MODERATE RECOMMENDATION The high quality study of adolescent, female Speak Takraw athletes by Yarsiasat (2019) demonstrated that incorporating a training program that included strengthening maneuvers, plyometric and sports-specific agility exercises significantly reduced the rate of complete ACL tears 5.32 (1.11 to 15.58). There is no discussion of whether these ACL injuries are primary or secondary. The rate of partial ACL tears was not significantly different between groups.
A moderate quality study of male NCAA soccer athletes by Silvers-Granelli (2017) demonstrated significant reductions in total injuries (p <0.001), total knee injuries (p <0.001), and ACL injuries (p=0.21) in athletes performing the training program. There is no discussion of whether these ACL injuries are primary or secondary and no distinction between complete and partial ACL injury.
A moderate quality study of adolescent, female Danish football (soccer) athletes by Walden (2012) showed a significant reduction in ACL injury rate ration (.36 95%CI 0.15 to 0.85, P=0.02). Partial ACL injuries with clinical instability and MRI confirmation were treated equal to complete ACL injuries in the analysis.
Benefits/Harms of Implementation
There are three moderate quality studies (Walden 2012, Silvers-Granelli 2017, Olsen 2005) and one high quality study (Johnson 2020) demonstrating benefit of exercise training in ACL injury prevention. No high or moderate quality studies have demonstrated harm.
Outcome Importance
ACL injury is a major source of musculoskeletal cost and morbidity. Additionally, it is a major source of time lost from sport participation. Many athletes and individuals never return to their pre-injury sport participation activity level.
Cost Effectiveness/Resource Utilization
The cost of implementing training programs designed to prevent primary ACL injury is not well studied.
Acceptability
Effective exercise programs capable of reducing primary ACL injury should be accepted widely by the sports medicine community.
Feasibility
Compliance with structured exercise programs depends on the demands of the athlete in terms of time, space, equipment, and motivation.
Future Research
Future research should examine ways to optimize exercise programs by decreasing their length/complexity while maximizing injury prevention benefits, elucidate the optimal timing/duration of program and the length of prevention effect, and assess the cost effectiveness of these programs. Additionally, recognizing that ACL injury risk increases dramatically from 11-17 years of age in both sexes and coincides with the increasing risk in females over males and additional research understanding the increased risk in pediatric patients, timing of this risk and subsequent intervention for prevention strategies.
- Yarsiasat, J., Sumannont, S., Manimmanakorn, N., Srilamarth, S. Effectiveness of the Prevent Injury Enhance Performance (PEP) training program in reducing injury incidence rates among adolescent female SEPAK takraw players: A randomised controlled trial. Journal of the Medical Association of Thailand 2019; 6: 98-105
- Walden, M., Atroshi, I., Magnusson, H., Wagner, P., Hagglund, M. Prevention of acute knee injuries in adolescent female football players: cluster randomised controlled trial. BMJ 2012; 0: e3042
- Silvers-Granelli, H. J., Bizzini, M., Arundale, A., Mandelbaum, B. R., Snyder-Mackler, L. Does the FIFA 11+ Injury Prevention Program Reduce the Incidence of ACL Injury in Male Soccer Players?. Clinical Orthopaedics & Related Research 2017; 10: 2447-2455
- Olsen, O. E., Myklebust, G., Engebretsen, L., Holme, I., Bahr, R. Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial. BMJ 2005; 7489: 449
- Johnson, J. L., Capin, J. J., Arundale, A. J. H., Zarzycki, R., Smith, A. H., Snyder-Mackler, L. Secondary Injury Prevention Program May Decrease Contralateral Anterior Cruciate Ligament Injuries in Female Athletes: 2-year Injury Rates in the ACL-SPORTS Randomized Control Trial. Journal of Orthopaedic & Sports Physical Therapy 2020; 0: 1-28