A week does not pass that we do not hear about
another athlete that has ruptured their ACL for the second time. Whether it is a US Olympic Athlete like Lindsey
Vonn or a professional athlete like George St-Pierre. It can happen to even the best but the harsh
reality is, most of these are preventable.
So why is there not a bigger focus on prevention? Simply and sadly, because prevention does not
win games…..or does it?
In 2013, there were over 900 papers published
in peer reviewed journals in the area of anterior cruciate ligament (ACL) injuries,
ACL surgery and biomechanics associated with non-contact ACL injuries. With this plethora of research, the research
community, the sports community and insurers are becoming more and more aware
of the complexity of this issue as well as the epidemic levels it has arisen
to. According to the research, there are
over 250,000 ACL injuries every year and 20% of those individuals will suffer a
second injury in just 2 years and 79% will have osteoarthritis in 12
years. Not including the downstream cost
of the second injury or the osteoarthritis, this is ~$5B health care cost every
year. If you included all the downstream
costs, this would easily be over a $10B annual cost. Outside of sports, if there was any other
health issue that had similar numbers with such a high reoccurrence and cost
(both human and financial), it would be labeled an epidemic.
ACL injuries have hit epidemic proportions and
the impact they are having on young lives is significant. According to sports equipment sales estimates,
nearly 70% of children in the US are playing team sports. With all the knowledge we have in the area of
ACL injuries and prevention and the number of kids playing sports, we would
expect the rates of these injuries to decrease.
However, Lyman et
al showed in 2009 that ACL reconstructions were on a dramatic rise
nationwide from 2000 to 2009.
Nationally, this increased from 21.5% to 67.8% for all ages. As dramatic as that is, according to the
latest research by Dodwell
et al, we are seeing even greater increases in our younger athletes. According to Dodwell’s study, there has been
a 189% increase in ACL injuries (17.6/100,000 vs. 50.9/100,000) in those 3
years of age to 20 years of age over the last 20 years. For 17 year olds, there has been a 900%
increase in ACL injuries (17.6/100,000 to 176.7/100,000). Why is that?
Simply put, unlike concussions, youth throwing
injuries or overuse injuries, you cannot simply put a policy in place that will
dramatically reduce injury rates. With
concussions, you can put policies in place about where hits should and should
not occur and what to do with those suspected of a concussion. These policies will greatly influence
concussion injury rates. With overuse
and throwing injuries, you can put policies in place that prevent certain types
of throws for certain age groups or pitch counts for certain age groups. These policies will dramatically reduce throwing
and overuse injury rates. With ACL
injuries, there is not a policy you can put in place that will dramatically
reduce injuries. The complexity of the
issue is too great and the majority of these injuries are non-contact in
orientation. It is a movement related
injury and there are no policies that will change the root cause of the
movement dysfunction. So what will drive
change? As with most health related
issues, changes in the way insurance carriers pay for re-injury drives
innovation and as well as the way colleges and professional teams make
decisions about the athletes they are going to recruit. The impact on their financial status will
change the way they make decisions which will drive innovation in the area of
prevention.
Rugg
et al recently published a study that could potentially greatly influence
both insurance carrier positions on re-injury as well as college recruitment
policies. According to this study
performed over 5 years, the authors looked at Division I athletes who had a
prior knee surgery and who had an ACL reconstruction prior to DI pre-participation
physicals. What they found was that
those athletes who had prior knee (not ACL) surgery and ACL surgery were 6.8
and 19.6 fold more likely to sustain a knee injury and 14.4 and 892.9 fold more
likely to undergo a knee surgery during their collegiate athletic career. These same athletes consumed 50% more days on
the DL than athletes without prior knee or ACL surgery. Considering these results, this could greatly
influence the way that colleges recruit athletes. Coaches are hired to win games. If coaches now have a way to determine
whether the athlete they are recruiting is 6 to 20 times more likely to end up
on the DL instead of playing in the game and contributing to the team’s
performance, then this might influence his decision. If the athletic director is operating on a
tight operating budget for the program and they have a limited amount of scholarships,
this may also influence. If you have an
athlete you are recruiting who is 6 to 20 times more likely to end up on the
DL, drive up your health care costs and have limited contribution to the team
performance, then this may influence whether you recruit that athlete or one of
equal skill without that risk. For the
athletic director & the school, they are sacrificing the educational
dollars and paying the additional health care costs associated with this increased
risk in addition to the impact it has on the team’s performance and potential
financial contribution to the institution.
If this influences recruitment decisions, then this could have a huge lifelong
impact on the athlete as well. For many
athletes, if a scholarship is their only avenue for getting a college
education, then this could have huge future implications.
These studies also have big influences on
insurance carriers. These may influence
the way carriers view an individual’s private plan as well as the universities
or professional team’s insurance.
Considering how similar data has influenced carriers in health care,
studies like this could lead to waivers in insurance policies that limit
payment on injuries sustained or future injuries after an injury has occurred. This could also influence increases in a team’s
or universities deductibles they pay annually.
It is insurance policies such as these that have a huge financial impact
on universities and drive decisions and may influence more initiatives toward
preventative measures.
The
positive side of all this is that the research is also showing us that you can identify
those that are at greater risk. GSP and
Lindsey Vohn both demonstrated similar movement patterns that made them more susceptible
to re-injury. These movement patterns can
be identified in pre-participation physicals and if improved, cannot
only reduce risk for injury but also improve athletic performance. Don’t let necessity drive your innovation but
let your innovation drive performance to a higher level.
About
the author: Trent Nessler, PT, DPT, MPT is CEO
of A.C.L., LLC and is a practicing physical therapist with 15 years in sports
medicine and orthopedics. He has masters in physical therapy and doctorate with
focus in biomechanics and motor learning. He is the founder/developer of the Dynamic Movement Assessment™, Fatigue Dynamic
Movement Assessment™ and author
of a textbook “Dynamic Movement
Assessment™: Prevent Injury and Enhance Performance”. Trent is also
associate editor of the International Journal of Athletic Therapy and Training
and Member of the USA Cheer Safety Council.
For more information, please see our website at www.aclprogram.com.
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