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ARTICLEPEDIATRICS Volume 139 , number 3 , March 2017 :e 20161877
ACL Tears in School-Aged Children and Adolescents Over 20 YearsNicholas A. Beck, MD, a J. Todd R. Lawrence, MD, PhD, b James D. Nordin, MD, MPH, c Terese A. DeFor, MS, c Marc Tompkins, MDd
abstractBACKGROUND: Anterior cruciate ligament (ACL) tears are thought to occur with increasing
frequency in young patients. No study has shown increased incidence over time. We
hypothesized the incidence of ACL tears in young patients has increased over the past 20
years.
METHODS: This descriptive epidemiology study is a retrospective review of insurance billing
data of all patients aged 6 to 18 years with Current Procedural Terminology, Fourth Revision
codes for ACL tear and reconstruction or International Classification of Diseases, Ninth
Revision, Clinical Modification codes from 1994 to 2013. Injuries were normalized to
persons per year enrolled in the insurance database based on age and sex. Analysis was
performed based on sex and age (6–14, 15–16, and 17–18 years).
RESULTS: The rate of ACL tears per 100 000 person-years averaged 121 ± 19 (range 92–151).
All trends increased significantly except for the male 6- to 14-year-old and 17- to 18-year-
old age groups. Overall there was an annual increase of 2.3%. Females had significantly
higher incidence except in the 17- to 18-year-olds. Females peaked at age 16 years and
males at age 17 years, with rates of 392 ACL tears and 422 ACL tears per 100 000 person-
years, respectively.
CONCLUSIONS: The incidence of ACL tears in pediatric patients increased over the last 20
years. Females were at higher risk except in the 17- to 18-year -old group. Peak incidence
is noted during high school years. These data help target the most at-risk patients for ACL
prevention programs.
aUniversity of Minnesota, Minneapolis, Minnesota; bChildren’s Hospital of Philadelphia, Philadelphia,
Pennsylvania; cHealthPartners, Minneapolis, Minnesota; and dTRIA Orthopaedic Center, Bloomington, Minnesota
Dr Beck conceptualized and helped design the study, drafted the initial manuscript, and edited
the fi nal manuscript; Dr Lawrence conceptualized and helped design the study and reviewed
and revised the manuscript; Dr Nordin helped design the study and reviewed and revised the
manuscript; Mrs DeFor collected the data, carried out the initial analyses, and reviewed and
revised the manuscript; Dr Tompkins conceptualized and helped design the study, acted as the
senior author, and reviewed and revised the manuscript; and all authors approved the fi nal
manuscript as submitted.
DOI: 10.1542/peds.2016-1877
Accepted for publication Dec 20, 2016
Address correspondence to Nicholas A. Beck, MD, 2450 Riverside Ave South, Suite R200,
Minneapolis, MN 55454. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2017 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant
to this article to disclose.
FUNDING: Funds provided by the University of Minnesota Clinical Research Committee.
To cite: Beck NA, Lawrence JTR, Nordin JD, et al. ACL Tears
in School-Aged Children and Adolescents Over 20 Years.
Pediatrics. 2017;139(3):e20161877
WHAT’S KNOWN ON THIS SUBJECT: Recent reports
of anterior cruciate ligament (ACL) injuries in
young patients suggest the incidence is increasing.
However, true incidence data are scarce. Female
patients are at higher risk of ACL injury than males
participating in similar activities.
WHAT THIS STUDY ADDS: We present incidence data
for ACL tears in young patients and show that the
incidence increased over the past 20 years. Girls
exhibit higher risk until age 17. The ages most at risk
are 16 for girls and 17 for boys.
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BECK et al
Midsubstance tears of the anterior
cruciate ligament (ACL) were
classically thought to be rare injuries
in young patients, with tibial spine
avulsion fractures supposedly
representing the equivalent injury in
patients with open physes. 1 Others
have noted that ACL tears seem to be
presenting with greater frequency
in pediatric patients, including
patients as young as 5 years
old. 1 – 6 The increase in ACL surgical
consultations in young patients has
been attributed to multiple factors,
including increased participation in
high-demand year-round sports at an
earlier age, better clinician awareness
and recognition of the signs and
symptoms of ACL tears, increased
female athletic participation, and
the expanded role of magnetic
resonance imaging in the diagnosis
of intra-articular knee pathology. 1, 7, 8
Identifying these injuries may
be important to avoid additional
intra-articular knee injuries and
chondral damage through activity
modification or recently developed
surgical reconstruction techniques
that minimize or avoid physeal
damage. 9 –13
Most studies of ACL injury rates
report on adult athletes or military
personnel. 4, 14 – 21 Large population-
based epidemiologic studies often
group young patients together and
report very low rates of ACL injuries
in school-aged patients, and none to
our knowledge have looked at the
change in incidence over time.22, 23
Thus, the goal of this study was to
review the billing database of a large
metropolitan insurance network to
determine whether the number of
ACL tears has increased over the past
20 years. We also sought to examine
differences between sex, age, and
delay in surgery over the study
period. We hypothesized that there
would be an increase in the incidence
of ACL tears in patients ≤18 years
of age over the past 20 years, with
female patients showing a higher rate
of increase than male patients.
METHODS
A retrospective review of insurance
billing data in a large metropolitan
network was performed for all
children and adolescents aged
6 to 18 years with International
Classification of Diseases, Ninth
Revision, Clinical Modification
(ICD-9-CM) codes for ACL tears and
Current Procedural Terminology,
Fourth Revision (CPT-4) codes for
ACL reconstruction from January
1994 to December 2013. Patients
were included if they had ≥2
occurrences of ACL diagnosis
codes (844.2 or 717.83) on medical
claims ≤4 months apart, or ≥1
ACL procedure codes (29888)
during the study period. Therefore,
all patients with ACL tears were
included, not just those with surgical
reconstruction. Multiple ACL injuries
per patient were counted if >4
months elapsed between diagnoses.
Patients were excluded if they were
outside the included age ranges, if
the first diagnosis code was outside
a member’s enrollment period, or if
they had only 1 ICD-9-CM code.
Analysis included year-by-year
total incidence of ACL injury and a
breakdown by sex and ages grouped
6 to 14 years, 15 to 16 years, and
17 to 18 years. Denominators were
normalized to patients per year
enrolled in the insurance database
based on age and sex to calculate
rates per 100 000 person-years
specific to that cohort. Because
we used the insurance network,
all patients in the network were
captured by the insurance data
search. In addition, because we
queried it on a yearly basis, we were
able to control for patients entering
and leaving the insurance network.
Delay in surgery was calculated by
time between first ICD-9-CM code
and Current Procedural Terminology
code for each ACL injury. The annual
percent of ACL tears surgically
reconstructed was calculated.
The trend of annual incidence
for each age and sex cohort was
tested for significance with Poisson
regression analysis. Logistic
regression was used to look for
significant change in annual surgery
rates. Linear regression was used
to look for significant change in the
delay in surgery. Differences between
sexes were tested with Poisson
regression analysis for change in
annual incidence and for differences
in overall and age-specific rates.
RESULTS
Total patients enrolled in the
insurance database within our study
age range averaged 136 000 ± 15 000
per year, with approximately an
even number of male and female
patients each year. A total of 3303
ACL tears were identified over the
study period, 1584 (48%) ACL tears
in male patients and 1719 (52%) in
female patients. The overall annual
incidence of ACL tears averaged
121 ± 19 (range 92–151) per 100 000
person-years (or 0.121%) ( Fig 1
and Table 1). The incidence in male
patients averaged 114 ± 22 (range
83–160) per 100 000 person-years
(or 0.114%). The incidence in female
patients averaged 129 ± 24 (range
98–184) per 100 000 person-years
(or 0.129%). The breakdown by
age groups over time for overall
patients, male patients, and female
patients is shown in Figs 2, 3, and 4,
respectively.
The incidence of ACL tears by age
overall is shown in Fig 5. Poisson
regression analysis indicated that
differences in incidence between
male and female patients by age
were statistically significant for
each age category (P < .001).
Female patients peaked at age 16
years with an incidence of 392 ACL
tears per 100 000 person-years (or
0.392%), and male patients peaked
at age 17 years with an incidence of
422 ACL tears per 100 000 person-
years (or 0.422%). We found no
significant difference between
the amount of change in ACL tear
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PEDIATRICS Volume 139 , number 3 , March 2017 3
FIGURE 1Rates of ACL tears per 100 000 person-years for the overall male and female groups over the 20-year study period.
TABLE 1 Rates per 100 000 Person-Years for the Overall Male and Female Groups Over the 20-y Study Period
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Female
rate
per
100 000
117 113 109 98 118 107 118 127 99 110 131 143 120 127 142 133 167 184 176 131 140
Male rate
per
100 000
122 90 99 87 83 98 119 103 85 119 88 132 132 130 160 134 127 118 117 145 82
FIGURE 2Rates of ACL tears per 100 000 person-years for male and female patients broken down by age groups over the 20-year study period.
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incidence over time between male
and female patients overall
(P = .6) and across the age groups
(P = .2); however, overall incidence
was significantly higher in female
patients (129 ACL tears per 100 000
person-years vs 114 ACL tears per
100 000 person-years; P < .001)
and in the 6- to 14-year-old (33 ACL
tears per 100 000 person-years vs
26 ACL tears per 100 000 person-
years; P < .01) and 15- to 16-year-
old (371 ACL tears per 100 000
person-years vs 250 ACL tears per
100 000 person-years; P < .001) age
groups over our study period. Male
patients had significantly higher
incidence in the 17- to 18-year-
old age group (394 ACL tears per
100 000 person-years vs 337 ACL
tears per 100 000 person-years;
P < .01).
Results of the calculated changes in
incidence over time are summarized
in Table 2. All analyzed trends
increased significantly over time
except for the male 6- to 14-year-
olds and male 17- to 18-year-olds.
Overall we found that the number
of ACL tears per 100 000 person-
years increased 2.3% per year. Male
patients had an increase of 2.2%
per year, and female patients had
an increase of 2.5% per year. The
subgroup with the highest increase
was female 15- to 16-year-olds,
whose incidence increased 2.6% per
year.
4
FIGURE 3Rates of ACL tears per 100 000 person-years for the male patients broken down by age groups over the 20-year study period.
FIGURE 4Rates of ACL tears per 100 000 person-years for the female patients broken down by age groups over the 20-year study period.
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PEDIATRICS Volume 139 , number 3 , March 2017
Logistic regression showed that the
percentage of ACL tears surgically
reconstructed significantly increased
(P < .001) ( Fig 6 and Table 3), and
linear regression analysis identified
a significant increase in the delay to
surgery over the study period
(P = .04) ( Fig 7 and Table 4).
DISCUSSION
Through analysis of insurance data on
a captured population of patients, we
were able to calculate true incidence
numbers for a large metropolitan
population of pediatric patients. Over
the 20 years analyzed, we found a
2.3% annual increase in the number
of ACL tears in patients aged 6 to 18
years. Female patients had significantly
higher rates of injury in the younger
ages, but in the 17- to 18-year-old age
group male patients had a significantly
higher incidence. Subgroup analysis
showed that female patients in all 3
age groups had a significant increase
in incidence of ACL tears over the
study period, whereas only the male
patients aged 15 to 16 years had an
increased incidence. We also found
that the percentage of ACL injuries
surgically reconstructed increased, and
the average time from injury to surgery
increased significantly over our study
period.
This study is the first of its kind to
identify an increase in the incidence
of ACL tears in young patients over
the last 20 years. These data are novel
in that they report incidence of ACL
injury within a known, closed cohort.
Data were obtained on a yearly basis,
so the insurance database allows
for correction of patients entering
and leaving the insurance plan. In
addition, using the insurance database
means data are not restricted to a
single institution because the ACL tear
could be diagnosed in >1 location,
or the surgery could be performed
in a separate location, and all of
this information would be captured
within the insurance database. These
measures should add to a more
complete understanding of what we
have suspected in terms of increases
in pediatric ACL injury over time.
5
FIGURE 5Rates of ACL tears per 100 000 person-years for male and female patients over the study period broken down by age.
TABLE 2 Change per Year for Each Analysis, With Confi dence Intervals
Data Group Change per Year, % 95% Confi dence Interval, %
All ages
Female and male patients 2.3 1.7 to 2.9
Female patients 2.5 1.6 to 3.3
Male patients 2.2 1.3 to 3.0
Breakdown by age
Female and male patients
6- to 14-y-olds 2.1 0.70 to 3.6
15- to 16-y-olds 2.5 1.6 to 3.5
17- to 18-y-olds 1.3 0.40 to 2.2
Female patients
6- to 14-y-olds 2.5 0.50 to 4.5
15- to 16-y-olds 2.6 1.4 to 3.9
17- to 18-y-olds 1.5 0.10 to 2.8
Male patients
6- to 14-y-olds 1.8 −0.30 to 3.9
15- to 16-y-olds 2.4 0.90 to 3.9
17- to 18-y-olds 1.2 −0.04 to 2.4
Percentage reconstructed 3.0 2.0 to 4.0
Time to reconstruction 0.90 0.03 to 1.8
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FIGURE 6Percentage of ACL tears surgically reconstructed by year over the 20-year study period.
TABLE 3 Percentage of ACL Tears Surgically Reconstructed by Year Over the 20-y Study Period
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Percentage
ACL tears
surgically
repaired
57 65 70 57 66 68 73 80 69 73 74 74 78 70 77 70 70 76 75 73 70
FIGURE 7Median delay in days to surgical reconstruction for patients treated surgically over the 20-year study period.
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PEDIATRICS Volume 139 , number 3 , March 2017
The average annual incidence of
ACL injuries found in our study
(0.12%) is similar to those found
in large population-based studies.
Nordenvall et al 23 used data from the
Swedish National Patient Register
to estimate the sex- and age-specific
incidence of ACL tears in Sweden.
They found the average annual
incidence to be 78 per 100 000
inhabitants (or 0.078%). Very few
injuries were found in patients <10
years old, and the incidence was
similar in male and female patients
in the 11- to 20-year-old age group
of 144 per 100 000 inhabitants (or
0.14%). Gianotti et al 22 reported
data from New Zealand’s Accident
Compensation Corporation showing
a similar breakdown of incidence
by age and sex. They also showed
very few ACL injuries in patients <10
years old. Their incidence in 15- to
19-year-olds was between 65 and
100 per 100 000 person-years for
female and male patients respectively
(or 0.065%–0.10%).
It is important to note that previous
studies define rates of injury in
different units. Studies looking at risk
for ACL injuries in athletes or military
personnel present their rates based
on exposure-based denominators to
the sport or activity by either hours
or season. Population-based studies
often define rates based on absolute
time-based denominators such as
incidence per 100 000 person-years.
Moses et al 24 attempted to compare
multiple studies by converting
incidence rates in exposure-based
studies to annual units. They found
studies reporting population
incidence with a low annual median
incidence of 0.03%. Studies of
ACL injury data from military and
professional sports showed much
higher annual incidences of up to
2.14% and 3.67%, respectively.
Dodwell et al 25 showed an increase
in the rate of ACL reconstructions
performed on pediatric (defined as
ages 3 to 20 years old) patients in
New York State from 1990 to 2009.
In their study, population estimates
from the US Census Bureau were
used as the denominator to obtain
rates per 100 000 population.
They found that the rate rose
from 17.6 ACL reconstructions
per 100 000 population in 1990
to 50.9 ACL reconstructions per
100 000 population in 2009, or a
190% increase over their study
period. This compares to the more
modest 2.3% yearly increase in our
population. Their analysis by sex
found that male patients had a 15%
higher rate of ACL reconstructions,
where our study showed higher
rates in female patients except for
the 17- to 18-year-old patients.
Lively and Feathers 17 found an
increasing incidence of ACL injuries
in a collegiate population based on
incoming athletes’ injury history
at a single institution from 1996 to
2008. An athlete had a 2.7 greater
odds of having a previous ACL injury
in 2008 than those who arrived in
1996. Although their analysis showed
a nearly linear increasing trend
by year, there was no significant
correlation with sport (P = .41) or sex
(P = .71).
In this study, female patients on
average had a higher incidence
overall and across the 6- to 14-year-
old and 15- to 16-year-old age groups
than their male counterparts. ACL
injury rates have been shown in
multiple studies to be 2 to 8 times
higher in female than male patients
when comparing exposure to sex-
comparable sports. 4, 14, 20 Reasons
for this observed difference are
thought to be related factors such as
geometry of the intercondylar notch
and smaller size of ACL, as well as
biomechanical and neuromuscular
factors such as higher quadriceps-to-
hamstring ratio and landing from a
jump with less hip and knee flexion
and more hip adduction, leading to
increased dynamic knee valgus with
greater knee abduction angles. 26 It is
interesting that male patients in the
17- to 18-year-old age group of our
study surpassed female patients, with
significantly higher rates. Proposed
explanations for this observation
include higher intensity of collision
sports in older male athletes, fewer
female adolescents participating in
sports at this age, and female athletes
prone to ACL injury having already
sustained injuries and no longer
competing.
Through subgroup analysis by age
and sex, we attempted to identify the
most at-risk patients over our study
period. Much effort has recently
been put forth in the sports medicine
community to develop prevention
programs with neuromuscular and
proprioceptive training, especially for
female athletes. 26 Noyes and Barber-
Westin 27 conducted a systematic
review of 8 neuromuscular retraining
studies in female athletes. Three
studies found a significant reduction
7
TABLE 4 Median Delay in Days to Surgical Reconstruction for Patients Treated Surgically Over the 20-y Study Period
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Median delay in
days to surgical
reconstruction
for patients
treated
surgically
26 29 26 31 28 24 33 28 31 34 27.5 32 26 31 28 30 27.5 26 23 25 23
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BECK et al
in the number of noncontact
ACL injuries, with a relative risk
reduction ranging from 75% to
100%. The remaining 5 studies
found no significant decrease with
their programs; however, the overall
ACL injury rates in these studies
were much lower. There was a large
discrepancy in how the programs
were performed, based on the
frequency, duration, supervision, and
compliance. Myer et al 28 performed
a meta-analysis of neuromuscular
training studies, specifically looking
at the effectiveness the programs
for different age participants. They
included 14 clinical trials and found
a significant age-related reduction
in injury rate, with an odds ratio of
0.28 in the 14- to 18-year-old female
athletes, compared with an odds ratio
of 0.48 in the 18- to 20-year-olds and
1.01 in the >20-year-olds. Thus the
programs seem to be more effective
in younger patients. In our cohort, all
subgroups of the female patients and
the male 15- to 16-year-old subgroup
showed a significant increase in ACL
injury incidence over time. Because
the injury rates in these cohorts seem
to be increasing, they may also be
the most likely to benefit from injury
prevention programs.
Two additional findings of this study
are that the percentage of injuries
surgically reconstructed increased
and the average time to surgery
increased over our study period,
although the time to surgery increase
was small (<1%) and clinically
insignificant. A traditional treatment
approach for ACL injuries in young
patients has been to attempt a trial
of conservative treatment until the
child is close to the end of growth,
based on the assumption that the
risk of limb length discrepancy
and angular growth disturbances
decreases as the patient approaches
skeletal maturity. 1, 3, 7, 29 Recent
studies have shown poor outcomes
with nonoperative treatment.
Lawrence et al11 showed that
delaying surgery of a complete ACL
tear for >12 weeks correlated with
a significant increase in the number
of irreparable medial meniscal tears
and lateral compartment chondral
injuries. Because of this risk, multiple
new surgical techniques have been
developed that range from physeal-
sparing, to partial transphyseal, to
complete transphyseal reconstruction
with smaller, more vertical tunnels. 1
Studies reporting on these techniques
are small retrospective cohorts,
and the procedures are technically
demanding, but the outcomes are
encouraging. Our data suggest that
because of the encouraging results
in the recent literature, surgeons
are more confident treating these
injuries with surgical reconstruction
at younger ages.
Our study has several limitations.
The data were pulled from a specific
regional geographic insurance
database. Therefore, the injury
and surgical treatment rates may
reflect regional differences and
thus may not be representative of
other areas of the United States
or in other countries. The people
covered under this insurance plan
also probably represent people
of a certain socioeconomic class.
Patients with a different quality of
insurance or no insurance may have
more or less exposure to at-risk
activities and higher barriers to
access of care, which may affect the
overall incidence rate. The insurance
database itself has limitations.
We attempted to identify repeat
injuries in patients who have a new
diagnosis code after 4 months, and
this assumption fails to include
new injuries that occur in the first
4 months after return to sport. For
patients with multiple injuries, we
were unable to distinguish between
primary tear of the contralateral
knee and a recurrent tear of the
originally injured knee. In addition,
patients with ACL injuries could
have been missed by entering or
leaving the health insurance plan
before getting the 2 ICD-9-CM
codes required for inclusion, so the
incidence may actually be higher
than that which is reported here.
Despite these limitations, this is the
first study quantifying and showing
an increase in the incidence of ACL
tears in school-aged children and
adolescents.
CONCLUSIONS
This study is the first to show that the
incidence of ACL tears in pediatric
patients (age 6 to 18 years) has
significantly steadily increased by
about 2.3% annually over the last
20 years. Female patients in all age
categories and male patients in the
15- to 16-year-old category showed
the greatest increases and accounted
for most of the overall increase. Both
male and female adolescents have a
peak incidence during high school
years (age 16 years for female and
17 years for male adolescents).
Future studies identifying the
mechanism of injury in young
patients will be helpful for proposing
prevention training.
8
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.
ABBREVIATIONS
ACL: anterior cruciate ligament
ICD-9-CM: International
Classification of
Diseases, Ninth
Revision, Clinical
Modification
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PEDIATRICS Volume 139 , number 3 , March 2017
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DOI: 10.1542/peds.2016-1877 originally published online February 22, 2017; 2017;139;Pediatrics
TompkinsNicholas A. Beck, J. Todd R. Lawrence, James D. Nordin, Terese A. DeFor and Marc
ACL Tears in School-Aged Children and Adolescents Over 20 Years
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DOI: 10.1542/peds.2016-1877 originally published online February 22, 2017; 2017;139;Pediatrics
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ACL Tears in School-Aged Children and Adolescents Over 20 Years
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