Monday, April 7, 2014

Will Current ACL Research Influence Recruiting Trends?

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

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