6/12/2013 1 Edward M. Wojtys, M.D. University of Michigan ACL Prevention Programs Conflicts of Interest None Disclosures NIH/NIAMS—R01 AR054821 Coulter Foundation Grant KIA Research—Consultant Center for Organogenesis NFL—Injury and Safety Panel Sports Health—Editor Damaging Forces ⇓ Failed Dynamic Protection ⇓ ACL Tears ACL Injury Cascade Mechanisms of Injury ? Remains Unopened… ACL Injury Prevention secrets ? ? ? ? ? ? The Big Black Box Scandanavian registry: •Median age ~25 •Range= 5-70 years Granan Acta Orthop 2009 Danish registry Lind Acta Orthop 2009 Adolescent females Age Distribution
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6/12/2013
1
Edward M. Wojtys, M.D.
University of Michigan
ACL Prevention
Programs
Conflicts of InterestNone
DisclosuresNIH/NIAMS—R01 AR054821
Coulter Foundation Grant
KIA Research—Consultant
Center for Organogenesis
NFL—Injury and Safety Panel
Sports Health—Editor
Damaging Forces
⇓
Failed
Dynamic Protection
⇓⇓⇓⇓
ACL Tears
ACL Injury Cascade
Mechanisms of Injury
?
Remains Unopened…
ACL Injury
Prevention
secrets
??
?
?
??
The Big Black Box
Scandanavian
registry:
•Median age ~25
•Range= 5-70 years
Granan Acta Orthop 2009
Danish registry
Lind Acta Orthop 2009
Adolescent females
Age Distribution
6/12/2013
2
Risk Factors for
Contralateral ACL
(Systematic Review – 13 Prospective)
Contralateral 1st Time
Risk Risk
Sward KSST 2010
# 1 Risk Factor for
Contralateral ACL Injury
Return to High
Level Activity
Sward KSST 2010
ACL Injury Prevention Programs
• Kinetics
• Kinematics
• Education
• Compliance
Females have 100% longer rise times in isometric force development.
Komi Acta Physiol Scand 1978
• 52 NCAA athletes– High risk sports of basketball, volleyball,
soccer
(12 male, 12 female)
– Low risk sports of cycling, rowing, running
(14 male, 14 female)
• Body-matched male/female pairs for age and sport
• Strength testing (Biodex)
• Rotational knee stiffness device
Gender Differences in Rotational
Knee Stiffness
Wojtys JBJS 2003
• Females increased volitional knee stiffness significantly less than males (p<0.05).
• Female athletes in pivot sports had lowest volitional increase in knee joint stiffness.
Female (pivot sport) 171%
Female (non-pivot sport) 198%
Male (non-pivot sport) 207%
Male (pivot sport) 258%
Gender Differences in Rotational
Knee Stiffness
Wojtys JBJS 2003
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Coordinated,
efficient muscle effort.
Engrams
Kottke Arch Phys Med 1980
ACL Injury Prevention
in Alpine Skiing
• Injury Mechanism Education
(Avoiding hazardous positions)
• Prospective
• 62% Reduction in ACL Injuries
Ettlinger AJSM 1995
ACL Prevention
Kinematics, Kinetics, Education
Neuromuscular Prevention
(Youth Soccer)
• Knee, ankle, lower extremity
• 60 teams - 32 trained
28 control
• Males & females
• Cluster randomized trial
• Stretches, eccentrics, agility,
jumping, & balance
Emery BJSM 2010
Injury Rate
Per 1,000 player hours
Trained – 2.08 injuries
Control 3.35
Neuromuscular Training is
Protective!
Emery BJSM 2010
Adolescent & Female
Football
• Stratified cluster randomized trial
• 230 Swedish clubs(121 – intervention)
• 4.564 players (12-17 y.o.)
• 15 min warm-up 2x week(core, balance, allignment)
Walden BMJ 2012
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ACL Injuries
Intervention – 7 (0.28%)
Control – 14 (0.67%)
Reduction in ACL – Injury rate
64%
Walden BMJ 2012
Knee Injuries - Soccer
• 1,506 females (13-19 y.o.)
• Community based intervention
• Motor skills, body control, & muscle
activation & education
Kiani Arch Int. Med. 2010
Intervention – 3 injuries
Incidence – 0.04/1000 player hrs
Control – 13 injuries
0.20/1000 player hrs
77% reduction knee injuries
90% reduction noncontact
Kiani Arch Int. Med. 2010
Prevention of Knee Injuries
• Systematic review (1966-2001)
• 328 studies identified � 14 included
• 5 brace studies � Negative
• 3 shoe cleats / ski boot-binding � ?
• 6 prospective, neuromuscular � Positive
Thacker J Sports Med Phys Fit 2003
Knee Ligament Injury Prevention
(KLIP)
• 577 female athletes
(soccer, b-ball, v-ball)
862 controls
• 20 min / session – 2x / week
• Non randomized – coach resistance
No Reduction in ACL Injuries!
Pfeiffer JBJS 2006
Injury Prevention - Soccer
• Randomized trial – high and low risk
Intervention and control
• Ankle, knee, hamstrings, groin
• Training compliance (HR)
27.5% Ankle
29.2% Knee
21.1% Hamstrings
19.4% Groin
Engebretsen AJSM 2008
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Effectiveness of ACL
Injury Prevention
• Meta-analysis of prospective
controlled studies
• 909 studies identified
9 included
Sadoghi JBJS 2012
Caraffa 1996
Gilchrist 2008
Heidt 2000
Hewett 1999
Mandelbaum 2005
Petersen 2002
Petersen 2005
Pfeiffer 2006
Sadoghi JBJS 2012
Sadoghi Studies
• Scientific quality – low
• Issues – blinding, randomization,
few matched pairs, drop-out rates
• Only 1 study with power analysis
• Study outcome heterogeneity
• 5/9 – soccer
• Low numbers
Sadoghi JBJS 2012
Pooled Risk Ratio
Females 0.48 95% C.I. = 0.26-0.89
Males 0.15 95% C.I. = 0.08-0.28
ACL injury risk reduction significant
for females 52% (p=0.021) and
males 85% (p<0.001)
Sadoghi JBJS 2012
Meta-Regression
Balance Board � no effect (p=0.712)
Video assistance � no effect (0.914)
F/U duration � no effect (0.437)
Year of publication � no effect (0.358)
On the pooled risk
Sadoghi JBJS 2012
? Best Program ?
• Study heterogeneity
• At least 10 min – 3 x / week
Neuromuscular
Sadoghi JBJS 2012
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Meta-Regression (Training)
Preseason vs. playing season reduced risk by 19.1% (p=0.691)
Sadoghi JBJS 2012
ACL Injury Prevention and
Performance Enhancement
• Systematic Review (1995-2011)
• 57 Studies – 42 Programs
Sportsmetrics
Myklebust
17 Studies KLIP
PEP
11 (HOLM)
Noyes Sports Health 2012
ACL Injury Incidence Reduction
(AE*)
PEP and Sportsmetrics
*Athletic Performance Improvements
Noyes Sports Health 2012
Clinical Incidence Rate
Injuries
Athletes
At Risk (N)
ACL Injury Rate
Injuries
Athletic
Exposures (AE)
Sportsmetrics
ACL Injury
Reduction
• Very successful
Improved Athletic
Performance
• 60-120 min / 3x week
• Pre-Season
Noyes Sports Health 2012
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PEP
• Very Good
In-Season – 20 min before practice
? Athletic Performance ?
Noyes Sports Health 2012
ACL Injury
Reduction
Prevention Programs
• Landing technique
• Cutting maneuvers
• Deceleration
Tailored to the Athlete
Sports Specific
Artificial Turf vs Grass
• Prospective Cohort –
2020 players (109 teams)
• Young female football players (2005)
Risk of Acute Ankle/Knee Injury was
Similar!
Steffen BJSM 2007
Field Turf vs. Grass
(NFL)
• Descriptive Retrospective Study
• 2000-2009 (5360 team/games)
Injury Rate 67% on Field Turf
Hershman AJSM 2012
Compliance
Athletic Injury
Performance Prevention
Balance
Summary
• Injury prevention hampered by lack
of ACL injury mechanism
understanding
• Still not sure what Sportsmetrics,
PEP, and other successful
programs change?
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Thank You
ACL Injury Prevention
(Meta-Analysis)
Plyometric Balance
Strength Training Training
*Most effective – females (<18 yo) soccer
Yoo KSST 2010
Warm-up Program
(cluster randomized trial)
• 1892 female footballers (13-17 y.o.)
• Foot, ankle, leg, knee, thigh, groin, & hip
• Strength, awareness, & NM control
Risk of all injuries, severe & overuse, was reduced!