By Julie Hubbard

Is ACL injury prevention actually effective? In this post, we examine ACL injury prevention programs, and what components need to be included in order to be effective.

 

It’s no secret – I like to be in control. Now, I don’t mean that in a narcissistic or manipulative way. I just mean that I like to call the shots in my life. I like deliberately choosing who I hang out with and how I spend my free time. I like managing my own finances. I like having the ability to book a plane ticket to anywhere on a whim. And I like the freedom to sometimes eat two Chipotle burritos in one sitting without judgment.

 

I don’t like losing control, and I imagine that neither do many of you. Remember from my last post, autonomy refers to the feeling of having control over what you do. Similarly, perceived control is the belief that one can determine one’s own internal states and behavior, influence one’s environment, and bring about desired outcomes. It is when we lose our sense of autonomy or perceived control that crisis ensues and our emotions go haywire.

 

Control the Controllable

I’ve recently learned that the mind is an incredibly powerful thing. Amazing transformative change can take place in your life when you decide to control the controllable. I realize that we can’t necessarily control what happens to us and we certainly can not control how other people behave. Maybe someone tackled you studs up, leaving you on the sidelines for the big game. Maybe the boy you liked dumped you via text message on Friday night. Maybe you received news that someone you love is struggling with a difficult diagnosis. 

 

We can’t control the hand we are dealt, but we can control how we react. If you were on Instagram earlier this week, you might recall my post on some of the things we can control in our lives. We have power over our punctuality (to some degree – God Bless you if you take the T in Boston during the wintertime), our effort, our body language, our mindset, our actions, and our preparation.

 

Now, stay with me…

 

In the United States alone, nearly 38 million youth and adolescents participate in organized sport. Awesome. 

 

Organized sport is the leading cause of injury in youth and adolescents. Less awesome. 

But here comes the confusing part. Many studies have explored the benefits of ACL injury prevention programs and proved their efficacy. So then why is adherence to these programs so incredibly low?

 

Mindsets Associated with Sports

This is a frequently posed question in the world of sports medicine and rehabilitation. Sports injuries are often predictable and preventable, yet there remains this disconnect that we have no control over the injury. Too many of our athletes have the mindset, “it won’t happen to me” because of their lack of perceived control. I remember 15-year-old Jules sitting in the front seat of my Mom’s Nissan Murano on our way to soccer practice over a decade ago. She asked me what I would do if I ever got hurt and couldn’t fulfill my dream of playing professional soccer. I gave her the silent treatment after simply replying, “I’m just not going to get hurt.” Duh.

 

Welp. Spoiler alert: Mom was right. I got hurt over, and over, and over again. And it wasn’t until recently that I started to question why. I bought into three of the most popular and dangerous mindsets associated with sports. These mindsets are fatalism, invincibility, and acceptance. 

1. Fatalism is the idea that accidents happen, especially when engaging in inherently risky behavior like sport. 

2. Invincibility is a dangerous combination of denial and deflection, where an athlete thinks that injury won’t happen to them and that if it does, is attributed to sheer luck rather than his/her (in)action. Sure, some injuries are just straight-up bad luck. But many of them can actually be avoided with the proper neuromuscular training. 

3. Acceptance is the idea that pain is just a part of the sport. Sports culture normalizes injury and often rewards athletes for ignoring and playing through pain or injury. 

 

While serenity and acceptance are wonderful attributes to embody, they should not be used as scapegoats when engaging in risky behavior. That would be like saying, “Well if I get smacked by a car while crossing this busy highway, it is what it is.” ……No. You stop and look both ways. You don’t just carelessly step out into traffic.

 

Fatalism, invincibility, and acceptance often cloud our judgment when it comes to implementing injury prevention programs. Many people even advocate for eliminating the phrase “injury prevention” and moving more towards an “injury reduction” mindset. I certainly see the validity in that verbiage, but also understand that some injuries can outright be prevented. These injuries include the non-contact deceleration, cut, pivot, land, or twist that so many of us have unfortunately experienced.

 

The Facts About ACL Injury Prevention Programs

Here are the facts. Last year, Webster and Hewett published an article where they pooled together data from various meta-analyses that looked at the effectiveness of ACL injury prevention programs with the intent of summarizing the results into one single source. They used five different databases and eight different meta-analyses. What they found was that there was an overall 50% reduction in the risk of all ACL injuries in all athletes (males and females) and a 67% reduction for non-contact ACL injuries in females. Read that again. FACT: ACL prevention programs reduce the risk of all ACL injuries by half in all athletes and non-contact ACL injuries by two-thirds in female athletes.

 

In July, the American Journal of Sports Medicine published a similar clinical update. This article aimed to evaluate the common and effective components in ACL injury prevention programs and to develop an efficient, user-friendly tool that can assess the quality of such programs. In this systematic review and meta-analysis (*pushes glasses further up nose* level 1 evidence here, guys), the researchers looked at 18 studies with over 27,231 participants. What they found was that programs targeting middle or high school-aged athletes reduced injury risk to a greater degree than did programs for college- or professional-aged athletes. They also found that ACL prevention programs are more effective when implemented throughout the sports season and not just simply in the pre-season (…go figure).

 

They concluded that effective ACL injury prevention programs should include lower body strength exercises (specifically nordic hamstrings, lunges, and heel/calf raises) with a special focus on landing stabilization (jump and hold, drop and land). Injury prevention programs that include balance, core-strengthening, stretching, or agility are no more effective than programs that do not incorporate these components. 

 

All of the effective ACL injury prevention programs also included some sort of formal implementer training like an instructional workshop, video, or brochure, where coaches or parents were trained in safe body mechanics. What good is an ACL injury prevention program if it is poorly instructed? The researchers came up with this awesome checklist that clinicians, coaches, athletes, and parents can use to gain insight into the quality of their current injury prevention practices. How much benefit are you getting from your current program?

 You might be wondering how long or how often you should perform your injury prevention program. Although Petushek et al. did not describe optimal dosing, the Journal of Orthopedic and Sports Physical Therapy did in their most recent update of clinical practice guidelines regarding exercise-based knee and anterior cruciate ligament prevention. The authors state that these programs should involve multiple trainings per week and that training sessions should last longer than 20 minutes, with a cumulative training volume of longer than 30 minutes per week.

 

Talk about an awesome year for ACL research and health nerds alike. We’ve learned that:

• ACL injury prevention programs do actually work

• ACL injury prevention programs should include certain strength exercises and landing drills

• Programs should be performed both in- and out-of-season

• Training sessions should be at least 20 minutes long with at least 2 sessions performed each week

• implementers should be trained in proper body mechanics prior to teaching these programs

In Closing

For some reason, people don’t like to hear about injury prevention. They just don’t buy into it. I usually sugarcoat the discussion with aspects of performance enhancement – because when you think about it – if you move better, you’ll play better. If you’ve made it this far (kudos and a sincere thank you), I’ve somehow tricked you into reading about a boring topic with images of me housing ungodly amounts of Mexican food and an angsty teenager staring out a car window not speaking to her mother. Remember to always control the controllable.

If you knew you could have prevented yourself or your child from sitting on the sidelines for 9-12 months, wouldn’t you?

 

If you or someone you know would like to be trained in ACL injury prevention implementation, feel free to email me at Julie@MoveStrongPhysicalTherapy.com. Thanks for reading, and until next time, be well.

 

References

1. Webster KE, Hewett TE. Meta-analysis of meta-analyses of anterior cruciate ligament injury reduction training programs. J OrthopRes 2018.

2. Petushek, E., Sugimoto, D., Stoolmiller, M., Smith, G., & Myer, G. (2018). Evidence-Based Best-Practice Guidelines for Preventing Anterior Cruciate Ligament Injuries in Young Female Athletes: A Systematic Review and Meta-analysis. The American Journal of Sports Medicine., (78), 6-6.

3. Arundale AJH, Bizzini M, Giordano A, et al. Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention. J Orthop Sports Phys Ther 2018; 48:A1.

4. Deci, E. L., & Ryan, R. M. (1985). Intrinsic Motivation and Self‐Determination in Human Behavior. New York: Plenum Press.

5. Deci, E. L., & Ryan, R. M. (2000). The ‘‘what’’ and ‘‘why’’ of goal pursuits: Human needs and the self‐determination of behavior. Psychological Inquiry, 11, 227‐268.

6. Emery, C. A. & Meeuwisse, W. H. (2008). The effectiveness of a neuromuscular training program to reduce injuries in youth soccer: A cluster‐randomized controlled trial. British Journal of Sports Medicine, 42, 497.

7. Emery, C. A., Rose, M. S., McAllister, J. R., & Meeuwisse, W. H. (2007). A prevention strategy to reduce the incidence of injury in high school basketball: A cluster randomized controlled trial. Clinical Journal of Sports Medicine, 17, 17‐24.

8. Hemenway, D. (2013). Three common beliefs that are impediments to injury prevention. Injury Prevention, 19, 290‐293. Hughes, R. & Coakley,

9. J. (1991). Positive deviance among athletes: The implications of overconformity to the Sport Ethic. Sociology of Sport Journal, 8, 307‐325.

10. Hughes, R. & Coakley, J. (1991). Positive deviance among athletes: The implications of overconformity to the Sport Ethic. Sociology of Sport Journal, 8(4), 307‐325.