Association Between Static and Dynamic Postural Control and ACL Injury Risk
Among Female Elite Handball and Football Players: A Prospective Study of 838

K, Nilstad A, Krosshaug T, Pasanen K, Killingmo A, & Bahr R. Br J Sports Med. 2017; 51:253-259.
doi: 10.1136/bjsports-2016-097068

Take Home Message: Balance assessments were not associated
with anterior cruciate ligament injury risk among elite female handball and
soccer athletes. 

Clinicians and researchers are
seeking screening tests to determine who is at greater risk for an anterior
cruciate ligament (ACL) injury.  Balance
exercises are often integrated into ACL prevention programs since many believe
poor balance is associated with increased lower extremity injury risk.  However, there is little research to quantify
the ACL injury risk associated with balance deficits.  The authors of this prospective study
screened 838 elite female handball and football players and followed them to
see if they suffered an ACL injury over an eight-year period. After an initial
baseline screening, new athletes and athletes on new teams to the premier
leagues were evaluated. Balance screening consisted of a single leg
stabilization on a foam pad on a balance platform (static and following a drop
down), as well as dynamic stability through a simplified star excursion balance
test.  The investigators assessed balance
on both legs. They also assessed the consistency of the balance assessment among
a subset of people at 1 to 5 years after the initial screening. The authors
recorded all complete ACL injuries, which were verified with MRI or surgery,
and asked the athletes if the injury was direct contact, indirect contact, or
noncontact. Eighty-one players reported a history of ACL injury prior to
screening. Among these athletes, 12 players experienced another ACL injury during
the follow-up period.  Over the follow-up
period 67 athletes had 80 ACL injuries. The most common ACL injury mechanism
was non-contact, and there was a total of 55 new non-contact ACL injuries analyzed
during the study period.  Within those
that suffered noncontact ACL injuries, there were no differences between the uninjured
and injured legs for static balance, drop-down balance, or dynamic
balance.  There were also no differences
between those who did and did not suffer a noncontact ACL injury in any of the
3 baseline balance assessments.  The only
significant finding was that a previous ACL injury history tripled the risk for
suffering another ACL injury.

This study shows that baseline
balance data are poor predictors for ACL injury risk.  The authors noted that these balance tests had
poor reproducibility because people demonstrated an improvement over time.  These assessments may be inappropriate among
elite female athletes. Therefore, we need to wonder if another test may be
better suited for screening or if screening needs to occur every preseason.  It would have been interesting to see how
balance assessments changed over the years, and whether there were any
clinically meaningful changes over the course of the study.  The authors indicated that fatigue may have
been a factor in how the players performed on the tests.  It would be interesting to further
investigate this idea.  Some people think
that fatigue can adversely affect performance and increase injury risk. Hence
some think that you should try to prevent fatigue to prevent injury.  Most importantly, we need to increase our
efforts in primary prevention of an ACL tear since that is the strongest risk
factor for suffering an ACL tear.  Bottom
line based on this research study, is that clinicians lack a balance-screening
test to identify elite athletes at risk for ACL injury. This study also
highlights that primary prevention among young athletes is critical.    

for Discussion:  What do you use for ACL
injury risk assessments?  What are your
thoughts on fatigue and injury risk?    

Nicole Cattano
by: Jeffrey Driban


Steffen K, Nilstad A, Krosshaug T, Pasanen K, Killingmo A, & Bahr R (2017). No association between static and dynamic postural control and ACL injury risk among female elite handball and football players: a prospective study of 838 players. British Journal of Sports Medicine, 51 (4), 253-259 PMID: 28148513