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Prevention of Anterior Cruciate Ligament (ACL) Injury

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Prevention of Anterior Cruciate Ligament (ACL) Injury Journal of Athletic Training 2018;53(1):5–19 doi: 10.4085/1062-6050-99-16 Ó by the National Athletic Trainers’ Association, Inc Position Statement www.natajournals.org National Athletic Trainers’ Association Position Statement: Prevention of Anterior Cruciate Ligament Injury Darin A. Padua, PhD, ATC*; Lindsay J. DiStefano, PhD, ATC†; Timothy E. Hewett, PhD‡; William E. Garrett, PhD, MD§; Stephen W. Marshall, PhD*; Grace M. Golden, PhD, ATC, CSCS||; Sandra J. Shultz, PhD, ATC, FNATA, FACSM¶; Susan M. Sigward, PhD, PT, ATC# *University of North Carolina at Chapel Hill; †University of Connecticut, Storrs; ‡Mayo Clinic, Rochester, MN; §Duke University, Durham, NC; ||University of Oregon, Eugene; ¶University of North Carolina at Greensboro; #University of Southern California, Los Angeles Objective: To provide certified athletic trainers, physicians, and indirect-contact ACL injuries and strongly recommended and other health care and fitness professionals with recommen- for reducing noncontact and indirect-contact knee injuries dations based on current evidence regarding the prevention of during physical activity. These programs are advocated for noncontact and indirect-contact anterior cruciate ligament (ACL) improving balance, lower extremity biomechanics, muscle injuries in athletes and physically active individuals. activation, functional performance, strength, and power, as Background: Preventing ACL injuries during sport and well as decreasing landing impact forces. A multicomponent physical activity may dramatically decrease medical costs and injury-prevention training program should, at minimum, pro- long-term disability. Implementing ACL injury-prevention training vide feedback on movement technique in at least 3 of the programs may improve an individual’s neuromuscular control following exercise categories: strength, plyometrics, agility, and lower extremity biomechanics and thereby reduce the risk of balance, and flexibility. Further guidance on training dosage, injury. Recent evidence indicates that ACL injuries may be intensity, and implementation recommendations is offered in prevented through the use of multicomponent neuromuscular- this statement. training programs. Recommendations: Multicomponent injury-prevention Key Words: knee injuries, lower extremity biomechanics, training programs are recommended for reducing noncontact neuromuscular control, injury prevention ower extremity injuries make up 66% of all sports physical activity may dramatically decrease medical costs injuries, the knee being the most commonly injured and long-term disability. L joint.1 A particularly important and devastating type Most ACL injuries do not involve a direct blow to the of knee injury is rupture of the anterior cruciate ligament knee15–17 but rather are noncontact or indirect contact in (ACL). Unfortunately, surgical reconstruction and rehabil- nature, involving uncontrolled lower extremity biomechan- itation do not prevent long-term morbidity or decrease the ics. Thus, ACL injury prevention may be achieved by risk of future ACL injury.2–7 The costs associated with implementing training programs that improve an individ- surgically reconstructed ACL injuries range from $5000 to ual’s neuromuscular control and lower extremity biome- $17 000 per patient; however, the estimated long-term chanics. societal costs may be as high as $38 000 per patient.8–13 Compared with single-component training programs, Perhaps even more alarming than the high financial costs multicomponent training programs, or programs that was a report14 indicating that the rate of ACL injuries is require more than 1 type of exercise (eg, agility, balance, rising rapidly. Preventing ACL injuries during sport and flexibility), appear more effective in reducing ACL Journal of Athletic Training 5 injury rates.18–21 However, no researchers have identified 3. Multicomponent training programs are advocated to a single optimal preventive training program. As such, improve lower extremity biomechanics (eg, increasing general guidelines and recommendations are provided for sagittal-plane motion, decreasing frontal- and trans- developing a multicomponent training program for verse-plane motion, and decreasing knee-joint preventing ACL injury. Based on available evidence, loads)48–62 and muscle activation (eg, increasing we recommend that a multicomponent injury-prevention hamstrings and gluteal muscle activation)51,63–65 and training program include, at minimum, feedback on to decrease landing impact forces.50,59,63,66–68 SOR: C proper exercise technique for at least 3 of the following 4. Multicomponent training programs are advised for exercise types: strength, plyometrics, agility, balance, improving balance.44,59,69–71 SOR: C and flexibility. More detailed information on the 5. Multicomponent training programs are endorsed rationale, development, and implementation of a multi- for improving lower extremity strength and component training program, as well as identification of power.48,49,51–53,61,63,72–75 SOR: C target populations, is offered in the ‘‘Background and 6. Multicomponent training programs are promoted for Literature Review’’ section. improving measures of functional performance (eg, Therefore, the purpose of this position statement is to vertical-jump height, hop distance, hop speed, estimat- 48–52,61,63,69,73,76,77 provide certified athletic trainers (ATs), physicians, and ed V˙ O2max, sprint speed). SOR: C other health care and fitness professionals with recom- mendations based on current evidence regarding the prevention of noncontact and indirect-contact ACL Development of Multicomponent Injury-Prevention injuries in athletes and physically active individuals. Training Programs (Exercise Selection, Intensity, and Recommendations are supported using the Strength of Volume) 22 Recommendation Taxonomy (SORT) system. The The acute variables for injury-prevention training (ie, letter indicates the consistency and evidence-based specific exercises to perform, order of exercises, repeti- strength of the recommendation (A has the strongest tions, sets, intensity, tempo, rest periods between exercis- evidence base). For the practicing clinician, any es, and training-session duration) vary among programs recommendation with an A grade warrants attention that successfully decrease injury rates and improve and should be inherent to clinical practice. Less neuromuscular function and physical performance. Thus, research supports recommendations with grade B or C; we cannot recommend a specific multicomponent training these should be discussed by the sports medicine staff. program or group of exercises to prevent ACL injury. Grade B recommendations are based on inconsistent or However, certain common features of the preventive limited controlled research outcomes. Grade C recom- training programs have been shown to be successful in mendations should be considered as expert guidance reducing injury rates and improving neuromuscular despite limited research support. function and physical performance. Therefore, general guidelines regarding the organization and types of RECOMMENDATIONS exercises to include in multicomponent training programs are provided. Effects of Injury-Prevention Training Programs on Injury Reduction and Performance Enhancement Exercise Selection and Training Intensity Two primary areas of benefit are associated with injury- 7. A multicomponent preventive training program involves prevention training programs: decreased risk of ACL and offering feedback on movement technique (eg, ‘‘land other knee injuries and improved performance. softly,’’ ‘‘keep your knees over your toes,’’ ‘‘bend your 1. Multicomponent training programs that include feed- knees and hips’’) and should include at least 3 of the following exercise categories: strength, plyometrics, back regarding technique and at least 3 of the exercise 18–20,23–27,29–31,78–84 categories (ie, strength, plyometrics, agility, balance, agility, balance, and flexibility. SOR: B and flexibility) are recommended to reduce noncon- 8. Injury-prevention training exercises should be per- tact and indirect-contact ACL injuries during physical formed at progressive intensity levels that are chal- 18–21,23–31 lenging and allow for excellent movement quality and activity. Strength of Recommendation 18,25,27,30,31 (SOR): B technique. SOR: C a. Females (aged 12 to 18 years) are strongly advised to perform a multicomponent training program to reduce Training Volume (Frequency and Duration) the risk of noncontact and indirect-contact ACL injury during physical activity.18,20 SOR: A 9. Multicomponent training programs should be per- b. Males are advised to perform a multicomponent formed during the preseason and in-season.18,20,26,30,31 training program to reduce the risk of noncontact and SOR: B indirect-contact ACL injury during physical activi- 10. Multicomponent training programs should be per- ty.21,27 SOR: B formed at least 2 to 3 times per week throughout the 2. Multicomponent injury-prevention training programs preseason and in-season.18,19,23,27,31 SOR: B are strongly endorsed for reducing noncontact and 11. To maintain the benefits of reduced injury rates and indirect-contact knee injuries other than ACL improved neuromuscular function and performance injuries during physical activity in females and over time, multicomponent training programs (pre- males.18,24,27,31–47 SOR: A season, in-season, and off-season) should be per- 6 Volume 53 Number 1 January 2018 formed each year and not discontinued after a single training
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