ACL Injury Prevention

Dr. Timothy Hewett, in action

I had the good fortune (and space in my clinic schedule) to attend a lecture given earlier this month by Tim Hewett, PhD, FACSM.  Dr. Hewett is a man of many titles.  I know him best as the Director of Research and Director of the Sports Health & Performance Institute at Ohio State University Sports Medicine, and his talk was on “Understanding and Preventing First and Second ACL Injuries.”

If you have never heard Tim speak, you are missing out on a treat.  I learn so much from his talks: ranging from the ones I catch at the annual American College of Sports Medicine (ACSM) gatherings to the ones I occasionally can attend here in Columbus, Ohio, the city we both call home.

It stands to reason: the man has authored over 248 peer reviewed articles and has been awarded millions of dollars of grant money.  We have had the fortune here at CJSM to have published a number of his manuscripts, including one in the most recent September 2014 journal (on gender differences in hip abduction/adduction) and one in 2012 on  the incidence of ACL re-injury after primary reconstruction.

Oh, my reconstructed ACL: Where have you gone?

The issue of primary- and secondary-prevention of ACL injury is huge. We’ve lived, for instance,  through a virtual epidemic of ACL ruptures in the NBA over the past couple years.  Derrick Rose is returning (yet again) to the hardcourt after his terrible injury in the 2012 playoffs, and that’s great news for the Bulls and fans of great basketball in general.   In his talk Dr. Hewett suggested that at least part of this statistical uptick  in ACL injuries was likely due to the NBA lockout, resulting in an abbreviated 2011 – 2012 season preceded by an ‘abnormal’ preseason.  “These teams have a very structured offseason training program where they do a lot of injury prevention-type neuromuscular training”  (NMT), Hewett has been quoted in interviews.  The absence of such pre-season NMT work, he thinks, is associated with the litany of ACL injuries seen that season, capped off by Derrick Rose’s.

ACL injury prevention is both needed and achievable.  In his lecture, Dr. Hewett stated that there is evidence to suggest that anywhere from 50% to 100% of patients who sustain an ACL rupture go on to develop osteoarthritis (OA) of the knee, even in those who go on to have an ACL reconstruction (ACLR) (in the United States, the rate of  ACLR post injury is upwards of 90%).  Primary prevention is essential to address this problem, because despite adequate surgical treatment, the progression to OA is unacceptable.  Secondary prevention, too, is critical:  in Hewett’s 2012 CJSM study he found the risk ratio of ACL injury post ACLR was 15 times greater than that of control subjects.   But it gets worse, specifically for female athletes:  they are 4 times more likely than men to suffer a second ACL injury and 6 times more likely to suffer a contralateral knee ACL injury.

Aside from the fact that these numbers are born out in my clinic–there isn’t a week that goes by this time of year I don’t see an individual with an ACL tear, and I see more women than men sustaining this injury–they boggle the mind.

What can be done?

Well, we know that stretching and proprioceptive training (alone) don’t work….largely due to Dr. Hewett’s work.  What does is dynamic NMT training, and the evidence is quite compelling.

I want to remind the blog readers of a couple of the other ACL prevention items we’ve published this year in CJSM.  The Canadian Academy of Sport and Exercise Medicine issued their position statement on NMT training and ACL prevention, which we published, and made freely available, in the May 2014 issue.  We followed that up with a podcast interview with one of the manuscript’s authors, Dr. James Carson.  There is indeed compelling evidence that introducing a FIFA 11+ type NMT training warm-up can substantially decrease ACL injuries.  The problem I think we have is one of implementation.  The evidence is there.   The knowledge is there.  It’s time to see these injury prevention techniques more broadly applied to athletes at all stages, from youth to elite levels.

This weekend offers a wide variety of sporting options.  Will Barcelona or Real Madrid win El Clasico?  Can the Giants even the series with the Royals?  Will the Mississippi teams continue their run of success and have the Magnolia state dream of national championships for one more week?  We shall see.  I do hope in all these endeavors we can see the athletes compete safely….Here’s to a weekend slate of games without an ACL injury!  We can, in the future, make the prospect more likely if we embrace NMT as prevention.