Perspectives on Modern Orthopaedics

Noncontact Anterior Cruciate Ligament Injuries:

Risk Factors and Prevention Strategies

Letha Y. Griffin, MD, PhD, Julie Agel, MA, ATC, Marjorie J. Albohm, MS, ATC,
Elizabeth A. Arendt, MD, Randall W. Dick, MS, William E. Garrett, MD, PhD, James G. Garrick, MD,
Timothy E. Hewett, PhD, Laura Huston, MS, Mary Lloyd Ireland, MD, Robert J. Johnson, MD,
W. Benjamin Kibler, MD, Scott Lephart, PhD, ATC, Jack L. Lewis, PhD, Thomas N. Lindenfeld, MD,
Bert R. Mandelbaum, MD, Patricia Marchak, ATC, Carol C. Teitz, MD, and Edward M. Wojtys, MD

Abstract
An estimated 80,000 anterior cruciate ligament (ACL) tears occur annually in Daniel and Fritschy also reported that
the United States. The highest incidence is in individuals 15 to 25 years old 70% of the injuries were the result of
who participate in pivoting sports. With an estimated cost for these injuries of sports participation. Therefore, it
almost a billion dollars per year, the ability to identify risk factors and develop appears that the vast majority of ACL
prevention strategies has widespread health and fiscal importance. Seventy per- injuries occur during a 30-year period
cent of ACL injuries occur in noncontact situations. The risk factors for non- (15 to 45 years of age)Ña period that
contact ACL injuries fall into four distinct categories: environmental, anatomic, encompasses roughly 47% of the pop-
hormonal, and biomechanical. Early data on existing neuromuscular training ulation of the United States. During
programs suggest that enhancing body control may decrease ACL injuries in those three decades of life, the annual
women. Further investigation is needed prior to instituting prevention pro- incidence of ACL injuries is one
grams related to the other risk factors. injury for every 1,750 persons.
J Am Acad Orthop Surg 2000;8:141-150

The information in this article was derived in

part from discussions at the Hunt Valley
Significant advances in the diagno- General population studies of the Consensus Conference on Prevention of
sis and treatment of anterior cruci- incidence of this injury are somewhat Noncontact ACL Injuries (conducted under
ate ligament (ACL) injuries were misleading as to its societal signifi- the joint sponsorship of the American
made during the 1970s and 1980s. cance. For instance, in a study of the Orthopaedic Society for Sports Medicine, the
In the 1990s, attention focused on incidence of ACL injuries in a large Orthopaedic Research and Education Foun-
dation, the National Athletic Trainers
identifying noncontact injury mech- managed-careÐinsured population, Association Research and Education Foun-
anisms in an effort to define risk Daniel and Fritschy 1 reported an dation, and the National Collegiate Athletic
factors for injury. The ultimate annual rate of one ACL injury per Association), Hunt Valley, Md, on June 10,
goal of defining the risk factors 3,500 enrollees. Projecting this rate 1999.
was the development of effective across the United States yields only
injury prevention programs. In a about 80,000 injuries per year. One or more of the authors or the departments
with which they are affiliated have received
1999 review of the epidemiology of However, certain segments of the something of value from a commercial or other
ACL injuries, Garrick noted that population (the very young, the party related directly or indirectly to the sub-
Òof the 3,572 Medline citations elderly, and those who are sedentary) ject of this article.
under the ACL topic heading, only rarely sustain this injury. In the study
133 are subheaded ÔpreventionÕ by Daniel and Fritschy, the average Reprint requests: Dr. Griffin, Peachtree
and less than 10 of these deal with age of those with ACL sprains was 26, Orthopaedic Clinic, Suite 705, 2001 Peachtree
Road, Atlanta, GA 30309.
prevention of the injury rather and virtually every study of ACL
than prevention of some surgical reconstructions has noted that the Copyright 2000 by the American Academy of
complicationÓ (J. G. Garrick, MD, average age is in the third decade of Orthopaedic Surgeons.
unpublished data, 1999). life. Consistent with other authors,

Vol 8, No 3, May/June 2000 141

Noncontact Anterior Cruciate Ligament Injuries

Because of the greater absolute futureÑthat is, the cost of treating hip angle, laxity, notch size), hor-
number of male participants in the long-term complications of the monal, and biomechanical (e.g.,
sports activities, more males than posttraumatic degeneration that muscular strength, body move-
females sustain this injury. How- occurs in many patients who sus- ment, skill level, neuromuscular
ever, National Collegiate Athletic tain ACL injuries, even those who control).
Association statistics show that in undergo reconstruction. Consid-
those activities in which males and ering not only this economic loss
females both participate, with simi- but also the significant emotional Environmental Risk
lar rules and equipment (e.g., soc- and physical burden this injury Factors
cer, basketball, volleyball), the like- inflicts on the individual who sus-
lihood of sustaining an ACL injury tains it, efforts toward developing Role for Knee Braces
is two to eight times greater for prevention strategies seem pru- During the late 1970s, prophy-
females than for males.2 No inves- dent. lactic knee braces were introduced
tigator has found any evidence of to protect the collateral ligaments.
systematic bias that might be re- Some braces had a unilateral hinge
sponsible for this difference; thus, it Etiology and were taped or strapped in
would appear that, at least in these place; others had bilateral hinges
sports, females are more likely to Approximately 30% of all ACL incorporated into an elastic or neo-
sustain this particular injury, even injuries result from direct contact prene sleeve. Early reports indicated
though the preponderance of male with another player or object (R. A. a decrease in the number of knee
participation in these and other Malinzak, MD, unpublished data, injuries in braced collegiate and
sports results in more males actually 1999). Although several authors high school athletes.4 Later stud-
being injured. have speculated on the etiology of ies, however, did not confirm this
Approximately 50,000 ACL re- the 70% of ACL injuries that do not finding; in fact, several studies
constructions are done each year,3 result from direct contact, the basic even reported an increase in the
at an approximate cost of $17,000 mechanism for this injury still number of knee injuries in braced
per procedure; therefore, the finan- eludes us. Activities that appear to athletes.5,6 In 1984, the American
cial impact is just under a billion be associated with significant risk Academy of Orthopaedic Surgeons
dollars ($850,000,000). This figure include decelerating and pivoting, issued a position statement on knee
does not take into account the cost awkward landings, and Òout of braces, in which it was noted that
of the initial care of all ACL injuries controlÓ play. Potential risk factors there was no definitive evidence
or the conservative management that have been identified as associ- that prophylactic knee braces can
and rehabilitation of the patients ated with noncontact injuries can be prevent knee injuries.
who do not undergo ACL recon- classified as environmental (e.g., Despite such negative reports,
struction. Moreover, it does not equipment, shoe-surface interac- high school, college, and professional
consider the economics of the tions), anatomic (e.g., knee angle, players continue to use prophylactic

Dr. Griffin is Team Physician, Georgia State University, Atlanta, and Staff Physician, Peachtree Orthopaedic Clinic, Atlanta. Ms. Agel is
Research Coordinator, Orthopaedics Department, University of Minnesota, Minneapolis. Ms. Albohm is Director, Orthopaedic Research
Foundation, Orthopaedics Indianapolis, Center for Hip and Knee Surgery, Mooresville, Ind. Dr. Arendt is Associate Professor of
Orthopaedics, University of Minnesota, Minneapolis. Mr. Dick is Senior Assistant Director of Health and Safety, National Collegiate Athletic
Association, Indianapolis. Dr. Garrett is Frank C. Wilson Professor and Chairman, Department of Orthopaedics, University of North Carolina
School of Medicine, Chapel Hill. Dr. Garrick is Clinical Professor of Pediatrics, University of California Center for Sports Medicine, San
Francisco. Dr. Hewett is Assistant Professor and Director of Applied Research, Cincinnati Sportsmedicine Research and Education
Foundation, University of Cincinnati, Cincinnati. Ms. Huston is Senior Research Associate, Section of Orthopaedic Surgery, University of
MichiganÐMedSport, Ann Arbor. Dr. Ireland is Professor and Team Physician, Department of Orthopaedics, Eastern Kentucky University,
Lexington. Dr. Johnson is Vice Chairman, Academic Affairs, and Head, Division of Sports Medicine, Department of Orthopaedics and
Rehabilitation, University of Vermont, Burlington. Dr. Kibler is Medical Director, Lexington Sports Medicine Center, Lexington, Ky. Dr.
Lephart is Associate Professor of Orthopaedic Surgery and Director, Neuromuscular Research Laboratory, University of Pittsburgh,
Pittsburgh. Dr. Lewis is Professor, Orthopaedic Surgery Department, University of Minnesota, Minneapolis. Dr. Lindenfeld is Associate
Director, Cincinnati Sports Medicine and Orthopaedic Center, Cincinnati. Dr. Mandelbaum is Fellowship Director, Santa Monica
Orthopaedic and Sports Medicine Group, Santa Monica, Calif. Ms. Marchak is Research Analyst, Department of Orthopaedics, Duke
University Medical Center, Durham, NC. Dr. Teitz is Associate Professor of Orthopaedics, University of Washington, Seattle. Dr. Wojtys is
Professor of Orthopaedic Surgery, University of Michigan, Ann Arbor.

142 Journal of the American Academy of Orthopaedic Surgeons

 Letha Y. Griffin, MD, PhD, et al

bracing, citing psychological and the shoe and the surface are gener- with conflicting results. 12-14 In a
unmeasured proprioceptive bene- ally associated with better perfor- profiling study of noncontact ACL
fits. NŽmeth et al 7 showed that mance but a higher injury risk. basketball injuries during the 1998-
functional braces do modify elec- Hence, a shoe-surface design that 1999 NCAA season, no evidence of
tromyographic activity and timing. results in a safer environment may hyperlaxity or tight hamstrings was
However, the significance of this not allow optimal performance. evident in either male or female
finding has yet to be fully explored. athletes (E. A. Arendt, MD, unpub-
Because of the many variables that lished data, 1999).
must be considered (e.g., position Anatomic Risk Factors There is a mild increase in both
played, condition of playing sur- anterior and posterior knee laxity
face, skill and experience of the There are obvious anatomic differ- (18% to 20%) when certain sports
player, effect of rule changes, influ- ences in lower-extremity alignment, (basketball and jogging) are per-
ence of coaching), a study to evalu- joint laxity, and muscle develop- formed for more than 30 minutes.15
ate the effectiveness of braces on ment between males and females. This increased laxity returns to nor-
ACL injury rates requires a large Less obvious are the differences in mal after 60 minutes. Such data
sample size and a study population femoral notch and ACL size. Static raise the issue of whether there
that is homogeneous enough to measurements of lower-extremity could be a relationship between
yield statistically significant infor- alignment (e.g., hip varus, knee val- exercise-associated increased laxi-
mation. gus, foot pronation, hip rotation) ty, which is considered to be a nor-
can be made, but the real question mal physiologic response to exer-
Influence of Shoe-Surface is which differences, if any, con- cise, and subsequent ligamentous
Interaction tribute to an increased risk of ACL injury. At present, the relationship
Many of the early studies assess- injury. between hypermobility and knee-
ing the influence of the playing sur- There is increased femoral ante- ligament injuries is still unresolved.
face on ACL injury lacked ade- version, increased Q angle, excessive Of the 15 published studies on
quate controls on variables such as tibial torsion, and excessive foot the relationship of the femoral
surface (e.g., hardness, age, weath- pronation in the female (Fig. 1). notch to ACL injuries, 9 address
er conditions) and shoe type. The However, the influence of these gender differences (E. A. Arendt,
surface was viewed as the sole con- variables on functional movement MD, unpublished data, 1999). De-
tributor to injury, despite the fact patterns has not been fully explored.
that the friction associated with a Such information is critical for relat-
foot-plant injury must involve two ing these variables to risk factors for
surfaces. More recently, a high ligament injury. In a brief prelimi- Female Male
level of friction between shoes and nary report, Meister and co-workers
the playing surface has been identi- compared the thigh-foot angle in a
fied as a major risk factor for non- group of 51 ACL-injured female ath-
contact ACL injury in the sport of letes with that in a matched cohort
team handball.8 In football, cleat of 65 uninjured female athletes and
design has not only been found to found that an increase in the thigh-
be an important factor in torsional foot angle may be a risk factor for
resistance in the laboratory; it has noncontact ACL injuries, but that fe-
also been found to influence ACL moral anteversion was not (K. Meis-
injury rates. 9 Noncontact ACL ter, MD, unpublished data, 1999).
injuries appear to occur most fre- Laxity (the combination of joint
quently when playing surfaces are hypermobility and musculotendi-
dry.10 nous flexibility) is more prevalent
Shoe-surface considerations not among women than men.11 Joint
only must center on the complex hypermobility appears to be a
nature of that relationship, with its genetically inherited trait, but mus-
many contributing factors (e.g., culotendinous flexibility can be
axial load, weather conditions), but altered through conditioning. A Figure 1 In general, when compared with
men of equal ages, women have wider
also must deal with the balance number of studies exploring the pelvises as well as greater hip varus, knee
between performance and safety. relationship of hypermobility or valgus, and foot pronation.
Higher levels of friction between laxity to injury have been reported,

Vol 8, No 3, May/June 2000 143

Noncontact Anterior Cruciate Ligament Injuries

spite the limitations of the various erties of the ACL.16,17 For example, this lack of agreement, more rigor-
measurement techniques and the both fibroblast proliferation and ous studies must be performed
potential lack of a controlling leg the rate of collagen synthesis are before treatment or prevention rec-
rotation, the literature supports reduced with increasing estradiol ommendations can be made.
the following general statements: concentrations,16 and the adminis-
(1) The notch width (regardless of tration of estrogen reduces the ten-
measurement technique) in pa- sile properties of rabbit ACL.17 Biomechanical Risk
tients with bilateral ACL injuries is Several investigators have at- Factors
less than that in patients with uni- tempted to link hormone fluctua-
lateral ACL injuries. (2) The notch tions during the menstrual cycle to Role of Proprioception and
width in knees with bilateral and the rate of ACL injuries, but with Neuromuscular Control in Joint
unilateral ACL injuries may be less conflicting results. Wojtys et al18 re- Stability
than that in normal control subjects. ported more injuries than expected The term Òfunctional joint stabili-
(3) On average, the width of the in the ovulatory phase of the men- tyÓ refers to the joint stability re-
notch is less in females than in males. strual cycle (days 10 to 14, when es- quired to perform a functional activ-
(4) On average, the notch width trogen levels surge); fewer injuries ity. This stability is provided by
index (relation of condylar width to occurred in the follicular phase both static and dynamic stabilizers
notch width) in females is less than (days 1 to 9, when estrogen and in varying degrees depending on
that in males. (5) There is a rela- progesterone levels are low). My- the activity. The dynamic contribu-
tionship between the total width of klebust et al19 found fewer injuries tions emerge from precise neuromo-
the condyles and the width of the during the midcycle estrogen surge tor control over the skeletal muscles
notch; the smaller the femur, the (days 8 to 14) in a group of Nor- crossing the joint. Skeletal muscle ac-
smaller the notch. (6) There is too wegian team handball players. The tivation may be conscious (initiated
much variability in measurement difference in the findings of these directly by voluntary command) or
techniques used in the various two studies is likely related to an unconscious (initiated automatically
published studies to allow de- important difference in the patient as part of a motor program or in re-
finitive statements concerning populations. Wojtys et al examined sponse to sensory stimuli).
either the size of the ACL within women with regular menstrual The term Òneuromuscular con-
the notch or the relationship of cycles who were not taking oral trolÓ specifically refers to uncon-
notch width to unilateral ACL contraceptives; in contrast, half of scious activation of the dynamic
injury. the subjects in the study by My- restraints surrounding a joint in
In summary, the association of klebust et al were taking oral con- response to sensory stimuli. In
anatomic variables with an in- traceptives. Oral contraceptive use 1906, Sherrington initially described
creased risk for ACL injury is in- has been previously linked to lower proprioception as the afferent infor-
triguing, but to date no anatomic injury rates in women20; however, mation arising from the periphery
variable has been directly correlated the injuries in these studies were concerning regulation of postural
with an increased risk for unilateral classified only as general traumatic equilibrium, joint stabilization, and
noncontact ACL injury. injuries and did not isolate knee or several conscious peripheral sensa-
ACL injuries. A 1998-1999 survey tions.21,22 Proprioception is the sen-
of 103 ACL-injured female NCAA sory source best suited for provid-
Hormonal Risk Factors basketball players found that ath- ing the information necessary for
letes tended to be injured just mediating neuromuscular control,
The possible role of hormones in before or after the onset of menses, thereby enhancing functional joint
predisposing female athletes to regardless of their use of oral con- stability.
injury of the ACL has recently been traceptives (E. A. Arendt, MD, un- Sources of proprioceptive infor-
an area of active investigation. In published data, 1999). mation include mechanoreceptors
1996, estrogen and progesterone Although the results of studies so located in muscular, articular, and
receptor sites were found in human far are compelling regarding the cutaneous tissues that are responsible
ACL cells,16 suggesting that female interaction between female hormone for transducing mechanical events
sex hormones may play a role in concentrations and compositional into neural signals. The stimuli
ACL structure. Several researchers changes to the ACL, consensus is recorded by these receptors are con-
have since determined that female lacking regarding the relationship of veyed via afferent neurons to the
sex hormones can influence the menstrual cycle phase to the inci- spinal cord. Many afferent neurons
composition and mechanical prop- dence of ACL injuries. In light of bifurcate, with the projections syn-

144 Journal of the American Academy of Orthopaedic Surgeons

 Letha Y. Griffin, MD, PhD, et al

apsing directly with gamma motor detection of effects from the arrival activation of the biarticular muscles
neurons, alpha motor neurons, or in- of the event or stimuli. 23 Both (hamstrings and quadriceps), de-
terneurons. Some interneurons pro- forms of control have unique but creased hip-muscle activation re-
vide the basis for sensory integration interrelated roles in control over the duces maximal possible quadriceps
and motor control at the spinal level; dynamic restraints. and hamstring activation.25,27 This
others form the ascending tracts lead- Proprioception plays an integral decreased activation alters optimal
ing to higher central nervous system role in maintaining functional joint load-bearing capacity.25,27 Females
structures. The spinocerebellar path- stability. Appropriate adaptations show a significantly shorter dura-
ways probably provide the organiza- to preparatory activation of muscle, tion of gluteus medius activation in
tional core of supraspinal control mediated by proprioceptive signals, stance, or load-absorbing, phase
over the dynamic restraints, which is may provide the most efficient when executing a cutting maneu-
an element of functional joint stabili- means of inducing prophylactic ver (W. B. Kibler, MD, unpublished
ty. Working subconsciously, the cer- mechanisms that could shield the data, 1999). This results in higher
ebellum has an essential role in plan- ACL from extreme in vivo forces loads per unit of body weight in
ning and modifying motor activities and reduce the incidence of ACL anteroposterior and varus/valgus
by comparing the intended move- injury in the female athlete. directions in females. In addition,
ment with the outcome movement.23 the peak loads are reached in a
Continual inflows of information Hip-Trunk Contributions to ACL shorter time in females (W.B. Kib-
from the motor control areas and cen- Injury ler, MD, unpublished data, 1999).
tral and peripheral sensory areas pro- Gender differences have been Further studies are needed to
vide the means by which the cerebel- found in motion patterns, positions, clarify the exact role these alter-
lum can accomplish this task (Fig. 2). and forces generated from the hip ations play in ACL injury. How-
Control over the dynamic re- and trunk to the knee. These differ- ever, strengthening programs that
straints, independent of the motor ences are important because hip emphasize hip controlÑgluteal
control level, can be considered to position and motion influence knee and hamstring activation in a
occur both in preparation and in position, loads, and stiffness, 24-26 closed-chain fashionÑhave been
response to external events. Pre- and the moment that is developed shown to be beneficial in injury
paratory actions occur on the iden- at the knee has been characterized prevention programs.28
tification of the beginning of an as being ÒslavedÓ to the moment
impending event or stimulus as produced at the hip.27 The largest Influence of Other Kinetic,
well as its effects, whereas reactions single contributor to production of Gravitational, and Muscle
occur in direct response to sensory motion, stabilization of position, Forces
and development of moments of Frequently, patients who sustain
any joint or body segment is coordi- noncontact ACL injuries will state
nated muscle activation.25 Females that the injury occurred when they
Cerebral cortex
have been shown to have both less were decelerating (e.g., when chang-
hamstring and less gluteus medius ing directions or landing from a
activation than males (W. B. Kibler, jump). These types of actions in-
MD, unpublished data, 1999; L. J. volve eccentric force generation by
Huston, MS, unpublished data, the quadriceps (i.e., the muscle is
Brainstem
Cerebellum 1999). lengthening under tension) and
Vision Perhaps because females have slight knee flexion angles. Interest-
Vestibular
weak hip extensors, which requires ingly, the quadriceps exerts its maxi-
their use of the iliopsoas muscles mum anterior shear force when knee
Spinal cord for trunk control over the hips, flexion angles are small (10 to 30
they land from a jump in a more degrees)(T. J. Noonan, MD, unpub-
upright hip position, resulting in lished data, 1999). The activated
an altered knee angle on landing.24 quadriceps with the knee nearly in
Decreased hip-muscle activation full extension places a measurable
Figure 2 The role of proprioception in also decreases maximal possible strain on the ACL. Eccentric activa-
mediating neuromuscular control of joint quadriceps and hamstring activa- tion of the quadriceps at high veloci-
stability. (Adapted with permission from
Lephart SM, Fu FH [eds]: Joint Stability. tion. Moreover, because the stabi- ties provides even more force to
Champaign, Ill: Human Kinetics, 2000.) lizing function of the monoarticular strain the ACL, much more than is
muscles (the glutei) facilitates the normally seen in a maximal isomet-

Vol 8, No 3, May/June 2000 145

Noncontact Anterior Cruciate Ligament Injuries

ric quadriceps contraction. In fact, Evaluation of ACL Injury training of the rectus abdominis,
integrated electromyographic stud- Videotapes iliopsoas, and gastrocnemius-soleus
ies demonstrate eccentric quadriceps To gain greater insight into the muscles) and a program to encour-
muscle activation to be more than biomechanics of noncontact ACL age better lower-extremity rotational
twofold greater than maximum vol- injuries, videotapes have been ana- and angular control (including
untary contraction during such ac- lyzed. In one study in which 54 strength and endurance training of
tivities as running, cutting, and videotapes of ACL injuries occur- hip abductor and external rotator
landing from a jump (R. A. Malin- ring in basketball and soccer play- muscles).
zak, MD, unpublished data, 1999). ers were analyzed, 100% of the
Valgus knee moments may further male basketball players were in-
stress the ACL, whereas hamstring jured landing from a jump, whereas Neuromuscular Prevention
activation provides a posterior pro- roughly half the women were in- Programs
tective force to the ligament. 29,30 jured landing from a jump, and half
Biomechanical ÒperturbationÓ (i.e., a were injured when they stopped Several prevention programs based
hit or jolt that makes the athlete suddenly while running down the on altering biomechanical risk fac-
unbalanced) or a sudden change in a court (C. C. Teitz, MD, unpublished tors through neuromuscular train-
planned activity further influences data, 1999). The center of gravity ing have been triedÑall with im-
these voluntary movement patterns. appeared to be behind the knee in pressive success. After a 10-year
Examination of videotapes of two thirds of the injuries. Ground study of ACL injuries in female bas-
noncontact ACL injuries frequently contact in the Òflat footÓ position ketball players, Henning formulated
reveals that just prior to an injury was noted in two thirds of the in- a prevention program based on
athletes are slightly bumped or jured female basketball players and altering what he called the Òquad-
perform an awkward movement, in all injured male players. In soc- cruciate interactionÓ(N. D. Griffis,
from which they quickly recover by cer players, the flat-foot position unpublished data, 1999). He be-
initiating a new movement pattern. was noted in two thirds of the ath- lieved that when the knee is straight
For example, a basketball player letes at the time of injury. Fre- during weight bearing, the ACL
begins her move to the basket, but quently, the lower-limb position acts as a major restraint of forward
suddenly another player causes her noted at the time of injury was less movement of the tibia on the femur,
to quickly change her direction of than 30 degrees of knee flexion, providing an average of 86% of the
movement and alter her already knee valgus, and external rotation total resistive force. With quadri-
initiated movement pattern. With of the foot relative to the knee. ceps contraction, the tibia moves
insufficient time to obtain informa- Making ground contact at the forward, thus tightening and load-
tion, the central nervous system toes rather than in a flat-foot posi- ing the ACL. When the knee is near
tries to recover, and frequently the tion makes it virtually impossible full extension, anterior displace-
activity becomes more quadriceps- for the center of gravity to be be- ment of the tibia on the femur pro-
dominant as the player tries to re- hind the knee. Theoretically, when duced by a powerful quadriceps
gain balance. Unfortunately, this the center of gravity falls behind the contraction could strain the ACL. If
occurs at a time when the ACL is knee, the rectus femoris, acting as a the quadriceps contracts when the
most susceptible to the shear forces hip flexor, may be used to bring the knee is flexed 60 degrees or more,
of the quadriceps. trunk forward. This attempt may the anterior displacement of the
Women have been shown to per- result in a powerful contraction of tibia on the femur and, therefore,
form cutting and landing maneu- the rectus femoris, with a large the ACL strain are less.
vers in a more erect posture than anterior force being delivered to the Henning concluded that the
men, that is, with less hip and knee tibia at the tubercle. most common mechanisms of in-
flexion. Theoretically, therefore, Therefore, from video analysis, it jury were planting and cutting
they should be at a greater risk for can be hypothesized that a neuro- (29%), straight-knee landing (28%),
ACL injury than men when per- muscular training program to aid in and one-step stop with the knee
forming these activities (R. A. Mal- the prevention of noncontact ACL hyperextended (26%). Therefore,
inzak, MD, unpublished data, 1999; injuries sustained in pivoting sports his program consisted of drills in
L. J. Huston, MS, unpublished data, should include the following ele- which he had athletes practice sub-
1999). Moreover, the increase in ments: a kinesthetic program to stituting an accelerated rounded
knee valgus and greater quadriceps keep the center of gravity forward turn off a bent knee for the pivot
activation in women may further and the athlete on his or her toes and cut, landing on a bent knee
increase their risk for injury.31 (including strength and endurance instead of landing on a straight

146 Journal of the American Academy of Orthopaedic Surgeons

 Letha Y. Griffin, MD, PhD, et al

knee, and a three-step stop with the and is intriguing as a pilot study, hypothesized that such deficits
knee bent instead of one-step stop confirmation by others appears rea- were the major factors contributing
with the knee hyperextendedÑall sonable before widespread use can to ACL injury. This program has
techniques designed to decrease the be suggested. three phases, each approximately 2
quadriceps-cruciate interaction. Hewett et al28 designed a three- weeks in duration: the technique
Preliminary data from institution of part prevention program consisting phase (phase I), during which prop-
his program in a limited population of stretching, plyometrics (jumping er jumping techniques are taught
of Division I basketball players over drills), and strength training drills (emphasizing correct posture and
a 2-year span demonstrated an 89% to address potential deficits in the alignment, straight up-and-down
decrease in ACL injury rate (N. D. neuromuscular strength and coor- jumps with no excessive side-to-
Griffis, unpublished data, 1999). dination of the stabilizing muscles side or forward-to-back movement,
HenningÕs teaching tape consisted about the knee joint (Table 1). They soft landings, and instant recoil);
of examples of noncontact ACL
injuries that occur in play situa-
tions, followed by illustrations of
the recommended drills done in the Table 1
gym as well as on the practice field. Sportsmetricsª Training Program*
He believed that young athletes are
the most receptive to technique Exercise/Activity Duration/Repetitions
modification and, therefore, en-
couraged teaching his Òimproved Phase I (Technique): Week 1: Week 2:
1. Wall jumps 20 sec 25 sec
player technique skillsÓ to children.
2. Tuck jumpsà 20 sec 25 sec
Caraffa et al 32 reasoned that 3. Broad jumps, stick land 5 reps 10 reps
since restoration of proprioceptive 4. Squat jumpsà 10 sec 15 sec
function is essential in ACL-injured 5. Double-leg cone jumps, 30 sec/30 sec 30 sec/30 sec
and reconstructed knees, a prophy- side-to-side/back-to-frontà
lactically instituted program might 6. 180 jumps 20 sec 25 sec
decrease the occurrence of ACL 7. Bounding in place 20 sec 25 sec
injuries in an at-risk population. Phase II (Fundamentals) Week 3: Week 4:
They developed a five-phase pro- 1. Wall jumps 30 sec 30 sec
prioceptive program based on 2. Tuck jumpsà 30 sec 30 sec
increasingly difficult skills per- 4. Jump, jump, jump, vertical jump 5 reps 8 reps
formed initially without a balance 5. Squat jumpsà 20 sec 20 sec
board and progressing through the 6. Bounding for distance 1 run 2 runs
use of a series of balance boards of 7. Double-leg cone jumps, 30 sec/30 sec 30 sec/30 sec
various designs. Athletes partici- side-to-side/back-to-frontà
pated in the program 20 minutes a 8. Scissor jump 30 sec 30 sec
9. Hop, hop, stickà 5 reps/leg 5 reps/leg
day beginning 30 days before the
beginning of the season. The inci- Phase III (Performance): Week 5: Week 6:
dence of ACL injuries in the 300 1. Wall jumps 30 sec 30 sec
semi-professional and amateur soc- 2. Step, jump up, down, vertical 5 reps 10 reps
cer players who participated in 3. Mattress jumps, 30 sec/30 sec 30 sec/30 sec
side-to-side/back-to-frontà
their program was 0.15 injury per
4. Single-leg jumps for distanceà 5 reps/leg 5 reps/leg
team per year over the 3 years sur- 5. Squat jumpsà 25 sec 25 sec
veyed, whereas the incidence of 6. Jump into boundingà 3 runs 4 runs
injury in 300 players of equally 7. Single-leg hop, hop, stick 5 reps/leg 5 reps/leg
matched talent playing with similar
equipment on similar fields was * Adapted with permission from Hewett TE, Stroupe AL, Nance TA, Noyes FR:
1.15 ACL injuries per team per year Plyometric training in female athletes: Decreased impact forces increased hamstring
(P<0.001). Criticisms of this study, torques. Am J Sports Med 1996;24:765-773.
however, are that subject selection Prior to jumping exercises: stretching, 15-20 minutes; skipping, 2 laps; side shuffle, 2
laps. Each jumping exercise is followed by a 30-second rest period. Posttraining:
was not randomized, and program
cool-down walk, 2 minutes; stretching, 5 minutes.
standardization is difficult to assess. à These jumps performed on mats.
Therefore, although it has merit

Vol 8, No 3, May/June 2000 147

Noncontact Anterior Cruciate Ligament Injuries

the fundamentals phase (phase II), ing the downhill ski. When all six
which concentrates on building elements of this profile are present at
strength, power, and agility; and the same time, injury to the down-
the performance phase (phase III), hill leg is imminent.
which focuses on achieving maxi- The initial prevention program
mum vertical jump height. undertaken by the Vermont group
This program was found to de- during the 1993-1994 ski season
crease peak landing forces, decrease was termed an Òinjury awareness
varus and valgus moments at the programÓ and consisted of having
knee, increase hamstring power and participants (4,700 ski patrollers
strength, and increase hamstring-to- and instructors in 20 ski areas) ana-
quadriceps peak torque ratio. In a lyze injury videos and develop
trial involving 1,263 volleyball, soc- strategies to avoid the events that
cer, and basketball athletes who result in injury.34 The incidence of Figure 3 The Òphantom footÓ mechanism
participated in the program 3 days a serious knee sprains was 62% lower of injury in skiing. Note the internal rotation
of the tibia with the knee flexed well beyond
week beginning 6 to 8 weeks before in the Òawareness-trainedÓ group 90 degrees. (Adapted with permission from
their season opened, untrained than in the control group of ski Vermont Safety Research: ACL Awareness
females had an incidence of knee instructors and patrollers. Since Training: Phase II. Copyright 1994.)
injury 3.6 times higher than trained then, the Vermont Ski Research
females; however, the rate of injury Safety Group has created a teaching
in trained females was the same as video available to the skiing public, risk factors and their associated
that in untrained males. which stresses the mechanism of prevention strategies, the partici-
In a 26-year case-control study in ACL injury in skiing and addresses pants formulated the following
northern Vermont, ACL sprains ac- avoidance strategies. For example, consensus statements:
counted for 2,006 of 15,550 (12.9%) if a skier senses that the elements of
of all ski injuries.33 The risk of ACL the phantom-foot mechanism are Environmental Risk Factors
injury in alpine skiing was found to about to occur, an appropriate ini- (1) At present there is no evi-
be 2.2 times greater for females than tial response is to keep the arms dence that knee braces prevent
for males, and ACL injuries in- forward, the feet together, and the ACL injuries.
creased from 4.5% of all injuries in hands over both skis. Data on the (2) Increasing the shoe-surface
1972 to 19.3% in 1999. It was deter- effectiveness of the program in this coefficient of friction may improve
mined from a review of ACL injury study population are currently performance but also may increase
tapes and data that the majority of being analyzed. the risk of injury to the ACL. Be-
ACL injuries in recreational skiing cause shoe-surface interaction is
resulted from the Òphantom footÓ modifiable, this area merits further
mechanism, which involves inter- Hunt Valley Consensus investigation.
nal rotation of the tibia with the Conference on Prevention
knee flexed well beyond 90 degrees of Noncontact ACL Injuries Anatomic Risk Factors
(Fig. 3). Currently available ski- (1) There is much literature on
boot-binding systems do not ÒsenseÓ Recognizing a need to critically the role of the femoral notch size
the type of loading that results in examine and summarize existing and ACL injury, but because of the
this ACL injury and, therefore, are data on prevention strategies and difficulty of obtaining valid and
incapable of preventing injury in their implied risk factors for non- reliable measurements, no consen-
this situation. contact ACL injuries, 22 orthopae- sus on the role of the notch in ACL
The events that result in the dists, family physicians, biomech- injury has been reached as yet.
phantom-foot mechanism include anists, and athletic trainers met in (2) At present, there are insuffi-
the following: (1) the skier is off Hunt Valley, Md, in June 1999. cient data on ACL size (absolute or
balance to the rear; (2) the uphill Their goals were to increase aware- proportional) to support the con-
arm is back; (3) the hips are below ness in the at-risk population and cept that ligament size is related to
the knees (knees flexed beyond 90 medical support personnel about the risk of injury.
degrees); (4) the uphill ski is un- prevention strategies and to stimu- (3) There are insufficient data to
weighted; (5) the weight is on the late increased efforts in injury pre- relate lower-extremity anatomic
inside edge of the downhill ski; vention research. After carefully alignment to ACL injury; therefore,
(6) the upper body is generally fac- reviewing available data on injury further research is needed.

148 Journal of the American Academy of Orthopaedic Surgeons

 Letha Y. Griffin, MD, PhD, et al

Hormonal Risk Factors (5) Strong quadriceps activation of the risk of ACL injury and the
(1) At present, there is no con- during eccentric contraction was possibilities for prevention.
sensus in the scientific community considered to be a major factor in
that sex-specific hormones play a injury to the ACL.
role in the increased incidence of Summary
ACL injury in female athletes, but Prevention Strategies
further research in this area is After reviewing the existing The morbidity from ACL injuries in
encouraged. neuromuscular training prevention the young athletic population is of
(2) Hormonal intervention for programs, participants agreed on great concern. Furthermore, the eco-
ACL injury prevention cannot be the following statements regarding nomic impact of these injuries adds
justified. prevention strategies: significantly to our rising medical
(3) There is no evidence to recom- (1) Early data show that specific costs. Therefore, efforts to prevent
mend modification of activity or training programs that enhance or at least decrease the rate of occur-
restriction from sport for females at body control reduce ACL injury rence of these injuries seem prudent.
any time during the menstrual cycle. rates in female athletes and may Until recently, attempts to develop
increase athletic performance. prevention programs centered on
Biomechanical Risk Factors (2) Training and conditioning first clearly defining risk factors and
(1) The knee is only one part of a programs for male and female ath- injury mechanisms. Although these
kinetic chain; therefore, it must be letes in the same sport may need to research efforts have yielded much
borne in mind that anatomic sites be different. information, they have not, with the
other than the knee, including the (3) Those involved in the care of exception of research efforts in
trunk, hip, and ankle, may have a athletes should identify sport-specific downhill skiing, resulted in a clear
role in ACL injury. at-risk motions and positions and understanding of the cause of non-
(2) Common biomechanical fac- encourage athletes to avoid these sit- contact ACL injuries.
tors involved in many injuries uations when possible. It does appear, however, that neu-
include impact on the foot rather (4) Strategies for activating pro- romuscular control and balance as
than the toes during landing or tective neuromuscular responses well as avoidance strategies for at-
changing directions, awkward dy- when at-risk situations are encoun- risk situations are critical factors for
namic body movements, and bio- tered should be identified. injury prevention. Prevention pro-
mechanical perturbation prior to grams designed to increase neuro-
the injury. Future Research Directions muscular control, improve balance,
(3) The common at-risk situation The consensus group empha- and teach avoidance strategies for at-
for noncontact ACL injuries appears sized the need to continue to define risk situations appear to be effective
to be deceleration, which occurs specific neuromuscular, proprio- in decreasing injury rates. Therefore,
when the athlete cuts, changes ceptive, and motor control factors until research more clearly defines
direction, or lands from a jump. associated with injury. However, risk factors and injury mechanisms, it
(4) Neuromuscular factors are until specific predictive and protec- seems reasonable to increase aware-
important contributors to the in- tive factors are definitively identi- ness and encourage implementation
creased risk of ACL injuries in fied, training and prevention pro- of existing neuromuscular preven-
females and appear to be the most grams should continue to be imple- tion programs, while continuing to
important reason for the differing mented, assessed, and improved. closely monitor their results and im-
ACL injury rates between males There is a pressing need to improve prove their design as additional data
and females. public and participant awareness become available.

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150 Journal of the American Academy of Orthopaedic Surgeons