Anterior Cruciate Ligament

Injury
Mechanisms of Injury and Strategies for Injury
Prevention

a,b, c,d
Judith R. Peterson, MD *, Brian J. Krabak, MD, MBA

KEYWORDS
 Knee  Anterior cruciate ligament  Sports injury  Injury prevention
 Lower extremity injury  Knee injury reduction

KEY POINTS
 Anterior cruciate ligament injuries are common in athletes.
 Anterior cruciate ligament injuries can have long-term consequences for the affected
athlete.
 Widespread implementation of anterior cruciate ligament injury prevention programs has
not occurred.
 This article reviews some strategies for prevention of anterior cruciate ligament injuries
based on current research.

INTRODUCTION

Anterior cruciate ligament (ACL) injury is a common and severe sports injury. The fe-
male athlete is at particular risk for this type of injury. ACL injuries have immediate
and long-term consequences for affected athletes.1,2 Despite much medical literature
concerning these injuries, widespread implementation of effective injury prevention
programs has not occurred. The aim of this article is to review ACL injury epidemi-
ology, including risk factors, mechanisms for injury, and strategies for ACL prevention
based on current research.

a
Department of Neurosciences, Sanford School of Medicine, University of South Dakota, 1400
West 22nd Street, Sioux Falls, SD 57105, USA; b Yankton Medical Clinic, 1104 West 8th Street,
Yankton, SD 57078, USA; c Rehabilitation, Orthopedics, and Sports Medicine, University of
Washington Sports Medicine, 3800 Montlake Boulevard Northeast, Box 354060, Seattle, WA
98195, USA; d Seattle Children’s Sports Medicine, 4800 Sand Point Way Northeast, Seattle,
WA 98145, USA
* Corresponding author. Yankton Medical Clinic, 1104 West 8th Street, Yankton, SD 57078.
E-mail address: [email protected]

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814 Peterson & Krabak

EPIDEMIOLOGY

ACL injury is a common sports injury that often occurs during adolescence and young
adulthood. It often occurs from a noncontact knee injury, but can occur from direct
trauma, such as a blow to the knee. It is estimated that year-round high-level female
soccer and basketball participants have approximately a 5% risk of having an ACL
tear.3 Defining 1 athletic exposure (AE) as 1 athlete participating in 1 game or prac-
tice, studies at the high school level suggest football has the highest rate of knee
injury at 6.29 per 10,000 AE. High school girls’ soccer and girls’ gymnastics are
also huge contributors to knee injuries with 4.53 per 10,000 AE in girls’ soccer and
4.23 per 10,000 AE in girls’ gymnastics. When we examine the specific risk of ACL
injury for girls compared with boys in sex-comparable sports at the high school level,
we find that girls are generally at a profoundly higher risk of ACL injury with a relative
risk (RR) of 2.38. This statement remains valid for softball versus baseball (RR, 4.99),
basketball (RR, 4.54), and soccer (RR, 2.33)4 Joseph and colleagues,5 in a recent
epidemiologic multisport comparison of high school athletics at 100 representative
US high schools, found that 74.9% of ACL injuries occurred during competition
versus practice. They found the highest injury rates per 100,000 AE in girl’s soccer
(12.2) followed by football (11.1) and girl’s basketball. Interestingly, boy’s basketball
had a relatively low risk at 2.3.
Studies of collegiate athletes note that men’s spring football and women’s gym-
nastics have equal ACL injury rates per 1000 AE (0.33). The authors also note that 3
of the 4 collegiate sports with the highest ACL injury rate included women’s gym-
nastics (0.33), women’s soccer (0.28), and women’s basketball (0.23).6
Given the above epidemiology and that ACL injuries frequently require surgery, the
expense of these injuries becomes a significant public health concern.4,7 A 2013 study
of 2 prospective orthopedic cohorts estimated the costs for surgical repair and reha-
bilitative conservative care of ACL injuries. The Multicenter Orthopedics Outcomes
Network cohort included 988 primary ACL tears followed up for a minimum of 6 years.
The KANNON (knee anterior cruciate ligament, nonsurgical vs surgical treatment)
cohort studied 121 patients for a minimum of 2 years. The societal costs of each
type of treatment of this injury are significant. The lifetime cost estimate for ACL sur-
gical repair was $38,121 compared with $88,538 for rehabilitative conservative care.
The author’s acknowledge that the long-term economic cost predictions were based
on lower levels of evidence than level I. The authors additionally note that ACL tears
may cause profound long-term issues for patients regardless of treatment approach,
highlighting the importance of primary prevention.7
Although the above comments concern the long-term issues that arise after ACL
injuries, there are immediate immense impacts of ACL injuries on health care expendi-
tures. This serious injury necessitates physician evaluation, radiography, and rehabil-
itation in addition to potential surgical intervention and postoperative care; these
represent a public health emergency. Given the huge health, economic, and societal
tolls of ACL injury, it becomes imperative for physicians to better understand how to
prevent this catastrophic injury. Third-party payer data on ACL injury costs are difficult
to obtain. It is estimated, however, that up to 250,000 ACL injuries occur yearly in the
United States, at a cost of more than $2 billion per year.8 Given the above startling and
troubling statistics, it is critical that physicians have a thorough understanding of the
causes of ACL injuries and the ways in which ACL injuries can be prevented.
It is difficult to prevent acute knee injuries secondary to direct knee trauma because of
the large contact forces on the joint encountered with direct knee impacts. In the United
States, football participation is the leading cause of sports trauma overall and a
 Anterior Cruciate Ligament Injury 815

common cause of injury to the ACL.9 However, it is surprising that most sports-related
ACL injuries are actually secondary to noncontact-related forces on the knee joint. Con-
tact causes fewer ACL tears than cutting maneuvers or speed decelerations.10
Immediate morbidity and loss of function in the athlete are significant public health
concerns. Larger public health concerns are the long-term sequelae of sports-related
knee injuries. Of young adults with knee injuries, 13.9% will have knee osteoarthritis
by age 65 compared with 6.0% in those without histories of knee injuries.11,12 A
study of female soccer players with a prior history of ACL injury found arthritic radio-
graphic changes such as joint space narrowing or osteophytes in 82% of those
examined radiographically 12 years after injury. Fifty-one percent of women fulfilled
the radiographic requirements for radiographic knee osteoarthritis in the cohort with
a median age of 31 years (range, 26 to 40 years old.) The cutoff for radiographic oste-
oarthritis in this study approximated grade 2 on the Kellgren/Lawrence scale.
Seventy-five percent of respondents in this study noted symptoms affecting their
knee-related quality of life. These symptoms resulted in lifestyle modifications in
50% of respondents.13
A study of male soccer players noted similar outcomes. Male soccer players with a
history of ACL injuries were radiographically assessed 14 years after ACL injury. This
radiographic examination documented abnormalities in 78% of evaluated knees with
41% of the injured knees showing findings of Kellgren/Lawrence grade 2 or higher.
Surgical versus conservative treatment of these injured knees did not affect the radio-
graphic outcome. Noninjured knees by contrast showed advanced changes in only
4% of knees. Study participants also responded to a questionnaire to further assess
patient-relevant outcomes 14 years after ACL injury. Eighty percent of the study par-
ticipants reported reduced activity level. Of these, 69% noted the knee injury as the
cause of reduced activity. Thirty percent experienced severe changes in lifestyle.14
In addition to the physical toll of these injuries, the emotional functioning of other-
wise healthy young people may be negatively affected. The long-term impact of the
depression experienced by some of those who have an ACL injury remains to be
determined.15,16

Anatomy
The cruciate ligaments are integral to knee joint stability (Fig. 1). The knee is described
as having a screw-home mechanism where the tibia rotates as the knee flexes and ex-
tends through the tibiofemoral articulation. As the knee straightens, the tibia externally
rotates. During this motion, contact points of the joint actually migrate anteriorly with
knee extension. Knee ligaments become more taut with extension. The ACL is
described as the primary structure preventing anterior tibial translation.17 ACL strain
injury occurs primarily through shear forces with additional contributions to injury
from coronal and axial plane stress.18,19 The ACL is actually 2 discrete anatomic bun-
dles (Fig. 2). The anteromedial and posterolateral bundles begin from the posterome-
dial portion of the lateral femoral condyle and insert between and slightly anteriorly to
the tibial intercondylar eminence. The bundles’ names are descriptive of their relation-
ship at this tibial insertion.20 There are 2 bundles that comprise the ACL, which spiral
and increase in tension with tibial internal rotation.19 The bundles also have variable
tension based on knee flexion angle and varus/valgus and rotational stress.19,21,22
Because of this, the ACL is at particular risk with sidestepping or cutting maneuvers
in knee flexion angles of 0 to 40 .21,22
The majority of the blood supply to the ACL is through the middle genicular artery,
which derives from the popliteal artery. There are additional blood flow contributions
816 Peterson & Krabak

Fig. 1. Magnetic resonance imaging of normal knee with intact anterior cruciate ligament
and posterior cruciate ligament. (From Snyder RR, Pacicca DM, Dewire P. Soft tissue injuries
(Chapter 44). In: Becker JM, Stucchi AF, editors. Essentials of surgery. Philadelphia: Saunders
Elsevier; 2006. p. 537; with permission. Copyright 2006, Elsevier Inc. All rights reserved.)

from the inferomedial and inferolateral genicular arteries, which traverse the anterior
fat pad.20 Tears of the ACL commonly result in permanent damage to the blood supply
of the ligament, which impairs innate healing potential.19

Injury Risk Factors

Our knowledge of the various risk factors for a tear of the ACL and our ability to predict
which athletes are at particularly high risk for this injury continue to evolve. Both

Fig. 2. Cadaveric dissection shows the 2 distinct bundles of the ACL. AM, anteromedial; PL,
posterolateral. (From Hofbauer M, Muller B, Wolf M, et al. Contemporary ACL surgery
anatomic double-bundle anterior cruciate ligament reconstruction. Oper Tech Sports Med
2013;21(1):47–54; with permission.)
 Anterior Cruciate Ligament Injury 817

extrinsic factors and intrinsic factors impact ACL injury risk. It remains unsettled, how-
ever, as to how all risk factors interplay and coalesce in each individual athlete to result
in ACL injury.1,3,10,23
Several external and internal risk factors appear to predispose some athletes to ACL
injury risk.10,23 Playing American style football exposes the athlete’s knee to large
direct contact forces. Tackling or being tackled leads to most ACL injuries in football
players. From 1987 to 2000, ACL reconstruction was the third most common orthope-
dic procedure incurred by National Football League prospects and the most common
medical condition noted for players who received a medical fail with regard to their
projected ability to play successfully in the National Football League.24,25
External ACL injury risk factors such as shoe type worn and type of playing surface
have been evaluated. For example, football cleat design is found to have an impact on
ACL injury risk.26 A 3-year prospective study of high school football players found that
wearing a shoe with an increased torsional resistance was associated with a signifi-
cantly higher risk of ACL injury. In this study, the edge design of longer irregular cleats
at the shoe sole periphery with smaller pointed cleats positioned interiorly was a
higher-risk design than shoe designs with less torsional resistance.26
Playing surface coefficient of friction may also affect ACL injury risk. In a Norwegian
handball study, the higher friction floor type increased the ACL injury risk for female
handball players by a factor of 2.35. Their male counterparts did not accrue any
statistically significant additional risk secondary to change in floor type.27 A 3-year
prospective study of game-related football injuries in college athletes evaluated the
impact of FieldTurf, a polyethylene fiber blend with ground rubber infill versus natural
grass turf. No significant difference in knee injuries was noted on FieldTurf versus
natural grass.28
Intrinsic factors also play a role. There is a known familial predisposition to ACL
tears. In a study by Flynn and colleagues,29 23.4% of individuals with an ACL tear
were noted to have a first-degree relative with such an ACL injury compared with
11.7% of a control group of matched individuals without a history of an ACL tear. Post-
humus and colleagues30 noted that variants in matrix metalloproteinase genes on
chromosome 11q22 were associated with increased risk of ACL tears.
Anatomic indices such as femoral intercondylar notch width, notch width index,
(Fig. 3) and femoral intercondylar notch morphology are assessed as independent
risk factors for ACL injury. Ireland and colleagues31 evaluated the radiographs of
108 individuals (55 women, 53 men) with a history of ACL injury and compared the
radiographic findings with those of 186 cases (94 women, 92 men) with an intact
ACL. Small intercondylar notches were noted in those with ACL injury with a mean
notch of 18.94.0 mm in those with ACL injury compared with 20.73.9 mm in those
whose ACLs were intact. A smaller notch width index (ration of intercondylar notch
width to width of distal femur) may also potentially increase ACL injury risk.31
The slope of the posterior tibia may also have an impact on ACL injury risk
(Fig. 4).10,32 The posterior tibial slope is the posterior inclination of the tibial plateau.
The tibial slope is associated with an anterior position of the tibia.33 In one study con-
cerning those with chronic ACL rupture, each 10 increase in posterior tibial slope led
to increased anterior laxity with a 6-mm increase in anterior tibial translation when the
individual was in monopodal stance at 20 of flexion.34
The potential effect of hormones and oral contraceptives on ACL rupture risk also
remains a matter for continued investigation. In a study by Bell and colleagues,35 30
women were studied to assess the effect of oral contraceptives on hamstring function
in physically active female study participants. Oral contraceptive use did not alter mus-
cle neuromechanics. Wild and colleagues36 evaluated the role of the female
818 Peterson & Krabak

Fig. 3. Two-dimensional measurements of notch geometry. The NWI is the ratio of the inter-
condylar notch width (a) to the bicondylar width of the distal femur (b) at the level of the
popliteal groove. (From Swami VG, Mabee M, Hui C, et al. Three-dimensional intercondylar
notch volumes in a skeletally immature pediatric population: a magnetic resonance imag-
ing–based anatomic comparison of knees with torn and intact anterior cruciate ligaments.
Arthroscopy 2013;29(12):1954–62; with permission. Copyright 2013 Arthroscopy Association
of North America)

adolescent growth spurt with its large estrogen increases as a contributor to knee laxity
and the risk of ACL injury. All participants were premenarchal 10- to 13-year-old girls to
exclude cyclic hormone variation. Participants were biomechanically assessed up to 4
times during the 12-month period of the adolescent growth spurt. Interestingly, estra-
diol concentrations remained constant. Although quadriceps strength increased
during the study, hamstring strength did not. The authors theorize that strength imbal-
ance might place the ACL at injury risk. Passive knee joint laxity of study participants
also increased during the testing period. It has also been observed that the peak veloc-
ity for lower limb growth precedes the peak height velocity. This growth rate discrep-
ancy has an unclear biomechanical impact on lower extremity vulnerability.37
Hormonal influences remain an area of intense interest. A recent symposium, ACL
Research Retreat VI, highlighted the complexity of studying the effects of hormonal in-
fluences on mechanical properties of the ACL and ACL injury vulnerability.38
The injury predisposition in women may also be enhanced by properties of the ACL
itself. The female ACL has an 8.3% lower tensile load to failure compared with the
male ACL in one cadaveric study. The female ACL also had a 22.49% lower modulus
of elasticity.39 An additional cadaveric study found that the female ACL is shorter than
the male ACL, with ACL mass correlating with height in women but not in men.40 A
retrospective cohort of subjects referred for knee magnetic resonance imaging noted
that ACL volume correlated with height differences rather than gender.41 The maximal
ACL area is noted to be smaller in women than men when standardized for body
weight.42 A prospective study evaluating the effect of generalized joint laxity noted
 Anterior Cruciate Ligament Injury 819

Fig. 4. Radiograph with 2 lines. (From Hohmann E, Bryant A, Reaburn P, et al. Does posterior
tibial slope influence knee functionality in the anterior cruciate ligament–deficient and
anterior cruciate ligament–reconstructed knee? Arthroscopy 2010;26(11):1496–502; with
permission. Copyright 2010.)

that passive knee hyperextension and asymmetry of knee anterior-posterior laxity

enhanced ACL injury risk.43
Research suggests that neuromuscular activation in a gender-specific pattern likely
contributes to ACL injury risk. The proposed differences include female athletes land-
ing differently from jumps than male athletes. Findings include landing from jumps with
a relatively straight knees. A study of adolescent soccer players noted that female ath-
letes exhibited decreased hip and knee flexion in jump tests.44 Women have a greater
vertical ground reaction force than is found in male athletes while performing jump
tests. Knee valgus moments were significantly increased compared with those in
male athletes for single and bilateral leg landings.45 A retrospective analysis of 1718
athletes with ACL injury noted the dynamic alignment at time of injury in 1603 subjects
(781 men, 822 women).The alignment of knee-in and toe-out was the most common,
noted in 793 of 1603 with no significant difference in male and female subjects.46
The trunk also contributes to the ground reaction forces on the ACL. Relatively
greater hip adduction, decreased hip abductor strength, and diminished trunk control
can contribute to knee injury risk.47 Proprioceptive deficiency has been correlated with
knee injury in women but not in men. Impaired core proprioception in women was
highly predictive of knee injury risk in this prospective study.48 Another prospective
study of 277 college athletes found that decreased trunk control was strongly predic-
tive of knee injury in female athletes.49
The morphology of the knee joint articulation surface is also smaller in the female
athlete.11,50 magnetic resonance imaging of the joint surface of 18 healthy subjects
820 Peterson & Krabak

found interesting differences in male and female joint anatomy. Compared with those
in men, women’s medial tibias had 32.9% less surface area and women’s lateral tibias
had 33.4% less lateral tibial surface area and 21% less femoral joint surface area.50
The quadriceps angle or Q angle is greater in women than in men (Fig. 5).51 This
measure of the femoral to tibial angle is an additional factor that may increase load
on the ACL through increased lateral quadriceps pull.17 Increased knee joint laxity
has also been proposed to increase the risk of ACL injury in the athlete. As previously
noted, the ACL is the principal restraint to anterior tibial translation. Anterior knee laxity
in non–weight bearing is a test of ACL integrity. Shultz and colleagues52 found that
increased anterior knee laxity was in fact associated with increased anterior tibial
translation, as the knee accepted weight.52
Athlete fatigue has been investigated as a potential risk factor for ACL injury. Fatigue
may occur centrally, which causes reduction in muscle activity proximal to the neuro-
muscular junction, and peripherally, which adversely affects the muscle distal to the
neuromuscular junction. In either case, fatigue may impair knee kinematics. In a study
by McLean and Samorezov,53 20 female National Collegiate Athletic Association
(NCAA) athletes had knee joint motion assessment during jump landings. A standard-
ized fatigue protocol of 3 single-leg squats was followed by a landing trial, and the
sequence was repeated until the athlete could not complete 3 sequential squats
without assistance. Unilateral fatigue decreased initial contact knee flexion and

Fig. 5. Illustration depicting the measurement of the Q angle. The Q angle is measured by
the intersection of a line drawn from the anterior superior iliac spine through the center of
the patella and a line from the tibial tubercle through the center of the patella. (From
Sherman SL, Plackis AC, Nuelle CW et al. Patellofemoral anatomy and biomechanics. Clin
Sports Med 2014;33(3):397; with permission. Copyright 2014 Elsevier Inc.)
 Anterior Cruciate Ligament Injury 821

increased hip internal rotation. Unanticipated landings compared with anticipated

landings in fatigued athletes provoked greater decreases in hip flexion and more hip
internal rotation.53
Interestingly, fatigue also has a negative effect on knee laxity. Shultz and col-
leagues54 examined the changes in knee joint laxity associated with strenuous exer-
cise in the athlete. This study deliberately imitated the demands of a soccer match
on athletes through a strenuous intermittent exercise protocol of 90 minutes’ duration.
Twenty-nine women and 30 males completed the study. Exercise-related increases in
sagittal and frontal laxity were more pronounced in women than men. Compared with
a control condition of no exercise, female athletes showed increased sagittal and fron-
tal laxity with an intermittent exercise protocol, whereas male athletes did not show
such increases (P<.037). Interestingly, male and female athletes showed increased
transverse laxity with exercise (P 5 .007). However, 33% of women in this study
and 10% of men showed increases in sagittal plane laxity 1.9 mm and frontal plane
laxity 2.8 with exercise indicating that a small number of male athletes experience
significant knee laxity changes with exercise.54

Prevention
Increasing awareness of the major public health implications and costs of ACL injuries
has led researchers to devise programs that might help prevent these injuries. Effec-
tive ACL injury prevention seems even more critical when we reflect on the fact that
once an athlete sustains an ACL injury and undergoes reconstructive surgery, that ath-
lete’s risk of additional knee injury remains elevated in both the affected extremity and
the contralateral extremity.55
Mandelbaum and colleagues created the Prevent Injury Enhance Performance
injury prevention program (PEP). The PEP program involves warm-up, stretching,
strengthening, and plyometrics agility exercises and stretching.56 Warm-up and cool-
ing down are stressed. Warm-up includes exercises such as jogging forward and
backward and shuttle runs. Strengthening includes walking lunges, Russian hamstring
exercises, and repeated single-leg toe raises. Plyometric exercises emphasize landing
technique and knee positioning. Plyometrics include forward, backward, and lateral
hops over a 2-inch cone and single leg hops over a cone. Straight vertical jumps
and scissors jumps are performed. Agility drills such as forward runs with decelera-
tions, lateral diagonal runs, and bounding runs are completed. Finally, proper stretch-
ing technique is emphasized with a focus on calf muscles, quadriceps, hamstrings,
inner thigh muscles, and hip flexors. The program in its entirety is designed to be
completed in 15 to 20 minutes on the field without the use of specialized equipment
or personnel. Year one of a study of PEP efficacy found 37,476 AEs for trained athletes
and 68,580 AEs for the control athletes. Two ACL tears were noted in the protocol
group, and 32 ACL tears were noted in control athletes. The authors note an 88%
reduction in ACL tears for participants (1041 trained, 1905 controls). Year 2 of the
study (844 trained, 1913 controls) again found striking decreases in ACL injury through
training in the prevention program. A total of 30,384 AEs occurred in the trained group
and 68,868 AEs occurred in the untrained group. Four ACL tears were noted in the
treatment group, and 35 ACL tears were noted in the control group, representing a
74% ACL injury reduction in participants compared with controls.56,57
The Cincinnati SportsMedicine Research and Education Foundation program used
preseason conditioning for 6 weeks to successfully reduce knee injury rates. The pro-
gram involved training 3 days per week for 60 to 90 minutes per training session. An
athletic trainer and physical therapist demonstrated proper stretching. Flexibility,
plyometrics, and weight training were used to decrease the landing forces for
822 Peterson & Krabak

athletes. A total of 1263 female athletes in soccer, volleyball, and basketball were
studied. AEs were 23,138 in the untrained female group and 17,222 in the trained
female group with 21,390 in the male control group. Knee injury incidence per
1000 athlete exposures was 0.12 in the trained group of female athletes and 0.43
in the untrained group of female athletes. The trained female group injury incidence
of 0.12 was similar to that of the control males, with 0.09 the incidence of all knee in-
juries in the male controls. No trained female athlete suffered a noncontact ACL injury
compared with 5 such injuries in untrained female athletes in this study.58 Preseason
and in-season neuromuscular training was found to decrease ACL injury risk factors
in a follow-up study by Brent and colleagues.59 The Cincinnati SportsMedicine
Research and Education Foundation has developed a separate program of 20 exer-
cises in 20 minutes called Warm-up for Injury Prevention and Performance (WIPP).60
A study by Grandstrand and colleagues61 evaluated the effects of this briefer pro-
gram. WIPP was performed twice weekly for the 8-week duration of the soccer sea-
son by a girls youth soccer club (age 9–11 years). The WIPP program had to be
modified to meet the athlete’s abilities. The effect of this modified training was
assessed using Sportsmetrics Software for the Analysis of Jumping Mechanics. Ath-
letes failed to improve landing knee kinematics or maximum vertical jump height.61
A prospective study by Pfeiffer failed to show a reduction in ACL injuries in female
athletes who participated in a twice-weekly program through the sports season.62
The Knee Ligament Injury Prevention (KLIP) study compared 577 trained athletes
with 862 controls. The PEP study involves athletes in training 3 times per week. This
may explain the greater effect of the PEP program compared with the KLIP program.
A new study by Waldén using a different protocol of 6 exercises performed twice weekly
after a running warm-up did, however, show a positive impact on ACL injury reduction.
This protocol, approximately 15 minutes in duration twice weekly, progressed through
levels of difficulty and included single and 2-legged squats, pelvic lifts, the bench, and
the lunge. Female soccer players age 12 to 17 experienced fewer injuries than the con-
trol group. A total of 2479 in the intervention group and 2085 in the control group fully
participated in this study. Seven players in the group that did neuromuscular exercises
experienced an ACL injury. Fourteen players in the control group experienced an ACL
injury. AEs were not calculated in this study. Instead, this study calculated playing time
through minutes of actual soccer sport participation including practices and matches.63
The effectiveness of these programs in ACL injury prevention is summarized in
Table 1.
A meta-analysis by Sadoghi and colleagues64 looked at the effectiveness of ACL
prevention programs. These authors systematically reviewed the available literature
and noted a pooled risk ratio of 0.38 (95% confidence interval, 0.20–0.72) representing
a significant reduction in ACL injury secondary to prevention program adherence. The
combined data from the studies in the meta-analysis show that athletes involved in
prevention programs reduce ACL injuries by 62% compared with controls. The bene-
fits of injury prevention programs apply to both male and female athletes. Risk reduc-
tion of an ACL injury through compliance with an ACL injury prevention program is
85% in male athletes and 52% in female athletes. An earlier meta-analysis of neuro-
muscular training by Hübscher and colleagues65 noted that intervention, which could
incorporate strengthening, stretching, and plyometrics, decreased risk of acute knee
injuries by 54%. Compliance with the programs also affects outcomes. In one study,
girls age 12 to 17 in football (soccer) with the highest compliance with a neuromuscular
training program had an 88% decreased ACL injury rate compared with the players
with lower compliance with the program.66 It remains unclear which athlete groups
will most benefit from an ACL injury prevention program.3,67
Table 1
ACL injury program effectiveness

No of ACL Injury in Treatment Statistically

Study Description Participants Controls Group ACL Injury in Control Group Significant
Pfeiffer et al,62 2006 HS female athletes twice 577 862 0.167 noncontact ACL 0.078 noncontact ACL No
weekly for 20 min injury per 1000 injury/athlete/1000
program exposures. exposures
Player exposure defined as
1 player participating in
1 game or practice
Mandelbaum et al,57 Female soccer players 1041 1905 0.05 per 1000 exposures 0.47 injury/athlete/1000 Yes
2005, year 1 age 14–18 Exposure defined as exposures
Year 1 PEP program participation in any
3 times/wk practice or game in which
athlete exposed to
possibility of injury
Mandelbaum et al,57 PEP program year 2 844 1913 0.13 injuries/athlete/1000 0.51 injuries/athlete/1000 Yes
2005, year 2 exposures exposures

Anterior Cruciate Ligament Injury

Hewett et al,58 1999 High school soccer, 366 girls 463 girls 0 noncontact ACL injuries in 0.35 noncontact ACL injury Yes
volleyball, basketball, 434 boys trained athlete/1000 in untrained girls; 0.05
6-wk preseason training exposures noncontact ACL injuries
Exposure defined as 1 in male controls
athlete participating in 1
practice or match
Waldén et al,63 2012 Exercises twice a week, 2479 2085 7 ACL injuries 14 ACL injuries Primary outcome
progressive difficulty 149 214 h 129 084 h rate of ACL injury
throughout season; Yes
female age 12–17;
Swedish football

823
824 Peterson & Krabak

Given that youth athletic participation rates continue to increase in the United
States, the optimal age at which to introduce neuromuscular training has been
debated. Concerns regarding exposing athletes to the risk of overuse injuries are valid.
Interestingly, poor physical conditioning is one of the principal risk factors for sports
injury. Myer and coworkers68 suggest that neuromuscular education be introduced
before the growth spurt that occurs at age 12 in girls and at age 14 in boys.
Quatman-Yates and colleagues69 noted in a study the potentially adverse strength
imbalances which emerge as girls mature from prepubertal status. Carter and
Micheli70 that training generally improves the overall health of the young athlete by
increasing bone mass, improving cardiovascular fitness, assisting in injury prevention,
and most likely enhancing self-esteem.70
Specific effects of neuromuscular training include positive effects on landing kine-
matics. Training improves the biomechanics of landing and may help reduce relative
muscular strength imbalances that increase the ACL injury risk.68,71 These benefits
may accrue even to very young sports participants. Soccer players younger than
12 years (37 boys, 28 girls) were enrolled in a study that compared a conventional
ACL prevention program (static flexibility with lower limb stretching, balance, strength-
ening, plyometrics, and speed drills) with a program designed specifically for a pedi-
atric population. The pediatric ACL injury prevention program progressed through 3
phases over 9 weeks. One significant difference of the pediatric program was the in-
clusion of timing runs, which forced 2 participants to complete at the same time diag-
onal runs crossing another player. The goal of this exercise is to improve the
processing of visual information on the playing field. Another difference in the pediatric
program was an exercise that involved sustaining single-leg balance while a partner
pushed the balancing athlete. The pediatric program also progressively increased
the proportion of plyometric exercises completed as the training through the phases
progressed. A total of 22 athletes (11 girls, 11 boys) completed the traditional program
for 9 weeks. A total of 19 athletes (8 girls, 11 boys) completed the pediatric program of
skills program. No injuries were reported in either group; the traditional ACL prevention
program improved young athletes’ vertical jump height and balance.72 Despite the
potential benefits of an ACL injury prevention program, integration of these programs
in youth sports has not been universal. In a recent study of Utah girls soccer coaches,
of athletes age 11 to collegiate, only 19.8% of survey respondents had adopted an
ACL injury prevention program.73

SUMMARY

ACL injury is a common sports injury with severe negative consequences. Neuromus-
cular factors that increase risk, such as knee landing kinematics and fatigue-induced
joint kinematic changes, may be ameliorated through training. Effective ACL injury
prevention programs exist, although the ideal program is yet to be determined. It is
imperative that athletes in high-risk sports participate in ACL injury prevention
programs to reduce the risk of sustaining this injury. Effective ACL injury prevention
programs would have positive effects on knee health and long-term knee quality of
life for athletes.

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