention,
while the control players were only tested twice (before
and after the intervention period). The case group
players thus had more opportunity to practise in the
biomechanical laboratory and this could have been a
confounding variable through learning opportunity.
Follow-up studies should ensure equal test occasions
between the two study groups.
The control players’ peak ground reaction force was
lower than that of the case group players. However, the
results of the study still clearly indicate that the exercise
intervention had a positive effect on the landing
technique by decreasing the vertical ground reaction
forces of the case subjects significantly. Future research
should attempt to recruit players who are comparable
with respect to all dependant biomechanical parameters.
Despite the limited number of subjects in this study,
significant findings were noted between the case group
and the control group. Further studies incorporating
greater subject numbers should be conducted to validate
the findings of this pilot study.
5. Practical applications and clinical relevance
The findings of this study suggest that the neuromus-
cular exercise programme resulted in favourable adapta-
tions during the landing phase when players performed a
jump shot. These adaptations may contribute towards
knee injury prevention when a player lands from a
jump. The exercises have been designed for implementa-
tion during training sessions and do not require expensive,
specialised equipment. Clinically, these neuromuscular
exercises can be incorporated into rehabilitation pro-
grammes to restore knee dynamic stability and thereby
contribute towards prevention of recurrent knee injuries.
6. Conclusion
Neuromuscular exercise training was found to im-
prove landing technique in such a manner that it is
biomechanically safer for adolescent basketball players.
These improvements noted in the performance among
players in the intervention group suggest that neuro-
muscular exercises could aid in the reduction of injury
rate or severity of knee injuries sustained during game
play. This research contributes towards current under-
standing of knee injury prevention strategies among
adolescent basketball players. The findings of this study
can also be applied to other jump-sports such as netball.
The challenge lies in understanding which mechanisms
are responsible for the changes in performance noted in
 ARTICLE IN PRESS
Q. Louw et al. / Physical Therapy in Sport 7 (2006) 65–73
individuals post a specific training technique. Further
research should affirm that the training technique that
produces optimal improvements in laboratory testing
also leads to the best on-field results with respect to
injury prevention.
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