Menu

COMBINED EFFECTIVENESS OF PLYOMETRICS AND BALANCE TRAINING IN THE PREVENTION OF ANKLE SPRAINS IN HIGH SCHOOL BASKETBALL PLAYERS – A RANDOMIZED CONTROLLED TRIAL By MOHAMMED YOUNS SOFI Reg

COMBINED EFFECTIVENESS OF PLYOMETRICS AND BALANCE TRAINING IN THE PREVENTION OF ANKLE SPRAINS IN HIGH SCHOOL BASKETBALL PLAYERS – A RANDOMIZED CONTROLLED TRIAL
By
MOHAMMED YOUNS SOFI
Reg.No. 17038XXX
Dissertation Submitted to the
Dr.N.T.R University of Health Sciences, Vijayawada.

In partial fulfillment
of the requirements for the degree of
MASTER OF PHYSIOTHERAPY
IN
SPORTS MEDICINE
Under the guidance of
Dr.Y.VENKATESWARA RAO. B.Sc., B.P.T., M.P.T.,
1878330186055
KUGLER MEMORIAL PHYSIOTHERAY DEGREE COLLEGE
Annex Campus, Beside A.C. College, Main Road, GUNTUR- 522001, A.P
2017 – 2019
COMBINED EFFECTIVENESS OF PLYOMETRICS AND BALANCE TRAINING IN THE PREVENTION OF ANKLE SPRAINS IN HIGH SCHOOL BASKETBALL PLAYERS – A RANDOMIZED CONTROLLED TRIAL
By
MOHAMMED YOUNS SOFI
Reg.No. 17038XXX
Dissertation Submitted to the
Dr.N.T.R University of Health Sciences, Vijayawada.

In partial fulfillment
of the requirements for the degree of
MASTER OF PHYSIOTHERAPY
IN
SPORTS MEDICINE
193929020955
External ExaminerInternal Examiner
KUGLER MEMORIAL PHYSIOTHERAY DEGREE COLLEGE
Annex Campus, Beside A.C. College, Main Road, GUNTUR- 522001, A.P
2017 – 2019
DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation / thesis entitle “Combined effectiveness of plyometrics and balance training in the prevention of ankle sprains in high school Basket ball players – A randomized controlled trial” is a bonafide and genuine research work carried out by me under the guidance of Dr.Y.Venkates wararao, B.Sc., B.P.T., MPT., Principal & Professor in Physiotherapy Kugler Memorial Physiotherapy Degree College, Guntur.

Date:Signature:
Place: Guntur Name : Mohammed Yonus Sofi

-1943100
CERTIFICATE BY GUIDE
This is to certify that the dissertation “Combined effectiveness of plyometrics and balance training in the prevention of ankle sprains in high school Basket ball players – A randomized controlled trial ” is a bonafide research done by Mohammed Yonus Sofi in partial fulfillment of the requirement for the degree of Master of Physiotherapy.

Date : Signature of the Guide
Place: Guntur

-19431081280

ENDORSEMENT BY THE PRINCIPAL
This is to certify that the dissertation entitled “Combined effectiveness of plyometrics and balance training in the prevention of ankle sprains in high school Basket ball players – A randomized controlled trial ” is a bonafide research done by Mohammed Yonus Sofi under the guidance of Dr.Y.Venkates wararao, B.Sc., B.P.T., MPT., Principal & Professor in Physiotherapy, Kugler Memorial Physiotherapy Degree College, Guntur.

Date: Principal
Place:Guntur
.

COPYRIGHT
I hereby declare that the Dr.NTR University of Health Sciences, Vijayawada, Andhra Pradesh, shall have the rights to preserve, use and disseminate this dissertation / thesis in printout electronic format for academic / research purpose.

Date: Signature:
Place:Guntur Name :Mohammed Yonus Sofi
© Dr.N.T.R University of Health Sciences, Vijayawada, A.P.

ACKNOWLEDGMENT
It is my great pleasure to thank people who helped and encouraged me for the guidance and completion of this project work.
I consider myself fortunate for the constant encouragement given by Dr.Karra Hanoch Benjamin Garu, Correspondent, Kugler Memorial Physiotherapy Degree College, Guntur throughout the course of the study.

It has been my privilege to receive the able guidance Dr.Y.Venkaeswararao, B.Sc., B.P.T., MPT., Principal, Kugler Memorial Physiotherapy Degree College, Guntur. I sincerely acknowledge my indebtedness to him, for his keen interest and guidance throughout the work.

I am highly indented to my staffs and colleges for their comments and suggestions. I am forever grateful for love and support of my parents & friends. Last but not the least, my heartfelt and sincere thanks to all the subjects on whom this study was carried out.

Above all, I would like to thank the Almighty God without whose grace this project would not have taken this form.
Mohammed Yonus Sofi
LIST OF ABBREVIATIONS

SSC – Stretch-Shortening Cycle.

ATFL – Anterior talofibular ligament.

CFL – Calcaneofibular ligament.

IG – Interventiom Group.

CG – Control Group.

RR – Relative Risk.

ACL – Aterior cruciate ligament.

TFA – Tibiofemoral angle.

BMI – Body mass index.

EMG – Electromyography.

CMJ – Counter movement jump.

SJ – Squat jump.

Cms – Centimeters.

Kg – Kilogram.

ABSTRACT
Objective
The purpose of this study is to determine the combined effect of plyometric and balance training in the prevention of ankle sprains in high school basketball players.

Methods
60 High school basketball players of age 14 to 16 years were randomly assigned into two groups. Group A received balance training and Group B received plyometrics and balance training. The outcome measures were Illinois agility test, standing stork test with eyes open and eyes closed. Pre and post training intervention values of outcome measures were noted and the number of ankle sprain that occurred during the tournament was recorded. It was carried out by using paired and unpaired “t” test, chi square test and test of proportional, p<0.0001.

Results
This study revealed that there was significant change in Illinois agility run test score (p<0.0001) and reduction in the incidence of ankle sprain (p<0.0001).

Conclusion
This randomized controlled trial consisting of plyometric training and balance training for 6 weeks and 5 weeks respectively showed reduction of Illinois agility test scores, improvement in standing stork test scores both with eyes open and eyes closed and a reduction in the incidence of ankle sprain following the intervention. Combination of plyometrics with balance training is an effective preventive measure for ankle sprain in high school basketball players.

Key words
Plyometrics; Balance Training; Ankle Sprain; High School Basketball Players.

TABLE OF CONTENTS
Sl. No. Contents Page. No.

1 Abstract ix
2 Introduction 15
3 Need of the Study 21
4 Aims and Objectives of study 23
5 Hypothesis 24
6 Review of Literature 25
7 Materials and Methodology 33
8 Data Analysis 45
9 Results 46
10 Discussion 60
10 Conclusion 66
11 Summary 67
11 Limitations & Recommendations 68
12 Bibliography 70
14 Annexure 75
LIST OF FIGURES

Sl. No. FIGURES Page. No.

1 Instruments 40
2 Illinois Agility Test 41
3 Standing Stork Test 41
4 Single-leg stance while performing dribbling 42
5 Single leg squat (300 -450) 42
6 On board swinging the raised leg 42
7 Double-leg stance while rotating the board 43
8 Standing jump and reach 43
9 Side to side ankle hops 43
10 Lateral jump single leg 44
11 Diagonal cone hops 44
12 Cone hops with 1800 turn 44
LIST OF TABLES

Sl. No. TABLES Page. No.

1 Age and Anthropometric variables for control and
intervention group 46
2 Sex distribution for control and intervention group 48
3 Leg dominance distribution for control and intervention group. 49
4 Pre and Post training Illinois agility test score for control and intervention group. 50
5 Pre and Post training Standing stork test score (eyes open) for control and intervention group. 52
6 Pre and Post training Standing stork test score (eyes closed) for control and intervention group. 54
7 Mean changes of pre and post training test scores between the control and intervention group 56
8 Rate of ankle sprain for control and intervention group 58
LIST OF GRAPHS
Sl. No. GRAPHS Page. No.

1 Age and Anthropometric variables for control and intervention group. 47
2 Sex distribution for control and intervention group. 48
3 Leg dominance distribution for control and intervention group. 49
4 Pre and Post training Illinois agility test score for control and intervention group. 51
5 Pre and Post training Standing stork test score (eyes open) for control and intervention group. 53
6 Pre and Post training Standing stork test score (eyes closed) for control and intervention group. 55
7 Mean changes of Pre and Post training test scores between the control and intervention group 57
8 Rate of ankle sprain for control and intervention group 59
LIST OF ANNEXURES
Sl. No. Annexure Page. No.

1 Ethical Clearance Certificate 75
2 Consent Form 76
3 Data Collection Form 78
4 Mater Data Chart 80
5 Plagiarism 82
INTRODUCTION

The ankle is subjected to considerable compression forces during sport. Compression forces as high as 5 times body weight have been calculated during walking and up to 13 times body weight during running(Brudett,1982).The ankle may be unstable during the process of loading or unloading but is usually stable once fully loaded (Evert Verhagen 2004).

Ankle injuries in the general population are common, with inversion associated with fractures occurring in an estimated 1 person per 10,000 per day.8 Ankle sprain is one of the most common injuries in athletes, particularly in sports in which participants frequently jump and land on one foot or are expected to make sharp cutting maneuvers (for example; basketball, soccer, football and volleyball) (Stephen B. Thacker 1999).

Ankle sprains comprise approximately 14% of all sports related problems, with an injury rate of 6 per 100 participants per season: i.e., one ankle injury is anticipated for every 17 participants over a season (Reid C. David 1992). A sprain represents an injury to the constraining ligaments and capsule of the ankle joint caused by twisting or rotational motion of the talus in the ankle mortise. This injury can range from a stretching to a complete disruption of this ligaments. Mechanism of injury may be inversion or eversion with dorsi flexion or plantar flexion. Sprains to the ankle involve the lateral side more frequently than the medial side. Inversion and plantar flexion is the most frequent mechanism of injury and results in injury to the lateral ligaments of the ankle, usually the anterior talo fibular (ATFL) and calcaneo fibular (CFL) ligaments. Disruption of the anterior talo fibular ligament is the most frequent and most serious ligamentous injury because the ligament is a primary stabilizer of the ankle.

Correct and timely practice is a vital component of sports injury prevention. Because ankle sprains are common and may result in days or weeks lost from practice and competition, efforts have been made to prevent such injuries either through directly protecting the athlete with better shoe, ankle wrapping, taping, or bracing, or by altering the environment through revised rules, changes in the sport (for example improved playing fields), and instruction to coaches and trainers in methods of injury prevention (Stephen B. Thacker 1992).

Braces and tapes are widely used measures to prevent ankle sprain. It is known from previous research that use of braces reduces incidence of ankle sprain and it is argued that taping also has a preventive effect because the working is thought to be similar to braces. However both measures have negative side effects; for example, where as braces can be irritating if not fitted properly and are argued to negatively affect performance, tape loosens during play, needs to be applied by qualified personnel, and can cause skin irritation (Evert Verhagen 2004).

Sprained ankles and a variety of other injuries common to highly trained athletes, often have nothing to do with strength. They often have little to do with flexibility also. And rarely do they have anything to do with endurance. More often than not, sprains and strains have to do with balance- Proprioception to be exact. The term proprioception refers to a sense of joint position. Proprioception training is highly common in rehabilitation of injured athletes, but it can just as easily be used to prevent injury. Even a strong ankle can sprain when running on uneven ground if the runner hasn’t trained the neuromuscular system to react appropriately. Slight deviations in terrain require slight adjustments of balance to avoid injury. Proprioceptive balance board training is another measure, presumably as effective as braces and tapes but without the above mentioned negative side effects. This training has been suggested as an alternative to taping or bracing in prevention of ankle sprain (Elizabeth Quinn 2008).

Plyometrics refers to exercise that enables a muscle to reach maximum force in the shortest possible time. Plyometrics are training techniques used by athletes in all types of sports to increase strength and explosiveness (Michael G. Miller 2006). A muscle that is stretched before concentric contraction, will contract more forcefully and more rapidly (Bosco C 1980, Schmidtbleicher D 2004). A classic example is a “dip” just prior to vertical jump. By lowering the center of gravity quickly, the muscles involved in the jump are momentarily stretched producing a more powerful movement. However two models have been proposed to explain this phenomenon. All plyometric movements involve three phases:
The first phase is the Preloading, Setting or Eccentric phase which refers to the early moments in the movement in which the muscle spindles are loaded and stretched during an eccentric contraction, such as stepping from a box onto the ground and squatting as one lands to absorbs the ground reaction forces. This is when the storing of the elastic energy takes place. The time interval of this phase depends on how much stretch facilitation is desired for the subsequent phases.

The second phase is the time interval between the end of the pre-stretch and the start of the concentric muscle action. This phase should be as short as possible, because with a long interval there is a risk of losing much of the elastic energy as heat within the muscle. The quicker an athlete can overcome the yielding eccentric force and produce a concentric contraction, the more power he or she can produce. This brief transition period from stretching to contracting is known as the Amortization phase.

The third and final phase is the actual muscle contraction. In practice, this is the movement the athlete desires- the powerful jump or throw.

This sequence of three phases is called the Stretch- Shortening Cycle (SSC). In fact, plyometrics could also be called SSC (Fleck SJ 2004). The faster a muscle is allowed to shorten during pre-stretch position, the greater the acceleration. Receptors within the muscles called muscle spindles react to a sudden pre-stretch and serves to resist the stretch and protect against possible injury. The simple act of running or walking utilizes the SSC with each stride that begins with the loading response through an eccentric contraction of the quadriceps, soleus and gastro nemius muscles followed by a concentric push off action. Hence, the SSC of plyometric exercise is a natural motion, given the mechanical properties of the musculoskeletal system.

While majority of the studies have focused on untrained subjects, trained athletes such as soccer and basketball players have improved their performance with plyometrics (Wagner DR 1998). Several researchers have explicitly stated that no injuries occurred during their plyometric studies (Blattner SE 1979).

Agility is the ability to decelerate, stabilize, accelerate and change direction quickly while maintaining proper posture and moving in the intended direction (Clark M 2001). Any change of running direction is caused by an external impulse to the ground. The greater and quicker the direction change desired during high running speed, the greater force and shorter time of push off to the ground in the optimal direction is necessary (Kraemer W 2002).

Agility training enhances eccentric neuromuscular control, dynamic flexibility, dynamic postural control, functional core strength and proprioception which can lead to overall increase in athletic performance. Agility can also help to prevent injury by enhancing eccentric neuromuscular control and improving the structural integrity of the connective tissue.
This concept holds similarities to the characteristics of reactive/elastic/plyometric activity. Both forms of movement require a rapid eccentric action (deceleration for agility), an amoritization phase (the actual change of direction or impulse), and a concentric action (acceleration for agility). The amoritization phase of foot contact with the ground in changing of running direction or turning can be considered the eccentric phase. The muscle must contract concentrically to execute the take off in the desired direction. If the change from eccentric muscle action to concentric muscle action is performed quickly, the resultant concentric action is more powerful than if no eccentric action was performed or if there was a pause between the eccentric and concentric muscle contraction phase (Kraemer W 2002)
Teaching the body to correctly decelerate and stabilize during dynamic movements can lead to a decrease in the potential for injury. Agility training is thought to be a re-inforcement of motor programming through neuromuscular conditioning and neural adaptation of the muscle spindles, golgi tendon organ and joint receptors through quick change in direction (Craig 2004, Potteiger 1999). It has been suggested that increase in power and efficiency due to plyometrics may increase agility training objectives.
Balance training is been said to reduce the incidence of ankle sprain in high school basketball players and studies have also suggested that training that focuses on agility and flexibility (which is achieved by plyometric training) decreases the risk for ankle injury. However, the combined effect of balance and plyometric training remains to be determined. Such studies on Indian high school basketball players are rare and hence this study aims to determine the combined effect of plyometric and balance training on high school basketball players in the Indian population.

NEED OF THE STUDY
Ankle sprains are the most common sports-related injury. They are especially prevalent in sports requiring frequent jumping, directional changes and pivoting such as basket ball, foot ball, soccer, handball, netball, and volleyball. Ankle sprains often result in pain, disability, dysfunction, time lost from activity, the requirement for treatment, and economic burden. Furthermore, athletes who sprain their ankle are prone to reinjure the same ankle with recurrent ankle sprains commonly leading to ongoing impairment and chronic instability.

Popular interventions for preventing ankle sprains include tape, ankle braces, evertor muscle strengthening and proprioceptive training. Braces and tape have been shown to be effective preventive methods against ankle sprains however, they do have disadvantages. Exercise programmes may avoid those disadvantages, although compliance is a potential barrier.

Athletes may also choose to utilize several preventative measures in conjun ction, such as taping and an exercise programme. Proprioception is a complex neuromuscular process concerned with the internal kinesthetic awareness of body position and movement. It is reliant on appropriate afferent and efferent signaling and plays an important role in joint stability and injury prevention. Proprioceptive training involves exercises that challenge the ability of the targeted joint to detect and react to afferent input regarding joint position. Examples of proprioceptive exercises include balancing on a wobble board or ankle disc, throwing and catching or dribbling a ball whilst in single leg stance, or balancing with eyes closed.
Components of these exercise programmes have included proprioceptive training, strengthening, agility, plyometrics, sport-specific exercises or a combination of several components.

While most existing studies have concluded that exercise programmes reduce ankle sprain injuries, no studies have focused exclusively on the effects of proprioceptive training alone without the addition of co-interventions such as strengthening, plyometrics or agility training.
Balance training is been said to reduce the incidence of ankle sprain in high school basketball players and studies have also suggested that training that focuses on agility and flexibility (which is achieved by plyometric training) decreases the risk for ankle injury. Nevertheless, the burden of these lower extremities injuries especially ankle sprain will always making the players or coach physiological and psychological stress. This is because the lack of awareness to the importance of balance training as their normal training routine will increase the risks of ankle sprain among the basketball players and thus affect the performance
However, the combined effect of balance and plyometric training remains to be determined. Such studies on Indian high school basketball players are rare and hence this study aims to determine the combined effect of plyometric and balance training on high school basketball players in the Indian population.

RESEARCH QUESTION
Combined effectiveness of plyometrics and balance training in the prevention of ankle sprains in high school Basket ball players – A randomized controlled trial.

AIMS AND OBJECTIVE OF THE STUDY
The objective of this study is to compare the effects of of plyometrics and balance training in the prevention of ankle sprains in high school Basket ball players. Specifically, to determine
To study the effect of effects of plyometrics training in the prevention of ankle sprains in high school Basket ball players.

To study the effect effects of balance training in the prevention of ankle sprains in high school Basket ball players.

To compare the effect effects of plyometrics and balance training in the prevention of ankle sprains in high school Basket ball players.

HYPOTHESIS

Alternate Hypothesis
There will be a significant effect of plyometrics and balance training in the prevention of ankle sprains in high school Basket ball players
Null Hypothesis
There will be a no significant effect of plyometrics and balance training in the prevention of ankle sprains in high school Basket ball players
.

REVIEW OF LITERATURE
Rachel Bellows et al (2018) conducted a review to compare the effect of balance training and bracing in reducing the incidence and relative risk of ankle sprains in competitive athletes, with or without prior injury, across different sports. A literature search of four databases was conducted for randomized control trials that reported ankle sprain incidence published from 2005 through 2016 included articles studied high school, college, or professional level athletes with or without a history of a prior sprain, who received bracing or balance training as an intervention compared to a non-intervention control group. Results showed athletes who wore braces had fewer ankle sprains (p=0.0037) and reduced their risk of sprains by 64% (RR=0.36) compared to controls, based on analysis of 3,581 subjects. Athletes performing balance training had fewer ankle sprains (p=0.0057) and reduced their risk by 46% (RR=0.54) compared to controls, based on analysis of 3,577 subjects. The study concluded that the use of bracing and balance training to reduce the incidence and relative risk of ankle sprains in athletic populations.
Lukas Ondra et al (2017) conducted study was to examine the effect of a 20-week in-season multi-intervention proprioceptive neuromuscular training program on postural stability in male youth basketball players on 21 elite male youth basketball players were divided into an intervention group (n?=?10, age 17.3?±?1.3 years) and a control group (n?=?11, age 16.5 ± 1.8 years). During the in-season period (20 weeks), the intervention group followed a proprioceptive and neuromuscular training program, three times per week and 20 minutes per session. Balance was tested in a quiet unipedal stance (on both the dominant and non-dominant leg) on a foam mat with eyes open, before and after a 20-week period in both groups. Results showed that the combined effect (pre-post test × group) showed that intervention resulted in significant improvement in the mean COP velocity for both the dominant and non-dominant limb in the anterior-posterior direction (p?=?.013 and p?;?.001, respectively) and in the medial-lateral direction (p?=?.007 and p?;?.001, respectively) as well as in the total COP velocity (p?=?.009 and p?;?.001, respectively).The study concluded that the specific proprioceptive and neuromuscular training had a positive effect on postural stability for both the dominant and non-dominant limb in basketball players.

Kerim Sozbir et al (2016) conducted a study to determine the effects of 6-week plyometric training on vertical jump performance and electromyography (EMG) activities of vastus lateralis (VL), vastus medialis (VM), and gastrocnemius (GAS) muscles during countermovement jump (CMJ). 24 highly physically active physical education students were randomly assigned either to a plyometric (PLY) group or a control group. The experimental group performed plyometric exercises 2 times a week for 6 weeks, whereas the control group participated only in their lectures. The results revealed that there were no significant changes in either vertical jump height or EMG activities of selected muscles for the control group (p greater than 0.05). However, after 6 weeks of plyometric training, significant improvements (p less than 0.05) were observed in EMG activities of VL (13.25%), VM (9.60%), and GAS (13.93%) muscles, and no significant increase (p greater than 0.05) was found in CMJ (2.77%) in the PLY group. The study concluded that 6 weeks of PLY training, in addition to the regular academic program, induced significant improvements in EMG activities of lower extremity muscles but no significant increases in vertical jump height.

Ai Choo Lee et al (2016) investigated the effectiveness of four weeks sports specific balance training program to improve balance, thus reducing the risk of ankle sprain among 14 males basketball players (aged 19-24 years) volunteered in this study. They were randomized into two groups i.e experimental group (EG: n=7) and control group (CG: n=7). The EG undergone the four weeks sports specific balance training program three times per week while the CG followed their normal standard basketball training program. Balance Error Scoring System (BESS) was used to assess static balance while Star Excursion Balance Test (SEBT) is utilized to examine the dynamic balance. Pretest and posttest of balance measures were recorded using BESS and SEBT for both EG and CG. The data were analyzed using independent sample t-test (p=0.05).The study findings indicated that there were significant differences between EG and CG for the static balance on firm surface (t=-4.642, p=0.001) and on foam surface (t=-8.590, P=0.000) as well as dynamic balance on left leg stance (t=2.350, P=0.037) and on right leg stance (t=3.145, P=0.008). Conclusion: The study concluded that the four weeks sports specific balance training program could improve balance ability in male basketball players, thus may reducing the risk of ankle sprain.

Ingrid Vriend et al (2016) assessed the preventive effect of NMT for first-time and recurrent ankle sprains in sports. An electronic literature search of PubMed, SPORTDiscus and EMBASE was conducted (until 24 March 2016) to identify published randomised controlled trials (RCTs), controlled trials (CTs) and time trend analyses related to NMT as a preventive measure for ankle sprains. A total of 30 studies met the inclusion criteria and were analysed (24 RCTs, 3 CTs and 3 time interventions). A total of 14 studies focussed solely on the effectiveness of balance training, and 16 studies evaluated the effect of balance training combined with adjunct interventions. Pooled data showed a significant reduction in the occurrence of ankle sprains (relative risk (RR)=0.60; 95% CI 0.51 to 0.71). Single-component interventions specifically targeted at ankle sprains achieved preventive effects (RR=0.58; 95% CI 0.48 to 0.72) as opposed to multi-component interventions (RR=0.67; 95% CI 0.37 to 1.24). With respect to interventions targeted at general injuries, significant effects were found using both single component (RR=0.71; 95% CI 0.52 to 0.97) and multi-component interventions (RR=0.55; 95% CI 0.41 to 0.74). The study concluded that NMT is effective in reducing ankle sprains in a sporting population, and in athletes with a previous ankle sprain.
Raffalt PC et al (2016) investigated muscle activity, intra-subject variability in muscle activity and co-contraction during vertical jumps and landings in children and adults. Ten male children and 10 male adults completed 10 countermovement jumps (CMJ), 10 drop jumps (DJ) from 30 cm, 10 low and high landings from 30 and 60 cm for the children and 60 and 90 cm for the adults. The adults also performed ten DJ from 60 cm. EMG was recorded from nine lower limb muscles in the right leg and normalized to isometric MVC. Statistical parametric mapping was used to reveal differences in the muscle activity and intra-subject variability in the muscle activity. Co-contraction was quantified for two thigh muscle pairs and one plantar flexor/ dorsi flexor muscle pair and group differences were assessed (two-way ANOVA). Results indicate that vertical jumps/landings involving a high amount of eccentric muscle contraction constrain the muscle activation in children, possibly because of immature motor control.

Gabriella Sophie Schiftan et al (2015) conducted a study to analyse the effectiveness of proprioceptive training in reducing the incidence and recurrence rates of ankle sprains in the sporting population. A computer-based literature search of MEDLINE, EMBASE, CINAHL, SPORTDiscus and PEDro (to October 2013) was conducted. Methodological quality of individual studies was assessed using the PEDro scale. Meta-analysis was performed on eligible studies to produce a pooled estimate of the effectiveness of the intervention. Results showed Seven moderate-to-high quality randomised controlled trials involving 3726 participants were included. Results of the meta-analysis combining all participants, irrespective of ankle injury history status, revealed a significant reduction of ankle sprain incidence when proprioceptive training was performed compared to a range of control interventions (relative risk = 0.65, 95% CI 0.55–0.77). Results favouring the intervention remained significant for participants with a history of ankle sprain (relative risk = 0.64, 95% CI 0.51–0.81). Results looking exclusively at primary prevention in those without a history were also statistically significant (relative risk = 0.57, 95% CI 0.34 to 0.97), although the pooled effect was obtained from two non-significant trials. The study concluded that Proprioceptive training programmes are effective at reducing the rate of ankle sprains in sporting participants, particularly those with a history of ankle sprain. Current evidence remains inconclusive on the benefits for primary prevention of ankle sprains.

ABBAS ASADI,
1
EDUARDO SAEZ DE VILLARREAL,
2
AND HAMID ARAZI
3
ABBAS ASADI,
1
EDUARDO SAEZ DE VILLARREAL,
2
AND HAMID ARAZI
3
Gaurav S et al (2013) conducted study to investigate whether conventional (wobble board) proprioceptive training or multi-station proprioceptive training is an effective way to improve vertical jump performance on 30 basketball players divided into the two groups, Group A (n = 15) and Group B (n = 15). The group A underwent the wobble board proprioceptive training program lasting for four weeks. The group B was administered the multistation proprioceptive training program lasting for four weeks. Both the training programs consisted of one-leg and double-leg static and dynamic balance drills. The demands and duration of those exercises increased progressively. The vertical jump height was estimated by Sergeant Jump Test at the beginning, after second week and at the end of the experiment. The results of this study indicate that Multi-station training showed greater improvements as compared to the conventional balance training and the results were significant at p;0.01.

Gregory D. Myer et al (2006) conducted a study to analyze the effects of Plyometric Versus Dynamic Stabilization and Balance Training on Lower Extremity Biomechanics on 18 high school female athletes participated in 18 training sessions during a 7-week period. The pylometric group (n = 8) performed maximum-effort jumping and cutting exercises, and the balance group (n = 10) used dynamic stabilization/ balance exercises during training. Lower extremity kinematics were measured during the drop vertical jump and the medial drop landing before and after training using 3D motion analysis techniques. Results showed during the drop vertical jump, both plyometric and balance training reduced initial contact (P = .002), maximum hip adduction angle (P = .015), and maximum ankle eversion angle (P = .020). During the medial drop landing, both groups decreased initial contact (P = .002) and maximum knee abduction angle (P = .038). Plyometric training increased initial contact knee flexion (P = .047) and maximum knee flexion (P = .031) during the drop vertical jump, whereas the balance training increased maximum knee flexion (P = .005) during the medial drop landing. The study concluded that both plyometric and balance training can reduce lower extremity valgus measures. Plyometric training affects sagittal plane kinematics primarily during a drop vertical jump, whereas balance training affects sagittal plane kinematics during single-legged drop landing.

Malachy.P et al (2006) studied the risk factors for noncontact ankle sprains in high school athletes, the role of hip strength and balance ability on 169 school athletes (101 male, 68 female) were observed for 2 years. Balance in single-limb stance on an instrumented tilt board and hip flexion, abduction, and adduction strength (handheld dynamometer) were assessed in thepreseason. Body mass, height, generalized ligamentous laxity, previous ankle sprains, and ankle tape or brace use were also documented. Result showed that there were 20 noncontact inversion ankle sprains. Balance ability, hip abduction strength, hip adduction strength, and hip flexion strength were not significant risk factors for ankle sprains. The incidence of grade II and grade III sprains was higher in athletes with a history of a previous ankle sprain (1.12 vs 0.26 per 1000 exposures, P ; .05). A higher body mass index in male athletes was associated with increased risk (P ; .05). The combination of a previous injury and being overweight further increased risk (P ;.01).

Holme E et al (1999) conducted a study to analyze the effect of an early rehabilitation program, including postural training, on ankle joint function after an ankle ligament sprain was investigated prospectively on 92 subjects, matched for age, sex, and level of sports activity, were randomized to a control or training group. All subject received the same standard information regarding early ankle mobilization. In addition, the training group participated in supervised physical therapy rehabilitation (1 h, twice weekly) with emphasis on balance training. Postural sway, position sense and isometric ankle strength were measured 6 weeks and 4 months after the injury, and at 12 months re-injury data were obtained. Result showed in the training group, there was a significant difference between the injured and uninjured side for plantar flexion (P ; 0.01), eversion (P ; 0.01) and inversion (P ; 0.05), but not for dorsiflexion at 6 weeks. In the control group, there was a significant difference between the injured and uninjured side for plantar flexion (P ; 0.01), eversion (P ; 0.01), inversion (P ; 0.01), and dorsiflexion (P ; 0.05) at 6 weeks. Postural sway, but not position sense, differed between the injured and uninjured side in both groups (P ; 0.01) at 6 weeks. The side-to-side percent differences were similar in both groups for all variables (P ; 0.05) at 6 weeks, and there were no side-to-side differences at 4 months in either group. In the control group, 11/38 (29%) suffered a re-injury, while this number was only 2/29 (7%) in the training group (P ; 0.05). The study concluded that supervised rehabilitation may reduce the number of re-injuries, and therefore may play a role in injury prevention.

MATERIALS ; METHODOLOGY
STUDY DESIGN
Randomized clinical trial .

SAMPLING METHOD
Sampling design used for this research was Purposive sampling with random allocation to 2 study groups (Envelope method).

SAMPLE SIZE
The sample size for this study was 60 participants, 30 in each group. Sample size was calculated based on the incidence of ankle sprain in basketball players. The study sample consisted of both male and female participants who were basketball players of age group between 14 to 16 years.

SETTING OF SAMPLING
All the study subjects were recruited from the central school, Guntur and Oxford public school, Guntur.

STUDY DURATION
6 weeks.

SAMPLING CTITERIA
Inclusion criteria
All male and female High School Basketball players.

Age group between 14 to 16 years.

Players willing to participate in the study.

Players who were not involved in any similar type of training.

Exclusion criteria
Players with a history of ankle sprain within 12 months.

Chronic ankle instability.

Any history of surgeries to the lower limbs.

Congenital deformities of foot or ankle.

MATERIALS USED IN THE STUDY
Consent form.

Record or data collection sheet.

Exercise protocol handouts.

Pen.

Paper.

APPARATUS AND EQUIPMENTS
Balance board
It is a circular wooden disk which is 16 inches in diameter with a 4-inch half sphere attached to the bottom.

Measuring Tape
A non stretchable measuring tape of total length of 15 meters was used to measure the height of the participants and also to layout the field for Illinois agility test.

Weighing machine
A standard bathroom weighing machine with 1 kilogram (Kg) increment was used to measure the weight of each participant in Kg.

Cones
Standard durable plastic cones of 18 inches in height were used as markers for training the players.

Stop watch
A pacer electronic watch with 10 lap memories, SW-101 was used to record the timing for the Illinois agility run scores and for both the standing stroke test. The watch consisted of accurate measurement of elapsed time with the touch of a button. The watch could record 1/100 seconds – 10 hours.

Outcome measurement
Standing stork test
This test is to assess the balance in standing. The test requires pen, paper and a stop watch. The participants were made to remove shoes and place the hands on the hips, then to position the non-supporting foot against the inside knee of the supporting leg. The participants were asked to raise their heel to balance on the ball of the foot; the participants were given one minute to practice the test. Recording of the score was done by starting the stop watch as the heel was raised from the floor and it was stopped when any of the following occurred:
Hands come off the hips
The supporting foot swivels or moves (hops) in any direction
The non-supporting foot loses contact with the knee
The heel of the supporting foot touches the floor.
The mean of three scores was taken for analysis.

Illinois Agility Test
Agility is the ability to maintain or control body position while quickly changing direction during a series of movements. The objective of the Illinois Agility
Test is to monitor the development of athlete’s agility. The test included 8 cones and an area of 400 meters track. The length of the course was 10 meters and the width (distance between start and finish points) was 5 meters.4 cones were used to mark the start, finish and two turning points. Each cone in the centre was spaced 3.3 meters apart. The athletes were made to lie prone with head end at the start and shoulders besides the body. On a ‘GO’ command the stopwatch was started, and the athlete got up as quickly as possible and ran around the course in the direction indicated, without knocking the cones over, to the finish line, at which the timing was stopped. A pre and post training scores were taken for analysis of data.

Number of ankle sprain
The number of ankle sprains was checked during the matches of the participant.

Procedure
Ethical clearance was obtained from the ethical committee of Kugler Memorial Physiotherapy Degree College, Guntur. Central school and Oxford public school basketball players were screened. After finding their suitability as per the inclusion & exclusion criteria, they were requested to participate in the study. Those willing to participate were briefed about the nature of the study & the intervention. Prior to the study, a written consent was taken from the parents of each participant. The demographic data consisting of name, age, sex, school, address and phone number were recorded. 60 participants were randomly allocated into two groups of 30 each. The two groups were Group (A) who received balance training only and Group (B) who received plyometrics in addition to balance training.

Prior to the commencement of procedure the following parameters were recorded. weight (in Kg) was measured using a simple bathroom-weighing machine, height (in Cms) was recorded using a measuring tape, the participants were made to stand against a wall with the head and heel touching the wall and a mark was made on wall at the vertex of head. The distance between the floor and the mark was measured in Cms and recorded. Leg dominance was recorded by asking the participants to kick the ball. Standing stork test with eyes open and closed and Illinois agility test were demonstrated to the participants and they were asked to perform the test for three repetitions with a rest period of 10-15 seconds. The average score of the three trails of Illinois agility test and standing stork test with eyes open and eyes closed were taken as the final pre training and post training scores. The incidence of ankle sprain was recorded during the matches. An ankle sprain was defined as trauma that (1) disrupted the ligaments of the ankle; (2) occurred during a coach-directed competition;(3) caused the athlete to miss the rest of the competition or miss the next schedule of coach-directed practice or competition.

During the study all the participants were instructed on how to perform each exercise for both balance training and plyometric training. All the participants underwent their regular exercise schedule which included stretching, warm up and ball handling following which the balance training and plyometrics was given.

In the 5 weeks balance training program, phases 1 through 4 consisted of 5 exercise sessions per week for 4 weeks. In phase 5 (maintenance phase), the players performed the program 3 times per week for 10 minutes throughout the competitive season. In all the phases, each exercise was performed for 30 seconds, and the legs were alternated during a 30 second rest interval between each exercise.

Plyometric training was performed twice a week for 6 weeks. This is to allow sufficient recovery between the workouts. The training volume was in terms of number of foot contacts.

BALANCE TRAINING PROGRAM
PHASE SURFACE EYES EXERCISE
WEEK-1 Floor Open Single-leg stance
Open Single-leg stance while swinging the raised leg
Open Single-leg squat(300-450)
Open Single-leg stance while performing
functional activities (dribbling, catching)
WEEK-2 Floor Closed Single-leg stance
Closed Swinging the raised leg
Closed Single-leg squat(300-450)
WEEK-3 Board Open Single –leg stance
Open Swinging the raised leg
Open Single-leg squat(300-450)
Open Double-leg stance while rotating the board
WEEK-4 Board Closed Single-leg stance
Open Swinging the raised leg
Open Single-leg squat(300-450)
Open Single-leg stance while rotation the board
WEEK-5+ Board Closed Single –leg stance
Open Single-leg squat(300-450)
Open Single-leg stance while rotating the board
Open Single-leg stance while performing functional
activities (dribbling, catching)
PLYOMETRIC TRAINING PROGRAM
TRAINING WEEK PLYOMETRIC DRILL FOOT
Contact SETS x REPS TRAINING INTENSITY
WEEK 1 Side to side ankle hops
Standing jump and each
Front cone hops 90 2 x 15
2 x 15
5 x 6 Low
Low
Low
WEEK 2 Side to side ankle hops
Standing long jump
Lateral jump over barrier
Double leg hops 120 2 x 15
5 x 6
2 x 15
5 x 6 Low
Low
Medium
Medium
WEEK 3 Side to side ankle hops
Standing long jump
Lateral jump over barrier
Double leg hops
Lateral cone hops 120 2 x 12
4 x 6
2 x 12
3 x 8
2 x 12 Low
Low
Medium
Medium
Medium
WEEK 4 Diagonal cone hops
Standing long jump with lateral sprint
Lateral cone hops
Single leg bounding
Lateral jump single leg 140 4 x 8
4 x 8
2 x 12
4 x 7
4 x 6 Low
Medium
Medium
High
High
WEEK 5 Diagonal cone hops
Standing long jump with lateral sprint
Lateral cone hops
Cone hops with 180 degree turn Single
leg bounding
Lateral jump single leg 140 2x 7
4 x 7
4 x 7
4 x7
4 x 7
2 x 7 Low
Medium
Medium
Medium
High
High
WEEK 6 Diagonal cone hops
Hexagon drill
Cone hops with change f direction sprint
Double leg hops
Lateral jump single leg 120 2 x 12
2 x 12
4×6
3x 8
3x 6 Low
Low
Medium
Medium
High
254635145415
Figure 1: Instruments
462280107950
Figure 2: Illinois Agility Test
434975209550
Figure 3: Standing Stork Test
463550-142875
Figure 4: Single-leg stance while performing dribbling
415925247015
Figure 5: Single-leg squat (300 -450)
396875215900
Fig 6: On board swinging the raised leg
400685-180975
Fig 7: Double-leg stance while rotating the board
273050-635
Fig 8: Standing jump and reach
3759200144780273050144780
Fig 9: Side to side ankle hops
25400010477520256501047753797300104775
Fig 10: Lateral jump single leg
254000-635
Fig 11: Diagonal cone hops
3835400161290282575161290
Fig 12: Cone hops with 1800 turn
DATA ANALYSIS
The present study was done on “Combined Effectiveness of Plyometrics and Balance Training in The Prevention of Ankle Sprains in High School Basketball Players -Randomized Controlled Trial”. The study included 60 subjects, out of which 30 players were allocated in Group A (Balance training) and 30 to Group B (Balance Training and Plyometrics).
Statistical analysis for the present study was done manually as well as using statistical software “MedCalc” version 10.2 so as to verify the results obtained. For this purpose data was entered into an excel spread sheet, tabulated and subjected to statistical analysis. Various statistical measures such as mean, standard deviation and tests of significance such as test of proportion, chi square test, paired and unpaired ‘t’ test, were utilized for this purpose for all the available data. Demographic data of participant’s i.e. age, height, weight were analyzed using unpaired ‘t’ test and sex distribution, leg dominance were analyzed using chi square test. Comparison of the pre training and post training outcome measures within the groups was done by using student paired ‘t’ test and between the groups was done using unpaired ‘t’ test and test of proportion. Probability values less than 0.05 were considered statistically significant and probability values less than 0.0001 were considered highly significant.

RESULTS
Table 1: Age and Anthropometric variables for control and intervention
group
Groups Mean Age (Years) Mean Height (Cms) Mean Weight (Kgs)
Control (Group A) 14.90 ± 0.84 155.86 ± 10.71 44.63 ± 7.36
Intervention (Group B) 14.76 ± 0.77 157.10 ± 11.01 45.46 .± 8.12
P value 0.5263 0.6619 0.6787
Inference Not significant Not significant Not significant
Age of the participants in this study was between 14 to 16 years. The mean age of the participants in Group A was 14.9±0.84 and the mean age of participants in Group B was 14.76±0.77. The difference in mean age of two groups was not statistically significant (p= 0.5263).
The average height of the subjects in Group A was 155.86 ± 10.71 and in Group B was 157.10 ± 11.01. There was no significant difference between the heights of the subjects in both the groups. (p =0.661).

The mean body weight of the subjects in Group A was 44.63 ± 7.36 and the mean body weight of the subjects in Group B was 45.46 ± 8.12. There was no significant difference in body weight in both the groups (p=0.678).

Graph 1: Age and Anthropometric variables for control and intervention
Group

Table 2: Sex distribution for control and intervention group
Groups Male Female X2 p value Inference
Control (Group A) 17 13 0.0673 0.7952 Not significant
Intervention (Group B) 16 14 33 out of 60 participants who participated in the study were males and 27 were females. There were 17 males and 13 females in Group A, 16 males and 14 females in Group B. There was no statistically significant difference between the groups (X2 = 0.6171, p=0.7345).

Graph 2: Sex Distribution

Table 3: Leg dominance distribution for control and intervention group
Groups Right Left X2 p value Inference
Control (Group A) 30 00 0 1 Not significant
Intervention (Group B) 30 00 All the 60 participants who participated in the study were right dominated. There was no significant difference between group A and group B. (X2 = 0, p = 1).

Graph 3: Leg dominance distribution for control and intervention group

Table 4: Pre and Post training Illinois agility test score for control and
intervention group
ILLINOIS AGILITY TEST (seconds)
Groups Pre Training Post Training P value Inference
Group A 20.72 ± 1.18 20.44 ± 1.32 0.0001 Significant
Group B 20.25 ± 1.12 18.87 ± 1.26 0.0001 Significant
In the Group A, the mean Illinois agility test pre training score was 20.72 ± 1.18, which was reduced to a mean of 20.44 ± 1.32 post training. The paired ‘t’ test value was found to be p ; 0.0001 which was statistically highly significant. In Group B, the mean Illinois agility test pre training score was 20.25 ± 1.12, which was reduced to a mean of 18.87 ± 1.26 post training. The paired’t’ test value was found to be p; 0.0001 which was statistically highly significant.
Graph 4: Pre and Post training Illinois agility test score for control and
intervention group

Table 5: Pre and Post training Standing stork test score (eyes open) for
control and intervention group
STANDING STORK TEST(EYES OPEN)
Groups Pre Training Post Training P value Inference
Group A 3.61 ± 0.74 5.80± 0.86 0.0001 Significant
Group B 3.75±0.61 6.23± 0.82 0.0001 Significant
In the Group A, the pre training mean standing stork test score with eyes open was 3.61 ± 0.74, which increased to a mean of 5.80 ± 0.86 post training. The paired ‘t’ test value was found to be p ; 0.0001 which was statistically highly significant.

In Group B, the pre training mean standing stork test score with eyes open was 3.75 ± 0.61, which increased to a mean of 6.23 ± 0.82 post training. The paired ‘t’ test value was found to be p ; 0.0001 which was statistically highly significant.

Graph 5: Pre and Post training Standing stork test score (eyes open) for
control and intervention group

Table 6: Pre and Post training standing stork test score (eyes closed) for
control and intervention group
STANDING STORK TEST(EYES CLOSED)
Groups Pre Training Post Training P value Inference
Group A 1.97 ± 0.52 3.01± 0.41 0.0001 Significant
Group B 1.89±0.51 3.21± 0.61 0.0001 Significant
In the Group A, the pre training mean standing stork test score with eyes closed was 1.97 ± 0.52, which increased to a mean of 3.01 ± 0.41 post training. The paired ‘t’ test value was found to be p ; 0.0001 which was statistically highly significant.

In Group B, the pre training mean standing stork test score with eyes closed was 1.89 ± 0.51, which increased to a mean of 3.21 ± 0.61 post training. The paired ‘t’ test value was found to be p ; 0.0001 which was statistically highly significant.

Graph 6: Pre and Post training standing stork test score (eyes closed) for
control and intervention group

Table 7: Mean changes of pre and post training test scores between the
control and intervention group
GROUPS ILLINOIS TEST (Seconds) STANDING STORK TEST EYES OPEN (Seconds) STANDING STORK TEST EYES CLOSED (Seconds)
Pre training Post training Pre training Post training Pre training Post training
Group A 20.72±1.18 20.44±1.32 3.61±0.74 5.80±0.86 1.97± 0.52 3.01±0.41
Group B 20.25±1.12 18.87±1.26 3.75 ±0.61 6.23±0.82 1.89± 0.51 3.21±0.61
p value 0.0001 0.0488 0.229
Inference Significant Significant Not significant
On comparing the pre training values between Group A and B there was no statistically significant difference p;0.125, whereas post training values between the groups were statistically highly significant p; 0.0001.
On comparing the pre training values between Group A and B there was no statistically significant difference p= 0.54 where as post training values between the groups were statistically significant p; 0.048.
On comparing the pre training values between Group A and B there was no statistically significant difference p= 0.31 and the post training values between the groups were also statistically not significant p; 0.22.
Graph 7: Mean changes of pre and post training test scores between the
control and intervention group

Table 8: Rate of ankle sprain for control and intervention group
Groups Subjects Ankle sprain Rate per Player % p value Inference
Yes No Controls (Group A) 30 5 25 16.66 0.04 Significant
Intervention (Group B) 30 1 29 3.33 Total 60 6 54      
In Group A, the rate of ankle sprain was 16.66% (5 ankle sprains occurred out of 30 participants) and in Group B 3.33% (1 ankle sprain occurred out of 30 participants). Comparison of the number of ankle sprains between both the groups was done by using the test of proportion. The test revealed that there was statistically significant difference seen with p; 0.0426.
Graph 8: Rate of ankle sprain for control and intervention group

DISCUSSION
The present control trial was conducted to see the combined effectiveness of plyometrics and balance training in the prevention of ankle sprains in high school basketball players. The study showed that a combination of 6 week plyometric with 5 weeks balance training was effective in reducing the incidence of ankle sprains in high school basketball players without a history of previous ankle sprain. It also showed difference in the Illinois agility scores and standing stork test scores post training with p; 0.0001.
In the present study Group A, received Balance Training and Group B received Balance Training and Plyometrics. The two groups had equal number of participants and showed no significant difference between the groups, which could have altered results of the study.
The age of the participants included in this study was between 14 to 16 years with the mean age 14.90 ± 0.84 of the participants in Group A and 14.76 ± 0.77 in Group B. In this age group large population of athletes participate in basketball and has shown that the rate of participation has increased by 10% in boys and 20% in girls in past 20 years in the study conducted by Laurel A. Borowski 2008. One study found the most common cause of pediatric injuries was sports (Hambridge SJ 2002) with the highest incidence of sports injuries, in children of 5 to 15 years (Conn JM 2003).
The age group of the present study matched with the previous studies on plyometrics as well as balance training conducted by Carmelo Bosco and Paavo Komi 2008. Gabbett in 2002 reviewed from the study on Rugby league players that the physiological characteristics of sub elite junior and senior rugby players that plyometric training is a safe method in children from 12 to 16 years.

In our study the mean height of the participants in Group A was 155.86 ± 10.71 and Group B was 157.10 ± 11.01. The mean weight in Group A was 44.63 ± 7.36 and Group B was 45.46 ± 8.12. There was no statistically significant difference between the groups and hence did not contribute to any variation in the results
The distribution of male and female participants in the study was near equal in Group A and Group B with p value of 0.79. In our study number of ankle sprain was found to be more in females than males which is in accord to a study conducted by Whiteside PA 1980 on men’s and women’s injuries in comparable sports and found that more number of female athletes were injured as compared to male. Hosea et al 2000 conducted a study on the gender Issue – epidemiology of ankle injuries in athletes who participated in basketball and the study evaluated the RR of ankle injuries in scholastic and collegiate basketball player, with 4940 female and 6840 males. There were 1052 ankle injuries with females had a 25% greater risk of sustaining a grade 1 ankle sprain overall, female had a 25%This could be attributed to the physiological difference such as increased joint laxity among women (Chandy TA 1985, Haycock CE 1976). Other studies by Gray J 1985, Wojtys EM 1998 has suggested that the hormone estrogen is directly involved in increased injury rates in women.

In the present study all the participants were right leg dominant where as in the previous research conducted by Liz Abernethy 2007, Michael G. Miller 2006, Evert Verhagen 2004 the players were both right and left leg dominant.

Our study which included participants without the history of ankle sprain did not show reduction in the incidence of ankle sprain in the control group, however reduction was seen in the interventional group. These results are similar to the results of study by Bahr R 1997 which was done on players in Norway, for whom an injury prevention program was developed; they demonstrated a substantial decrease in the incidence of ankle sprain with no changes in the occurrence of other injuries. Gregory D. Myer 2006 conducted a study on 12 soccer teams, with 15 men each, in which the teams were randomized into an intensive season-long prevention program or a standard training program, found that intensive, sustained conditioning reduces the occurrence of ankle sprains over the course of a 6-month season.
Plyometric exercises have become popular over the last ten years. It has been used in various sports such as football, tennis, soccer, and basketball, as well as others as a tool used for physical training. Plyometrics have been verified by research to improve acceleration; joint awareness, proprioception and agility Michael G. Miller 2006. These are very basic exercises that can be used at the beginners’ level. The chance of injury from this type of exercise program is minimal but still possible due to intensity and type of jumps that were been performed. The present study also used various plyometrics exercises which were very basic and of varying intensities and there was no single injury sustained by the players during the training sessions.

The improvement in agility was tested by using Illinois agility test. Difference in the test scores was seen in both the groups in the present study. In Group A the mean Illinois agility tests score were pre training were 20.72±1.18 and post training were 20.44 ±1.32.with p<0.0001. In Group B the mean pre training score were 20.25 ±1.12 and post training were 18.87±1.26 with p value of 0.0001. Group B showed significant improvement in Illinois agility scores than Group A. Various authors investigated the effect of plyometrics training on agility. Our findings are similar to those of Michael G Miller et al 2006 who studied the effect of six weeks plyometric training program on agility and three agility outcomes measures were used in this study which included T-Test, Illinois agility test and the force plate test. All the tests revealed an improvement in agility scores. Renfro 1999 measured agility using test with plyometric training, while Robinson and Owins 2004 used vertical, lateral and horizontal plyometrics jumps and showed improvement in agility.

Plyometric drills usually involve stopping, starting and changing direction in an explosive manner. The relationship between plyometrics exercise and increase performance in agility tests may be high due to their similar pattern of movements to facilitate power and movement efficiency by the immediate change in direction upon landing. These movements are components that can assists in developing agility(Craig et al 2004, Miller et al 2001) which can be enhanced by plyometrics training. The plyometric program used in this study were based from the previous studies performed to monitor similar outcomes by Michael G. Miller 2006, Ekstrand J 1983).
Standing stork test improvements were seen post training in the groups with p<0.0001. However Group B showed significantly better results than Group A p< 0.0001. Standing stork test was a good predictor for improvement in balance. A study done by McGuine Timothy A 2000 on 210 high school basketball players with a mean age of 16.1 ± 1.1 years was done to determine if preseason measurement of balance while in a unilateral stance could predict susceptibility to ankle injury and it was concluded that preseason balance measurement served as a predictor of ankle sprain susceptibility. The improvements in test scores were due to increased proprioception which was achieved by balance training in Group A and significant improvement in Group B due to addition of plyometric training over balance training which further increased the proprioception.

In the present study the rate of ankle sprain was 16.66% (5 ankle sprains occurred out of 30 participants) in Group A and 3.33% (1 ankle sprain occurred out of 30 participant)in Group B. Comparison of the number of ankle sprains between both the groups revealed that Group B was effective in reducing the number of ankle sprains which was statistically significant with p< 0.0426.

Following the plyometric training the muscles adapt acutely to eccentric exercise by changing the optimal length or the group of the more fragile, stress- susceptible fibers is reduced in number after the first bout while stronger fibers survive and provide a protective effect (Armstrong RB 1983, Friden J 2001). Even light eccentric training protocols that result in little to no muscle damage are sufficient to bring about the protective effect. In addition to the production of much higher forces, eccentric contraction has another unique attribute: the metabolic cost is greatly reduced.

The results of the present study are very encouraging and demonstrate the benefit of adding plyometric training over balance training in the prevention of ankle sprains. Not only can players use plyometrics to break the monotony of training, but they can also improve strength and proprioceptive awareness which will help them enhance the performance.
The results support that the preventive effect brought about by a combination of balance training and plyometrics can be achieved by as less as 6 weeks and in players without a history of previous ankle sprain. The findings highlight a potential value of combined fitness training in a regular training program which should be carried out throughout the sporting season to prevent ankle sprains.

CONCLUSION
The results of the present study are very encouraging and demonstrate the benefit of adding plyometric training over balance training in the prevention of ankle sprains. Not only can players use plyometrics to break the monotony of training, but they can also improve strength and proprioceptive awareness which will help them enhance the performance.
The results support that the preventive effect brought about by a combination of balance training and plyometrics can be achieved by as less as 6 weeks and in players without a history of previous ankle sprain. The findings highlight a potential value of combined fitness training in a regular training program which should be carried out throughout the sporting season to prevent ankle sprains.

SUMMARY
This research was done to study the combined effectiveness of plyometrics and balance training in the prevention of ankle sprains in high school basketball players. 60 participants between age group of 14 to 16 years who were basketball players were randomly allocated into two groups A and B respectively, each group comprising of 30 participants. Group A received balance training, Group B balance and plyometrics training. Quantification of participants’ performance i.e. agility was measured by the Illinois agility test, balance by Standing stork test before and after training. The incidence of ankle sprain was monitored during the season. The analysis of significance was carried out by using paired and unpaired ‘t’ test for Illinois agility test and standing stork test scores and test of proportion was used to analyze the incidence of ankle sprain.

In the present study intra group improvements was seen in Illinois agility test as well as standing stork test post training. Between the group analyses showed that post training values of both the groups were statistically significant. However Group B values were statistically more significant as compared to Group A p; 0.0001. In the above study parameters ‘p’ value stood at ; 0.0001 in post training scores of the two groups indicating a very high degree and significant improvement when plyometrics and balance training was given. The incidence of ankle sprains was less in Group B which received balance and plyometric training than Group A which received balance training alone p;0.0426.

LIMITATIONS OF THE STUDY
Small sample size.

Subjects were not blinded and hence there may be some amount of bias.

.
RECOMMENDATION FOR FUTURE RESEARCH
Conduct the study with large number of sample size.

Conduct the study with other sports and other injuries.

Studies with longer duration are recommended with longer follow-up period to assess long term benefits.

BIBLIOGRAPHY
Ai Choo LEE, Pitt Fang KUANG: The effectiveness of four weeks sports specific balance training program to improve balance, thus reducing the risk of ankle sprain among basketball players: Int J Physiother. Vol 3(6), 731-736, December (2016).

Armstrong RB, Ogllvie RW, Schwane JA. Eccentric exercise-induced injury to rat skeletal muscle. J Appl Physiol, 1983; 54:80-93.

Bahr R, Lian O, Bahr IA. A twofold reduction in the incidence of acute ankle sprains in volleyball after the introduction of an injury prevention program. A prospective cohort study. Scand J Med Sci Sports,1997;7:172-177.

Blattner SE, Noble L. Relatve effects of isokinetic and plyometric training on vertical jumping performance. Research Quarterly.1979.

Bosco C, Komi PV. Influence of countermovement amplitude in potential tion of muscular performance. Biomechanics VII proceedings (1980) Baltimore: University Park Press. (pp 129-135).

Bosco C, PV Komi. Potentiation of mechanical behavior of the human skeletal muscles through pre stretching. Acta Physiologica Scandinavia ; 106 :467-472. 2008
Chandy TA, Grana WA. Secondary school athletic injury in boy and girls: A three-year comparison. Physician Sportsmed, 1985;13(3):106-111.

Clark M. National Academy of sports medicine: Performance Enhance ment Specialist Manual. Integrated Speed Training: Section Ib. NASM, Az. 2001.

Conn JM, Annest JL, Gilchrist J. Sports and recreation related injury episodes in the US population. Inj Prev.2003;9: 117-123.

Ekstrand J, Gillquit J, Lijedahl SO. Prevention of soccer injuries, super vision by doctor or physiotherapist. Am J Sports Med, 1983;11:116-120
Evert Verhagen, Allard Van der Beek, Jos Twisk, et al. The Effect of Proprioceptive Balance Board Training Program for the Prevention of Ankle Sprains. American Journal of Sports Medicine,2004; 32(6):1385-1393.

Fleck SJ and Kraemer WJ. Designing resistance training Programs, 3rd Edition, and Champaign, IL: Human kinetics. 2004.

Friden J, Lieber RL. Eccentric exercise-induced injuries to contractile and cytoskeletal muscle fibre components. Acta Physiol Scand, 2001; 171: 321-326.

Gabbett. Physiological characteristic of junior and senior rugby league players.Br J Sports Med, 2002’36:334-339.

Gabriella Sophie Schiftan, Lauren Ashleigh Ross, Andrew John Hahne : The effectiveness of proprioceptive training in preventing ankle sprains in sporting populations: A systematic review and meta-analysis: Journal of Science and Medicine in Sport 18 (2015) 238–244.

Gaurav , S., Pooja, A., Shishir , N., Tanvi , A Comparative Analysis of Effectiveness of Conventional Proprioceptive Training and Multistation Proprioceptive Training on Vertical Jump Performance in Indian Basketball Players : Journal of Exercise Science and Physiotherapy, Vol. 9, No. 2: 97-104, 2013
Gray J, Taunton JE, Mckenzie DC, et al. A survey of injuries to the anterior cruciate ligament of the knee in female basketball players. Int J Sports Med, 1985;6:314-316.

Gregory D. Myer, Kevin R. Ford, MS, Scott. G, McLean, Timothy E. Hewette, The Effect of Plyometric Versus Dynamic Stabilization and Balance Training on Lower Extremity Biomechanics. The American Journal of Sports Medicine, 2006;34(3):445-455.

Hambridge SJ, Davidson AJ, Gonzales R, Steiner JF. Epidemiology of pediatric injruy-related primary care office visits in the United States. Pediatrics, 2002;109: 559-565.

Haycock CE, Gillette JV. Susceptibility of women athletes to injury: Myth vs reality. JAMA, 1976:163-165.

Holme E, Magnusson SP, B Echer K, Bieler T, Aagaard P, Kjaer M. The effect of supervised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain. Scandinavian journal of medicine & science in sports, 1999;9(2):104-109.

Hosea, Timothy M. MD; Carey, Christopher C. MD:Harrer, Michael F. MD. The Gender Issue: Epidemiology of Ankle Injuries in Athletes Who Participate in Basketball. Clinical Orthopedics’ and Related Research. March 2000. 372: 45-49.

Huston LJ, Wojtys EM. Neuromuscular performance characteristic in elite female athletes. Am J Sports Med, 1996;24:427-436.

Ingrid Vriend, Vincent Gouttebarge, Willem van Mechelen, Evert Verhagen:Neuromuscular training to prevent ankle sprains in a sporting population: JISAKOS 2016;1(4):202–13
Kerim Sobir :Effects of 6-Week Plyometric Training on Vertical Jump Performance and Muscle Activation of Lower Extremity Muscles: The sports Journal: 32(3):123-129
Kraemer w, Hakkinen K. Strength Training for sport. Blackwell science Ltd. 2002.

Laurel A, Borowski , Ellen E. Yard, Sarah K. Fields, R. Dawn Comstock. The Epidemiology of US High School Basketball Injuries, 2005-2007. The American Journal of Sports Medicine, 2008;36(12):2328-2335.

Liz Abernethy, Chris Bleakley. Strategies to prevent injury in adolescent sport: a systematic review. British Journal of Sports and Medicine, 2007; 41:627-638.

Lukas Ondra, Petr Natesta, Lucia Bizovska : Effect of in-season neuromuscular and proprioceptive training on postural stability in male youth basketball players: Acta Gymnica 2017, 47(3):144-149
McGuine Timothy A, Green Joe J, Best Thomas, Leverson Glen. Balance As a Predictor of Ankle Injuries in High School Basketball Players. Clinical Journal of Sports Medicine, October 2000;10:239-244.

Michael G. Miller, Jeremy.J.Herniman, Mark.D.Ricard, Christopher. C.Ch eatham, Timothy.J.Micheal. The Effects of a 6-Week Plyometric Training Program on Agility. Journal of Sports Science and Medicine. 2006; 5: 459-465.

Proprioceptive Balance Training.January 22, 2008. By Elizabeth Quinn. accessed on 11-09-2009 at 7.30 pm
Rachel Bellows, Christopher Kevin Wong: To compare the effect of balance training and bracing in reducing the incidence and relative risk of ankle sprains in competitive athletes, with or without prior injury, across different sports. The International Journal of Sports Physical Therapy | Volume 13, Number 3 | June 2018 | Page 379
Raffalt PC, Alkjaer T, Simonsen EB: Intra-subject variability in muscle activity and co-contraction during jumps and landings in children and adults. Scandinavian Journal of Medicine ; Science in Sports: 2016, 27(8):820-831
Reid C. David.Sports injury assessment and rehabilitation.Churchill Livingstone 1992:215
Renfro G. Summer plyometric training for football and its effects on speed and agility. Strength and Conditioning , 1999; 21(3):42-44.

Robinson BM and Owens B. Five-week program to increase agility, speed, and power in the preparation phase of a yearly training plan. Strength and Conditioning, 2004; 26(5): 30-35.

Schmidt bleicher D, Komi P.V. Training for power events. Strength and power in sport. Oxford, UK: Blavkwell scientific. 2004.(pp381-395).

Stephen B. Thacker, Donna E Stroup, Christine M. Branche et al. The preventionof Ankle Sprains in Sports. A Systematic Review of the Literature. The American Journal Of Sports Medicine.1999:27(6):753-760.

Laurel A, Borowski , Ellen E. Yard, Sarah K. Fields, R. Dawn Comstock. The Epidemiology of US High School Basketball Injuries, 2005-2007. The American Journal of Sports Medicine, 2008;36(12):2328-2335.

Whiteside PA. Men’s and women’s injuries in comparable sports. Physici an Sportsmed, 1980; 8(3): 130-140.

Wojtys EM, Huston LJ, Lindenfled TN, et al. Association between Menstrual Cycle and Anterior Cruciate Ligament injuries in female athletes. Am J Sports Med, 1998;26:614-619.

Wagner DR, Kocak MS. A multivariate approach to assessing anaerobic power following a plyometric training program. J strength Cond Res, 1998 :11:251-255.

ANNEXURE – I
ETHICAL CLEARANCE CERTIFICATE
ANNEXURE – II
CONSENT FORM
I Mohammed Youns Sofi have explained to…………………………………….the purpose of the research, the procedures required and the possible risks and benefits to the best of my ability.

Date: Investigator Signature
Place:
CONSENT TO PARTICIPATE IN THE STUDY
Purpose of study
Combined effectiveness of plyometrics and balance training in the prevention of ankle sprains in high school Basket ball players – A randomized controlled trial
Statement of consent
I ______________________________ hereby consent to participate in the physical assessment on the following terms:
I have been informed about the assessment procedures and understand what I will be required to do.

I understand that I will be taking part in physical examination procedures, some of which is at maximal intensity. I understand that there is always a risk of injury associated with high-intensity exercise.

I understand that I can withdraw my consent, freely and without prejudice, in case of health issues at any time.

I understand that the information obtained from the test will be kept confidential, with my right to privacy assured. However, the information obtained may be used for statistical analysis or scientific purpose with my right to privacy retained.

I understand that the videographs/photographs taken for publication purpose and will be stored and accessed by researchers and guides. If required permission will be obtained from me for the use of photographs in journals as per journal guidelines.

I release the physiotherapist from any liability for any injury or illness that may occur during physical assessment, or subsequently occurring in connection with the assessment, or that is to any extent contributed to by it.

_________________________ _________________________
Name of the subject Signature / Left thumb impression
_________________________ _________________________
Name of the Parents Signature / Left thumb impression
_________________________ _________________________
Signature of Investigator Signature of Guide
ANNEXURE – III
DATA COLLECTION FORM
Date Participant No.
Name Age
Sex:Male/ Female Height Weight
Address
Dominant LegRight Left
ILLINOIS AGILITY TEST
S.No Pre Intervention (Duration) Post Intervention (Duration
1 2 3 4 5 STANDING STORK TEST(EYES OPEN)
S.No Pre Intervention (Duration) Post Intervention (Duration
1 2 3 4 5 STANDING STORK TEST(EYES CLOSED)
S.No Pre Intervention (Duration) Post Intervention (Duration
1 2 3 4 5 Ankle Sprain Yes / No
_________________________ _________________________
Name of the subject Signature / Left thumb impression
_________________________ _________________________
Signature of Investigator Signature of Guide
ANNEXURE – IV
MASTER DATA CHART
-108204010795
-131254569850
ANNEXURE – V
PLAGIARISM