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ABCs of Evidence-Based Anterior Cruciate Ligament Injury Prevention Strategies in Female Athletes

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Abstract

Anterior cruciate ligament (ACL) injury is a major concern in physically active females. Although ACL reconstruction techniques have seen significant advances in recent years, risk associated with re-injury and future osteoarthritis remains a major concern. Thus, prevention of ACL injury is a logical step to protect and preserve healthy knee joints in young athletes. The current report aims to summarize a list of evidence-based prevention strategies to reduce ACL injury in female athletes. A list of six critical principles, which come from documented, large-scale clinical trial studies and further analyses, were presented with ABC format including age, biomechanics, compliance, dosage, exercise, and feedback. Also, a grade for evidence and implications of future research are noted. Finally, in the conclusion section, importance of collaborative efforts from healthcare practitioners, researchers, and personnel associated with athletics is addressed.

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References

Papers of particular interest, published recently, have been highlighted as: •• Of major importance

  1. Arendt EA, Agel J, Dick R. Anterior cruciate ligament injury patterns among collegiate men and women. J Athl Train. 1999;34(2):86–92.

    CAS  PubMed  PubMed Central  Google Scholar 

  2. Walden M, Hagglund M, Werner J, Ekstrand J. The epidemiology of anterior cruciate ligament injury in football (soccer): a review of the literature from a gender-related perspective. Knee Surg Sports Traumatol Arthrosc. 2011;19(1):3–10.

    PubMed  Google Scholar 

  3. Walden M, Hagglund M, Magnusson H, Ekstrand J. Anterior cruciate ligament injury in elite football: a prospective three-cohort study. Knee Surg Sports Traumatol Arthrosc. 2011;19(1):11–9.

    PubMed  Google Scholar 

  4. Cimino F, Volk BS, Setter D. Anterior cruciate ligament injury: diagnosis, management, and prevention. Am Fam Phys. 2010;82(8):917–22.

    Google Scholar 

  5. Wojtys EM, Brower AM. Anterior cruciate ligament injuries in the prepubescent and adolescent athlete: clinical and research considerations. J Athl Train. 2010;45(5):509–12.

    PubMed  PubMed Central  Google Scholar 

  6. Silvers HJ, Mandelbaum BR. Prevention of anterior cruciate ligament injury in the female athlete. Br J Sports Med. 2007;41(Suppl 1):i52–9.

    PubMed  PubMed Central  Google Scholar 

  7. Dugan SA. Sports-related knee injuries in female athletes: what gives? Am J Phys Med Rehabil. 2005;84(2):122–30.

    PubMed  Google Scholar 

  8. Hootman JM, Albohm MJ. Anterior cruciate ligament injury prevention and primary prevention of knee osteoarthritis. J Athl Train. 2012;47(5):589–90.

    PubMed  PubMed Central  Google Scholar 

  9. McCullough KA, Phelps KD, Spindler KP, et al. Return to high school- and college-level football after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) cohort study. Am J Sports Med. 2012;40(11):2523–9.

    PubMed  PubMed Central  Google Scholar 

  10. Paterno MV, Schmitt LC, Ford KR, et al. Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport. Am J Sports Med. 2010;38(10):1968–78.

    PubMed  PubMed Central  Google Scholar 

  11. 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):3145–52.

    CAS  PubMed  Google Scholar 

  12. Oiestad BE, Holm I, Engebretsen L, Risberg MA. The association between radiographic knee osteoarthritis and knee symptoms, function and quality of life 10-15 years after anterior cruciate ligament reconstruction. Br J Sports Med. 2011;45(7):583–8.

    CAS  PubMed  Google Scholar 

  13. Hewett TE, Myer GD, Ford KR, Slauterbeck JR. Dynamic neuromuscular analysis training for preventing anterior cruciate ligament injury in female athletes. Instr Course Lect. 2007;56:397–406.

    PubMed  Google Scholar 

  14. Hewett TE, Shultz SJ, Griffin LY. Understanding and preventing noncontact ACL injuries. American Orthopaedic Society for Sports Medicine. Human Kinetics; 2007.

  15. Beynnon BD, Hall JS, Sturnick DR, et al. Increased slope of the lateral tibial plateau subchondral bone is associated with greater risk of noncontact ACL injury in females but not in males: a prospective cohort study with a nested, matched case-control analysis. Am J Sports Med. 2014;42(5):1039–48.

    PubMed  PubMed Central  Google Scholar 

  16. Webb JM, Salmon LJ, Leclerc E, Pinczewski LA, Roe JP. Posterior tibial slope and further anterior cruciate ligament injuries in the anterior cruciate ligament-reconstructed patient. Am J Sports Med. 2013;41(12):2800–4.

    PubMed  Google Scholar 

  17. Bell DR, Blackburn JT, Norcorss MF, et al. Estrogen and muscle stiffness have a negative relationship in females. Knee Surg Sports Traumatol Arthrosc. 2012;20(2):361–7.

    PubMed  Google Scholar 

  18. Lo IK, Marchuk LL, Hart DA, Frank CB. Comparison of mRNA levels for matrix molecules in normal and disrupted human anterior cruciate ligaments using reverse transcription-polymerase chain reaction. J orthop Res. 1998;16(4):421–8.

    CAS  PubMed  Google Scholar 

  19. Nakase J, Tsuchiya H, Kitaoka K. Contralateral anterior cruciate ligament injury after anterior cruciate ligament reconstruction: a case controlled study. Sports Med Arthrosc Rehabil Ther Technol. 2012;4(1):46.

    PubMed  PubMed Central  Google Scholar 

  20. Posthumus M, September AV, Keegan M, et al. Genetic risk factors for anterior cruciate ligament ruptures: COL1A1 gene variant. Br J Sports Med. 2009;43(5):352–6.

    CAS  PubMed  Google Scholar 

  21. Hewett TE, Stroupe AL, Nance TA, Noyes FR. Plyometric training in female athletes. Decreased impact forces and increased hamstring torques. Am j Sports Med. 1996;24(6):765–73.

    CAS  PubMed  Google Scholar 

  22. Baldon Rde M, Lobato DF, Carvalho LP, Wun PY, Santiago PR, Serrao FV. Effect of functional stabilization training on lower limb biomechanics in women. Med Sci Sports Exerc. 2012;44(1):135–45.

    Google Scholar 

  23. Myer GD, Ford KR, Palumbo JP, Hewett TE. Neuromuscular training improves performance and lower-extremity biomechanics in female athletes. J Strength Cond Res. 2005;19(1):51–60.

    PubMed  Google Scholar 

  24. Myer GD, Ford KR, Brent JL, Hewett TE. The effects of plyometric vs. dynamic stabilization and balance training on power, balance, and landing force in female athletes. J Strength Cond Res. 2006;20(2):345–53.

    PubMed  Google Scholar 

  25. Markolf KL, Burchfield DM, Shapiro MM, Shepard MF, Finerman GA, Slauterbeck JL. Combined knee loading states that generate high anterior cruciate ligament forces. J Orthop Res. 1995;13(6):930–5.

    CAS  PubMed  Google Scholar 

  26. Donnelly CJ, Elliott BC, Ackland TR, et al. An anterior cruciate ligament injury prevention framework: incorporating the recent evidence. Res Sports Med (Print). 2012;20(3–4):239–62.

    CAS  Google Scholar 

  27. •• Myer GD, Sugimoto D, Thomas S, Hewett TE. The influence of age on the effectiveness of neuromuscular training to reduce anterior cruciate ligament injury in female athletes: a meta-analysis. Am J Sports Med. 2012;41(1):203–15. This study displayed age influence on ACL injury reduction, which was a core component of section A: Age: Start early.

    PubMed  PubMed Central  Google Scholar 

  28. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. Am J Sports Med. 1999;27(6):699–706.

    CAS  PubMed  Google Scholar 

  29. Soderman K, Werner S, Pietila T, Engstrom B, Alfredson H. Balance board training: prevention of traumatic injuries of the lower extremities in female soccer players? A prospective randomized intervention study. Knee Surg Sports Traumatol Arthrosc. 2000;8(6):356–63.

    CAS  PubMed  Google Scholar 

  30. Heidt RS Jr, Sweeterman LM, Carlonas RL, Traub JA, Tekulve FX. Avoidance of soccer injuries with preseason conditioning. Am J Sports Med. 2000;28(5):659–62.

    PubMed  Google Scholar 

  31. Myklebust G, Engebretsen L, Braekken IH, Skjolberg A, Olsen OE, Bahr R. Prevention of anterior cruciate ligament injuries in female team handball players: a prospective intervention study over three seasons. Clin J Sport Med. 2003;13(2):71–8.

    PubMed  Google Scholar 

  32. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. 2005;33(7):1003–10.

    PubMed  Google Scholar 

  33. Olsen OE, Myklebust G, Engebretsen L, Holme I, Bahr R. Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial. BMJ (Clinical research ed.). 2005;330(7489):449.

    PubMed  PubMed Central  Google Scholar 

  34. Petersen W, Braun C, Bock W, et al. A controlled prospective case control study of a prevention training program in female team handball players: the German experience. Arch Orthop Trauma Surg. 2005;125(9):614–21.

    PubMed  Google Scholar 

  35. Pfeiffer RP, Shea KG, Roberts D, Grandstrand S, Bond L. Lack of effect of a knee ligament injury prevention program on the incidence of noncontact anterior cruciate ligament injury. J Bone Joint Surg Am. 2006;88(8):1769–74.

    PubMed  Google Scholar 

  36. Pasanen K, Parkkari J, Pasanen M, Kannus P. Effect of a neuromuscular warm-up programme on muscle power, balance, speed and agility: a randomised controlled study. Br J Sports Med. 2009;43(13):1073–8.

    CAS  PubMed  Google Scholar 

  37. Steffen K, Myklebust G, Olsen OE, Holme I, Bahr R. Preventing injuries in female youth football–a cluster-randomized controlled trial. Scand J Med Sci Sports. 2008;18(5):605–14.

    CAS  PubMed  Google Scholar 

  38. Gilchrist J, Mandelbaum BR, Melancon H, et al. A randomized controlled trial to prevent noncontact anterior cruciate ligament injury in female collegiate soccer players. Am J Sports Med. 2008;36(8):1476–83.

    PubMed  Google Scholar 

  39. Kiani A, Hellquist E, Ahlqvist K, Gedeborg R, Michaelsson K, Byberg L. Prevention of soccer-related knee injuries in teenaged girls. Arch Intern Med. 2010;170(1):43–9.

    PubMed  Google Scholar 

  40. LaBella CR, Huxford MR, Grissom J, Kim KY, Peng J, Christoffel KK. Effect of neuromuscular warm-up on injuries in female soccer and basketball athletes in urban public high schools: cluster randomized controlled trial. Arch Pediatr Adolesc Med. 2011;165(11):1033–40.

    PubMed  Google Scholar 

  41. Walden M, Atroshi I, Magnusson H, Wagner P, Hagglund M. Prevention of acute knee injuries in adolescent female football players: cluster randomised controlled trial. BMJ (Clinical research ed.). 2012;344:e3042.

    PubMed  PubMed Central  Google Scholar 

  42. Morrison S, Sosnoff JJ. Age-related changes in the adaptability of neuromuscular output. J Mot Behav. 2009;41(3):274–83.

    PubMed  Google Scholar 

  43. Sosnoff JJ, Voudrie SJ. Practice and age-related loss of adaptability in sensorimotor performance. J Mot Behav. 2009;41(2):137–46.

    PubMed  PubMed Central  Google Scholar 

  44. Myer GD, Faigenbaum AD, Chu DA, et al. Integrative training for children and adolescents: techniques and practices for reducing sports-related injuries and enhancing athletic performance. Phys Sportsmed. 2011;39(1):74–84.

    PubMed  Google Scholar 

  45. Myer GD, Faigenbaum AD, Ford KR, Best TM, Bergeron MF, Hewett TE. When to initiate integrative neuromuscular training to reduce sports-related injuries and enhance health in youth? Curr Sports Med Rep. 2011;10(3):155–66.

    PubMed  PubMed Central  Google Scholar 

  46. Myer GD, Kushner AM, Faigenbaum AD, Kiefer A, Kashikar-Zuck S, Clark JF. Training the developing brain, part I: cognitive developmental considerations for training youth. Curr Sports Med Rep. 2013;12(5):304–10.

    PubMed  Google Scholar 

  47. •• Hewett TE, Myer GD, Ford KR, 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. Am J Sports Med. 2005;33(4):492–501. This study explained critical components of section B: Biomechanics: Change the risk movements.

  48. Hewett TE, Torg JS, Boden BP. 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. Br J Sports Med. 2009;43(6):417–22.

    CAS  PubMed  PubMed Central  Google Scholar 

  49. Zazulak BT, Hewett TE, Reeves NP, Goldberg B, Cholewicki J. Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiologic study. Am J Sports Med. 2007;35(7):1123–30.

    PubMed  Google Scholar 

  50. Hewett TE, Myer GD. The mechanistic connection between the trunk, knee, and ACL injury. Exerc Sport Sci Rev. 2011;39(4):161–6.

    PubMed  PubMed Central  Google Scholar 

  51. •• Sugimoto D, Myer GD, Bush HM, Klugman MF, Medina McKeon JM, Hewett TE. Compliance with neuromuscular training and anterior cruciate ligament injury risk reduction in female athletes: a meta-analysis. J Athl Train. 2012;47(6):714–23. This study encompassed importance of adherence and compliance of NMT, which was addressed in section C: Compliance: If you don’t do it, it does not work.

  52. Joy E, Taylor JR, Novak M, Chen M, Fink B, Porucznik C. Factors influencing the implementation of ACL injury prevention strategies by girls soccer coaches. J Strength Cond Res. 2013;27(8):2263–9.

    PubMed  Google Scholar 

  53. •• Sugimoto D, Myer GD, Foss KD, Hewett TE. Dosage effects of neuromuscular training intervention to reduce anterior cruciate ligament injuries in female athletes: meta- and sub-group analyses. Sports Med. 2014;44(4):551–62. This study generated evidence of inverse dose-response relationship, which was a crucial point described in section D: Dosage: The more you do it, less ACL injury.

    Google Scholar 

  54. Padua DA, DiStefano LJ, Marshall SW, Beutler AI, de la Motte SJ, DiStefano MJ. Retention of movement pattern changes after a lower extremity injury prevention program is affected by program duration. Am J Sports Med. 2012;40(2):300–6.

    PubMed  Google Scholar 

  55. •• Sugimoto D, Myer GD, Barber Foss KD, Hewett TE. Specific exercise effects of preventive neuromuscular training intervention on anterior cruciate ligament injury risk reduction in young females: meta-analysis and subgroup analysis. Br J Sports Med. 2014. doi:10.1136/bjsports-2014-093461. This study demonstrated specific exercise effects of NMT and pointed out importance of exercise variations within NMT, which was synthesized in section E: Exercise: Include a variety of exercises.

    PubMed  Google Scholar 

  56. Lim BO, Lee YS, Kim JG, An KO, Yoo J, Kwon YH. Effects of sports injury prevention training on the biomechanical risk factors of anterior cruciate ligament injury in high school female basketball players. Am J Sports Med. 2009;37(9):1728–34.

    PubMed  Google Scholar 

  57. Irmischer BS, Harris C, Pfeiffer RP, DeBeliso MA, Adams KJ, Shea KG. Effects of a knee ligament injury prevention exercise program on impact forces in women. J Strength Cond Res. 2004;18(4):703–7.

    PubMed  Google Scholar 

  58. Vescovi JD, Canavan PK, Hasson S. Effects of a plyometric program on vertical landing force and jumping performance in college women. Phys Ther Sport. 2008;9(4):185–92.

    PubMed  Google Scholar 

  59. Myer GD, Ford KR, McLean SG, Hewett TE. The effects of plyometric versus dynamic stabilization and balance training on lower extremity biomechanics. Am J Sports Med. 2006;34(3):445–55.

    PubMed  Google Scholar 

  60. Parsons JL, Alexander MJ. Modifying spike jump landing biomechanics in female adolescent volleyball athletes using video and verbal feedback. J Strength Cond Res. 2012;26(4):1076–84.

    PubMed  Google Scholar 

  61. •• Myer GD, Stroube BW, DiCesare CA, et al. Augmented feedback supports skill transfer and reduces high-risk injury landing mechanics: a double-blind, randomized controlled laboratory study. Am J Sports Med. 2013;41(3):669–77. This study was the highest evidence to support importance of biofeedback system, which was discussed in section F: Feedback: Your voice is powerful.

    PubMed  PubMed Central  Google Scholar 

  62. Ettlinger CF, Johnson RJ, Shealy JE. A method to help reduce the risk of serious knee sprains incurred in alpine skiing. Am J Sports Med. 1995;23(5):531–7.

    CAS  PubMed  Google Scholar 

  63. •• Sugimoto D, Myer GD, McKeon JM, Hewett TE. Evaluation of the effectiveness of neuromuscular training to reduce anterior cruciate ligament injury in female athletes: a critical review of relative risk reduction and numbers-needed-to-treat analyses. Br J Sports Med. 2012;46(14):979–88. This study focused on identifying specific percent (%) of risk reduction of ACL injury performing NMT intervention, which emphasized section G: Grade of the Evidence: Practice evidence-based medicine.

    PubMed  PubMed Central  Google Scholar 

  64. Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. J Am Board Fam Pract. 2004;17(1):59–67.

    PubMed  Google Scholar 

  65. Ford KR, Myer GD, Smith RL, Vianello RM, Seiwert SL, Hewett TE. A comparison of dynamic coronal plane excursion between matched male and female athletes when performing single leg landings. Clin Biomech (Bristol, Avon). 2006;21(1):33–40.

    Google Scholar 

  66. Ford KR, Myer GD, Hewett TE. Valgus knee motion during landing in high school female and male basketball players. Med Sci Sports Exerc. 2003;35(10):1745–50.

    PubMed  Google Scholar 

  67. Chappell JD, Creighton RA, Giuliani C, Yu B, Garrett WE. Kinematics and electromyography of landing preparation in vertical stop-jump: risks for noncontact anterior cruciate ligament injury. Am J Sports Med. 2007;35(2):235–41.

    PubMed  Google Scholar 

  68. Jacobs CA, Uhl TL, Mattacola CG, Shapiro R, Rayens WS. Hip abductor function and lower extremity landing kinematics: sex differences. J Athl Train. 2007;42(1):76–83.

    PubMed  PubMed Central  Google Scholar 

  69. Alentorn-Geli E, Mendiguchia J, Samuelsson K, et al. Prevention of anterior cruciate ligament injuries in sports. Part I: systematic review of risk factors in male athletes. Knee Surg Sports Traumatol Arthrosc. 2014;22(1):3–15.

    PubMed  Google Scholar 

  70. Alentorn-Geli E, Mendiguchia J, Samuelsson K, et al. Prevention of non-contact anterior cruciate ligament injuries in sports. Part II: systematic review of the effectiveness of prevention programmes in male athletes. Knee Surg Sports Traumatol Arthrosc. 2014;22(1):16–25.

    PubMed  Google Scholar 

  71. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42(2):311–9.

    PubMed  PubMed Central  Google Scholar 

  72. 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):959–64.

    PubMed  Google Scholar 

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Acknowledgments

The authors would like to acknowledge funding support from National Institutes of Health/NIAMS Grants R01-AR049735, R01-AR05563, and R01-AR056259. The authors acknowledge members and supporting personnel of the Micheli Center for Sports Injury Prevention at Waltham, Massachusetts, the Human Performance Laboratory of the Cincinnati Children’s Hospital Sports Medicine, and Sports Health & Performance Institute and Sports Medicine Biodynamics Laboratories of The Ohio State University. All authors are independent of any commercial funder, had full access to all of the data in the study, and take responsibility for the integrity of the data and the accuracy of the data analyses.

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Correspondence to Timothy E. Hewett.

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This article is the part of the Topical collection on Musculoskeletal Rehabilitation.

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Sugimoto, D., Myer, G.D., Micheli, L.J. et al. ABCs of Evidence-Based Anterior Cruciate Ligament Injury Prevention Strategies in Female Athletes. Curr Phys Med Rehabil Rep 3, 43–49 (2015). https://doi.org/10.1007/s40141-014-0076-8

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