Anterior cruciate ligament injuries in netball: the elephant in the room - Part 3
Back to Part 2 of Anterior cruciate ligament injuries in netball: the elephant in the room
Risk factors for sustaining an ACL injury can be broadly categorised into extrinsic; outdoor weather, playing surface, footwear, level of competition and intrinsic, sex, anatomical (intercondylar notch width), biomechanical (landing patterns), neuromuscular (quadriceps-to-hamstring ratio), physiological and hormonal18. Both retrospective and prospective studies have identified several modifiable risk factors for ACL injuries in female athletes including, reduced hip strength, increased knee abduction moment during vertical drop jump and increased quadriceps-to-hamstring ratios19. One study observed a hamstring-to-quadriceps ratio less than 60% was attributed to an increased risk of ACL injury in female athletes20. Hamstring activation – especially during jump landing – is essential for reducing load on passive restraints of the knee and stabilising the knee from external valgus or varus load21. This lack of neuromuscular control, along with joint laxity from hormonal control, can destabilise the knee and be predictive for risk of ACL injuries.
Figure 1. Reported risk factors for ACL injury and Patello Femoral Pain (PFP)19.
Research around modifiable risk factors of ACL injuries have led to the development of various ACL injury prevention programs, including the Cincinnati Sportsmetrics programme22, Henning programme23, Prevent Injury Enhance Performance (PEP)24, the FIFA Medical and Research Centre (F-MARC), Federation International de Football Association (FIFA) 11 and FIFA 11+25. These multicomponent programmes focus on muscle strengthening and recruitment patterns, landing biomechanics, deceleration, proprioception and plyometrics by incorporating agility, balance, mobility, plyometrics, running and strength activities26. Incorporation of FIFA 11+ ACL injury prevention programme in football has led to an overall risk reduction of 34% (RR= 0.66) for all injuries and 29% (RR=0.71) for lower limb injuries27. Furthermore, implementation of universal neuromuscular preventative training programme can reduce the incidence of ACL injuries among young athletes, from 3% to 1.1% per season with an average saving of £72 per-player per-season28.
With the number of ACL injuries in children and adolescents increasing, Sporting Knee Injury Prevention Programme (SKIPP) charity recently launched an ACL injury prevention initiative called ‘Power Up To Play’ in the United Kingdom. This initiative utilises the PEP ACL injury prevention program and is geared towards reducing knee injuries in children and adolescents playing various sports. The readily accessible and standardised PEP program focuses on five domains, including warm-up, strengthening, plyometrics, agility and stretches and can easily be adopted to any sports from grassroots to professional levels. The organisation has set up regional ‘hubs’ – more recently in south Wales – to deliver workshops for coaching staff and physiotherapists from local clubs representing various sports including football, basketball and netball29.
Although netball specific lower limb injury prevention programmes are scarce, they have been demonstrated to be of benefit in the literature. Netball coaches implementing the Down-to-Earth (D2E) lower limb injury prevention program for safe landing in netball observed several benefits including improved landing technique (88%), strength, balance, co-ordination, and flexibility (83%) and injury risk reduction (79%)30. Australian netball have devised the KNEE programme, an on court warm-up programme to enhance movement efficiency and prevent injury. The KNEE programme focuses on four key principles of netball emphasising on good techniques for safe take-off and landing and conditions athletes for efficient deceleration and change of direction manoeuvres. The programme – which includes warm-up, strength, balance/landing, and agility sections – is recommended to be performed twice a week and can be adapted for junior, recreational and elite netball players31.
Through collaborative work with Welsh Netball, we are currently working towards raising awareness of ACL injuries in netball and implementation of an ACL injury prevention program that would be beneficial from grassroots to elite level in Wales.
Change can often be daunting, unless coming directly from a vending machine. With an increasing number of ACL injuries observed in children, adolescents and athletes, and given the short and long-term consequences of such injuries, it is essential we focus on modifiable risk factors among ‘at risk’ groups, including female athletes participating in high-risk sports such as netball and football. Whether you adopt the KNEE program for netball, FIFA 11+ for football or the more generic PEP programme, it is important to raise awareness and adopt these evidence-based programmes that have been highlighted to reduce ACL injuries from grassroots to elite level. As Orthopaedic surgeons, it is essential to lead a collaborative approach to tackle this rising problem, and engage with allied healthcare professionals and local sporting communities to help deliver such programmes.
Tim Spalding and Professor Haddad have kindly granted permission for the use of their table (in Part 2) in this article.
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