ACL Injuries in Football (soccer)
What is the ACL and why does it matter?
The Anterior Cruciate Ligament (ACL) is an important ligament in the knee helping to stabilise the knee, particularly the tibia, from translating anteriorly. It also helps prevent the excessive rotation of the tibia, prevents valgus and varus movements in extension, and provides important mechanoreception and proprioception, all of which helps your locomotor system navigate through three demential space.
What are the risks of ACL injuries in soccer?
Unfortunately, ACL injuries are quite serious and relatively common in soccer. Injury to the ACL can end a sporting career, and it can have other downstream health consequences such as weight gain and early knee osteoarthritis. Surgeries and ACL repairs are often overhyped in the media, especially since they have not improved on long term outcomes. Once injured, a knee is always predisposed to high levels of degeneration, either with or without surgery. 36% of post ACLs injuries will end up with osteoarthritis 10 years after injury.
The recent metric used in a BJSM systematic review and meta analysis suggests that the incidents are more common in high level recreational players compared to professional players or social players. This means that serious, club-level players are at a greater risk.
Women are at a greater risk of ACL injuries due to several anatomical and physiological differences, as well as potentially some training and competition differences. The risk is traditionally 3:1 in female to males, though more men sustain an ACL injury due to larger numbers of men in the sport. As more women enter the sport globally, there seems to be some evidence of changes in the numbers of injuries. The take home message is that ACL injuries are both serious and common in male and female football players, and the number of injuries has the potential to increase as growth in the sport continues.
Can ACL injuries be treated or prevented?
Despite what media hype we hear about surgeries, the long term outcomes for an injured ACL are consequential. If the media put more emphasis on education and injury prevention programs, there might be a noticeable difference. Injury prevention programs can potentially reduce in the number of people suffering from the consequences of the injury. But this requires foresight. Education and broad implementation are key factors in reducing the number of injuries. It is estimated that 108 players need to implement an injury prevention program to prevent 1 ACL injury; therefore, broad scale efforts must be made toward implementing programs to demonstrate an effect.
As of 2022, most information found online in Australia is inaccurate, according to a recent study by Gamble et al. This study found a proportion of outdated or misleading information on websites, where athletes may be misinformed to expect that a return to sport is normal following surgery, or that a surgery somehow prevents degeneration.
What are preventative measures?
Some scientific guidelines now exist regarding ACL injury prevention programs. Petushek et al recommend:
Targeting younger, female demographics
Incorporating lower body strength exercises (ie, Nordic hamstrings, lunges, and heel-calf raises) with a specific focus on landing stabilization (jump/hop and hold) throughout the season.
Some high quality, football specific examples already exist. The FIFA 11+ is an evidence based program with a variety of resources online. Their youtube channel has the exercises available free of charge.
There is also the PEP program, amongst other programs which can be found online.
Gamble AR, McKay MJ, Pappas E, Dale M, O'Keeffe M, Ferreira G, Richardson K, Zadro JR. Online information about the management of anterior cruciate ligament ruptures in Australia: A content analysis. Musculoskelet Sci Pract. 2022 Mar 12;59:102555. doi: 10.1016/j.msksp.2022.102555. Epub ahead of print. PMID: 35305513.
Petushek EJ, Sugimoto D, Stoolmiller M, Smith G, Myer GD. Evidence-Based Best-Practice Guidelines for Preventing Anterior Cruciate Ligament Injuries in Young Female Athletes: A Systematic Review and Meta-analysis. Am J Sports Med. 2019 Jun;47(7):1744-1753. doi: 10.1177/0363546518782460. Epub 2018 Jul 12. PMID: 30001501; PMCID: PMC6592422.
Webster KE, Hewett TE. Anterior Cruciate Ligament Injury and Knee Osteoarthritis: An Umbrella Systematic Review and Meta-analysis. Clin J Sport Med. 2022 Mar 1;32(2):145-152. doi: 10.1097/JSM.0000000000000894. PMID: 33852440.