Many sports injuries have warning signs that make them predictable and preventable.In the case of ACL ruptures, we know there are certain risk factors that make an athlete more prone to suffering from this injury.
Before we get into the nitty-gritty, it’s important to remember that not all injuries can be prevented; especially in contact sports where we cannot predict how two players will collide.Some people in the sports medicine realm have suggested dropping the name “injury prevention” and instead use the term “injury reduction” because this more accurately represents our mindset. We can’t prevent all injuries, but we can reduce your risk.
Some ACL injuries can be outright prevented. 70% of all ACL injuries occur in non-contact situations. Yes, you read that correctly. This means that athletes are getting injured while landing, twisting, cutting, pivoting or decelerating without interference from other players.
There has been a fair amount of buzz regarding injury prevention programs and the evidence that they work is mounting up. Yet many athletes and teams fail to implement and adhere to a solid injury prevention program. In a survey of high school coaches, only 21% were using a program and only half of them reported performing the program as prescribed.
Injury prevention is often viewed as time-consuming, unexciting, and offering disputable results. Coaches are busy people, and many don’t have the time to find a program. There is also the concern that implementing an injury prevention program will take valuable practice time away from developing skills. Other coaches just don’t buy into it, period. Athletes may undervalue the benefits of injury prevention because they don’t believe they have control over injuries. “Injuries are the result of bad luck, so if I get injured, it can be attributed to sheer luck.” Athletes that think this way often have an external locus of control and believe that outside forces control their fate. I’m hoping that the information I share here demonstrates that you do have control over your injury risk. This is within your control, but you need to take action! Cultivating an internal locus of control will help in sports and nearly all other aspects of life.
It is normal for adolescent athletes to view themselves as uniquely invincible and have a “this will never happen to me” mindset. This way of thinking may limit their ability to assess situations, risks and consequences. For someone who thinks this way, it’s easy to see why spending time on an injury prevention program would seem futile.
Do these injury prevention programs really work? Do you actually have any control over whether or not you get injured? What factors may place an athlete at higher risk of suffering this injury? How can we mitigate these risks? Let’s look at the research.
Research:
ACL tears are common injuries, particularly among young and active individuals. It has been estimated that the yearly financial burden of ACL tears is over $7 billion. Being a common and costly injury has made it a hot topic to research over the past few decades. Check out this chart that shows the volume of studies performed on ACL tear etiology and prevention. This doesn’t even include all the studies that examined the best treatment strategies for ACL tears with and without surgery.
Evidence in Support of ACL Prevention Programs:
In 2018, research duo Ann Webster and Timothy Hewett performed a meta-analysis to examine the effectiveness of ACL injury prevention programs. They looked at the results from 8 different studies with the intent of summarizing the results into a single source. I’ll quote the results… “Combination of the results of the meta‐analyses showed an overall 50% reduction in the risk for all ACL injuries in all athletes and 67% reduction for non‐contact ACL injuries in females. These are substantial, clinically significant reductions and confirm the benefit of such interventions.” Impressive results. This was a really well-done meta-analysis, and the results are hard to argue. ACL injury prevention programs reduced the risk of all ACL injuries by 50% and non-contact ACL injuries by two-thirds in females.
Your Most Important Ability is Your Availability
ACL Injury Risk Factors:
There have been several risk factors for ACL injuries identified by the extensive literature. The chart below breaks the most common risk factors seen in the literature into two groups: modifiable and non-modifiable. The factors in the non-modifiable group are what they are; we can’t change them. We’re interested in the modifiable factors that can be addressed in prevention programs. These include things like resistance to fatigue, hamstring to quadriceps ratio, poor trunk stability and dynamic knee valgus during landing. Not shown here are other extrinsic factors such as footwear, playing surface and weather. We do know that there are associations between these extrinsic factors and ACL injuries, but they will not be addressed in prevention programs.
What Goes into a Prevention Program?
The Journal of Orthopaedic & Sports Physical Therapy (JOSPT) published comprehensive clinical guidelines for ACL injury prevention in 2018. This 42-page monster thoroughly breaks down the literature on knee injury prevention and then describes the critical components of a program including exercise selection, dosage and instruction.
JOSPT recommends:
· Injury prevention programs should last at least 20 minutes and be performed multiple times per week
· Injury prevention programs should be started in pre-season and continue throughout the regular season
· Clinicians, coaches, parents and athletes must ensure high compliance with the program
· Injury prevention should be implemented for all young athletes; not just those who have been screened as high risk
· Clinicians, coaches, parents, and athletes should support implementation of exercise-based knee injury prevention programs led by either coaches or a group of coaches and medical professionals
The American Journal of Sports Medicine also performed a systemic review and meta-analysis of the current literature and created a check list to ensure that the injury prevention program is beneficial and not a waste of time. 18 studies and over 27,000 participants were looked over in this paper!
I’ll sum up their findings
Programs targeting middle and high school aged athletes were more effective at preventing injury than did programs targeting collegiate or professional aged athletes
ACL injury prevention programs should include lower body strength exercises
Nordic hamstrings
Lunges
Calf raises
Programs should have special focus on landing stabilization
Balance training, stretching, agility drills did NOT make the program more effective
There should be a formal training through a workshop, video, brochure where the coaches, athletes and parents are trained in safe body mechanics.
Wrap Up:
First off, congrats to you if you’ve made it this far through a relatively boring topic. (Unless you’re a rehab nerd and enjoy this sort of thing)
Look, I get it, injury prevention programs aren’t exciting. It doesn’t draw the attention that performance enhancement programs are going to get, but it’s arguably more important! ACL tears are a big deal. They impact the individual to a large degree and their cumulative cost have a hefty economic impact. We now know that a large number of these ACL tears can be prevented, and we have great information on how to build effective programs.
Athletes, coaches, parents…you now know that you have the opportunity to reduce the risk that you, your athletes or your child have to watch from the sideline for 10+ months. It’s your move.
If you are interested in learning more about a program for your sport, please contact me at gfoland@kinetixptp.com. Thank you!
References:
1. Huang Y-L, Jung J, Mulligan CMS, Oh J, Norcross MF. A Majority of Anterior Cruciate Ligament Injuries Can Be Prevented by Injury Prevention Programs: A Systematic Review of Randomized Controlled Trials and Cluster–Randomized Controlled Trials With Meta-analysis. Am J Sports Med. 2020;48(6):1505-1515. doi:10.1177/0363546519870175
2. Nessler T, Denney L, Sampley J. ACL Injury Prevention: What Does Research Tell Us? Curr Rev Musculoskelet Med. 2017;10(3):281-288. doi:10.1007/s12178-017-9416-5
3. Petushek EJ, Sugimoto D, Stoolmiller M, Smith G, Myer GD. Evidence-Based Best-Practice Guidelines for Preventing Anterior Cruciate Ligament Injuries in Young Female Athletes: A Systematic Review and Meta-analysis. Am J Sports Med. 2019;47(7):1744-1753. doi:10.1177/0363546518782460
4. Arundale AJH, Bizzini M, Giordano A, et al. Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy and the American Academy of Sports Physical Therapy. J Orthop Sports Phys Ther. 2018;48(9):A1-A42. doi:10.2519/jospt.2018.0303
5. Hewett TE, Myer GD, Ford KR, Paterno MV, Quatman CE. Mechanisms, prediction, and prevention of ACL injuries: Cut risk with three sharpened and validated tools. Journal of Orthopaedic Research. 2016;34(11):1843-1855. doi:https://doi.org/10.1002/jor.23414
6. Meta‐analysis of meta‐analyses of anterior cruciate ligament injury reduction training programs - Webster - 2018 - Journal of Orthopaedic Research - Wiley Online Library. Accessed March 3, 2021. https://onlinelibrary.wiley.com/doi/full/10.1002/jor.24043
7. Boden BP, Sheehan FT, Torg JS, Hewett TE. Non-contact ACL Injuries: Mechanisms and Risk Factors. J Am Acad Orthop Surg. 2010;18(9):520-527.
8. Pfeifer CE, Beattie PF, Sacko RS, Hand A. RISK FACTORS ASSOCIATED WITH NON-CONTACT ANTERIOR CRUCIATE LIGAMENT INJURY: A SYSTEMATIC REVIEW. Int J Sports Phys Ther. 2018;13(4):575-587.
9. Smith HC, Vacek P, Johnson RJ, et al. Risk Factors for Anterior Cruciate Ligament Injury. Sports Health. 2012;4(2):155-161. doi:10.1177/1941738111428282
10. Mather RC, Koenig L, Kocher MS, et al. Societal and Economic Impact of Anterior Cruciate Ligament Tears. J Bone Joint Surg Am. 2013;95(19):1751-1759. doi:10.2106/JBJS.L.01705
11. Jayanthi N, Dugas L. The Risks of Sports Specialization in the Adolescent Female Athlete. Strength and Conditioning Journal. 2017;39:20-26. doi:10.1519/SSC.0000000000000293