April 29, 2009

Acute Cruciate Ligament (ACL) Injury among Young Female Athletes


When the Federal legislation called Title IX was passed in 1972, it changed the face of sports for girls and women in the U.S. In 1971, prior to the enactment of Title IX, the percentage of females in sports was 3.7%. By 1998, participation in sports by female athletes had risen to 33% (Giugliano, Solomon, 2007). Prior to the enactment of Title IX, there were less than 300,000 high school girls that participated in sports. In the school year 2005-2006 the number of high school female athletes had increase by over 1000% to almost 3 million (Lal, Hoch, 2007). With the higher rates of participation, there have been corresponding increases in rates of injury associated with athletic pursuits.

The knee joint is the site of the highest injury rates among youth athletes (Parkkari, Pasanen, Mattila, Kannus, Rimpela, 2008). It is estimated that 70% of anterior cruciate ligament (ACL) injuries occur during participation in a sporting event (game or practice) as opposed to the very low incidence of ACL tears seen by non-athletes in this age group. Most ACL injuries occur in sports where there is a preponderance of quick stopping, cutting, and change of direction. These maneuvers would be seen in basketball, soccer and handball. The majority of ACL injuries are non-contact in nature.

For the athletes who get injured, many are faced with the prospect of losing the entire season of play, expensive treatments such as surgery, long-term rehabilitation, possible loss of scholarship funding, emotional and mental impairment affecting quality of life, relationships and academics, permanent functional impairment and disability and the lifelong potential for future arthritis in the injured knee joint (Giugliano, Solomon, 2007; Parkkari, et al., 2008).

website compiled by Patricia Gannon and David Ogato

Trends in Related Injuries


With the increase in the numbers of female athletes at all levels of play, there is a related corresponding increase in sports related injuries among them. At the high school, collegiate and professional level, the rate of injury for lower extremity, musculoskeletal injury is greater in female versus male athletes (Lal, Hoch, 2005). The ACL injury is the largest single problem in orthopedic sports medicine. The injuries are much higher in female adolescents than in males of the same age. Female athletes suffer ACL tears at a 4-6 fold greater rate than their male counterparts in the same sport (Myer, Ford, Paterno, Nick, Hewitt, 2008).

Even though the ACL is the most commonly injured knee ligament, there are also common injuries to the menisci, other ligaments, joint cartilage and the underlying bone structure (Lohmander, Englund, Dahl, Roos, 2007). Knee joints that have been injured should be evaluated for tears of the meniscus, which occur in about 50% of the cases. Lateral meniscus tears are seen more often in the acute injury state while medial meniscus tears are more often seen in chronic cases (Renstrom et al., 2008). It has been found that at ten to twenty years, post injury, on average, 50% of those that were diagnosed with either an ACL tear or a meniscus tear, have the pain and functional impairment that occurs with osteoarthritis. ACL injuries are now viewed as responsible for much of the early-onset osteoarthritis of the knee joint with all of the pain, functioning limitations, and the associated lowered quality of life that had typically been seen only with older age groups (Lohmander, Englund, Dahl, Roos, 2007).

Variables that are Related to the Risk of Injury

  • the level of competition
  • skill level
  • shoes and equipment – more cleats and cleat placement increase risk. Knee brace effectiveness is inconclusive
  • playing surface – drier surfaces increase injury rates. Sythetic surfaces are controversial and more research is needed
  • age
  • gender
  • phase of the menstrual cycle/ligamatous laxity/neuromuscular control
  • prior injuries
  • fitness/limb dominance, flexibility, strength
  • body size/anatomic alignment (Lal, Hoch, 2007). Smaller joints and ACL’s have higher injury rates as do larger hip to knee joint angles

Factors Limiting Estimation of Injury Costs

  • Number of ACL injuries per year is placed at 250,000 in the United States
  • Estimates of the costs for 15 to 24 year old male and female athletes ranged from $1 billion annually in the U.S., not including diagnosis and rehabilitation (CDC, 2006), to roughly $17,000 per injury including the surgery and rehabilitation costs (Parkkari et al., 2008). These estimates do not include the non-dollar costs.
  • Recovery from an ACL injury typically can take as long as a year and can include:
  • emotional difficulties
  • academic problems/loss of scholarship money
  • ACL injured players drop out more quickly than their non-ACL injury teammates, showing a 44% reduction in high-risk sports participation (Giugliano, Solomon, 2007).
  • ACL injured athletes have higher rates of re-injury upon return to the game ranging from 2% to 13% (Giugliano, Solomon, 2007).
  • Rates of osteoarthritis vary widely within 10 to 20 years after the injury: between 10% to as many as 90% of those with a prior ACL injury experiencing osteoarthritis in the joint (Lohmander, et al., 2007).

Recommendations to Facilitate Progress in the Reduction of ACL Injuries

  • Additional research, specifically prospective, longitudinal studies (Lomander et al., 2007)
  • Evaluations of the effectiveness of current procedural methods for long-term prognosis
  • Evaluation of post diagnostic test accuracy (Renstrom, et al., 2008)
  • External and internal risk profile (Renstrom, et al., 2008)
  • Benefits/risks of surgical versus non-surgical interventions (Lomander, et al., 2007)
  • Studies ten-year post-injury about long-term disability issues (Renstrom, et al., 2008; Parkkari, et al., 2008)
  • Education and training: Trainers, coaches, parents, team health professionals, as well as the athletes, need to have best practices knowledge available. Including:
    • awareness of anatomic and neuromuscular differences between male and female athletes (Lal, Hoch, 2007; Renstrom, et al., 2008)
    • Effect of hormonal factors (Lal, Hoch, 2007; Renstrom, et al., 2008)
    • Misconceptions about strength training (Lal, Hoch, 2007; Renstrom, et al., 2008)
    • Effects of weather on the playing surface
    • Shoe/cleat considerations (Renstrom, et al., 2008; Giugliano, Solomon, 2007)
    • Prior knee injury predilection to higher re-injury risk
    • Overall athleticism and skill level of the athlete (Renstrom, et al., 2008; Parkkari, et al., 2008)

Haddon's matrix (Robertson 10; Barnett, et al., 2005)





Physical Environment

Socio-economic Environment

Pre-Injury Phase

Structured warm-up programs that focus on stretching, strengthening, improving balance and movements prior to sport participation

Proper fitting shoes and clothing

Use of relevant and correct size of tools and equipment

Favorable weather conditions

Well maintained and safe playing fields e.g., absence of potholes

Presence of athletic trainer during practice

Optimum preparation and practice

Strict supervision during the game

Injury Phase

Limit activity to individual ability

Strict adherence to rules and regulations

Use of personal protective equipments such as knee pads and braces

Hospital nearby with specialty in trauma care/sport injuries

Emergency response system ready such as phone, ambulance, and first aid kit

Post-Injury Phase

General physical health of the victim

Use of first aid kit

Availability of immediate trauma care

Availability of rehabilitation facility

Prompt ACL reconstruction

Sport-injury rehabilitation program

Family and social support

Haddon's 10 strategies (Robertson, 19-21)


  1. Prevent the creation of the hazard in the first place
    • Pre-participation musculoskeletal physical examinations to identify underlying pathological problems of the knee joints
    • Provide treatments and rehabilitation prior to sport participation
    • Warmup programs involving neuromuscular and proprioceptive training can be effective in stabilizing the knee
  2. Reduce the amount of the hazard into being
    • Limit the number of sports and frequency of participation (useful in reducing body stress and exhaustion)
  3. Prevent the release of the hazard that already exists
    • More ACL tears are likely to occur during ovulatory phase of the menstrual cycle (Wojtys, et al., 2002) The use of oral contraceptives may be a consideration
  4. Modify the rate or partial distribution of release of the hazard from it's source
    • Limiting activity to individuals' ability
    • Substituting players as necessary during the game
  5. Separate, in time or space, the hazard and that which is protected
    • ACL injuries may be eliminated or reduced by restricting sports participation to postovulatory phase.
  6. Separate the hazard and that which is to be protected by interposition of a material barrier
    • Use well fitting sports gear including shoes, knees pads and braces
  7. Modify basic relevant qualities of the hazard
    • Limiting sports to favorable weather conditions and avoiding surfaces that increase the potential for injury
  8. Make what is to be protected more resistant to damage from the hazard
    • Fitness training including stretching, strengthening, and improving balance and movements
  9. Begin to counter the damage already done by the environmental hazard
    • Seeking and receiving prompt medical care as soon as the injury is noted
  10. Stabilize, repair, and rehabilitate the object of the damage
    • Rehabilitation together with the use of stabilization devices such as knee braces


These ten strategies illustrate the various mechanisms of preventing, reducing the likelihood of happening, and minimizing the severity and consequences of ACL injuries when they occur. They are all useful when appropriately used, but cannot all be generalized in every situation. The most effective measures are those that would provide built-in, automatic protection, minimizing the frequency and the effort required of the individual’s involvement. We found strategies 1 and 4 and 6 - 10 to be more efficient than the others because they can be applied to individuals in most situations. Furthermore, they focus on all three levels of prevention: primary, secondary and tertiary prevention.


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May 17, 2009