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1062-6050-50.1.10.Pdf Journal of Athletic Training 2015;50(6):589–595 doi: 10.4085/1062-6050-50.1.10 Ó by the National Athletic Trainers’ Association, Inc original research www.natajournals.org The Landing Error Scoring System as a Screening Tool for an Anterior Cruciate Ligament Injury–Prevention Program in Elite-Youth Soccer Athletes Darin A. Padua, PhD, ATC*; Lindsay J. DiStefano, PhD, ATC†; Anthony I. Beutler, MD‡; Sarah J. de la Motte, PhD, MPH, ATC‡; Michael J. DiStefano, MA, ATC*; Steven W. Marshall, PhD* *Department of Exercise and Sport Science, University of North Carolina at Chapel Hill; †University of Connecticut, Storrs; ‡Uniformed Services University of the Health Sciences, Bethesda, MD Context: Identifying neuromuscular screening factors for Main Outcome Measure(s): Landings were scored for anterior cruciate ligament (ACL) injury is a critical step toward ‘‘errors’’ in technique using the LESS. We used receiver large-scale deployment of effective ACL injury-prevention operator characteristic curves to determine a cutpoint on the programs. The Landing Error Scoring System (LESS) is a valid LESS. Sensitivity and specificity of the LESS in predicting ACL and reliable clinical assessment of jump-landing biomechanics. injury were assessed. Objective: To investigate the ability of the LESS to identify Results: Seven participants sustained ACL injuries during individuals at risk for ACL injury in an elite-youth soccer the follow-up period; the mechanism of injury was noncontact or population. indirect contact for all injuries. Uninjured participants had lower Design: Cohort study. LESS scores (4.43 6 1.71) than injured participants (6.24 6 Setting: Field-based functional movement screening per- 1.75; t1215 ¼2.784, P ¼ .005). The receiver operator formed at soccer practice facilities. characteristic curve analyses suggested that 5 was the optimal Patients or Other Participants: A total of 829 elite-youth cutpoint for the LESS, generating a sensitivity of 86% and a soccer athletes (348 boys, 481 girls; age ¼ 13.9 6 1.8 years, specificity of 64%. age range ¼ 11 to 18 years), of whom 25% (n ¼ 207) were less Conclusions: Despite sample-size limitations, the LESS than 13 years of age. showed potential as a screening tool to determine ACL injury Intervention(s): Baseline preseason testing for all partici- pants consisted of a jump-landing task (3 trials). Participants risk in elite-youth soccer athletes. were followed prospectively throughout their soccer seasons for Key Words: children, knee, biomechanics, movement pat- diagnosis of ACL injuries (1217 athlete-seasons of follow-up). terns Key Points The Landing Error Scoring System (LESS) score may effectively identify elite-youth soccer athletes at higher risk of sustaining anterior cruciate ligament (ACL) injuries. Elite-youth soccer athletes with LESS scores of 5 or more were at higher risk of sustaining ACL injuries than athletes with LESS scores less than 5. Individuals with LESS scores of 5 or more may be targeted for ACL injury-prevention exercise programs. occer is the most popular sport in the world, with these athletes undergoing either surgery to the contralateral more than 265 million participants. It is also one of knee or revision surgery during the 5-year period after the S the sports most commonly associated with athletic index surgery.5 Given that surgery and rehabilitation do not injury, such as to the anterior cruciate ligament (ACL). prevent long-term morbidity, the need to prevent ACL More than 25% of individuals with ACL injuries do not injuries in youth soccer athletes is great. return to previous activity levels even after successful For effective injury prevention, prospective risk factors surgery and rehabilitation.1 Within 7 years after an ACL for injury should be established before preventive measures injury, 65% of individuals no longer play soccer.1 More are introduced.6 Most theorized risk factors for ACL injury, than one-third of skeletally immature children also face such as sex, hormonal changes, notch width, and static challenges returning to sports such as soccer within 2 years postural alignment, are not modifiable through prevention of an ACL injury.2 Regardless of treatment, patients also efforts. Abnormal lower extremity biomechanics, however, have reported moderate to severe disability with walking are modifiable and are critical factors for study because (31%) and activities of daily living (44%).3,4 Adolescent they produce abnormal knee loading. Specifically, 3- female soccer players appear to be at greatest risk for dimensional knee loading, including knee-extension mo- negative long-term consequences, with more than 22% of ment, proximal anterior tibial shear force, knee valgus- Journal of Athletic Training 589 in similar levels of competition and always on natural grass. All teams were simultaneously performing an injury- prevention program warm-up during this study. A total of 829 participants (348 [42%] boys, 481 [58%] girls; age ¼ 13.9 6 1.8 years) were enrolled in this study: 565 (68%) from North Carolina (261 [46%] boys, 304 [54%] girls) and 264 (32%) from Maryland (87 [33%] boys, 177 [67%] girls). Of these participants, 207 (24.9%) were from 11 to 12 years of age. The group accumulated 1217 athlete-seasons of observation. At the initial test session, all participants were free from any injury or illness that prohibited competitive soccer activity. Participants and their legal guardians provided written informed assent and consent, respectively, before the initial test session. All procedures were approved by the Biomedical Institutional Review Board of the University of North Carolina at Figure 1. The standardized jump-landing task consists of 2 Chapel Hill. segments: A, participant jumps down from box and lands on ground; B, participant immediately jumps vertically as high as possible. Procedures Each participant completed a baseline questionnaire and varus moment, and knee internal-external–rotation mo- movement assessment at the beginning of each soccer ment, often is implicated in ACL injury7,8 and imposes the season between August 2006 and January 2009. A brief greatest strain on the ACL.9,10 Data regarding ACL loading baseline questionnaire addressed demographics and sport- and injury mechanisms help clinicians understand what related injury history. The movement assessment consisted occurs at the time of injury.11 Prospective risk factors, of a jump-landing task that was graded using the LESS by however, provide information for identifying individuals at video review at a later date. Returning athletes were risk for sustaining injuries, potentially years before injury.11 retested at the start of their returning seasons using identical Only a small body of evidence exists on prospective procedures. biomechanical risk factors for ACL injury. A limitation of All participants were monitored prospectively for ACL these studies is the use of laboratory-based instrumentation injury from the date of their enrollment (August 2006 12,13 through May 2009). A member of the research team visited and testing procedures. Whereas these instruments are the criterion standard for biomechanical measures, they are each soccer team weekly during the monitoring period to impractical in time and cost for large-scale mass screenings record injuries that participants sustained. Coaches and on the athletic field. To be feasible, a field-assessment tool participants were instructed to identify any participant who for high-risk biomechanics should be brief; use minimal or missed a soccer-related activity during the previous week inexpensive equipment; facilitate large-scale, field-based due to an injury or an unknown reason. The research team screening; and provide a valid and reliable measure of the member followed up with all participants with suspected biomechanics that predict injury. injuries. All participants with reported ACL injuries completed a specific questionnaire to verify the injury The Landing Error Scoring System (LESS) is a field- and obtain information about the circumstances of injury. assessment tool for identifying potentially high-risk move- All reported ACL injuries were verified during surgical ment patterns (‘‘errors’’) during a jump-landing maneuver. 14 reconstruction and indicated on this self-reported question- Padua et al demonstrated that the LESS has concurrent naire. Noncontact and indirect-contact ACL injuries were validity using 3-dimensional motion analysis and that good defined operationally as injuries that occurred without interrater and intrarater reliability can be obtained. 15 direct contact to the lower extremity from an external However, few researchers have investigated the LESS source at the time of injury. We defined noncontact as a prospective screening tool. Therefore, the purpose of mechanism of injury as an injury that did not involve our study was to examine the validity of the LESS (total contact with the participant. We defined indirect-contact score and individual items) in identifying individuals at risk mechanism of injury as an injury due to contact with a body for ACL injury in elite-youth soccer athletes. We part other than the knee (ie, trunk). hypothesized that higher LESS scores, representing a greater number of movement errors, would predict ACL Jump-Landing Task injury in this population. Participants performed 3 trials of a standardized jump- METHODS landing task during each test session on a soccer field before practice (Figure 1). The participant began the task Design and Participants standing on a 30-cm-high box placed at a distance of half the body height away from a landing area, which was We used a prospective cohort design to evaluate the marked by a line on the ground. Participants were LESS as a predictor of ACL injury in elite-youth soccer instructed to jump forward so that both limbs left the box athletes. Two soccer leagues (1 from North Carolina, 1 simultaneously, to land just past the line, and to jump for from Maryland) with under-11 to under-18 age divisions maximal height immediately after landing. They practiced agreed to participate in the study. The 2 leagues competed until they were comfortable with the task and performed it 590 Volume 50 Number 6 June 2015 Table 1.
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