Anterior cruciate ligament injury

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IOC expert group publishes consensus statement on knee injury

5 May 2008

Non-contact anterior cruciate ligament (ACL) injury is a serious knee injury

which affects young women in much higher numbers than young men, especially in

sports like basketball, netball and team handball. A group of physicians,

physical therapists, biomechanists and other scientists were recently invited by

the IOC Medical Commission to discuss ACL, risk factors, prevention programmes

and the need for further research. The expert panel concluded that improved

education and greater awareness were key: " Athletes, coaches, and parents all

play a vital role in the fight to prevent ACL injuries, which remains the

largest single problem in orthopaedic sports medicine " .

The challenge

The incidence of anterior cruciate ligament (ACL) injury remains

high, especially in the young, athletic population 14-19 years of

age. The incidence of non-contact ACL tears as a function of gender

shows that female subjects have a much higher incidence in some

sports such as basketball, netball and team handball versus male

subjects. In spite of the fact that some successful ACL injury

prevention programmes have been introduced, the ACL injury continues

to be the largest single problem in Orthopaedic Sports Medicine

IOC President Jacques Rogge stated in 2001 that " the most important

goal of the IOC Medical Commission is to protect the health of the

athlete " .

As the ACL injury especially in young females in sports remains a

major problem, there is a need for improved prevention and

management.

ACL injury in the young female athlete.

We now know that, based on recent studies, there can be a

quantifiable reduction in ACL risk for athletes, particularly

females, who complete a well designed injury prevention programme.

Most of these programmes attempt to alter dynamic loading of the

tibiofemoral joint through neuromuscular and proprioceptive training.

Emphasis is placed on proper landing technique: landing softly on the

forefoot and rolling back to the rearfoot, engaging knee and hip

flexion upon landing. Two-feet landing is encouraged where possible.

When performing cutting manoeuvres, athletes should avoid excessive

dynamic valgus of the knee upon landing and squatting; they should

aim to achieve the " knee over toe position " . Intervention programmes

have focused on increasing hamstring, gluteus medius and hip

abductor strength, and addressing proper deceleration techniques.

Important factors for a successful prevention programme

· The programme should include strength and power exercises,

neuromuscular training, plyometrics and agility exercises

· Design as a regular warm-up programme increases adherence

· Focus on performance- hip-knee-foot line, avoid " kissing knees "

(excessive valgus strain)

· Maintenance of and compliance with prevention programmes before,

during and after the sports participation season is essential to

minimise injuries.

· Drop vertical jump test to find players at risk

· The programme must be well received by coaches and players to be

successful

· Evaluation of success or failure of a prevention programme requires

large numbers of athletes and injuries

Overall summary and future directions

There is consensus in the literature that females are at increased

risk of suffering an ACL injury in comparison to males when they

compete in the same sport at the same level of competition. However,

many studies have focused on the prevalence of ACL injuries

associated with high risk sports; only a limited number have

calculated injury incidence based on time at risk and compared males

and females competing in similar activities at the same level of

competition.

There appears to be mounting evidence that females are at

significantly greater risk of ACL injury during the pre-ovulatory

phase of the menstrual cycle compared with the post-ovulatory phase.

While it remains unclear whether estradiol and progesterone act

directly on the ACL in women and increase the likelihood that a

subject will sustain an injury, other hormones associated with the

menstrual cycle may modulate injury risk. Alternatively, hormones may

act on structures other then the ACL. Athletes with a decreased

intercondylar notch width, as measured radiographically on a standard

notch view, are at increased risk of suffering a non-contact ACL

injury.

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Carruthers

Wakefield, UK