ACL Injury Prevention: What Does Research Tell Us?

Purpose of ReviewMechanisms leading to anterior cruciate ligament (ACL) injury have been identified, yet re-injury or a secondary injury persists in the athletic population. The purpose of this review is to identify risk factors associated with ACL injury and investigate programs to prevent injury.Recent FindingsFaulty mechanics during dynamic movement that cause excessive valgus force at the knee increases the risk of ACL injury. Faulty mechanics may be a result of lateral displacement of the trunk, unequal limb loading, and lack of control to avoid the valgus knee position. Altered movements that place the ACL at risk are best identified in a fatigued state; however, could be recognized in a standard dynamic assessment. The faulty movement patterns are modifiable and should be addressed in an injury prevention program. Prevention programs include various modes of exercise such as plyometrics, neuromuscular training, and strength training.SummaryThis review concludes that those programs which utilize neuromuscular training and strength training at a young age show the most promise in reducing ACL injuries. An ongoing thorough dynamic examination is necessary for all athletes while adjusting the intervention program in order to decrease the risk of ACL injury.

[1]  Staci M Thomas,et al.  The Influence of Age on the Effectiveness of Neuromuscular Training to Reduce Anterior Cruciate Ligament Injury in Female Athletes , 2013, The American journal of sports medicine.

[2]  Gregory D Myer,et al.  Risk of Secondary Injury in Younger Athletes After Anterior Cruciate Ligament Reconstruction , 2016, The American journal of sports medicine.

[3]  T. Hewett,et al.  Optimization of the anterior cruciate ligament injury prevention paradigm: novel feedback techniques to enhance motor learning and reduce injury risk. , 2015, The Journal of orthopaedic and sports physical therapy.

[4]  Kevin R Ford,et al.  Utilization of modified NFL combine testing to identify functional deficits in athletes following ACL reconstruction. , 2011, The Journal of orthopaedic and sports physical therapy.

[5]  W. Dunn,et al.  Incidence of anterior cruciate ligament injury among active duty U.S. military servicemen and servicewomen. , 2007, Military medicine.

[6]  Christine D. Pollard,et al.  Altered Lower Extremity Movement Variability in Female Soccer Players During Side-Step Cutting After Anterior Cruciate Ligament Reconstruction , 2015, The American journal of sports medicine.

[7]  Kevin R Ford,et al.  Gender differences in the kinematics of unanticipated cutting in young athletes. , 2005, Medicine and science in sports and exercise.

[8]  R. Heidt,et al.  Avoidance of Soccer Injuries with Preseason Conditioning , 2000, The American journal of sports medicine.

[9]  T. Andriacchi,et al.  Inertial Sensor-Based Feedback Can Reduce Key Risk Metrics for Anterior Cruciate Ligament Injury During Jump Landings , 2012, The American journal of sports medicine.

[10]  R. A. Ekstrom,et al.  Electromyographic analysis of core trunk, hip, and thigh muscles during 9 rehabilitation exercises. , 2007, The Journal of orthopaedic and sports physical therapy.

[11]  C. Finch,et al.  Compliance with Sport Injury Prevention Interventions in Randomised Controlled Trials: A Systematic Review , 2016, Sports Medicine.

[12]  T. Hewett,et al.  The Mechanistic Connection Between the Trunk, Hip, Knee, and Anterior Cruciate Ligament Injury , 2011, Exercise and sport sciences reviews.

[13]  Arvind G. von Keudell,et al.  Effectiveness of anterior cruciate ligament injury prevention training programs. , 2012, The Journal of bone and joint surgery. American volume.

[14]  Kevin R Ford,et al.  Understanding and preventing acl injuries: current biomechanical and epidemiologic considerations - update 2010. , 2010, North American journal of sports physical therapy : NAJSPT.

[15]  K. Shea,et al.  Anterior Cruciate Ligament and Knee Injury Prevention Programs for Soccer Players , 2015, The American journal of sports medicine.

[16]  J. Sinclair,et al.  The Presence of Bilateral Imbalance of the Lower Limbs in Elite Youth Soccer Players of Different Ages , 2016, Journal of strength and conditioning research.

[17]  A. K. Aune,et al.  No Differences in Prevalence of Osteoarthritis or Function After Open Versus Endoscopic Technique for Anterior Cruciate Ligament Reconstruction , 2012, The American journal of sports medicine.

[18]  F. Mayer,et al.  Gain in Strength and Muscular Balance After Balance Training , 2001, International journal of sports medicine.

[19]  Kevin R Ford,et al.  Anterior Cruciate Ligament Injuries in Female Athletes , 2006, The American journal of sports medicine.

[20]  R. Marx,et al.  20 Years of Pediatric Anterior Cruciate Ligament Reconstruction in New York State , 2014, The American journal of sports medicine.

[21]  C. Powers,et al.  Improvements in Hip Muscle Performance Result in Increased Use of the Hip Extensors and Abductors During a Landing Task , 2014, The American journal of sports medicine.

[22]  H. Kanehisa,et al.  Effects of Stabilization Training on Trunk Muscularity and Physical Performances in Youth Soccer Players , 2013, Journal of strength and conditioning research.

[23]  Jiri Dvorak,et al.  Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial , 2008, BMJ : British Medical Journal.

[24]  Carlin Senter,et al.  Biomechanical Analysis of Tibial Torque and Knee Flexion Angle , 2006, Sports medicine.

[25]  James A. Ashton-Miller,et al.  The Relationship between Quadriceps Muscle Force, Knee Flexion, and Anterior Cruciate Ligament Strain in an in Vitro Simulated Jump Landing , 2006, The American journal of sports medicine.

[26]  L. Engebretsen,et al.  Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial , 2005, BMJ : British Medical Journal.

[27]  E. Roos,et al.  The Long-term Consequence of Anterior Cruciate Ligament and Meniscus Injuries , 2007, The American journal of sports medicine.

[28]  T. Zantop,et al.  A controlled prospective case control study of a prevention training program in female team handball players: the German experience , 2005, Archives of Orthopaedic and Trauma Surgery.

[29]  S. Cobley,et al.  The Efficacy of Injury Prevention Programs in Adolescent Team Sports , 2016, The American journal of sports medicine.

[30]  L. Engebretsen,et al.  The prevalence of patellofemoral osteoarthritis 12 years after anterior cruciate ligament reconstruction , 2013, Knee Surgery, Sports Traumatology, Arthroscopy.

[31]  K. Michaëlsson,et al.  Prevention of soccer-related knee injuries in teenaged girls. , 2010, Archives of internal medicine.

[32]  J. Karlsson,et al.  Variability in leg muscle power and hop performance after anterior cruciate ligament reconstruction , 2012, Knee Surgery, Sports Traumatology, Arthroscopy.

[33]  J. Katz,et al.  Effectiveness of Knee Injury and Anterior Cruciate Ligament Tear Prevention Programs: A Meta-Analysis , 2015, PloS one.

[34]  James R Andrews,et al.  Recent advances in the rehabilitation of anterior cruciate ligament injuries. , 2012, The Journal of orthopaedic and sports physical therapy.

[35]  Katherine Kaufer Christoffel,et al.  Effect of neuromuscular warm-up on injuries in female soccer and basketball athletes in urban public high schools: cluster randomized controlled trial. , 2011, Archives of pediatrics & adolescent medicine.

[36]  J. Oñate,et al.  Pivot task increases knee frontal plane loading compared with sidestep and drop-jump , 2011, Journal of sports sciences.

[37]  Dean Wang,et al.  Effects of Prior Knee Surgery on Subsequent Injury, Imaging, and Surgery in NCAA Collegiate Athletes , 2014, The American journal of sports medicine.

[38]  L. Engebretsen,et al.  Sport Participation and the Risk of Anterior Cruciate Ligament Reconstruction in Adolescents , 2016, The American journal of sports medicine.

[39]  F. Noyes,et al.  The Effect of Neuromuscular Training on the Incidence of Knee Injury in Female Athletes , 1999, The American journal of sports medicine.

[40]  H. Alfredson,et al.  Balance board training: prevention of traumatic injuries of the lower extremities in female soccer players? , 2000, Knee Surgery, Sports Traumatology, Arthroscopy.

[41]  A. Caraffa,et al.  Prevention of anterior cruciate ligament injuries in soccer , 1996, The Journal of orthopaedic and sports physical therapy.

[42]  DirkJan Veeger Dynamic modeling of musculoskeletal motion , 2002 .

[43]  F R Noyes,et al.  Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture , 1991, The American journal of sports medicine.

[44]  J. Andrews,et al.  Anterior cruciate ligament reconstruction , 2002 .

[45]  M. Ha,et al.  A meta-analysis of the effect of neuromuscular training on the prevention of the anterior cruciate ligament injury in female athletes , 2010, Knee Surgery, Sports Traumatology, Arthroscopy.

[46]  Poul Dyhre-Poulsen,et al.  The anterior cruciate ligament does play a role in controlling axial rotation in the knee , 1997, Knee Surgery, Sports Traumatology, Arthroscopy.

[47]  S. Piva,et al.  Evaluating Eccentric Hip Torque and Trunk Endurance as Mediators of Changes in Lower Limb and Trunk Kinematics in Response to Functional Stabilization Training in Women With Patellofemoral Pain , 2015, The American journal of sports medicine.

[48]  T. Hewett,et al.  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? , 2014, British Journal of Sports Medicine.

[49]  Kate E Webster,et al.  Return-to-Sport Outcomes at 2 to 7 Years After Anterior Cruciate Ligament Reconstruction Surgery , 2012, The American journal of sports medicine.

[50]  Xueliang Pan,et al.  Lumbopelvic Control and Days Missed Because of Injury in Professional Baseball Pitchers , 2014, The American journal of sports medicine.

[51]  R. Reina,et al.  Human-Assisted Invasions of Pacific Islands by Litoria Frogs: A Case Study of the Bleating Tree Frog on Lord Howe Island , 2015, PloS one.

[52]  D. Kirkendall,et al.  Effectiveness of a Neuromuscular and Proprioceptive Training Program in Preventing Anterior Cruciate Ligament Injuries in Female Athletes , 2005, The American journal of sports medicine.

[53]  L. Engebretsen,et al.  Prevention of anterior cruciate ligament injuries in female team handball players: a prospective intervention study over three seasons , 2003, Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine.

[54]  I. Holm,et al.  Design and implementation of a neuromuscular training program following anterior cruciate ligament reconstruction. , 2001, The Journal of orthopaedic and sports physical therapy.

[55]  C Castagna,et al.  Strong correlation of maximal squat strength with sprint performance and vertical jump height in elite soccer players , 2004, British Journal of Sports Medicine.

[56]  T. Nessler Using Movement Assessment to Improve Performance and Reduce Injury Risk , 2013 .

[57]  Marc Tompkins,et al.  Changes in Involved and Uninvolved Limb Function During Rehabilitation After Anterior Cruciate Ligament Reconstruction , 2015, The American journal of sports medicine.

[58]  R. Bahr,et al.  Preventing injuries in female youth football – a cluster‐randomized controlled trial , 2008, Scandinavian Journal of Medicine & Science in Sports.

[59]  J S Torg,et al.  Video analysis of trunk and knee motion during non-contact anterior cruciate ligament injury in female athletes: lateral trunk and knee abduction motion are combined components of the injury mechanism , 2009, British Journal of Sports Medicine.

[60]  M. Wünschel,et al.  The anterior cruciate ligament provides resistance to externally applied anterior tibial force but not to internal rotational torque during simulated weight-bearing flexion. , 2010, Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association.

[61]  T. Hewett,et al.  Deficits in Neuromuscular Control of the Trunk Predict Knee Injury Risk , 2007, The American journal of sports medicine.

[62]  Bing Yu,et al.  Understanding and Preventing Noncontact Anterior Cruciate Ligament Injuries , 2006, The American journal of sports medicine.

[63]  J. Ashton-Miller,et al.  Gender differences in knee angle when landing from a drop-jump. , 2001, The American journal of knee surgery.

[64]  T. Krosshaug,et al.  Comparison of Drop Jumps and Sport-Specific Sidestep Cutting , 2013, American Journal of Sports Medicine.

[65]  T. Hewett,et al.  Dosage Effects of Neuromuscular Training Intervention to Reduce Anterior Cruciate Ligament Injuries in Female Athletes: Meta- and Sub-Group Analyses , 2014, Sports Medicine.

[66]  B. Gaunt,et al.  Anthropometric and demographic factors affecting distance hopped and limb symmetry index for the crossover hop-for-distance test in high school athletes. , 2001, The Journal of orthopaedic and sports physical therapy.

[67]  T. Best,et al.  Lumbopelvic Control and Pitching Performance of Professional Baseball Pitchers , 2011, Journal of strength and conditioning research.

[68]  T. Bernasek,et al.  Risk factors for soft tissue knee injuries in active duty U.S. Army soldiers, 2000-2005. , 2013, Military medicine.

[69]  T. Hewett,et al.  Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes: A Prospective Study , 2005, The American journal of sports medicine.

[70]  Kevin R Ford,et al.  Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. , 2006, The Journal of orthopaedic and sports physical therapy.

[71]  Jiri Dvorak,et al.  A Randomized Controlled Trial to Prevent Noncontact Anterior Cruciate Ligament Injury in Female Collegiate Soccer Players , 2008, The American journal of sports medicine.

[72]  Staci M Thomas,et al.  The Utility of Limb Symmetry Indices in Return-to-Sport Assessment in Patients With Bilateral Anterior Cruciate Ligament Reconstruction , 2016, The American journal of sports medicine.

[73]  T. Hewett,et al.  Differential neuromuscular training effects onACL injury risk factors in"high-risk" versus "low-risk" athletes , 2007, BMC musculoskeletal disorders.

[74]  Barnett S. Frank,et al.  Trunk and Hip Biomechanics Influence Anterior Cruciate Loading Mechanisms in Physically Active Participants , 2013, The American journal of sports medicine.

[75]  A. Amis The functions of the fibre bundles of the anterior cruciate ligament in anterior drawer, rotational laxity and the pivot shift , 2012, Knee Surgery, Sports Traumatology, Arthroscopy.

[76]  Margareta Nordin,et al.  Basic Biomechanics of the Musculoskeletal Systm , 1989 .

[77]  K. Shea,et al.  Lack of effect of a knee ligament injury prevention program on the incidence of noncontact anterior cruciate ligament injury. , 2006, The Journal of bone and joint surgery. American volume.

[78]  John R Taylor,et al.  Factors Influencing the Implementation of Anterior Cruciate Ligament Injury Prevention Strategies by Girls Soccer Coaches , 2013, Journal of strength and conditioning research.

[79]  M. K. Todd,et al.  The Effect of Fatigue on Landing Biomechanics in Single-Leg Drop Landings , 2010, Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine.

[80]  Freddie H. Fu,et al.  Predictors of proximal tibia anterior shear force during a vertical stop‐jump , 2007, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[81]  T. Hewett,et al.  ABCs of Evidence-Based Anterior Cruciate Ligament Injury Prevention Strategies in Female Athletes , 2015, Current Physical Medicine and Rehabilitation Reports.

[82]  B. Koes,et al.  Core Stability: Inter- and Intraobserver Reliability of 6 Clinical Tests , 2010, Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine.

[83]  Kate E. Webster,et al.  Exploring the High Reinjury Rate in Younger Patients Undergoing Anterior Cruciate Ligament Reconstruction , 2016, The American journal of sports medicine.

[84]  Scott G McLean,et al.  Combined effects of fatigue and decision making on female lower limb landing postures: central and peripheral contributions to ACL injury risk. , 2008, Clinical biomechanics.

[85]  Susan M Sigward,et al.  Loading characteristics of females exhibiting excessive valgus moments during cutting. , 2007, Clinical biomechanics.

[86]  C. Ranson,et al.  Injury Risk in International Rugby Union , 2015, Orthopaedic journal of sports medicine.

[87]  Anthony M J Bull,et al.  Hip and knee joint loading during vertical jumping and push jerking. , 2013, Clinical biomechanics.

[88]  T. Birmingham,et al.  The Familial Predisposition toward Tearing the Anterior Cruciate Ligament , 2005, The American journal of sports medicine.

[89]  T. Hewett,et al.  Compliance with neuromuscular training and anterior cruciate ligament injury risk reduction in female athletes: a meta-analysis. , 2012, Journal of athletic training.

[90]  R. D'ambrosia,et al.  Muscular coactivation , 1988, The American journal of sports medicine.

[91]  Karl F Orishimo,et al.  Effect of fatigue on single-leg hop landing biomechanics. , 2006, Journal of applied biomechanics.