Originally published by Los Angeles Sports & Fitness, January/February 2015
The post on the local prep sports message board started innocently with a poster offering his condolences to a young high-school basketball player who tore her anterior cruciate ligament (ACL) in a spring league game. The thread continued with overwhelmingly positive messages, encouraging the player that she will return like nothing had happened, and she will have time to earn her college scholarship that appeared likely. Though the messages were supportive and positive, they were equally disheartening.
One message mentioned that many female athletes tear their ACLs and return to play again. This is true, as ACL injuries plague females in sports. According to estimates, 2200 ACL ruptures occur annually in female collegiate athletes (Hutchinson & Ireland, 1995), and 20,000 knee injuries occur in female high-school athletes (Chandy & Grana, 1985). In the high-school age group, the rate of non-contact ACL injuries in soccer was twice as high in females as in males, whereas the rate of injury in basketball for females is nearly four times that of males (Renstrom et al., 2008). In girls basketball alone, there are more than 7000 ACL ruptures in the United States on an annual basis (Ford et al., 2003), and the incidence rate (injuries per 1000 participant hours) of ACL injuries is higher in women’s gymnastics and soccer (Renstrom et al., 2008).
The truth of the statement, and more so the laissez-faire attitude toward its accuracy, is disheartening. In basketball, roughly 1 in 10 girls will tear her ACL in high school. Essentially, the statistics suggest that one girl on every basketball team will tear her ACL every year. These statistics are astounding, yet those who have been in the game for a long time have become immune. The possibility, or even the likelihood, of an ACL injury for a high-school basketball or soccer player is an acknowledged and accepted risk. It is a fait accompli.
How have we gotten to a point in time when we accept the eventuality of severe injury without questioning?
One problem, which was expressed in the encouragement on the thread, is the likelihood of return to play after an injury. Once upon a time, an ACL injury ended a soccer or basketball career. Now, surgery and rehab are so advanced that return to play is nearly automatic, with the only question being the amount of time away from the sport or the number of games missed. In fact, surgery and rehab are so good that a return to play at six months post-injury compared to more time missed was not associated with greater re-injury (Shelbourne et al., 2009). In a little more than one generation, ACL injuries have gone from career-ending to a six-month break.
Because the return to play is viewed as more imminent than questionable, the injury’s seriousness has diminished. The return to play after an injury is only one issue; quality of life is another. Females have a higher incidence of ACL injury to the contralateral knee after reconstruction compared to males (Shelbourne et al., 2009), meaning the potential for another painful injury, expensive surgery, and lengthy rehabilitation. The incidence of injury to either knee after reconstruction is associated with younger age and higher activity level (Shelbourne et al., 2009), such as a high-school basketball or soccer player. Furthermore, those who answered “achievement” as their motive for sports participation, such as an aspiring college athlete, were shown to experience more pain and worse function two years after injury than those with other motives (Roessler et al., 2014), and have an elevated risk of developing knee osteoarthritis (Lohmander et al., 2004; Oberlander et al., 2014; Roos, 2005). Therefore, even if she returns, plays, and earns her college scholarship, the injured player is at-risk for a second ACL injury, likely to experience pain two years post-injury, and may suffer from knee osteoarthritis by age 30. Are these outcomes that we should dismiss simply because she returns to play and performs at an acceptable level? What about her life after high-school or college athletics?
Rather than accept non-contact ACL injuries as a part of soccer or basketball participation, coaches, parents, and players should be more proactive in minimizing the risk of injury. Subjects who had suffered an ACL injury demonstrated reduced ankle dorsiflexion compared to uninjured controls, suggesting that a functional test measuring ankle dorsiflexion may identify players with an increased risk of ACL injury (Wahlstedt & Rasmussen-Barr, 2014).
Furthermore, Ford et. al (2003) suggested that there are three potential mechanisms underlying ACL injuries: Anatomical, hormonal, and biomechanical. Whereas anatomical and hormonal issues are hard to change, training can affect biomechanical issues. Simple neuromuscular training (NMT) programs have been shown repeatedly to reduce the incidence of non-contact ACL injuries (Hewett et al., 2005; Hewett et al., 2007; Kiani et al., 2010; Mykleburst et al., 2003; Steffen et al., 2008). In an intervention and study published by Hewett et. al (1999) in the American Journal of Sports Medicine, knee injuries declined by 62% in the female sports population. These programs include a combination of plyometrics, strengthening, stretching, and balance training (Sugimoto et al., 2012).
Neuromuscular training programs are more and more prevalent in high-school athletics and beyond, as many high-school soccer teams that I refereed this past season used some form of NMT in their pre-game warmups. Whereas this is a start, younger athletes may be more receptive to NMT than athletes in late adolescence or early adulthood (Myer et al., 2012). An early start with NMT programs, and the accompanying instruction, may prevent some bad habits from developing, and induce greater strength and power development. Teaching optimal techniques from the beginning, rather than attempting to correct suboptimal habits in late adolescence or later, may have greater and more lasting effects.
Returning to play after an ACL injury is highly likely, and many players return to the same or similar performance level as prior to the injury. These stories of athletes overcoming obstacles to perform again are inspirational, capture our attention, and tug at our emotions. However, the likelihood of a post-injury career should not obscure the problems facing athletes who have been injured. Few of us who are inspired by the athlete’s persistence and dedication will be there after the game when she is suffering from chronic pain or years later when she suffers from osteoarthritis.
Players cannot worry about the risk of injury when playing. However, coaches, parents, and players should make greater efforts to reduce the risk of an injury through better screening, testing, and biomechanical evaluations, and training programs designed to improve motor control, technique and strength. Rather than supporting an injured player through the physical and emotional strain of an injury, surgery, and rehabilitation, we should strive to prevent the occurrence in the first place.