World Pediatric Bone and Joint Day 2015 – Focus on ACL Tear Prevention
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This year’s focus for World Pediatric Bone and Joint Day on October 19 was anterior cruciate ligament (ACL) injuries in the knee. The American Academy of Pediatrics has acknowledged that in the past 20 years there has been a sharp increase in ACL tears due to a variety of reasons, including increased sport participation, increased detection with medical technology and education advances, and increased focus on intense training to develop athletic skills at a young age. While these factors have little effect on young children, this changes dramatically as children begin puberty and clinicians begin to see a sharp increase in ACL tears in the pubescent athlete.1
As clinicians, we know prevention of all injuries is not possible. A tear of the ACL is one injury that continues to occur despite our best efforts. One of the main reasons ACL injuries continue lies in the fact that these injuries are multifactorial. Researchers have identified intrinsic factors (anatomical, hormonal, biomechanical and neuromuscular) and extrinsic factors (level/type of athletic participation, playing surface, environmental factors and equipment).2,3 Understanding that there are so many contributing factors, where do we begin to address the issue?
Immediately, we can recognize there are certain factors we have no control over, such as: female sex, bony geometry of the knee joint (femoral notch and tibial plateau characteristics) and congenital knee joint laxity.3 The main factors athletes have the ability to modify include neuromuscular control at the hip and knee and postural stability.1 Extensive research has looked at jumping and landing mechanics and pathomechanics in athletes who have sustained ACL tears. Many researchers have developed prevention programs based on neuromuscular and biomechanical training, as these are modifiable risk factors that as clinicians we can focus on to decrease ACL tear or re-tear risk. Attention has been paid to the effect puberty has on these factors and the importance of retraining the hips and knees as the alignment changes in females. None of this is news to clinicians cued in to the pulse of ACL injuries.
So if we’re looking for something more novel, what about continuing up the kinetic chain? The Washington Post has put out a series of articles looking at students in schools at the elementary and middle school level. While these articles are focused on the cognitive realm, including concentrating in class and ADD/ADHD among students, their findings indicate a physical cause: core weakness or poor postural control. Postural assessments of these students demonstrate increased forward head, protracted scapulae and increased lumbar lordosis. Many of these students cannot truly engage their deep core musculature with abdominal exercises. Muscle imbalances begin at a very young age as a result. If athletes are heading into puberty and the prime years of athletic participation without core strength or postural control, are we setting up athletes for ACL tears that could be prevented?
1 LaBella CR, Hennrikus W, Hewett TE. ACL Injuries: Diagnosis, Treatment, and Prevention. Pediatrics. May 2015. 133(5): 1437-50.
2 Hewett TE, Myer GD, Ford KR. Anterior Cruciate Ligament Injuries in Female Athletes Part 1, Mechanisms and Risk Factors. Am J Sports Med February 2006 vol. 34 no. 2 299-311.
3 Smith HC, Vacek P, Johnson RJ et al. Risk Factors for Anterior Cruciate Ligament Injury A Review of the Literature — Part 1: Neuromuscular and Anatomic Risk. Sports Health. 2012 Jan; 4(1): 69–78.