Play safe: your guide to ACL Injury Prevention

An ACL injury can be devastating to an athlete. Injury prevention programs and specialised exercises can significantly help reduce the risk of sustaining an ACL injury.

Anterior cruciate ligament (ACL) injuries are prevalent in both recreational and professional sports, which often have a significant impact on both the individual’s physical and psychological function. An ACL injury is a significant setback for athletes and active individuals alike, taking us away from the sport we love and sports mates. In the world of sports, protecting your ACL is paramount; reducing the risk of an ACL injury is crucial for athletes and active individuals.

Role of the ACL

The ACL runs diagonally in the middle of the knee from the lateral aspect of the femoral condyle to the anterior medial aspect of the tibia and provides rotational stability to the joint. The orientation and direction of the bands of the ACL act as a restraint for rotation as well as limiting forward movement of the tibia (shin bone) on the femur (thigh bone). The combination of active muscle contraction with precise neuromuscular timing assists with knee stability during running, jumping, and cutting or pivoting maneuvers. Any alteration in the biomechanics or muscular control of the knee increases the risk of ACL injury.

How does an ACL injury occur?

Netball has a high incidence of ACL injury

Up to 70-80% of ACL injuries are non-contact which occur when landing from a jump, rapidly stopping, cutting or suddently decelerating with a change of direction. Other causes of ACL injuries occur during dynamic activities that primarily involve cutting and pivoting. Athletes in basketball, soccer, football, and skiing are particularly prone to ACL injuries due to the high demands on knee movement and stability. Females are at risk four to six times greater than their male counterparts partly due to anatomical differences and hormonal differences.

Associated Risk Factors

Mechanism of how an ACL rupture can occur

1.    Biomechanical Factors: Excessive knee valgus (inward knee movement), and improper landing mechanics increase ACL injury risk.

2.    Neuromuscular Control: Deficient neuromuscular control can result in improper muscle activation and joint stabilization.

3.    Previous Injuries: Prior knee injuries can predispose individuals to ACL tears.

4.    Gender: Female athletes have a higher risk due to biomechanical and hormonal differences.

5.    Environmental Factors: Playing surfaces, footwear, and weather conditions can influence injury risk.

Prevention Strategies

1. Neuromuscular Training Programs

Neuromuscular training programs can reduce ACL injury incidence. Given the demands on the field for a large portion of sports, preventative training should focus on interventions that incorporate elements of anticipation, perturbations, focus of attention and visual-motor control within complex task environmental interaction. These programs should also involve on improving strength, proprioception, balance, and movement mechanics. Key components include:

•    Strength Training: Emphasizing the hamstrings, quadriceps, and hip muscles to support knee stability.

•    Plyometrics: Exercises such as jump training to enhance explosive power and proper landing techniques.

•    Balance Training: Using unstable surfaces to improve proprioception and joint stability.

•    Agility Drills: Enhancing the ability to change direction safely.

Adequate musculature strength, along with appropriate muscle recruitment and timing, are important aspects of knee stability. Therefore, neuromuscular training programs could reduce ACL injuries by up to 50%.

2. Biomechanical Analysis and Feedback

Individualized biomechanical analysis can identify at-risk movement patterns. Using video analysis, coaches and trainers can provide feedback and corrective exercises to improve biomechanics. Real-time feedback during activities helps reinforce proper techniques.

Additionally, as part of injury prevention, instructions direct the athlete’s attention to various aspects of movements. Feedback involves attentional focus termed internal focus and instructions are directed towards the execution of the movements for example ‘land with soft knee’.

3. Education and Awareness

Educating athletes, coaches, and parents about ACL injury risks and prevention strategies is vital. Awareness campaigns and workshops can disseminate best practices and encourage adherence to prevention programs.

4. Be consistent

Prevention strategies are only helpful if they are implemented on a regular consistent basis. Program should also be implemented as part of a preseason program at least 6 weeks prior to the start of the sport participation and continuing as a maintenance program throughout the competitive season. The programs don’t need to take hours to complete however they do need to implement sport-specific interventions to account for the variation in playing situations which incorporate specific level and type of sports tailored to the individual athlete.

How can a physiotherapist help me?

At Back to Bounce Sports Physiotherapy, our physiotherapists are  well placed to assess jumping and landing technique. A thorough and comprehensive assessment is essential to identify the individual’s specific needs along with identifying risk factors that increase the likelihood of an ACL injury. From the assessment a personalized exercise and rehabilitation plan is developed to progressively target strength, balance, landing mechanics and agility. We understand specific requirements for a variety of sports and take into account when approaching the management of injury prevention from a holistic perspective.

Successful Programs and Implementation

Several well-known ACL prevention programs have been developed and tested:

•    FIFA 11+: A comprehensive warm-up program designed for soccer players, shown to reduce injury rates significantly.

•    PEP Program (Prevent Injury and Enhance Performance): A program focusing on strength, plyometrics, and agility, demonstrating efficacy in reducing ACL injuries among female athletes

•    Sportsmetrics: A training protocol emphasizing jump mechanics, flexibility, and strength, proven to decrease ACL injury rates in young athletes.

Conclusion

ACL injury prevention requires a multifaceted approach, incorporating neuromuscular training, biomechanical analysis, and education. Evidence-based programs like FIFA 11+, the PEP Program, and Sportsmetrics have shown significant success in reducing injury rates. Implementing these strategies broadly can help protect athletes and reduce the burden of ACL injuries. However, every body is different and may require specific assessment and an individual approach therefore speaking with your local physiotherapist is recommended.

We utilise VALD Force Decks to give information about landing technique, force distribution and asymmetries. With this information, we then create individualised programs.

At Back to Bounce, we specialise in ACL injury prevention and rehabilitation. We guide patients through the rehabilitation process to recover from injury and return to high level performance and sport.

If you would like to make an appointment to gain a plan for your physiotherapy management, you can book online or call our team on (07) 5378 1571.





References

1.    Myer, G. D., Ford, K. R., & Hewett, T. E. (2004). Rationale and clinical techniques for anterior cruciate ligament injury prevention among female athletes. Journal of Athletic Training, 39(4), 352–364.

2.    Gagnier, J. J., Morgenstern, H., & Chess, L. (2013). Interventions designed to prevent anterior cruciate ligament injuries in adolescents and adults: a systematic review and meta-analysis. American Journal of Sports Medicine, 41(8), 1952-1962.

3.    Soligard, T., Myklebust, G., Steffen, K., Holme, I., Silvers, H., Bizzini, M., ... & Bahr, R. (2008). Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial. BMJ, 337, a2469.

4.    Mandelbaum, B. R., Silvers, H. J., Watanabe, D. S., Knarr, J. F., Thomas, S. D., Griffin, L. Y., ... & Garrett, W. (2005). Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. American Journal of Sports Medicine, 33(7), 1003-1010.

5.    Hewett, T. E., Lindenfeld, T. N., Riccobene, J. V., & Noyes, F. R. (1999). The effect of neuromuscular training on the incidence of knee injury in female athletes: a prospective study. American Journal of Sports Medicine, 27(6), 699-706.