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Journal of Athletic Training
2018;53(1):5–19
doi: 10.4085/1062-6050-99-16
Ó by the National Athletic Trainers’ Association, Inc
www.natajournals.org
Position Statement
National Athletic Trainers’
Association Position Statement:
Prevention of Anterior Cruciate
Ligament Injury
Darin A. Padua, PhD, ATC*; Lindsay J.
DiStefano, PhD, ATC†; Timothy E. Hewett,
PhD‡; William E. Garrett, PhD, MD§; Stephen
W. Marshall, PhD*; Grace M. Golden, PhD,
ATC, CSCS||; Sandra J. Shultz, PhD, ATC,
FNATA, FACSM¶; Susan M. Sigward, PhD, PT,
ATC#
*University of North Carolina at Chapel Hill; †University of
Connecticut, Storrs; ‡Mayo Clinic, Rochester, MN; §Duke
University, Durham, NC; ||University of Oregon, Eugene;
¶University of North Carolina at Greensboro; #University of
Southern California, Los Angeles
Objective: To provide certified athletic trainers, physicians,
and other health care and fitness professionals with recommendations based on current evidence regarding the prevention of
noncontact and indirect-contact anterior cruciate ligament (ACL)
injuries in athletes and physically active individuals.
Background: Preventing ACL injuries during sport and
physical activity may dramatically decrease medical costs and
long-term disability. Implementing ACL injury-prevention training
programs may improve an individual’s neuromuscular control
and lower extremity biomechanics and thereby reduce the risk of
injury. Recent evidence indicates that ACL injuries may be
prevented through the use of multicomponent neuromusculartraining programs.
Recommendations: Multicomponent injury-prevention
training programs are recommended for reducing noncontact
L
ower extremity injuries make up 66% of all sports
injuries, the knee being the most commonly injured
joint.1 A particularly important and devastating type
of knee injury is rupture of the anterior cruciate ligament
(ACL). Unfortunately, surgical reconstruction and rehabilitation do not prevent long-term morbidity or decrease the
risk of future ACL injury.2–7 The costs associated with
surgically reconstructed ACL injuries range from $5000 to
$17 000 per patient; however, the estimated long-term
societal costs may be as high as $38 000 per patient.8–13
Perhaps even more alarming than the high financial costs
was a report14 indicating that the rate of ACL injuries is
rising rapidly. Preventing ACL injuries during sport and
and indirect-contact ACL injuries and strongly recommended
for reducing noncontact and indirect-contact knee injuries
during physical activity. These programs are advocated for
improving balance, lower extremity biomechanics, muscle
activation, functional performance, strength, and power, as
well as decreasing landing impact forces. A multicomponent
injury-prevention training program should, at minimum, provide feedback on movement technique in at least 3 of the
following exercise categories: strength, plyometrics, agility,
balance, and flexibility. Further guidance on training dosage,
intensity, and implementation recommendations is offered in
this statement.
Key Words: knee injuries, lower extremity biomechanics,
neuromuscular control, injury prevention
physical activity may dramatically decrease medical costs
and long-term disability.
Most ACL injuries do not involve a direct blow to the
knee15–17 but rather are noncontact or indirect contact in
nature, involving uncontrolled lower extremity biomechanics. Thus, ACL injury prevention may be achieved by
implementing training programs that improve an individual’s neuromuscular control and lower extremity biomechanics.
Compared with single-component training programs,
multicomponent training programs, or programs that
require more than 1 type of exercise (eg, agility, balance,
flexibility), appear more effective in reducing ACL
Journal of Athletic Training
5
injury rates.18–21 However, no researchers have identified
a single optimal preventive training program. As such,
general guidelines and recommendations are provided for
developing a multicomponent training program for
preventing ACL injury. Based on available evidence,
we recommend that a multicomponent injury-prevention
training program include, at minimum, feedback on
proper exercise technique for at least 3 of the following
exercise types: strength, plyometrics, agility, balance,
and flexibility. More detailed information on the
rationale, development, and implementation of a multicomponent training program, as well as identification of
target populations, is offered in the ‘‘Background and
Literature Review’’ section.
Therefore, the purpose of this position statement is to
provide certified athletic trainers (ATs), physicians, and
other health care and fitness professionals with recommendations based on current evidence regarding the
prevention of noncontact and indirect-contact ACL
injuries in athletes and physically active individuals.
Recommendations are supported using the Strength of
Recommendation Taxonomy (SORT) system.22 The
letter indicates the consistency and evidence-based
strength of the recommendation (A has the strongest
evidence base). For the practicing clinician, any
recommendation with an A grade warrants attention
and should be inherent to clinical practice. Less
research supports recommendations with grade B or C;
these should be discussed by the sports medicine staff.
Grade B recommendations are based on inconsistent or
limited controlled research outcomes. Grade C recommendations should be considered as expert guidance
despite limited research support.
RECOMMENDATIONS
Effects of Injury-Prevention Training Programs on
Injury Reduction and Performance Enhancement
Two primary areas of benefit are associated with injuryprevention training programs: decreased risk of ACL and
other knee injuries and improved performance.
1. Multicomponent training programs that include feedback regarding technique and at least 3 of the exercise
categories (ie, strength, plyometrics, agility, balance,
and flexibility) are recommended to reduce noncontact and indirect-contact ACL injuries during physical
activity. 18–21,23–31 Strength of Recommendation
(SOR): B
a. Females (aged 12 to 18 years) are strongly advised to
perform a multicomponent training program to reduce
the risk of noncontact and indirect-contact ACL injury
during physical activity.18,20 SOR: A
b. Males are advised to perform a multicomponent
training program to reduce the risk of noncontact and
indirect-contact ACL injury during physical activity.21,27 SOR: B
2. Multicomponent injury-prevention training programs
are strongly endorsed for reducing noncontact and
indirect-contact knee injuries other than ACL
injuries during physical activity in females and
males.18,24,27,31–47 SOR: A
6
Volume 53  Number 1  January 2018
3. Multicomponent training programs are advocated to
improve lower extremity biomechanics (eg, increasing
sagittal-plane motion, decreasing frontal- and transverse-plane motion, and decreasing knee-joint
loads)48–62 and muscle activation (eg, increasing
hamstrings and gluteal muscle activation)51,63–65 and
to decrease landing impact forces.50,59,63,66–68 SOR: C
4. Multicomponent training programs are advised for
improving balance.44,59,69–71 SOR: C
5. Multicomponent training programs are endorsed
for improving lower extremity strength and
power.48,49,51–53,61,63,72–75 SOR: C
6. Multicomponent training programs are promoted for
improving measures of functional performance (eg,
vertical-jump height, hop distance, hop speed, estimated V̇O2max, sprint speed).48–52,61,63,69,73,76,77 SOR: C
Development of Multicomponent Injury-Prevention
Training Programs (Exercise Selection, Intensity, and
Volume)
The acute variables for injury-prevention training (ie,
specific exercises to perform, order of exercises, repetitions, sets, intensity, tempo, rest periods between exercises, and training-session duration) vary among programs
that successfully decrease injury rates and improve
neuromuscular function and physical performance. Thus,
we cannot recommend a specific multicomponent training
program or group of exercises to prevent ACL injury.
However, certain common features of the preventive
training programs have been shown to be successful in
reducing injury rates and improving neuromuscular
function and physical performance. Therefore, general
guidelines regarding the organization and types of
exercises to include in multicomponent training programs
are provided.
Exercise Selection and Training Intensity
7. A multicomponent preventive training program involves
offering feedback on movement technique (eg, ‘‘land
softly,’’ ‘‘keep your knees over your toes,’’ ‘‘bend your
knees and hips’’) and should include at least 3 of the
following exercise categories: strength, plyometrics,
agility, balance, and flexibility.18–20,23–27,29–31,78–84 SOR: B
8. Injury-prevention training exercises should be performed at progressive intensity levels that are challenging and allow for excellent movement quality and
technique.18,25,27,30,31 SOR: C
Training Volume (Frequency and Duration)
9. Multicomponent training programs should be performed during the preseason and in-season.18,20,26,30,31
SOR: B
10. Multicomponent training programs should be performed at least 2 to 3 times per week throughout the
preseason and in-season.18,19,23,27,31 SOR: B
11. To maintain the benefits of reduced injury rates and
improved neuromuscular function and performance
over time, multicomponent training programs (preseason, in-season, and off-season) should be per-
formed each year and not discontinued after a single
season.85–87 SOR: C
Implementation of Multicomponent Injury-Prevention
Training Programs (Program Adoption and
Maintenance)
12. Multicomponent training programs should be regularly
supervised by individuals who are skilled in identifying
faulty movement patterns to ensure excellent movement quality and provide feedback on exercise
technique.18,19,23–25,31 SOR: C
13. Multicomponent training programs are effective when
implemented as a dynamic warm-up or as part of a
comprehensive strength and conditioning program.18,19,23,31 SOR: C
14. To facilitate the adoption of and compliance with
multicomponent training programs, we support the
education of athletes, coaches, parents, and administrators on the following points related to preventive
training programs.88–95 SOR: C
a. Lower extremity injuries are common in sports.
b. Anterior cruciate ligament injury is a lower extremity
injury that is particularly costly and potentially
debilitating.
c. Multicomponent training programs reduce ACL injury
rates.
d. Multicomponent training programs not only are effective in reducing injury but also can improve physical
performance.
e. Many elite-level athletes and coaches already incorporate injury-prevention training exercises as part of their
in-season and off-season training programs.
f. Multicomponent training programs can be seamlessly
incorporated into preseason, in-season, and off-season
training practices without taking time away from skill
development.
g. If time constraints are a concern, some evidence
indicates that multicomponent training programs can
be performed in 10 to 15 minutes as part of a dynamic
warm-up before the start of practices and games.
h. The rationale for exercise selection and the importance
of maintaining proper technique and movement quality
when performing exercises should be emphasized.
15. When implementing multicomponent training programs for children (ie, 15 years of age and younger),
the following are advocated. SOR: C
a. Incorporate movement patterns that are developmentally appropriate for children (eg, balancing, running,
skipping, landing, squatting) in addition to sportspecific movements (eg, jump landings, jump stops,
cutting maneuvers).55,96,97
b. Focus on body control and movement quality by
providing regular feedback about proper exercise
technique.55,96,98
c. Shorten the session or break it into multiple shorter
segments depending upon the child’s attention span.55,72,96
Targeting Individuals for Injury-Prevention Training
Programs
All individuals involved in sports and physical activity
are advised to participate in a multicomponent preventive
training program. However, those who are active in
particular sports or display certain traits should be targeted
for preventive training as they either are at a relatively
higher risk of ACL injury or have a greater potential for
benefit.
16. Athletes participating in high-risk sports that involve
landing, jumping, and cutting tasks (eg, basketball,
soccer, team handball), especially females, should be
targeted for injury-prevention training.21,81,99,100 SOR:
A
17. Because a history of ACL injury is one of the strongest
predictors of future ACL injury, individuals with such
a history, especially younger individuals who return to
sport-related activities, should be targeted for injuryprevention training.22,99,101–106 SOR: A
18. Children participating in higher-risk sports for ACL
injury that involve landing, jumping, and cutting tasks
(eg, basketball, football, soccer) should be targeted for
injury-prevention training.55,107–111 SOR: C
BACKGROUND AND LITERATURE REVIEW
Sport-related musculoskeletal injuries represent a serious
long-term health concern for millions of Americans and
need to be prevented when possible. Data suggest that
sport-related injuries cause 20% of injured schoolchildren
to miss at least 1 school day each year and 28% of injured
working adults to lose at least 1 workday each year.1,12 In
addition to immediate time lost from work, school, or sport,
musculoskeletal injuries are a primary reason people stop
being physically active, which has detrimental effects on
future health. Lower extremity injuries make up 66% of all
sport-related injuries, and the knee is the most commonly
injured joint.1 A particularly important and devastating type
of knee injury is rupture of the ACL.
Both females and males are at risk for ACL injury and
may benefit from injury-prevention programs. Recent
estimates from the general population indicate that 1 to 5
ACL injuries occur per 5000 persons over a lifetime.15,112,113 In the United States alone, an estimated
200 000 ACL injuries occur annually15; however, the
incidence of ACL injury is greater among athletic and
military populations.114 In Switzerland, the rate of ACL
injury in the general population is less than 1 injury per
100 000 athlete-hours of sports exposure,112 but the rate
rises dramatically in specific athlete subgroups: for
example, up to 1 injury per 1000 athlete-hours for females
playing in professional soccer games.115,116 Thus, the rate
may be 10 to 100 times higher in elite athletes than in the
general population. Males also sustain more ACL injuries
than females in the general population.15,108,113 Yet high
school- and college-aged females participating in comparable sports (eg, basketball, soccer, softball) are at 1.5 to 4.6
times greater risk of experiencing an ACL injury compared
with their male counterparts.99,100,102,104,112 This is not to
suggest that male athletes are at low risk for ACL injury.
Among male high school football athletes, the rate of ACL
injuries is 11.1 per 100 000 athlete-exposures, similar to
that in female high school soccer and basketball athletes.100
Perhaps most alarming are reports14,117 indicating the rate
of ACL injuries is rapidly rising.
Journal of Athletic Training
7
Table 1. Overview of Level of Evidence and Effectiveness of Injury-Prevention Training Programs With Anterior Cruciate Ligament Injury
as a Primary Outcome
Reference
Year
Strength of Recommendation
Taxonomy Rating
Sugimoto et al123
Hewett et al25
Heidt et al24
Myklebust et al31
Mandelbaum et al19
Olsen et al27
Petersen et al29
Steffen et al30
Gilchrist et al23
Pasanen et al28
Kiani et al26
LaBella et al18
Walden et al20
Soderman et al44,b
Pfeiffer et al43,b
Overall
1999
2000
2003
2005
2005
2005
2008
2008
2009
2010
2011
2012
2000
2006
2
1
2
2
1
2
1
1
1
2
1
1
2
2
PEDro Score
Taylor et al83
Myer et al121
3
4
3
3
7
3
8
4
Not reported
4
5
7
4
3
3
5
5
3
7
2
7
4
8
4
6
7
4
2
Odds Ratio
(95% Confidence Interval)a
0.503
0.762
0.870
0.179
0.318
1.497
0.705
0.563
1.182
0.085
0.340
0.419
5.310
1.497
0.541
(0.097,
(0.093,
(0.499,
(0.077,
(0.086,
(0.301,
(0.189,
(0.234,
(0.329,
(0.005,
(0.068,
(0.169,
(0.578,
(0.301,
(0.354,
2.609)
6.255)
1.516)
0.413)
1.181)
7.440)
2.633)
1.357)
4.246)
1.535)
1.688)
1.040)
48.779)
7.440)
0.828)
Significance
Levela
.414
.800
.624
.001
.087
.622
.603
.201
.798
.095
.187
.061
.140
.622
.005
Abbreviation: PEDro, Physiotherapy Evidence Database.
a
Odds ratio, 95% confidence interval, and significance level data adapted from Myer et al.121
b
Did not use a multicomponent injury-prevention training program.
Anterior cruciate ligament injury is a career-threatening,
if not career-ending, injury in athletes. After ACL
reconstructive surgery, an estimated 82% of individuals
return to sport participation; however, only 63% return to
their preinjury level of sport participation, and only 44%
return to competitive sport.118 The injury also carries other
long-term consequences, as the odds of developing knee
osteoarthritis are nearly 4 times greater after knee injury,119
making a previous knee injury a strong risk factor for early
knee osteoarthritis.120 The rates of osteoarthritis after ACL
injury range from 10% to 90% within 10 to 20 years.3
Progression of knee osteoarthritis after ACL injury is not
ameliorated by surgical reconstruction and rehabilitation:
the risk of developing osteoarthritis is the same in ACLinjured patients who undergo surgical reconstruction as in
those who do not.2–7
In addition to substantial long-term consequences and a
high level of disability, ACL injury places a large burden
on the health care system. A single ACL injury results in
multiple physician and rehabilitation visits, generating
significant costs to the health care system. A recent
estimate12 indicated that approximately $3 000 000 000 is
spent annually on the ACL reconstruction process. Thus,
given the associated frequency, disability, and costs, there
is a great need to prevent ACL injuries.
Most ACL injuries are noncontact or indirect contact in
nature and do not involve a direct blow to the knee.15–17
Noncontact or indirect-contact ACL injuries involve
uncontrolled lower extremity biomechanics, which suggests
that some ACL injuries may be preventable. Therefore, the
purpose of this position statement is to provide certified
ATs, physicians, and other health care and fitness
professionals with current best-practice recommendations
regarding the prevention of noncontact and indirect-contact
ACL injuries in athletes and physically active individuals.
This position statement provides recommendations based
on available current evidence related to the benefits,
development, and implementation of injury-prevention
training programs, as well as the identification of target
8
Volume 53  Number 1  January 2018
populations for these programs. The majority of effective
preventive training programs incorporate a multicomponent
exercise program including feedback on proper exercise
technique for at least 3 of the following types of exercises:
strength, plyometrics, agility, balance, and flexibility.
Benefits of Injury-Prevention Training Programs
Reduced ACL Injury Rate. Multicomponent preventive
training programs reduce the rate of ACL injury in males
and females participating in sport.18,19,23–31 In previous
systematic reviews with meta-analyses,83,121,122 the quality
of the included studies has been evaluated (Table 1). These
authors cited 7 level 1 studies18,20,23,24,27,28,30 and 7 level 2
studies.19,25,26,29,31,43,44 It should be noted that these reviews
incorporated 2 studies that did not use a multicomponent
training program 4 3 , 4 4 but …
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