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ACL Injuries in High School Sports: No Gender Difference Found

Football had most injuries, highest ACL injury rate; girls more likely to be injured than boys in sex-comparable sports

Player-to-player contact

One area identified by the study as an example of a potentially modifiable risk factor is player-player contact, which accounted for 42.8% of ACL injuries among the high school athletes, a rate significantly higher than the 23.9% to 30% found in previous studies.

While the reason for the increased percentage of player-player contact injuries was unclear, the study authors suggested that it could have been due to the fact that the earlier studies focused on collegiate athletes, sex-comparable sports only, or single sports; that collegiate athletes generally have more body control and are more skilled at their sports; that the pace and style of high school level of play may leave athletes at higher risk of contact of a contact injury; that, compared to prior studies, the data in the current study was skewed by the high frequency of football ACL injuries, where 6 out of 10 injuries were caused by contact almost 20% higher than the average across the 9 sports), or that athletes predisposed to ACL injury may be self-selected or medically selected out of sports before college.

Although saying that further research was needed to fully understand contact-related ACL injuries, the study suggests that player-player contact as a risk factor might be reduced via rule changes, enforcement of existing rules, increased emphasis on sportsmanship, and teaching proper sport-specific skills without affecting the underlying purpose or culture of individual sports. 

Substantial societal burden  

Anterior cruciate ligament (ACL) injuries are among the most devastating injuries a young athlete can sustain, given the frequent need for surgery and extensive long-term rehabilitation[2,3] as well as the potential for long-term health problems, putting a patient at risk for early osteoarthritis and chronic pain 10 to 20 years after the injury.[4,5]  

More than 7 million students participate in high school sports today. Although the benefits of sports for both boys and girls are well documented, injuries can exact economic, emotional, physical and social tolls. The knee joint is the second most commonly injured joint after the ankle [6] and the leading cause of sport-related surgeries, accounting for 60% of high school sport-related surguries.[7]  ACL injuries account for 50 percent or more of all knee injuries[2] and an estimated $1 billion is spent annually on ACL reconstruction in this country.[8]

While one recent study [9] found no clear evidence that ACL reconstruction improves the long-term symptomatic outcome, "raising the question of how many ACL injuries could be successfully treated by more conservative rehabilitation programs rather than surgery," writes Comstock, the issue is being hotly debated. A new study by researchers at KNG Health Consulting in Rockville, Maryland [10]  reported that, while in the short- and intermediate term, ACL reconstruction was only slightly less costly and more effective compared with rehabilitation, over the long term ACL reconstruction not only resulted in incremental cost savings of $50,417, but quality of life gains and reduced societal costs once indirect cost factors, such as work status and earnings are considered.

The bottom line, concludes the study, is that a "certain endemic level of ACL injury will always be associated with sports, yet an increased committment should be made to reduce the incidence and severity of ACL injuries sustained by high school athletes."  Until evidence-based, targeted ACL injury prevention efforts are developed, the incidence of ACL injuries should be expected to continue to rise with the increasing number of youths participating in sports." 

1.  Joseph AM, Collins CL, Henke NM, Yard EE, Fields SK, Comstock RD. A Multisport Epidemiologic Comparison of Anterior Cruciate Ligament Injuries in HIgh School Athletics.  J Athl Tr. 2013;48. DOI:10.485/1062-6050-48.6.03 (epub November 11, 2013).

2. Risberg MA, Lewek M, Snyder-Mackler L. A systematic review of evidence for anterior cruciate ligament rehabilitation: how much and what type? Phys Ther Sport. 2004;5(3):125-145.  

3. Cimino F, Volk BS, Setter D. Anterior cruciate ligament injury: diagnosis, management, and prevention.  Am Fam Physician. 2010;82(8);917-922. 

4. Lohmander LS, Englund PM, Dahl LL, Roos EM. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis.  Am J Sports Med. 2007;35(10):1756-1769.

5. Fleming BC, Hulstyn MJ, Oksendahl HL, Fadale PD. Ligament injury, reconstruction and osteoarthritis. Curr Opin Orthop. 2005;16(5):354-362.

6. Swenson D, Collins C, Fields S, Comstock R. Epidemiology of US High School Sports-Related Ligamentous Ankle Injuries, 2005/06-2010-11. Clin J Sport Med 2013;23(3):190-196.  

7. Ingram JG, Fields SK, Yard EE, Comstock RD. Epidemiology of knee injuries among boys and girls in US high school athletics.  Am J Sports Med. 2008;36(6):1116-1122. 

8. Streich NA, Zimmerman D, Bode G, Schmitt H. Reconstructive versus non-reconstructive treatment of anterior cruciate ligament insufficiency: a retrospective matched-pair long-term follow-up.  Int Orthop. 2011;35(4):607-613. 

9. Centers for Disease Control and Prevention A. GA. Preventing Injuries in Sports, Recreation, and Exercise. Atlanta, GA 2006. 

10. Mather RC, et al. Societal and Economic Impact of Anterior Cruciate Ligament Tears.  J Bone Joint Surg Am. 2013;95:1751-9.  

Posted November 14, 2013