Advertisement

Archives of Orthopaedic and Trauma Surgery

, Volume 138, Issue 1, pp 51–61 | Cite as

Evidence-based concepts for prevention of knee and ACL injuries. 2017 guidelines of the ligament committee of the German Knee Society (DKG)

  • Julian Mehl
  • Theresa Diermeier
  • Elmar Herbst
  • Andreas B. Imhoff
  • Thomas Stoffels
  • Thore Zantop
  • Wolf Petersen
  • Andrea AchtnichEmail author
Arthroscopy and Sports Medicine

Abstract

Introduction

Knee injuries and especially anterior cruciate ligament (ACL) tears are frequent in athletes. Therefore, primary and secondary prevention of sports-related lower limb injuries is an ongoing topic of interest. The aim of present study was to establish guidelines for the prevention of knee and ACL injuries on the basis of evidence-based concepts represented in current literature.

Methods

A comprehensive literature review regarding prevention programs for knee and ACL injuries was conducted.

Results

Several modifiable and non-modifiable risk factors for knee injuries in athletes have been reported in literature. Referring to the ACL, specific injury mechanisms have been identified and are well understood. In particular, it has been demonstrated that dynamic valgus is one of the most important modifiable risk factors. Simple tests like the drop jump test have shown their efficacy in screening and detecting athletes at risk. There is only few evidence for the preventive effect on knee and ACL injuries by single exercises. However, in order to prevent or correct endangering movement patterns including dynamic valgus, several complex prevention programs have been developed in the past. These prevention programs are included in standard warm-up exercises and are focusing on muscle strength, balance, and proprioception, as well as running and flexibility. It is reported that these training programs can reduce the incidence of knee injuries by up to 27% and ACL injuries by up to 51%.

Conclusions

Screening, identification, and correction of endangering movement patterns like the dynamic valgus are the first crucial steps in order to prevent knee and ACL injuries in athletes. Furthermore, jumping, running and flexibility exercises as well as balance and strength training are proven to reduce the incidence of these injuries and should, therefore, be integrated into the regular warm up program. Appropriate complete prevention programs are freely accessible via the Internet and should be adapted to the specific sport disciplines.

Keywords

Injury risk Knee ACL Prevention Screening Valgus Core stability Proprioception 

Notes

Acknowledgements

The ligament committee of the German Knee Society (DKG) developed this study to provide guidelines regarding the topic prevention of knee and ACL injuries. Members are listed below. Petersen W, Zantop T, Imhoff A, Müller P, Patt T, Scheffler S, Höher J, Stöhr A, Ellermann A, Stoffels T, Jung T, Herbort M, Akoto R, Achtnich A, Diermeier T, Mehl J, Herbst E, Stein T.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

There is no funding source.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

References

  1. 1.
    Ageberg E, Bennell KL, Hunt MA, Simic M, Roos EM, Creaby MW (2010) Validity and inter-rater reliability of mediolateral knee motion observed during a single-limb mini squat. BMC Musculoskelet Disord 11:265PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Ajuied A, Wong F, Smith C, Norris M, Earnshaw P, Back D, Davies A (2014) Anterior cruciate ligament injury and radiologic progression of knee osteoarthritis: a systematic review and meta-analysis. Am J Sports Med 42(9):2242–2252PubMedCrossRefGoogle Scholar
  3. 3.
    Alentorn-Geli E, Myer GD, Silvers HJ, Samitier G, Romero D, Lázaro-Haro C, Cugat R (2009) Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: mechanisms of injury and underlying risk factors. Knee Surg Sports Traumatol Arthrosc 17(7):705–729. doi: 10.1007/s00167-009-0813-1 PubMedCrossRefGoogle Scholar
  4. 4.
    Alentorn-Geli E, Myer GD, Silvers HJ, Samitier G, Romero D, Lázaro-Haro C, Cugat R (2009) Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 2: a review of prevention programs aimed to modify risk factors and to reduce injury rates. Knee Surg Sports Traumatol Arthrosc 17(8):859–879. doi: 10.1007/s00167-009-0823 PubMedCrossRefGoogle Scholar
  5. 5.
    Aune AK, Ekeland A, Nordsletten L (1995) Effect of quadrizceps or hamstring contraction on the anterior shear force to anterior cruciate ligament failure: an in vivo study in the rat. Acta Orthop Scand 66:261–265PubMedCrossRefGoogle Scholar
  6. 6.
    Ardern CL, Webster KE, Taylor NF, Feller JA (2011) Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med 45(7):596–606PubMedCrossRefGoogle Scholar
  7. 7.
    Bahr R, Lian O, Bahr O (1997) A twofold reduction of acute ankle sprains in volleyball after the introduction of an injury prevention program: a prospective cohort study. Scand J Med Sci Sports 7:172–177PubMedCrossRefGoogle Scholar
  8. 8.
    Barrata R, Solomonow M, Letson D, Chuinard R, D’Ambrosia R (1988) Muscular coactivation: the role of the antagonist musculature in maintaining knee stability. Am J Sports Med 16:113–122CrossRefGoogle Scholar
  9. 9.
    Boden BP, Dean GS, Feagin JA, Garrett WE (2000) Mechanisms of anterior cruciate ligament injury. Orthopaedics 23:573–578Google Scholar
  10. 10.
    Boyle MJ, Butler RJ, Queen RM (2016) Functional movement competency and dynamic balance after anterior cruciate ligament reconstruction in adolescent patients. J Pediatr Orthop 36(1):36–41PubMedGoogle Scholar
  11. 11.
    Caraffa A, Cerulli G, Projetti M, Aisa G, Rizzo A (1996) Prevention of anterior cruciate ligament injuries in soccer: a prospective controlled study of proprioceptive training. Knee Surg Sports Traumatol Arthrosc 4:19–21PubMedCrossRefGoogle Scholar
  12. 12.
    Colby S, Franciscos A, Yu B, Krikendahl D, Finch M, Garret W (2000) Electrimyographic and kinematic analysis of cutting maneuvers. Am J Sports Med 29:234240Google Scholar
  13. 13.
    Cook G, Burton L, Fields K, Kiesel K (1998) Movement assessment: the functional movement screen. Athletic Testing Services, Inc., Danville, VAGoogle Scholar
  14. 14.
    Cowling EJ, Steele JR (2001) The effect of upper-limb motion on lower-limb muscle synchronicity. J Bone Joint Surg 83:35–41PubMedCrossRefGoogle Scholar
  15. 15.
    Cowling EJ, Steele JR, McNair PJ (2003) Effect of verbal instructions on muscle activity and risk of injury to the anterior cruciate ligament during landing. Br J Sports Med 37(2):126–130PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Crossley KM, Zhang WJ, Schache AG, Bryant A, Cowan SM (2011) Performance on the single-leg squat task indicates hip abductor muscle function. Am J Sports Med 39:866–873PubMedCrossRefGoogle Scholar
  17. 17.
    Donnell-Fink LA, Klara K, Collins JE, Yang HY, Goczalk MG, Katz JN, Losina E (2015) Effectiveness of knee injury and anterior cruciate ligament tear prevention programs: a meta-analysis. PLoS One 10(12):e0144063PubMedPubMedCentralCrossRefGoogle Scholar
  18. 18.
    Dorrel BS, Long T, Shaffer S, Myer GD (2015) Evaluation of the functional movement screen as an injury prediction tool among active adult populations: a systematic review and meta-analysis. Sports Health 7(6):532–537PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Dunn WR, Spindler KP (2010) Predictors of activity level 2 years after anterior cruciate ligament reconstruction (ACLR): a Multicenter Orthopaedic Outcomes Network (MOON) ACLR cohort study. Am J Sports Med 38(10):2040–2050PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Ettlinger CF, Johnson RJ, Shealy JE (1995) A method to help reduce the risk of serious knee sprains incurred in alpine skiing. Am J Sports Med 23(5):531–537PubMedCrossRefGoogle Scholar
  21. 21.
    Gilchrist J, Mandelbaum BR, Melancon H, Ryan GW, Silvers HJ, Griffin LY, Watanabe DS, Dick RW, Dvorak J (2008) A randomized controlled trial to prevent noncontact anterior cruciate ligament injury in female collegiate soccer players. Am J Sports Med 36(8):1476–1483PubMedCrossRefGoogle Scholar
  22. 22.
    Griffin LY (2000) The henning program. In: Griffin LY (ed) Prevention of noncontact ACL injuries. American Academy of Orthopaedic Surgeons, RosemontGoogle Scholar
  23. 23.
    Griffis ND, Vequist SW, Yearout KM, Henning CE, Lynch MA (1989) AOSSM annual meeting. AOSSM, Traverse CityGoogle Scholar
  24. 24.
    Grimm NL, Jacobs JC Jr, Kim J, Denney BS, Shea KG (2014) Anterior cruciate ligament and knee injury prevention programs for soccer players: a systematic review and meta-analysis. Am J Sports Med. doi: 10.1177/0363546514556737 PubMedGoogle Scholar
  25. 25.
    Hart L (2005) Effect of stretching on sport injury risk: a review. Clin J Sport Med 15(2):113PubMedCrossRefGoogle Scholar
  26. 26.
    Hagood S, Solomonow M, Luo Z, D’Ambrosia R (1990) The effect of joint velocity on the contribution of the antagonist musculature to knee stiffness and laxity. Am J Sports Med 18:182–187PubMedCrossRefGoogle Scholar
  27. 27.
    Hewett TE, Stroupe AL, Nance TA, Noyes FR (1996) Plyometric training in female athletes: decreased impact forces and hamstring torques. Am J Sports Med 24:765–773PubMedCrossRefGoogle Scholar
  28. 28.
    Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR (1999) The effect of neuromusculsr training on the incidence of knee injury in female athletes: a prospective study. Am J Sports Med 27:699–706PubMedCrossRefGoogle Scholar
  29. 29.
    Hewett T, Ford K, Hoogenboom B, Myer G (2010) Understanding and preventing ACL injuries: current biomechanical and epidemiologic considerations—update 2010. N Am J Sports Phys Ther 5(4):234–243PubMedPubMedCentralGoogle Scholar
  30. 30.
    Hewett TE, Myer GD, Ford KR, Heidt RS Jr, Colosimo AJ, McLean SG, van den Bogert AJ, Paterno MV, Succop P (2005) Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med 33(4):492–501PubMedCrossRefGoogle Scholar
  31. 31.
    Hewett TE, Ford KR, Myer GD (2006) Anterior cruciate ligament injuries in female athletes: part 2, a metaanalysis of neuromuscular interventions aimed at injury prevention. Am J Sports Med 34(3):490–498PubMedCrossRefGoogle Scholar
  32. 32.
    Huston LJ, Woitys EM (1996) Neuromuscular performance characteristics in elite female athletes. Am J Sports Med 24:427–436PubMedCrossRefGoogle Scholar
  33. 33.
    Hirokawa S, Solomonow M, Baratta R, Zhou BH, D’Ambrosia R (1991) Muscular cocontraction and control of knee stability. J Electromyogr Kiesiol 1:199–208CrossRefGoogle Scholar
  34. 34.
    Johnson RJ, Beynnon BD, Nichols CE, Renstrom PA (1992) The treatment of injuries of the anterior cruciate ligament. J Bone Joint Surg Am 74:140–151PubMedCrossRefGoogle Scholar
  35. 35.
    Kiani A, Hellquist E, Ahlqvist K, Gedeborg R, Michaelsson K, Byberg L (2010) Prevention of soccer-related knee injuries in teenaged girls. Arch Intern Med 170(1):43–49PubMedCrossRefGoogle Scholar
  36. 36.
    Khayambashi K, Ghoddosi N, Straub RK, Powers CM (2016) Hip muscle strength predicts noncontact anterior cruciate ligament injury in male and female athletes: a prospective study. Am J Sports Med 44(2):355–361PubMedCrossRefGoogle Scholar
  37. 37.
    Lephart S, Riemann B (2000) The role of mechanoreceptors in functional joint stability. In: Griffin LY (ed) Prevention of noncontact ACL injuries. American Academy of Orthopaedic Surgeons, RosemontGoogle Scholar
  38. 38.
    Lephart S, Ferris CM, Riemann B, Myers JB, Fu F (2002) Gender differences in strength and lower extrmity kinematics during landing. Clin Orthop Rel Res 401:162–169CrossRefGoogle Scholar
  39. 39.
    Leys T, Salmon L, Waller A, Linklater J, Pinczewski L (2012) Clinical results and risk factors for reinjury 15 years after anterior cruciate ligament reconstruction: a prospective study of hamstring and patellar tendon grafts. Am J Sports Med 40(3):595–605PubMedCrossRefGoogle Scholar
  40. 40.
    Lohmander LS, Ostenberg A, Englund M, Roos H (2004) High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis Rheum 50(10):3145–3152PubMedCrossRefGoogle Scholar
  41. 41.
    Mandelbaum BR, Silvers HJ, Watanabe DS, Knarr JF, Thomas SD, Griffin LY et al (2005) Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med 33(7):1003–1010 (0363546504272261) PubMedCrossRefGoogle Scholar
  42. 42.
    Mayer SW, Queen RM, Taylor D, Moorman CT 3rd, Toth AP, Garrett WE Jr, Butler RJ (2015) Functional testing differences in anterior cruciate ligament reconstruction patients released versus not released to return to sport. Am J Sports Med 43(7):1648–1655PubMedCrossRefGoogle Scholar
  43. 43.
    Mizner RL, Chmielewski TL, Toepke JJ, Tofte KB (2012) Comparison of 2-dimensional measurement techniques for predicting knee angle and moment during a drop vertical jump. Clin J Sport Med 22(3):221–227PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Miyasaka KC, Daniel DM, Stone ML (1991) The incidence of knee ligament injuries in the general population. Am J Knee Surg 1:43–48Google Scholar
  45. 45.
    Myklebust G, Maehlum S, Holm I, Bahr R (1998) A prospective cohort study of anterior cruciate ligament injuries in elite Norwegian team handball. Scand J Med Sci Sports 8:149–153PubMedCrossRefGoogle Scholar
  46. 46.
    Myklebust G, Engebretsen L, Braekken IH, Skjolberg A, Olsen OE, Bahr R (2003) Prevention of anterior cruciate ligament injuries in female team handball players: a prospective intervention study over three seasons. Clin J Sport Med 13(2):71–78PubMedCrossRefGoogle Scholar
  47. 47.
    Noyes FR, Barber-Westin SD, Fleckenstein C, Walsh C, West J (2005) The drop-jump screening test: difference in lower limb control by gender and effect of neuromuscular training in female athletes. Am J Sports Med 33(2):197–207PubMedCrossRefGoogle Scholar
  48. 48.
    Ortiz A, Trudelle-Jackson E, McConnell K, Wylie S (2010) Effectiveness of a 6-week injury prevention program on kinematics and kinetic variables in adolescent female soccer players: a pilot study. P R Health Sci J 29(1):40–46PubMedGoogle Scholar
  49. 49.
    Olsen OE, Myklebust G, Engebretsen L, Holme I, Bahr R (2005) Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial. BMJ 330(7489):449 (bmj.38330.632801.8F) PubMedPubMedCentralCrossRefGoogle Scholar
  50. 50.
    Petersen W, Zantop T, Steensen M, Hypa A, Wessolowski T, Hassenpflug J (2002) Prävention von Verletzungen im Handballsport: erste Ergebnisse des Kieler Handball Präventionsprogrammes. Sportverletz Sportschaden 16:122–126PubMedCrossRefGoogle Scholar
  51. 51.
    Petersen W (2012) Does ACL reconstruction lead to degenerative joint disease or does it prevent osteoarthritis? How to read science. Arthroscopy 28(4):448–450PubMedCrossRefGoogle Scholar
  52. 52.
    W Petersen W, Zantop T, Rosenbaum D, Raschke M. Rupturen des vorderen Kreuzbandes bei weiblichen Athleten. Teil 1: Epidemiologie, Verletzungsmechanismen und Ursachen. DEUTSCHE ZEITSCHRIFT FÜR SPORTMEDIZIN Jahrgang 56, Nr. 6 (2005) 56, Nr. 6 (2005) Jahrgang 56, Nr. 6 (2005): 150–156Google Scholar
  53. 53.
    Petersen W, Zantop T, Rosenbaum D, Raschke M. Rupturen des vorderen Kreuzbandes bei weiblichen Athleten. Teil 2: Präventionsstrategien und Präventionsprogramme, DEUTSCHE ZEITSCHRIFT FÜR SPORTMEDIZIN, Jahrgang 56, Nr. 6 (2005) 56, Nr. 6 (2005) Jahrgang 56, Nr. 6 (2005): 157–164Google Scholar
  54. 54.
    Petersen W, Braun C, Bock W, Schmidt K, Weimann A, Drescher W, Eiling E, Stange R, Fuchs T, Hedderich J, Zantop T (2005) A controlled prospective case control study of a prevention training program in female team handball players: the German experience. Arch Orthop Trauma Surg 125(9):614–621PubMedCrossRefGoogle Scholar
  55. 55.
    Petersen W, Stöhr A, Ellermann A, Achtnich A, Müller P, Höher J, Herbort M, Akoto R, Zantop C, Zantop T, Best R (2016) Wiederkehr zum Wettkampfsport nach VKB Rekonstruktion im Leistungssport—Empfehlungen der DKG Expertengruppe Ligament. Orthop Unfallchir Praxis 166–176 DOI  10.3238/oup.2015.0166-0176
  56. 56.
    Petersen W, Ellermann A, Gösele-Koppenburg A, Best R, Rembitzki IV, Brüggemann GP, Liebau C (2014) Patellofemoral pain syndrome. Knee Surg Sports Traumatol Arthrosc 22(10):2264–2267PubMedCrossRefGoogle Scholar
  57. 57.
    Renstrom P, Ljungqvist A, Arendt E, Beynnon B, Fukubayashi T, Garrett W, Georgoulis T, Hewett TE, Johnson R, Krosshaug T, Mandelbaum B, Micheli L, Myklebust G, Roos E, Roos H, Schamasch P, Shultz S, Werner S, Wojtys E, Engebretsen L (2008) Non-contact ACL injuries in female athletes: an International Olympic Committee current concepts statement. Br J Sports Med 42(6):394–412PubMedPubMedCentralCrossRefGoogle Scholar
  58. 58.
    Schmidtlein O, Keller M, Kurz ET (2013) Testbatterie für Aktive functional movement screen. Physiopraxis 11:26–32CrossRefGoogle Scholar
  59. 59.
    Soderman K, Alfredson H, Pietila T, Werner S (2001) Risk factors for leg injuries in female soccer players: a prospective investigation during one out-door season. Knee Surg Sports Traumatol Arthrosc 9(5):313–321PubMedCrossRefGoogle Scholar
  60. 60.
    Solomonow M, Baratta R, Zhou BH (1987) The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability. Am J Sports Med 15:207–213PubMedCrossRefGoogle Scholar
  61. 61.
    Soligard T, Myklebust G, Steffen K, Holme I, Silvers H, Bizzini M, Junge A, Dvorak J, Bahr R, Andersen TE (2008) Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial. BMJ 9(337):a2469. doi: 10.1136/bmj.a2469 CrossRefGoogle Scholar
  62. 62.
    Sugimoto D, Myer GD, Foss KD, Hewett TE (2014) Dosage effects of neuromuscular training intervention to reduce anterior cruciate ligament injuries in female athletes: meta- and sub-group analyses. Sports Med 44(4):551–562. doi: 10.1007/s40279-013-0135-9 PubMedPubMedCentralCrossRefGoogle Scholar
  63. 63.
    Teitz C (2000) Video analysis of ACL injuries. In: Griffin LY (ed) Prevention of noncontact ACL injuries. American Academy of Orthopaedic Surgeons, RosemontGoogle Scholar
  64. 64.
    Thacker SB, Stroup DF, Branche CM, Gilchrist J, Goodman RA, Weitman EA (1999) The prevention of ankle sprains in sports. A systematic review of the literature. Am J Sports Med 27:753–760PubMedCrossRefGoogle Scholar
  65. 65.
    Thacker SB, Gilchrist J, Stroup DF, Kimsey CD Jr (2004) The impact of stretching on sports injury risk: a systematic review of the literature. Med Sci Sports Exerc 36(3):371–378PubMedCrossRefGoogle Scholar
  66. 66.
    Verhagen E, van der Beek A, Twisk J, Bouter L, Bahr R, van Mechelen W (2004) The effect of a proprioceptive balance board training program for the prevention of ankle sprains: a prospective controlled trial. Am J Sports Med 32(6):1385–1393PubMedCrossRefGoogle Scholar
  67. 67.
    Wedderkopp N, Kalthoft M, Lundgaard B, Rosendahl M, Froberg K (1999) Prevention of injuries in young female players in European team handball. A prospective intervention study. Scand J Med Sci Sports 9:41–47PubMedCrossRefGoogle Scholar
  68. 68.
    Wedderkopp N, Kalthoft M, Lundgaard B, Rosendahl M, Froberg K (2003) Comparison of two intervention programmes in young female players in European handball–with and without ankle disc. Scand J Med Sci Sports 13(6):371–375PubMedCrossRefGoogle Scholar
  69. 69.
    Yoo JH, Lim BO, Ha M, Lee SW, Oh SJ, Lee YS et al (2010) A meta-analysis of the effect of neuromuscular training on the prevention of the anterior cruciate ligament injury in female athletes. Knee Surg Sports Traumatol Arthrosc 18(6):824–830PubMedCrossRefGoogle Scholar
  70. 70.
    Zazulak BT, Hewett TE, Reeves NP, Goldberg B, Cholewicki J (2007) The effects of core proprioception on knee injury: a prospective biomechanical epidemiological study. Am J Sports Med 35(3):368–373PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  • Julian Mehl
    • 1
  • Theresa Diermeier
    • 1
  • Elmar Herbst
    • 1
  • Andreas B. Imhoff
    • 1
  • Thomas Stoffels
    • 2
  • Thore Zantop
    • 3
  • Wolf Petersen
    • 4
  • Andrea Achtnich
    • 1
    Email author
  1. 1.Department of Orthopaedic Sports MedicineKlinikum Rechts der Isar, TU MunichMunichGermany
  2. 2.Department of Trauma and Orthopaedic SurgeryUnfallkrankenhaus MarzahnBerlinGermany
  3. 3.Sporthopaedicum StraubingStraubingGermany
  4. 4.Department of Orthopaedic and Trauma SurgeryMartin-Luther-KrankenhausBerlinGermany

Personalised recommendations