ACL Injuries - Is This Really An Epidemic?

Throughout the history of our blog, we have devoted a lot of attention on ACL injuries.  Why?  At ACL, LLC our mission statement is as follows:

A lot of people and companies are passionate about certain things.  At ACL, LLC, to say we are passion about injury prevention and what we do is a gross understatement.  For us this is more than just want we do, it is what we have been called to do!  This calling came over 12 years ago when, as physical therapists, we had 22 patients come into our practice over a 2 week period with ACL reconstructions.  After treating these kids with traditional methods we had at the time and when preparing to discharge them and return them to sport, we began to notice certain movement patterns that we knew put them at risk for future ACL injury.  As a parents and clinicians, we felt like we failed and that we needed to figure out a way to do it better.  We were compelled to do something!  Hence began the lifelong journey.

What we have found (and what research is now showing), is that the same movement patterns associated with non-contact ACL injuries also increases risk for non-contact ankle injuries, hip injuries and low back injuries.  These same patterns are also associated with decrease in force generation and kinetic energy transfer.  Hence; these same mechanics have a negative impact on performance.  As common knowledge as that is today, ask most physical therapists, athletic trainers and performance coaches and they will tell you they know what the movements are and how to improve them.  Despite this fact, the harsh reality is this is not the case.  They will see movements like this but have no idea what it means or how to change it.  One of the most popular movement assessments used does not “directly” measure the movements we “know” are related to risk.  To assess adduction in the frontal plane (depicted here and which we know is directly related to risk) you must measure and quantify adduction in the frontal plane.  The most frequently used test does not.  Yet, most will not want to admit it and will somehow try to correlate the results to adduction in the frontal plane.  As much as they may want to correlate it, the research clearly indicates we are not doing a good job at impacting injury rates.

To highlight this fact, let’s look at what the research does tell us.  In one of our previous blogs, we cited a study by Dodwell et al in the Jan 14’ issue of the American Journal of Sports Medicine where they looked at ACL reconstruction injury rates over the last 20 years.  What they showed was significant increased rate of ACL injuries over the span of the last 20 years.  This study showed the rate of ACL reconstruction in the US rose from 17.6/100,000 in 1990 to 50.9/100,000 in 2009.  More alarming is the rate of ACL reconstructions in high school athletes, specifically those 17 year old (which rose to 176.7/100,000).  Now this study was retrospective analysis from a database in New York and all of the subject pool came from New York area.  So, although one might suggest that this might not be representative of the US population, it did have an N value of >100,000.  In research terms this is huge and provides strong statistical correlations for application to the US population.   

However, considering this discussion point, Mall et al published a study in the Aug 14’ issue of the American Journal of Sports Medicine that looked at incidence and trends of ACL reconstructions in the US.   This study was also a retrospective analysis but used data from 1994 and 2006 which was collected from two national databases.  This provided not only national data but also provided an N value > 200,000.  What they found was an increase from 32.9/100,000 in 1994 to 43.5/100,000 in 2006 (a 32% increase).  The largest increase in rates was for those under the age of 20 and females.  The rate of female ACL reconstructions rose from 10.36/100,000 in 1994 to 18.06/100,000 in 2006 (a 74% increase).  Although there are several factors that can influence all this (improved diagnosis of ACL injuries, improved surgical techniques, Title IX, etc), the fact remains there is still a 32% to 74% increase in ACL reconstructions.  So, despite all the knowledge, we still are not better at reducing rates.

Understanding the risk factors associated with is important.  For example, Beynnon et al published a study in July 14’ that looked at the effect of level of competition, sport and sex on incidence of first time non-contact ACL injuries.  What they found was the incidence rates for female athletes was higher when compared to male athletes and in fact that female athletes were twice as likely to have a non-contact ACL injury in comparison to male athletes. They also found that college athletes had a significantly higher injury risk than did high school athletes.  Their data also showed that among college athletes that soccer players and rugby players were at higher risk in comparison to other sports.   So, we know that females are at higher risk and especially female soccer players.

So is this really an epidemic and what do we do about it?  First, let’s answer the first question, is this really an epidemic?  According to the research there are over 200,000 ACL injuries in high school athletics.  This results in a $5B health care cost annually.  This cost does not even include those that have osteoarthritis later in life as a result of the ACL injury.  According to Holm et al study in 2012, 79% of athletes who have an ACL reconstruction have osteoarthritis in 12 years.  Studies also indicate that those who have an ACL reconstruction also have a higher rate of depression, obesity and decreased academic performance when compared to athletes who have not had an ACL reconstruction.  So, 200,000 kids suffering these injuries, a $5B annual health care cost and health/joint complications for the rest of their life.  That sounds like an epidemic.  What are you going to do about it?

ACL injuries are not like ulnar collateral ligament (elbow or Tommy John’s) injuries in baseball players or concussions in football players.  With both of these injuries, you can simply pass a policy which reduces the rate of the injuries.  You can limit certain pitches at a given age and number of pitches to have a direct and profound impact on elbow injuries in baseball players.  You can limit certain types of hits or prevent return to play without being cleared by an MD prior to have a direct and profound impact on concussions rates in football players.  But there is not a policy you can put in place to limited ACL injuries.  You can’t tell a player not to run or change direction or not to jump.  So what can we do?  Screen athletes for risk!

We know that 70-80% of ACL injuries are non-contact in orientation (meaning there is not contact with another player or object that results in the injury).  We know that over 50-70% of those are preventable IF the athlete is put on the right program.  So, of the 200,000 ACL injuries in high school athletes, over 140,000 to 160,000 are non-contact in orientation. This means we could potentially prevent between 70,000 to 128,000 ACL injuries every year.  In 5 years, this is 350,000 to 640,000 kids who could potentially be prevented from the agony of the initial injury and a lifetime of complications associated with.  As an athlete, as a coach or as a health care professional, if that does not motivate you, I don’t know what will.  There is a way to have THAT level of impact!  BUT you have to do something different today!

There is a call by physicians and athletic trainers alike to administrators, schools, coaches and organizations to do something about ACL injuries.  In a recent article in Athletic Business, ATCs and MDs are calling for ACL Prescreening.  But how do you do that?  We know from the research that there are certain movements that put athletes at risk for injury.  You can see it.  You just have to know how to look for it and to determine what it means.  For example, anyone can look at this DI athlete and see that does not look right. We can all make a pretty good assumption that she is probably at risk for an injury.  Ok, so what do we do?  Before we know what to do, we have to know what this movement means.  When you look at that motion, how does this guide our program development?  Is her program the same as the athlete below?  In order to determine that, we can’t simply take the results of this one motion and correlate that to a root cause.  In the lower kinetic chain and in a closed kinetic chain, this could be the result of weaknesses or limitations in any segment of the kinetic chain.  However, if we perform multiple tests, then through a process of elimination, we can come up with a root cause for the motion that is present.  But how do you do that in a way that is efficient so can be used in physicals, sensitive so you can see when you are making positive changes in movement and reliable so that it is not dependent on the skills of the evaluator?

Before we answer that, let’s go back to the beginning.  We shared with you what our mission statement is at ACL, LLC.  We are devoted to providing the tools to do this and have developed a tool to do this using the latest in 3D gaming technology.  An athletic biomechanical analysis designed for use in mass physicals that is fully automated, self-scoring, has a high sensitivity, is efficient and cost effective.   But this is not about the 3D-DMA™ (due to be released in Oct 14’ and really cool).  This is about preventing injuries however we can do it.  So, over the course of the next few weeks, we will share with you what we have learned.   Some may say this is a poor business decision as we are revealing some of the secret sauce that has led to dramatic injury reductions and improvement in performance with our assessment.  Some may say this may prevent people from buying our system.  But, like we said, this is a calling.  Whether we serve that calling by providing the technology or serve that calling by providing the education.  Either way, we are serving our calling. 

So, for the next few weeks, we will provide some insight.  We won’t use a lot of research references but more of what our research is showing and our methodology we have developed based on the research.  Stay tuned and if you like what you see, SHARE THE PASSION!  It is the biggest compliment you can give.  Follow us on Twitter @ACL_prevention and tweet about it.  #DMAOnTheMove and help us spread the passion and #movementonmovement.

Build Athletes to Perform…Build Athletes to Last!™

Trent Nessler, PT, MPT, DPT:  CEO/Founder ACL, LLC | Author | Innovator in Movement Science and Technology.  Dr. Nessler is a physical therapist and CEO/Founder of ACL, LLC.  He is the researcher and developer the Dynamic Movement Assessment™, Fatigue Dynamic Movement Assessment™, 3D-DMA™, author of the textbook Dynamic Movement Assessment: Enhance Performance and Prevent Injury, and associate editor for International Journal of Athletic Therapy & Training. For more information, please see our website at www.aclprogram.com