844 Training & Testing

Balance and Injury in Elite Australian Footballers

Authors C. Hrysomallis 1, P. McLaughlin 2, C. Goodman 1

1
Affiliations Centre for Ageing, Rehabilitation, Exercise and Sport, Victoria University, Melbourne, Australia
2
School of Health Sciences, Victoria University, Melbourne, Australia

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Key words Abstract
" postural sway
l !
" force plate
l This project measured pre-season balance ability
" balance mat
l
and determined its relationship to knee and an-
kle ligament injuries during the season for pro-
fessional Australian footballers. The balance test
involved the players stepping onto a foam bal-
ance mat on top of a force plate and maintaining
single limb balance. Throughout the playing sea-
son, injuries were monitored. The results from
two hundred and ten players participating in this
project were analysed. During the 2003 season,
8% (17 out of 210) sustained a knee ligament in-
jury and 10% (21 out of 210) sustained an ankle
ligament injury. Multivariate analysis revealed
that pre-season balance ability was a significant
independent predictor of ankle ligament injury.
Players with low balance ability had at least
twice as many ankle ligaments injuries as those
with average or good balance ability. Balance
ability was not a significant predictor of knee lig-
ament injuries. The height of the players was the
only significant independent predictor of knee
ligament injuries. Low pre-season balance ability
was associated with an increased risk of ankle
ligament injury. A modifiable injury risk factor
has been identified. Research is now required to
determine the optimal training regime to en-
hance balance ability and whether this translates
to a reduction in the incidence of ankle injuries.

Introduction It has been reported that low balance ability has

accepted after revision
August 31, 2006
Bibliography
DOI 10.1055/s-2007-964897
Published online March 20,
2007
Int J Sports Med 2007; 28:
844 – 847 © Georg Thieme
Verlag KG Stuttgart • New York •
ISSN 0172-4622
Correspondence
Dr. Con Hrysomallis
Victoria University
Centre for Ageing,
Rehabilitation, Exercise
and Sport
Footscray Park Campus
PO Box 14428
8001 Melbourne
Australia
Con.Hrysomallis@vu.edu.au
! been significantly associated with an increased
Australian football is one of the most popular
participation and spectator sports in the country.
It is a sport consisting of elements from the other
football codes. An oval shaped ball is moved
quickly, mainly by kicking but also by handball-
ing and running. It is played on a large oval field
and tackling of the player with the ball is permit-
ted. There are 18 players per team on the field.
Each game is divided into 20 minute quarters.
The premiere league is the Australian Football
League (AFL), comprising 16 teams of full-time
professional athletes that play 22 games per year,
excluding finals.
The AFL injury report [10] for the seasons from
1997 to 2004 showed that, on average, each team
suffered 2.2 knee ligament injuries and 2.5 ankle
injuries per season. Some of these injuries led to a
considerable absence from the game. The average
number of games missed per team per season for
knee ligament injuries and ankle ligament inju-
ries was approximately nineteen and six, respec-
tively. Continual effort is required to reduce the
incidence and severity of injuries.
risk of ankle injuries in male adult soccer players
[12], male adult Gaelic football and hurling play-
ers [13], adolescent male and female basketball
players [8] and male physical education students
[14]. No significant relationship was detected be-
tween balance ability and ankle injury risk for
collegiate soccer, lacrosse and field hockey par-
ticipants [1], female physical education students
[15] and high school athletes [9]. Surprisingly,
good balance ability was related to an increased
risk of lower limb injuries for young adult female
soccer players [11]. The conflicting findings may
indicate that the association between balance
ability and injury risk may be influenced by the
type of sport or level of play. None of the previous
studies have used elite professional athletes. The
aim of this project was to determine whether
pre-season balance ability was related to the in-
cidence of ankle and knee ligament injuries in
AFL footballers during the subsequent season.

Hrysomallis C et al. Balance and Injury … Int J Sports Med 2007; 28: 844 – 847

Table 1 Characteristics and balance scores of the athletes
Age (years) Height (cm)
Mean (SD) 22.9 (3.8) 187.6 (7.0)
Minimum 17.2 170.0
Maximum 33.7 208.0
max M-L sway = maximum mediolateral sway; both limbs = mean of right and left; r-l diff = right-left difference
Materials and Methods
!
A number of teams in the AFL were invited to take part in this
project. The project was approved by the Victoria University
Ethics Committee and the participants provided informed con-
sent. Balance ability was determined during the 2003 pre-sea-
son. Players with current lower limb injuries were excluded. Pri-
or to the balance testing, injury history, age, height and body
mass were recorded. A stepping balance task on an unstable sur-
face was used. The participants warmed up by cycling at a mod-
erate intensity for 5 min and performing static stretches
(2 × 20 s) for the quadriceps, hamstrings and gastrocnemius.
They were allowed two familiarisation trials per limb of the bal-
ance test. The participants wore the same athletic shoes and
stepped onto a foam balance mat (40 × 50 × 7 cm thick; Airex
Alusuisse, Sins, Switzerland) positioned on top of a force plate
(61 × 45 cm; Victoria University Technologies, Melbourne, Aus-
tralia) and were required to maintain single limb balance for
20 s. The eyes remained open and focused on a point 3 metres
ahead. The knee of the contralateral limb was flexed and held at
about 908 and not permitted to contact the support limb. The
upper limbs were in an akimbo position. Standardised instruc-
tions were provided to the participants. They were directed to
stand as motionless as possible. If the participant lost balance
and fell off the balance mat, the trial was aborted and then re-
peated. The participants commenced by stepping from a box
raised to the same height as the balance mat on top of the force
plate. The box was placed a constant distance from the force
plate. Each limb was tested 3 times in an alternating manner.
The maximum excursion of centre of pressure of the body in
the mediolateral direction (max M-L sway) was used as the bal-
ance indicator. Commencement of data collection was automati-
cally triggered by the participant stepping on to the mat on top
of the force plate. The sampling rate was 75 Hz. The mean of the
three trials of each limb was calculated. This was then used to
generate a combined mean value for both limbs and a value for
right-left limb difference.
When investigating the relationship between balance ability and
injury risk, the side-specific balance score or the mean of both
limbs could be used. In a parallel study [5], it was found that
there was no significant difference in balance ability between
the limbs for healthy athletes, so the mean value of both limbs
can represent the balance score. Injuries are analysed as occur-
ring to an individual rather than a limb. Other researchers in the
area have also used mean values [9,11] or a combined score [8].
Balance tests on a force platform and the use of the centre of
pressure data have been widely used and accepted in the assess-
ment of balance ability [8,12]. The reliability of the balance test-
ing protocol was previously determined [5] by assessing 10 par-
ticipants on two consecutive days. Each subject performed three
trials per limb. The ICC and 95 % CI for the balance score was
0.801 (0.564 – 0.916).
Training & Testing 845
Body mass (kg) Max M-L sway (mm)
Right limb Left limb Both limbs r-l diff
86.8 (7.8) 50.0 (9.0) 51.1 (7.5) 50.6 (7.0) 7.3 (5.3)
70.0 31.2 33.3 36.2 0.0
106.0 77.7 77.1 72.3 25.2
Table 2 Ankle and knee ligament injuries
Mild Moderate Severe
Ankle 12 5 4
Knee 2 7 8
Throughout the playing seasons, injuries were monitored. Foot-
ball clubs were contacted regularly to obtain data on knee and
Downloaded by: University of Massachusetts Boston. Copyrighted material.
ankle ligament injuries. The team medical doctor and/or physio-
therapist were present at all training sessions and games and a
record was made of the ankle and knee ligament injuries and
the number of days missed due to the injuries. A knee or ankle
ligament injury was recorded if diagnosed by medical personnel
and if it caused the athlete to cease participation in the current
session and precluded participation in the next official training
session or game. Only the first ankle or knee injury of each ath-
lete was used in the analysis.
Data analysis
The means and standard deviations of all players’ characteristics
and balance scores were calculated. To assess the relationship
between ankle and knee ligament injuries and potential risk fac-
tors (age, height, body mass, mean balance score of both limbs,
right-left limb balance difference, knee ligament injury history
and ankle ligament injury history), backward stepwise logistic
regression analysis was used. The p value for entry of the varia-
ble was set at 0.05 whilst the removal level was set at p > 0.10.
Each continuous variable was grouped into approximate tertile
for the multivariate analysis [2]. This separated the data into cat-
egories that may be considered as “below average”, “average”
and “above average” scores. In relation to the balance parameter,
below average scores refer to low postural sway, signifying good
balance. Injury rate was calculated per 1000 hrs exposure of
training and game time. The odds ratio and 95 % CI were calcu-
lated for the risk factors.
Results
!
A total of 210 players from 6 teams completed the participation
in this study. The participants’ characteristics and their balance
scores are depicted in l" Table 1. The balance scores of both limbs
ranged from about 36 to about 72 mm with a mean of about
51 mm. All clubs provided all the requested injury details for
every week of competition.
During the 2003 season, 21 out of the 210 players sustained an an-
kle injury while 17 players sustained an injury to knee ligaments.
Injury severity was defined as mild if absent from a game or train-
ing for < 7 days, moderate if absent from 7 – 21 days and severe if
> 21 [8]. The majority of the ankle injuries were mild while the
majority of the knee injuries were moderate to severe (l " Table 2).
Hrysomallis C et al. Balance and Injury … Int J Sports Med 2007; 28: 844 – 847
846 Training & Testing

Table 3 Ankle injuries amongst the various groups

Variable Group Range of n % injuries Injury rate Odds ratio p value

values in group (per 1000 hrs) (95 % CI)
Age (years) below average £ 20 58 6.9 0.83 reference 0.558
average 20 – 24 95 9.5 1.14 1.40 (0.39 – 4.98) 0.309
above average ‡ 24 57 14.0 1.67 2.18 (0.58 – 6.12) 0.436
Height (cm) below average £ 184 76 7.9 0.94 reference 0.556
average 184 – 191 62 11.3 1.35 1.73 (0.49 – 5.38) 0.834
above average ‡ 191 72 11.1 1.33 1.33 (0.39 – 4.45) 0.788
Body mass (kg) below average £ 83 81 7.4 0.89 reference 0.604
average 83 – 90 60 11.7 1.40 1.31 (0.39 – 4.45) 0.705
above average ‡ 90 69 11.6 1.39 1.63 (0.49 – 5.38) 0.752
Balance both limbs (mm) below average £ 48 65 7.7 0.92 reference 0.118
average 48 – 53 80 6.3 0.75 0.80 (0.22- 1.79) 0.091
above average ‡ 53 65 16.9 2.02 2.44 (1.91 – 7.48) 0.049*
Balance right-left below average £4 66 10.6 1.27 reference 0.330
difference (mm) average 4–9 73 6.8 0.81 0.44 (0.13 – 1.54) 0.994
above average ‡9 71 12.7 1.52 1.00 (0.34 – 2.99) 0.170
Ankle injury history no 97 7.2 0.86 reference
yes 113 11.6 1.48 1.79 (0.68 – 4.69) 0.239

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CI = confidence interval; * significant independent predictor of injury

Table 4 Knee injuries amongst the various groups

Variable Group Range of n % injuries Injury rate Odds ratio p value

values in group (per 1000 hrs) (95 % CI)
Age (years) below average £ 20 58 3.5 0.42 reference 0.357
average 20 – 25 95 10.5 1.26 3.13 (0.74 – 14.99) 0.153
above average ‡ 25 57 8.8 1.05 2.75 (0.50 – 15.07) 0.243
Height (cm) below average £ 184 76 3.9 0.47 reference 0.509
average 184 – 191 62 6.5 0.78 1.68 (0.36 – 2.80) 0.092
above average ‡ 191 72 13.8 1.65 3.93 (3.03 – 14.90) 0.045*
Body mass (kg) below average £ 83 81 6.2 0.74 reference 0.379
average 83 – 91 60 3.3 0.39 0.44 (0.70 – 2.72) 0.630
above average ‡ 91 69 14.5 1.73 1.64 (0.22 – 12.24) 0.177
Balance both limbs (mm) below average £ 47 65 9.2 1.10 reference 0.255
average 47 – 54 80 10.0 1.20 1.11 (0.33 – 3.32) 0.864
above average ‡ 54 65 4.6 0.55 0.36 (0.08 – 1.57) 0.163
Balance right-left below average £4 66 9.1 1.09 reference 0.680
difference (mm) average 4–9 73 6.8 0.81 0.71 (0.19 – 2.58) 0.857
above average ‡9 71 8.5 1.02 0.77 (0.22 – 2.74) 0.600
Knee injury history no 170 7.1 0.85 reference
yes 40 12.5 1.50 1.88 (0.46 – 5.06) 0.494

CI = confidence interval; * significant independent predictor of injury

The multivariate analysis revealed that only the mean balance
score of both limbs was a significant independent predictor of
sustaining an ankle ligament injury (l " Table 3). The player’s
height was the only significant independent predictor of a knee
ligament injury (l
" Table 4).
Discussion
! division II and III soccer players, good balance ability, as mea-
It was found that low balance ability was a risk factor for injury
to the ankle ligaments. The relationship between balance ability
and injury risk has been investigated for other football codes
with male subjects and found comparable results with the cur-
rent study. An early study [12] measured pre-season balance
ability with a force platform recording the CoP movement of
127 male division IV soccer players. During the playing season,
soccer players with poor balance had about four times the num-
ber of ankle injuries of those players with normal balance. A
study [13] involving high level Gaelic football and hurling male
subjects also found that subjects with poor balance ability, as
measured by timed static stance on a stable surface, sustained
almost twice as many ankle injuries as those athletes with nor-
mal balance. Other studies that have included female soccer
players have found conflicting results. In one study [11] of 146
sured by the KAT 2000, a commercial balance testing device,
was found to be associated with an increased risk of lower limb
injuries. It should be noted that all injuries to the lower limbs,
including muscle strains and contusions, were included in the
analysis. Another study [1] that included 118 college division I
female and male soccer, lacrosse and hockey players found no
significant association between ankle injury and balance ability

Hrysomallis C et al. Balance and Injury … Int J Sports Med 2007; 28: 844 – 847

as measured by anteroposterior sway angle on another commer-
cial devise, the NeuroCom balance system. A methodological dif-
ference between the previous study and the current one was the
plane in which balance was assessed. It could be argued that the
mediolateral plane is more appropriate since ankle inversion
sprains occur mostly in this plane.
The association between balance ability and injury risk may be
greater for other sports that involve more at risk movements
such as jumping. A study [8] of 210 male and female high school
basketball players measured balance as a compilation score of
sway velocity using the NeuroCom balance system. It was found
that players with poor balance had about seven times as many
ankle injuries as those with good balance. The football players
in the current study with poor balance had just over twice the
number of injuries compared to those with good balance.
Low balance ability may increase the likelihood of falling and in-
juring ligaments of the ankle. Excessive motion in the mediolat-
eral direction has been associated with loss of balance and injury
risk [6, 7]. There was a trend for players with a history of ankle
injury to be susceptible to a new ankle injury but the association
was not statistically significant. This lack of significant associa-
tion could suggest that a prior ankle ligament injury does not
produce a medium to long term deficit in balance ability that re-
sults in poor balance scores. This notion is supported by the find-
ings of a related project. A group of AFL players with prior ankle
injuries to only one side had the balance scores of their limbs
compared. There was no significant difference in the balance
scores of the previously injured limb versus the uninjured limb.
In fact, their balance scores did not significantly differ from an-
other group of players with no prior knee or ankle ligament inju-
ries [4].
Balance ability was not a significant independent predictor of
knee ligament injuries. The player’s height was the only signifi-
cant predictor. Taller players had a greater risk of sustaining an
injury. One possible explanation is that taller players have longer
limbs and therefore these longer levers have the potential to
generate excessive torques about the knee that increase the like-
lihood of injury. There was a trend for players with a prior knee
injury to be more susceptible to a new knee injury but this rela-
tionship was not significant.
A limitation of the study was that exact data on exposure time
during training and games was not available for each athlete. It
was assumed the athletes’ participation rates were similar. This
would tend to inflate the exposure time and therefore underes-
timate the injury rate. Post hoc power analysis for the multivari-
ate regression models revealed ‡ 85 % power to detect signifi-
cance when the effect size was ‡ 0.8 but the study was under-
powered to detect small-to-medium effect. Although this study
had one of the largest sample sizes of the non-intervention pro-
spective cohort studies on balance ability and injury risk, a larger
sample size is required in future research to detect significant re-
lationships between all possible risk factors and injury.
Training & Testing 847
It would appear that low pre-season balance ability increases
the risk of an ankle ligament injury during the competitive sea-
son. A modifiable injury risk factor has been identified. Football
clubs should give further consideration to testing and training
balance ability. There are many options to train balance ability
and they include stable and unstable surfaces as well as station-
ary and dynamic drills [3]. Research is now required to deter-
mine the optimal training regime to enhance balance in those
players with low balance ability and whether this translates to
a reduction in the incidence of ankle injuries.
Acknowledgement
Funding provided by an Australian Football League Research
Board Grant.
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