ACL Injuries: Let’s Get Serious About Prevention (Dr. Robin West)

Robin West, MD is the Director of Sports Medicine at Inova. Dr. West will be blogging on current topics and best practices in sports injury prevention and treatment.

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 Prevention Training is an important and cost-effective measure to help reduce the financial and physical costs experienced by athletes with ACL injuries.

An ACL injury is one of the most debilitating injuries an athlete can suffer. In today’s blog post, I will shed some light on:

• the growing number of ACL injuries in female athletes, and
• the crucial importance of neuromuscular training programs to help prevent these injuries from happening in the first place.

ACL: A Serious Injury

When the ACL (anterior cruciate ligament, one of four major ligaments in the knee) is damaged, it results in significantly decreased quality of life (both physical and psychological) for the athlete and their family.

ACL injuries result in lost productivity at school and work, financial hardship (between surgery and physical therapy), and an increased risk of osteoarthritis. Due to the poor outcomes of non-operative treatment, surgical treatment is usually recommended. Although published studies indicate largely positive surgical outcomes, many athletes still fail to return to their prior level of competition following the surgery.

ACL Risks for Female Athletes

Female athletes are currently experiencing a rate of ACL injury that is 4 to 6 times greater than their male counterparts. The implementation of Title IX (“Title Nine”) in 1972, the law which required
schools receiving federal funding to provide females with an equal opportunity to compete in sports, resulted in a fivefold increase in female athletic participation at the collegiate level and a tenfold increase at the high school level, thus increasing the overall incidence of ACL tears nationwide.

In addition, female athletes are physiologically at greater risk of ACL injury for several reasons. Click to watch a WUSA-9 feature on ACL injury where I discuss this issue (and hear my colleague, Dr. Jill McCabe, discuss post-concussion safety).

Breaking Down the Risk Factors

Approximately 70% of ACL tears occur from a “noncontact mechanism” — where the athlete sustains the injury from an awkward landing or twisting event. Many risk factors have been identified with ACL tears.  These risk factors can be divided into two types: non-modifiable and modifiable. The non-modifiable ones include anatomical, developmental, and hormonal issues.

Modifiable risk factors are neuromuscular imbalances that result in more strain across the ACL and potentially lead to these “non-contact” ACL tears. One example of a modifiable risk factor is poor landing techniques that result in inward collapse of the knee. Research has shown that modifiable risk factors can be mitigated through specific ACL injury prevention training programs.

Prevention Training

Prevention programs are typically done three times per week for 20 minutes and focus on a number of key aspects of training: balance, proprioception (sensing and positioning of the body), plyometrics (“jump training”), strengthening, endurance, and stability. They can be incorporated into a warm-up program. Well-designed ACL prevention programs have been proven to decrease the incidence of ACL tears, and should be incorporated into all athletic programs.

Since the number needed to treat in order to prevent one ACL injury is eighty-nine over the course of one season, it may be beneficial to “screen” at-risk athletes. However, universal screening programs are expensive and time consuming and have not been shown to be cost effective. On the contrary, universal neuromuscular training is cost-effective for several reasons:

• ACL injuries are common and are associated with a large cost due to a high rate of surgical treatment.
• Neuromuscular training programs have a relatively low cost combined with a large evident risk reduction, making primary prevention the best approach.

Learn More

Click here to read my article  (with Dr. William F. Postma) titled “Anterior Cruciate Ligament Injury-Prevention Programs”  from The Journal of Bone and Joint Surgery.
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Robin V. West, MD is a board certified physician in Sports Medicine and Orthopaedic Surgery. She is a practicing member of the Inova Medical Group Orthopedics and Sports Medicine practice, with offices in Arlington and McLean. She will be speaking at the Mohsen Ziai Pediatric Conference (November 7-8, 2014), an accredited Continuing Medical Education (CME) conference.

* In a 2012 meta-analysis, Sadoghi et al. found strong evidence for a significant, positive effect of ACL injury prevention programs. The pooled risk ratio was 0.38 or a risk reduction of 62% in all athletes.  Stratification by sex showed that female athletes had a risk ratio of 0.48 or a risk reduction of 52%, and male athletes had a risk ratio of 0.15 or a risk reduction of 85%. Many other well done studies have showed similar ACL injury reduction rates when athletes follow a specific ACL prevention training program.