practice/game time) was highest in
girls (Gortnizky AL, et al. Am J Sports
Med. 2016;44:2716-2723). In boys,
the highest risk sports for ACL tear included football, lacrosse and soccer, and
the highest risk sports in girls included
basketball, soccer and lacrosse. The relative risk of injury in girls basketball vs.
boys basketball and girls soccer vs. boys
soccer was 3.80 and 3.67, respectively,
highlighting the ACL injury gender gap.
After injury, reconstruction of the
ACL usually is recommended because
evidence shows that surgery results in
decreased rates of further intra-articular
injury (i.e., meniscal or cartilage tears)
due to persistent instability (Fabricant
PD, et al. J ISAKOS. 2016;1: 10-15)
as well as increased rates of return to
sport (Fabricant PD, et al. J ISAKOS.
Compounding the problem of youth
ACL injury is the fact that pediatric patients undergoing ACL reconstruction
continue to be at relatively higher risk
of re-injury or contralateral ACL tear
compared to adults. A recent study of
pediatric patients who had undergone
ACL reconstruction found that despite
a very high rate of return to sport (91%),
the overall ACL re-injury rate (e.g., ipsilateral or contralateral ACL tear) was
32%, which is significantly higher than
the reported re-injury rates of up to 5%
in adults (Dekker TJ, et al. J Bone Joint
Surg Am. 2017;99:897-904). Additionally, the authors found that the only
independent predictor of repeat ACL
tear in their cohort was time to return
to sport, with earlier return associated
with increased risk of re-injury.
Preventing new or repeat ACL tears
Studies have shown that certain modifiable risk factors related to altered bio-mechanics and neuromuscular control
(such as dynamic knee valgus) are associated with increased risk of non-contact
ACL tear. Injury prevention programs
aim to address these deficiencies in structured ways. These training programs focus on plyometric (i.e., jump training)
and balance exercises in addition to
traditional strengthening and stretching. Technique training and structured
feedback to athletes regarding proper
athletic form also are common components. Athletes are retrained to jump,
land and cut in biomechanical positons
that reduce the strain on the knee.
These programs have been shown
to be effective in lowering the rate of
ACL injuries. To be most effective, they
can be incorporated into preseason and
in-season training in high school athletic programs as well as return-to-sport
training following ACL reconstruction.
Because ACL injuries pose such a
significant burden on patients, families
and medical systems, participation in
injury prevention programs that target
children and adolescents in at-risk sports
is important and may be a cost-effective
strategy to address the rise in youth ACL
injury rates (Swart E, et al. J Bone Joint
Surg Am. 2014;96:705-711).
Take home points
• Youth ACL injury continues to be a
significant problem in the athletic pe-
• High school age female athletes are at
particularly high risk for ACL tear.
• Outreach, education and implementation of injury prevention programs
that have been proven to reduce the
risk of injury are important strategies
to help decrease the incidence of this
potentially devastating injury.
Dr. Cruz is a member of the AAP Section
on Orthopaedics. Dr. Ganley is a member
of the section’s executive committee.
Dr. Cruz Dr. Ganley
ACL continued from page16