Sports Medicine Research: In the Lab & In the Field: Short and Sweet: ACL Prevention Programs are Effective (Sports Med Res)


Wednesday, September 18, 2013

Short and Sweet: ACL Prevention Programs are Effective

Evaluation of the Effectiveness of Anterior Cruciate Ligament Injury Prevention Programme Training Components: A Systematic Review and Meta-Analysis

Taylor JB, Waxman JP, Richter SJ, & Schultz SJ. British Journal of Sports Medicine.  Epub ahead of print August 8, 2013; doi:10.1136/bjsports-2013-092358

Take Home Message:  ACL prevention programs, that are effective at reducing ACL injuries when focusing on stretching, strength, and agility activities, can be done in relatively short warm up periods with little to no disruption to practice activities.   

Anterior cruciate ligament (ACL) injury prevention programs have been developed in efforts to decrease the likelihood that an athlete suffers an injury, especially females.  There are a wide array of programs available, which has lead to confusion and mixed results.  The purpose of this meta-analysis was to investigate ACL prevention program and objectively quantify the duration, points of emphasis, and effectiveness in female athletes. A literature search yielded 13 studies that met the inclusion criteria: 1) randomized controlled trial or prospective cohort study, 2) ACL incidence reported or calculated, 3) included specific exercise descriptions, and 4) training session durations were reported.  Overall, the intervention programs reduced the rate of ACL injury.  The duration of a single training session ranged from 10 to 44 minutes and the programs included 10 to 108 sessions.  However, the authors found that the total training time (number or duration of training sessions) did not influence ACL injury rates.  The exercises within each program were further categorized into 5 areas: strength, explosive, balance, agility, or stretching.  Most programs (69%) included strength, explosiveness, and agility exercises, while less programs included balance exercises (54%) or stretching exercises (23%).  The majority of the programs emphasized balance and agility exercises.  Overall, ACL injury risk increased as the duration of balance exercises increased, but non-contact ACL injuries decreased as the duration of stretching exercises increased.  A subgroup analysis revealed no differences between athletes that did or did not receive feedback during the exercise program.

Clinically, this meta-analysis reveals that ACL prevention programs reduce the risk of ACL injury in females, and having an intervention program is more important than duration, number of sessions, or feedback.  Therefore, we can offer a short and efficient program to busy coaches and teams that may reduce the risk of ACL injury.  During this potentially short and efficient program, we may minimize the time dedicated to balance training and instead focus on stretching, strengthening, and agility activities.  While strength and agility exercises did not significantly influence the rate of ACL injuries, there was a trend suggesting they may be important.  More research needs to be done on these activities to determine whether ACL prevention programs improve strength and/or induce neural adaptations.  Regardless, this meta-analysis demonstrates that these programs may be short, focused on stretching as well potentially strength/agility activities, and introduced to a team to do on their own as part of their warm up.  Coaches may be able deploy these programs to reduce the risk of ACL injury and not take away precious time from practice.

Questions for Discussion: Do you think that we have enough information to potentially develop more efficient and effective ACL prevention programs?  Do you favor emphasis on a particular component of training or giving feedback during programs?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

Related Posts:

Taylor JB, Waxman JP, Richter SJ, & Shultz SJ (2013). Evaluation of the effectiveness of anterior cruciate ligament injury prevention programme training components: a systematic review and meta-analysis. British Journal of Sports Medicine PMID: 23922282


Unknown said...

This systematic review sheds light on the importance of incorporating stretching in ACL prevention programs. Despite my appreciation for flexibility programs in overall injury prevention, prior to reading this I may not have placed an emphasis on stretching in my ACL prevention programs. I feel this information will help me make more comprehensive ACL prevention programs for my athletes.

Jake Meyer said...

Evidence that the time needed to perform a formal ACL prevention program does not relate to the effectiveness of the program is extremely interesting. This seems important to know when developing programs and working on logistics about how to actually implement these programs into athletes' routines. It seems logical to think that some of these important points such as: strength, flexibility, and the implementation of plyometrics, can easily be translated to a 10 minute warm-up before practice without intruding on a coaches precious practice time, no matter the level of play. Doing something rather than nothing at all seems to be productive.

On a side note, in an effort to impact a large sample of individuals, it may be interesting to see how implementing some kind of 10 minute ACL prevention routine into grade school and junior high physical education classes affects these individuals as they begin playing at the high school and possibly collegiate level. Could we see a drastic increase in ACL injury a decade or two down the road? I don't think it would hurt to try.

Nicole Cattano said...

Thanks Jake for your comment. I think that there is some research also im out there that we can use to let cosches know that these short sessions may even improve athletic performance as well.

On your second point, I think earlier intervention may be a good key. So that thing athletes are developing appropriate motor patterns that may decrease likelihood of ACL injury. It is my opinion that this used to naturally occur when young athletes used to just "go outside and play' and had a variety of sports and activities in their lives. There is so much specialization within the sporting culture currently, I feel this may be detrimental.

Jess Schlesman said...

I think the idea of incorporating quick prevention programs into practices is a great idea however, because everyone's body reacts differently to exercise, the program may not benefit everyone the same way. Also, why would the program for non-contact injuries differ from contact injuries? What factor is most important to focus on during the prevention program?

Stephanie Michel said...

I agree with Jess. Having an ACL prevention program is a great idea since the number of ACL pathologies are on the rise. However, each person may respond differently to the program. Certain athletes have more flexibility or muscle strength, so the programs would need to be more specific than just a "team program". Feedback would definitely need to be given, to ensure that the athlete is completing the program correctly. Why does stretching not have the same effect on non-contact ACL's?

Nicole Cattano said...

Unfortunately contact ACL injuries occur as a result of being at the middle of the largest lever system on the body. These prevention programs may slightly reduce their incidence as well, but there is not enough literature to support this. Remember that non-contact injuries are more common and involve things that we may be able to control, unlike the less common contact ACL injury where there are many variables that we can't control for.

While I agree that (in an ideal world) each program should be individualized to address athlete's deficits and constant feedback given regarding form. This meta-analysis demonstrated that may not be necessary.

Morgan Hooven said...

I also agree with Jess and Steph. ACL prevention programs are very helpful with female athletes considering females are most effected by ACL injuries. Why would a prevention program differ for contact and non-contact athletes when in general we want to gain the same benefits? Also how would you determine when to focus on strength and agility rather then stretching and balance?

Kaitlyn Kelly said...

I agree with Morgan in wondering how the program would differ for contact and non-contact athletes. Since non-contact ACL tears may occur in contact sports do you recommend doing both in your ACL prevention program? Although females are mostly effected by ACL injuries do you feel it would also be worth the while of coaches of male sports to have an ACL prevention program in their workouts seeing as this is a debilitating injury?
Thank you

Alex Ruxton said...

Would it be beneficial for a male athletic team to incorporate an ACL prevention program into their practice schedule? I also agree with Jake. Why not try a prevention program at a grade school or junior high level to see if the number of ACL injuries decrease. I think that it might be able to decrease the number of non-contact ACL injuries.

Jeffrey Driban said...

Alex: Thanks for the comment. We've had a few posts on articles that suggest that prevention programs may be effective for males:

They might also be more effective in younger athletes...

SandraK said...

ACL prevention programs seem to be one of the best options, especially for females, to reduce injury rate when focused on strength and agility. If these programs are implemented early in an athletes career, to them it will be something they do every day before practice, like stretching for example, and not seem like they have to be performing extra exercises and work for their training session. I think it is imperative to explain to the athletes the importance of these programs and how they can save them time in the future by improving their neuromuscular control.
It is interesting that there was no difference in those that did and did not receive feedback, since there is no guarantee that the athlete is doing the exercises correctly, but it emphasizes the impact it can have on the athlete. An athletic trainer can provide a comprehensive but quick and mixed typical warm up to a coach and help administer it at first so the athletes understand the exercises, and can be performed on their own later. I would highly suggest a few different prevention programs that can be implemented to any given team, because research has shown the effectiveness and impact it can have on reducing ACL injuries in females.

Jeffrey Driban said...

Hi Sandra:Thanks for the comment. I agree that we should try to implement these programs early in an athletes career but we should also encourage them to performed through a person's athletic career. I think you are very right that we need to explain to the athletes the importance of these programs and how it can help their performance, reduce the risk of injury (which could lead to less time missed), and the long-term benefits of avoiding an injury (e.g. osteoarthritis). If you'd like more information on the available programs I recommend you check out the brochure on injury prevention programs that was put out by the OA Action Alliance and available on the NATA website (they helped create it):

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