DALLAS – The National Athletic Trainers’ Association (NATA) published online first its new position statement, “Prevention of Anterior Cruciate Ligament Injury.” Created by the NATA Foundation, the statement will appear in the January 2018 Journal of Athletic Training, NATA’s scientific publication.
Lower extremity injuries make up 66 percent of all sports injuries, with the knee being the most commonly injured joint.1 Anterior cruciate ligament (ACL) injuries are quite common in athletes, and unfortunately, surgical reconstruction and rehabilitation do not prevent long-term morbidity or decrease the risk of a future ACL injury.2-7 The costs associated with surgically reconstructed ACL injuries range from $5,000 to $17,000 per patient; however, the estimated long-term societal costs may be as high as $38,000 per patient.8-13 Perhaps even more alarming than the high financial costs was a report14 indicating that the rate of ACL injuries was rising rapidly.
“Preventing ACL injuries during sport and physical activity may dramatically decrease medical costs and long-term disability,” says lead author Darin Padua, PhD, ATC, professor and chair, department of Exercise and Sport Science and director, Sports Medicine Research Laboratory, University of North Carolina at Chapel Hill. “Implementing ACL injury prevention training programs may improve an individual’s neuromuscular control and lower extremity biomechanics to reduce risk of injury and improve one’s functional performance.”
The position statement offers guidelines for athletic trainers, physicians and other health care professionals on how to prevent noncontact and indirect contact ACL injuries in athletes and physically active individuals.
Position Statement Recommendations
Effects of Injury Prevention Training Programs on Injury Reduction and Performance Enhancement – two primary areas of benefit include decreased risk of ACL and other knee injuries as well as improved performance.
- Multicomponent training programs that include feedback regarding technique and at least three of the exercise categories (i.e., strength, plyometrics, agility, balance and flexibility) are recommended to reduce noncontact and indirect contact ACL and other knee injuries during physical activity in females and males.
- These programs are advised for improving balance, lower extremity strength and power and measures of functional performance.
Development of Multicomponent Injury Prevention Training Programs
Elements of injury prevention training can vary among programs to help decrease injury rates and improve neuromuscular function and physical performance. While these guidelines do not promote a specific program or group of exercises, general recommendations are provided.
Exercise Selection and Training Intensity
- A multicomponent preventive training program involves offering feedback on movement techniques and should include at least three of the following exercise categories: strength, plyometrics, agility, balance and flexibility.
- Injury prevention training exercises should be performed at progressive intensity levels that are challenging and allow for excellent movement, quality and technique.
Training Volume (Frequency and Duration)
- Multicomponent training programs should be performed during preseason and while in-season at least two to three times a week.
- To maintain the benefits of reduced injury rates and improved neuromuscular function and performance over time, multicomponent training programs (preseason, in season and offseason) should be performed each year and not discontinued after a single season.
Implementation of Multicomponent Injury Prevention Training Program (Program Adoption and Maintenance)
- Multicomponent training programs should be regularly supervised by individuals such as athletic trainers, who are skilled in identifying faulty movement patterns to ensure excellent movement quality and provide feedback on exercise technique.
- Multicomponent training programs are effective when implemented as a dynamic warmup or as part of a comprehensive strength and conditioning program. If time constraints are a concern, evidence shows they can be performed 10 to 15 minutes before the start of practices or games.
Targeting Individuals for Injury Prevention Training Programs
All individuals engaged in sports and physical activity are advised to participate in a multicomponent preventive training program. Those who participate in specific sports or display certain traits should be targeted for this training as they are either at a higher risk of ACL injury or have a greater potential for benefit.
- Athletes participating in high-risk sports that involve landing, jumping and cutting tasks (e.g., basketball, soccer, team handball), especially females, and those with a history of an ACL injury, especially young individuals who return to sport-related activities, should be targeted for injury prevention training.
- Children who participate in these sports should also be targeted.
“Our overall goal is to reduce and prevent ACL injury and improve performance,” adds Padua. “Working with athletic trainers, physicians and other health care and fitness professionals will help ensure athletes and those who are physically active are benefiting from injury prevention training programs with proper technique and education.”
1 Hootman JM, Macera CA, Ainsworth BE, Addy CL, Martin M, Blair SN. Epidemiology of musculoskeletal injuries among sedentary and physically active adults. Med Sci Sports Exerc. 2002;34(5):838-844.
2 Walden M, Hagglund M, Ekstrand J. High risk of new knee injury in elite footballers with previous anterior cruciate ligament injury. Br J Sports Med. 2006;40(2):158-162; discussion 158-162.
3 Lohmander LS, Englund PM, Dahl LL, Roos EM. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med. 2007;35(10):1756-1769.
4 Lohmander LS, Ostenberg A, Englund M, Roos H. High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis Rheum. 2004;50(10):3145-3152.
5 Toivanen AT, Heliovaara M, Impivaara O, et al. Obesity, physically demanding work and traumatic knee injury are major risk factors for knee osteoarthritis-a population-based study with a follow-up of 22 years. Rheumatology (Oxford). 2010;49(2):308-314.
6 Rugg CM, Wang D, Sulzicki P, Hame SL. Effects of prior knee surgery on subsequent injury, imaging, and surgery in NCAA collegiate athletes. Am J Sports Med. 2014;42(4):959-964.
7 Luc B, Gribble PA, Pietrosimone BG. Osteoarthritis prevalence following anterior cruciate ligament reconstruction: a systematic review and numbers-needed-to-treat analysis. J Athl Train. 2014;49(6):806-819.
8 Gottlob CA, Baker CL, Jr, Pellissier JM, Colvin L. Cost effectiveness of anterior cruciate ligament reconstruction in young adults. Clin Orthop Relat Res. 1999(367):272-282.
9 Farshad M, Gerber C, Meyer DC, Schwab A, Blank PR, Szucs T. Reconstruction versus conservative treatment after rupture of the anterior cruciate ligament: cost effectiveness analysis. BMC Health Serv Res. 2011;11:317.
10 Genuario JW, Faucett SC, Boublik M, Schlegel TF. A cost-effectiveness analysis comparing 3 anterior cruciate ligament graft types: bone-patellar tendon-bone autograft, hamstring autograft, and allograft. Am J Sports Med. 2012;40(2):307-314.
11 Lubowitz JH, Appleby D. Cost-effectiveness analysis of the most common orthopaedic surgery procedures: knee arthroscopy and knee anterior cruciate ligament reconstruction. Arthroscopy. 2011;27(10):1317-1322.
12 Mather RC, 3rd, 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.
13 Paxton ES, Kymes SM, Brophy RH. Cost-effectiveness of anterior cruciate ligament reconstruction: a preliminary comparison of single-bundle and double-bundle techniques. Am J Sports Med. 2010;38(12):2417-2425.
14 Lyman S, Koulouvaris P, Sherman S, Do H, Mandl LA, Marx RG. Epidemiology of anterior cruciate ligament reconstruction: trends, readmissions, and subsequent knee surgery. J Bone Joint Surg Am. 2009;91(10):2321-2328.