ACL Injury: Prevention Is Better Than Cure

I cover ACL injuries quite a bit in my blogs, and the reason for this is fairly straight forward:

They are one of the most devastating injuries to sustain in sport!

They can stop a blossoming sporting career dead in its tracks, or stop a player from reaching their full potential. Sometimes they can be the end of a player’s career. Furthermore, ACL injury comes at high physical, emotional and financial cost to the athlete, and the very sad thing is, a high percentage of ACL injuries can be prevented. Research tells us that between 50-70% of ACL injuries can be prevented with ACL prevention programs, or neuromuscular training programs [endif]--(1-3)![endif]--

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What are neuromuscular training programs, I hear you ask?

There are many definitions of what neuromuscular training programs are, but in a nutshell, they are programs designed to improve the strength, flexibility, control, balance and co-ordination of patients/athletes. A program typically consists of a series of exercises that addresses each of the aforementioned components. Importantly, the exercises are such that are specific to the sport being played. The programs are generally used as a “warm-up” activity and last between 15-30mins, and are usually implemented 2x per week and prior to games.

The PEP and Sportsmetrics programs are the most widely researched neuromuscular programs. The beauty of these 2 programs are that not only do they reduce ACL injury risk, they improve performance tests such as speed, agility, vertical jump, abdominal strength tests and estimated maximal aerobic capacity (4). I know I bang on about this a fair bit, but this reinforces that we need to be promoting these prevention programs to coaches, parents and players as “performance enhancing” programs, and not just boring injury prevention exercises (see previous blog).

Historically the programs were devised and implemented to reduce the risk of ACL injury, but what is starting to show in research is that all types of knee injuries (50%) and lower limb injuries (22%) can be reduced with the implementation of these programs [endif]--(5). Despite this evidence injuries are unfortunately still occurring at an alarming rate. As mentioned in a previous blog, between 2004-10 in Victoria alone, the financial cost of lower limb sporting injuries (including ACL injuries) to the public health sector increased by 26% during this period [endif]--(6).![endif]--![endif]--

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The reason for this spike in injury rate is no doubt multifactorial, but I often hear from coaches, players, parents alike that there is not enough time in the week or the training schedule to do the program. And I get that, but here are two things to ponder:

Firstly lets weigh up the cost: benefit ratio. The cost of an ACL reconstruction can start at least $5000 (and that doesn’t include pre-op physio, post-op physio and gym membership/programs), and the cost of implementing these programs range between $1.25 - $25 per player, per session [endif]--(7).![endif]--

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Secondly, re-read what I wrote earlier:

Neuromuscular training programs.

Enhance.

Player.

Performance.

So we need to stop making the excuse that we don’t have time. We need to make time. We need everyone (player, coach, parents) to buy in to the “performance enhancement” effects of these programs. If time is in an issue for the coach, get the players to do it independently before training commences, or simply adjust your training sessions to add these programs in to your planned sessions. All it takes is an extra 15-30mins per session, but the players, coach and the entire team will reap the rewards with lower injury rates, improved player performance, increased team continuity and increased team success.

In the event that all this useful information falls on deaf ears, there are certainly “high-risk” athletes that should be identified at pre-season screening who should be advised that conducting weekly neuromuscular training programs throughout the season is a non-negotiable. These players are:

- 14-18 year olds and males 19-25 year olds. These age groups have the highest incidence of ACL injury than any other age group (8).

- Those with a past history of ACL injury: It is widely publicised in the literature that past history is a contributing factor to future injury. Also, a 12% ACLR failure rate at 5 year follow-up and 10% ACL injury to opposite side within 5 years was found in subjects aged under 18 years of age at the time of primary injury (9).

- Those athletes with current or past history of PFJ pain: PFJ is thought to be a precursor to ACL injury [endif]--(10).![endif]--

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- Those with a family history of ACL injury (mother or father) (11).

Additionally, hormonal factors (higher risk in the pre-ovulatory phase) and players going through a growth spurt (biomechanical landing changes seen during growth spurts) need to be regularly monitored and training/playing adjusted accordingly throughout the pre-season and competitive season to minimise the risk of ACL injury [endif]--(12-14).![endif]--

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In closing up this blog, I firmly believe we can all be doing a better job with our athletes at the high-school level and community level of all sports, and implementing these injury prevention programs or “performance enhancement” programs are a very simple and cost-effective way to do so. From the literature, young females are consistently identified as a high-risk group, and with the huge success of the female Socceroos, the start of the women's AFL competition next year, and the rise and rise of the ANZ netball championship and the women’s Big Bash Cricket League, it is critical that we allow the current crop of young female athletes to strive for great heights and not be brought down by serious injuries, such as ACL injury.

As always please feel free to share this post far and wide. Injury prevention is a huge passion of mine, particularly in the adolescent athlete, and the more doctors, surgeons, physios, exercise physiologists, S&C coaches, personal trainers, players, parents, coaches and teachers that get on board with this information, it is my firm belief that we will start seeing lower injury rates across the nation, and better performances on the field.

For more on all things ACL injury, download my ACL rehab guide by clicking here, and/or watch my online ACL tutorials by clicking on the following links:

1) www.mickhughes.physio/lectures (delayed access, password required)

2) www.learn.physio/videos/100018 (instant access)

References:

1. Donnell-Fink LA, Klara K, Collins JE, Yang HY, Goczalk MG, Katz JN, et al. Effectiveness of Knee Injury and Anterior Cruciate Ligament Tear Prevention Programs: A Meta-Analysis. PloS one. 2015;10(12):e0144063. PubMed PMID: 26637173. Pubmed Central PMCID: PMC4670212. Epub 2015/12/05. eng.

2. Gagnier JJ, Morgenstern H, Chess L. Interventions designed to prevent anterior cruciate ligament injuries in adolescents and adults: a systematic review and meta-analysis. The American journal of sports medicine. 2013 Aug;41(8):1952-62. PubMed PMID: 22972854. Epub 2012/09/14. eng.

3. Taylor JB, Waxman JP, Richter SJ, Shultz SJ. Evaluation of the effectiveness of anterior cruciate ligament injury prevention programme training components: a systematic review and meta-analysis. British journal of sports medicine. 2015 Jan;49(2):79-87. PubMed PMID: 23922282. Epub 2013/08/08. eng.

4. Noyes FR, Barber Westin SD. Anterior cruciate ligament injury prevention training in female athletes: a systematic review of injury reduction and results of athletic performance tests. Sports health. 2012 Jan;4(1):36-46. PubMed PMID: 23016067. Pubmed Central PMCID: PMC3435901. Epub 2012/09/28. eng.

5. Finch CF, Twomey DM, Fortington LV, Doyle TL, Elliott BC, Akram M, et al. Preventing Australian football injuries with a targeted neuromuscular control exercise programme: comparative injury rates from a training intervention delivered in a clustered randomised controlled trial. Injury prevention : journal of the International Society for Child and Adolescent Injury Prevention. 2016 Apr;22(2):123-8. PubMed PMID: 26399611. Pubmed Central PMCID: PMC4819647. Epub 2015/09/25. eng.

6. Finch CF, Kemp JL, Clapperton AJ. The incidence and burden of hospital-treated sports-related injury in people aged 15+ years in Victoria, Australia, 2004-2010: a future epidemic of osteoarthritis? Osteoarthritis and cartilage / OARS, Osteoarthritis Research Society. 2015 Jul;23(7):1138-43. PubMed PMID: 25749009. Epub 2015/03/10. eng.

7. Swart E, Redler L, Fabricant PD, Mandelbaum BR, Ahmad CS, Wang YC. Prevention and screening programs for anterior cruciate ligament injuries in young athletes: a cost-effectiveness analysis. J Bone Joint Surg Am. 2014 May 7;96(9):705-11. PubMed PMID: 24806006. Pubmed Central PMCID: PMC4001460. Epub 2014/05/09. eng.

8. Sanders TL, Maradit Kremers H, Bryan AJ, Larson DR, Dahm DL, Levy BA, et al. Incidence of Anterior Cruciate Ligament Tears and Reconstruction: A 21-Year Population-Based Study. The American journal of sports medicine. 2016 Jun;44(6):1502-7. PubMed PMID: 26920430. Epub 2016/02/28. eng.

9. Morgan MD, Salmon LJ, Waller A, Roe JP, Pinczewski LA. Fifteen-Year Survival of Endoscopic Anterior Cruciate Ligament Reconstruction in Patients Aged 18 Years and Younger. The American journal of sports medicine. 2016 Feb;44(2):384-92. PubMed PMID: 26759030. Epub 2016/01/14. eng.

10. Myer GD, Ford KR, Di Stasi SL, Foss KD, Micheli LJ, Hewett TE. High knee abduction moments are common risk factors for patellofemoral pain (PFP) and anterior cruciate ligament (ACL) injury in girls: is PFP itself a predictor for subsequent ACL injury? British journal of sports medicine. 2015 Jan;49(2):118-22. PubMed PMID: 24687011. Pubmed Central PMCID: PMC4182160. Epub 2014/04/02. eng.

11. Smith HC, Vacek P, Johnson RJ, Slauterbeck JR, Hashemi J, Shultz S, et al. Risk factors for anterior cruciate ligament injury: a review of the literature-part 2: hormonal, genetic, cognitive function, previous injury, and extrinsic risk factors. Sports health. 2012 Mar;4(2):155-61. PubMed PMID: 23016083. Pubmed Central PMCID: PMC3435909. Epub 2012/09/28. eng.

12. Wild CY, Steele JR, Munro BJ. Why do girls sustain more anterior cruciate ligament injuries than boys?: a review of the changes in estrogen and musculoskeletal structure and function during puberty. Sports medicine (Auckland, NZ). 2012 Sep 1;42(9):733-49. PubMed PMID: 22784194. Epub 2012/07/13. eng.

13. Hewett TE, Zazulak BT, Myer GD. Effects of the menstrual cycle on anterior cruciate ligament injury risk: a systematic review. The American journal of sports medicine. 2007 Apr;35(4):659-68. PubMed PMID: 17293469. Epub 2007/02/13. eng.

14. Wild CY, Munro BJ, Steele JR. How Young Girls Change Their Landing Technique Throughout the Adolescent Growth Spurt. The American journal of sports medicine. 2016 May;44(5):1116-23. PubMed PMID: 26912286. Epub 2016/02/26. eng.

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https://www.ncbi.nlm.nih.gov/pubmed/22784194