Evidence-based ACL Injury Prevention Strategies: Translation of Research Findings into Clinical Practices

Dai Sugimoto, PhD, ATC, CSCS The Micheli Center for Sports Injury Prevention Boston Children’s Hospital - Sports Medicine

I. Effect of ACL injury

ICF Model

Health condition, disorder, disease: ACL tear

Body function & structures impairment: Constant pain, noticeable effusion, a lack of ROMs, and atrophy.

Activities limitation: Inability to walk and difficulties in ADL including taking shower, driving a car, and yard work.

Participation restriction: Incapability of participating in sporting activities. May miss a work or class duties.

Environmental factor Personal factor

Impact of Injury: Career

Return to play

- High School: 63%

- College: 69% (McCullough et al, AJSM 2012)

- Early adults: 73% (Brophy et al, AJSM 2012)

Impact of Injury: At 2 years

Return to sports

- Same level: 41%

- Lower level: 11%

- Different sport(s): 14% (Ardern et al, AJSM 2015)

Subsequent ACL Injury Risk

Second ACL injury in ACL-R: 23 - 29% (Paterno et al, AJSM 2010, Webster et al, AJSM 2014)

Second ACL injury risk in ACL-R: 15 times greater. (Paterno et al, CJSM 2012)

20010)

Effect of Previous Knee Surgery

Knee injury risk in college: 7 - 20 times greater. (Rugg et al, AJSM 2014) 20010)

Pre-mature Osteoarthritis Risk

Radiographic

osteoarthritis signs:

74% within 10 - 15

years (Øiestad et al, AJSM 2011)

Negative impact

on quality of life: 75% (Lohmander et al, Arth Rheum 2004)

II. Evidence-based ACL Injury

Prevention Strategies

Mechanism of ACL Injury

Direct or Indirect contact: 30%

Noncontact: 70% (Arendt et al, AJSM, 1995; Boden et al, Orthopedics, 2000; Agel et al, AJSM, 2005; Walden et

al, KSSTA, 2007)

Literature Search

Time: 1995 - May, 2012

Databases: PubMed and EBSCO (CINAHL, MEDLINE, SPORTDiscus)

Key words search

Meta-Analysis

Prophylactic Effectiveness

74% risk reduction for noncontact ACL injury

46% risk reduction for overall ACL injury

(Sugimoto et al, Curr Phys Med Rehabil Rep 2015)

Variable Odds ratio and 95% CI

Odds

ratio

p-Value

Early Adults 1.001

0.997

Late Teens 0.476

0.073

Mid Teens 0.265

0.001

0.01 0.1 1 10 100

Favors to

Preventive

Training

Favors to

Control

Age Influence of

Neuromuscular Training on

ACL Injury Reduction

• The earlier they start, the greater prophylactic effectiveness (Myer et al, AJSM 2013)

Studies: Biomechanics

205 female high school athletes

Laboratory assessment before a season

18 months Noncontact ACL

injury: 9 (Hewett et al, AJSM 2005)

8.4° greater knee abduction angles

- Sensitivity: 78%

- Specificity: 73% (Hewett et al, AJSM 2005)

ACL Injury Biomechanical Risk Factors

10.5° less knee flexion angle

Greater ground reaction force

Asymmetrical

landing pattern (Hewett et al, AJSM 2005)

ACL Injury Biomechanical Risk Factors

ACL injured:

Greater lateral

trunk flexion and

less trunk flexion

angles (Hewett et al, BJSM 2009)

ACL Injury Biomechanical Risk Factors

Variable Odds ratio and 95% CI

Odds

ratio

p-Value

Low Volume 0.655

0.045

Moderate Volume 0.461

0.059

High Volume 0.315

0.001

0.01 0.1 1 10 100

Favors to

Preventive

Training

Favors to

Control

Dosage Influence of

Neuromuscular Training on

ACL Injury Reduction

• The higher volume, the greater prophylactic effectiveness

(Sugimoto et al, Sports Med 2014)

Sub-group Analysis: Exercise

Exercise Categorizations:

Balance

Plyometrics

Strength

Proximal Control

Single vs. Multiple Exercise(s)

Effect of Strength on

ACL Injury Reduction

Steffen et al.

No strength

increases

Risk

reduction:

29%

(Steffen et al, Scand J Med Sci Sports 2008)

Effect of Strength on

ACL Injury Reduction

Mandelbaum et al. and Gilchrist et al.

Strength increases:

- +11.7% in hip abductor

- +9.8% in hamstrings

Risk reduction:

74 - 88%

(Mandelbaum et al, AJSM 2005;

Gilchristetal, et al, AJSM 2008)

Decreased hamstrings strength

Decreased hamstrings: quadriceps ratio

(Myer et al, CJSM 2009)

ACL Injury Neuromuscular Risk Factors

Poor trunk reposition

sense and history of

low back pain

- Sensitivity: 91%

- Specificity: 68%

(Zazulak et al, AJSM 2007)

ACL Injury Neuromuscular Risk Factors

Effect of Hip Abductor Strength

Decreased hip

abductor strength:

Increased knee

abduction angles. (Jacobs et al, JAT 2007; Heinert et al,,

JSR 2008)

Comparison of Hip Abductor and

Adductor Peak Torque and Ratio

(Sugimoto et al, CJSM 2014)

Study: Effect of Hip Strength

501 young athletes

Isometric hip strength tests before a season

One season Noncontact ACL

injury: 15 (Khayambashi et al, AJSM 2015)

Effect of Hip Strength: Results

(Khayambashi et al, AJSM 2015)

Conclusion: Exercise

Include a variety of exercises, especially strengthening and proximal control exercises.

Plyometrics on

Ground Reaction Force

Ground reaction force reduction in landing:

- 22.0% - 26.4% - 7.4%

(Vescovi et al, Phys Ther Sport 2008)

(Irmischer et al, JSCR 2004)

(Hewett et al, AJSM 1996)

Effect of Feedback on

Biomechanics

Spike jump landing:

- Verbal and video feedback

- 18.7° greater knee flexion angles

(Parson et al, JSCR 2012)

Neuromuscular Training with

vs. without Feedback

- Training with and without verbal feedback

Biofeedback Training on

Biomechanical Alteration

- Training with verbal feedback

- 6.9° and 6.5° less knee abduction angles

- Training without

verbal feedback

- 2.9° and 2.6° less

knee abduction

angles

(Myer et al, AJSM 2013)

An inverse dose-

response relationship

- High

compliance: 82%

- Moderate

compliance: 44%

- Low

compliance: 12% 0.01 0.1 0.2 0.5 1 2 5

Low

Compliance 0.88 (0.53, 1.47)

Moderate

Compliance 0.56 (0.05, 3.41)

High

Compliance 0.18 (0.02, 0.77)*

(Sugimoto et al, JAT 2012)

Sub-group Analysis: Compliance

Translation from research study to clinical practices

(Myklebust et al, BJSM 2013)

Access to Qualified Healthcare

HS soccer coaches (N=756): 20% - Length of coaching experiences (>7 years) - Additional support personnel (AT,CSCS) Barriers: - Lack of knowledge: 64% - Time restrictions: 43% - Lack of understanding & support: 43%

(Joy et al, JSCR 2013)