Active Support Increases Injury Prevention Program Use in Female Athletes

In-person workshops for coaches tripled the use of injury prevention protocols, though direct impact on ACL and concussion rates remains unclear.

For Doctors in a Hurry

Researchers investigated whether in-person support increases the use of injury prevention programs and reduces concussion or anterior cruciate ligament injuries.
This cluster randomized trial evaluated 2481 female Australian Football players across 165 teams using a stepped wedge implementation design.
Supported implementation increased program use to 29.7 percent compared to 13.1 percent for unsupported teams (Odds Ratio 3.7).
The authors concluded that while support improves program uptake, only high adherence significantly correlates with a reduction in total injuries.
Clinicians should emphasize that consistent adherence to neuromuscular training is necessary to achieve measurable reductions in athletic injury rates.

Implementation Barriers in Female Athlete Injury Prevention

The rising participation of women and girls in high-intensity contact sports brings a significant burden of musculoskeletal and neurological injuries, particularly anterior cruciate ligament (ACL) tears and sport-related concussions [1]. Multicomponent exercise programs demonstrate efficacy in reducing ACL injury risk by up to 45 percent in controlled research settings, but translating these results to community-level play remains a significant clinical challenge [2, 1]. Even when effective protocols exist, community implementation is often hindered by low adherence and inconsistent application by coaching staff [3]. Furthermore, while injury prevention programs can reduce concussion rates by approximately 34 percent, most existing research focuses on male cohorts, leaving a gap in evidence-based strategies tailored for female athletes [4]. To address this translation gap, a recent large-scale trial examines whether active implementation support strategies can improve adherence to injury prevention protocols and subsequently reduce trauma rates in real-world practice.

Trial Design and Active Support Strategies

To evaluate the Prep-to-Play injury prevention program, researchers conducted a hybrid implementation-effectiveness stepped wedge cluster randomized trial (a study design that measures how well an intervention is delivered while simultaneously assessing its clinical impact as it rolls out to different groups over time). Registered as NCT04856241, the study followed 165 women’s and girls’ Australian Football teams comprising 2481 players. During the 2021 and 2022 seasons, these teams were randomly allocated to transition from an unsupported implementation phase to a supported phase at one of five distinct time points. This structure allowed the authors to compare the uptake of the injury prevention protocol and the resulting injury incidence across different levels of institutional support.

The Prep-to-Play program itself is a comprehensive intervention featuring warm-up, contact, and strength activities specifically tailored for female athletes. During the unsupported phase, implementation consisted solely of providing coaches and team leaders with access to online resources. The supported phase introduced active in-person workshops and support visits to facilitate the correct application of the exercises. The primary outcome was the frequency of Prep-to-Play use, while secondary outcomes focused on the incidence of concussion and anterior cruciate ligament (ACL) injuries. To ensure data precision, the researchers defined weekly use as the implementation of at least 75 percent of the program elements during at least two-thirds of all team sessions conducted each week.

Statistical analyses were adjusted for clustering, time period, age group, competition level, and geographic region. By comparing the supported and unsupported phases, the trial sought to determine if direct professional guidance could bridge the gap between the availability of injury prevention resources and their consistent use in community sports. For sports medicine physicians and primary care providers, understanding these implementation barriers is critical for advising local sports organizations on effective injury reduction strategies.

Impact on Program Adherence and Injury Rates

Transitioning from passive online resources to active, in-person support resulted in a substantial increase in the consistent use of the Prep-to-Play protocol. During the unsupported phase, the average weekly use by teams was 13.1 percent (95% CI 11.5% to 14.9%). This figure more than doubled to 29.7 percent (95% CI 27.6% to 31.9%) once teams received direct workshops and support visits. The researchers calculated an odds ratio of 3.7 (95% CI 2.4 to 5.7) for program use in the supported versus unsupported phase, indicating that active implementation strategies significantly improve the likelihood of coaches adhering to injury prevention exercises.

When examining specific injury types, the raw incidence rates per 1000 game hours appeared lower during the supported phase. In the unsupported phase, the concussion incidence was 6.80 (95% CI 5.75 to 8.05) and the ACL injury incidence was 1.36 (95% CI 0.98 to 1.89). During the supported phase, these rates fell to 3.50 for concussions (95% CI 2.72 to 4.52) and 0.69 for ACL injuries (95% CI 0.44 to 1.15). However, after adjusting for variables such as age and competition level, the direct effect of the supported implementation strategy on these specific injuries remained statistically unclear. The incidence rate ratio (IRR) for concussion was 1.36 (95% CI 0.74 to 2.49), and the IRR for ACL injury was 2.27 (95% CI 0.56 to 9.12), suggesting that the support strategy alone did not definitively reduce these specific outcomes within the study period.

Despite this uncertainty regarding direct impact, the trial evaluated the dose-response relationship (a statistical analysis measuring whether higher levels of program participation correlate with better health outcomes) between adherence and injury incidence. The findings demonstrated that higher Prep-to-Play adherence was associated with fewer total injuries, yielding an IRR of 0.95 (95% CI 0.92 to 0.99). This indicates that for every incremental increase in adherence, there is a measurable reduction in the overall injury burden. For the practicing clinician, these results highlight a critical reality: while in-person workshops effectively triple the uptake of prevention protocols, the primary challenge remains achieving the high, sustained levels of adherence necessary to significantly reduce severe, low-frequency events like ACL ruptures and concussions.

Study Info

Supported implementation enhances injury prevention programme (Prep-to-Play) use in women and girls playing Australian Football: a pragmatic type III hybrid implementation-effectiveness stepped wedge cluster randomised trial

Brooke Patterson, Nicole M White, S. Cowan, Matthew G King, et al.

Journal British Journal of Sports Medicine

Published May 06, 2026