Skip to main content

Effect of a Concussion on Anterior Cruciate Ligament Injury Risk in a General Population

Abstract

Background

Recent studies indicate concussion increases risk of musculoskeletal injury in specific groups of patients. The purpose of this study was to determine the odds of anterior cruciate ligament (ACL) injury after concussion in a population-based cohort.

Methods

International Classification of Diseases, 9th and 10th Revision (ICD-9, ICD-10) codes relevant to the diagnosis and treatment of a concussion and ACL tear were utilized to search the Rochester Epidemiology Project (REP) between 2000 and 2017. A total of 1653 unique patients with acute, isolated ACL tears were identified. Medical records for cases were reviewed to confirm ACL tear diagnosis and to determine history of concussion within 3 years prior to the ACL injury. Cases were matched by age, sex, and REP availability date to patients without an ACL tear (1:3 match), resulting in 4959 controls. The medical records of the matched control patients were reviewed to determine history of concussion.

Results

39 patients with a concussion suffered an ACL injury up to 3 years after the concussion. The rate of prior concussion was higher in ACL-injured cases (2.4%) compared to matched controls with no ACL injury (1.5%). This corresponds to an odds ratio of 1.6 (95% CI 1.1–2.4; p = 0.015).

Conclusions

Although activity level could not be assessed, there are increased odds of ACL injury after concussion in a general population. Based on the evidence of increased odds of musculoskeletal injury after concussion, standard clinical assessments should consider concussion symptom resolution as well as assessment of neuromuscular factors associated with risk of injuries.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

References

  1. Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths 2002–2006. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.

    Book  Google Scholar 

  2. Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic brain injury-related emergency department visits, hospitalizations, and deaths—United States, 2007 and 2013. MMWR Surveill Summ. 2017;66(9):1–16.

    PubMed  PubMed Central  Article  Google Scholar 

  3. Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375–8.

    PubMed  Article  Google Scholar 

  4. McPherson AL, Nagai T, Webster KE, Hewett TE. Musculoskeletal injury risk after sport-related concussion: a systematic review and meta-analysis. Am J Sports Med. 2018;3:363546518785901.

    Google Scholar 

  5. Kardouni JR, Shing TL, McKinnon CJ, Scofield DE, Proctor SP. Risk for lower extremity injury after concussion: a matched cohort study in soldiers. J Orthop sports Phys Ther. 2018;48(7):533–40.

    PubMed  Article  Google Scholar 

  6. Reneker JC, Babl R, Flowers MM. History of concussion and risk of subsequent injury in athletes and service members: a systematic review and meta-analysis. Musculoskelet Sci Pract. 2019;42:173–85.

    PubMed  Article  Google Scholar 

  7. Baumeister J, Reinecke K, Weiss M. Changed cortical activity after anterior cruciate ligament reconstruction in a joint position paradigm: an EEG study. Scand J Med Sci Sports. 2008;18(4):473–84.

    CAS  PubMed  Article  Google Scholar 

  8. Borotikar BS, Newcomer R, Koppes R, McLean SG. Combined effects of fatigue and decision making on female lower limb landing postures: central and peripheral contributions to ACL injury risk. Clin Biomech. 2008;23(1):81–92.

    Article  Google Scholar 

  9. DeAngelis A, Needle A, Kaminski T, Royer T, Knight C, Swanik C. An acoustic startle alters knee joint stiffness and neuromuscular control. Scand J Med Sci Sports. 2015;25(4):509–16.

    CAS  PubMed  Article  Google Scholar 

  10. DeMont RG, Lephart SM, Giraldo JL, Swanik CB, Fu FH. Muscle preactivity of anterior cruciate ligament-deficient and-reconstructed females during functional activities. J Athl Train. 1999;34(2):115.

    CAS  PubMed  PubMed Central  Google Scholar 

  11. Hewett TE, Ford KR, Myer GD. Anterior cruciate ligament injuries in female athletes: part 2, a meta-analysis of neuromuscular interventions aimed at injury prevention. Am J Sports Med. 2006;34(3):490–8.

    PubMed  Article  Google Scholar 

  12. Hewett TE, Myer GD, Ford KR. Anterior cruciate ligament injuries in female athletes: part 1, mechanisms and risk factors. Am J Sports Med. 2006;34(2):299–311.

    PubMed  Article  Google Scholar 

  13. Swanik CB. Brains and sprains: the brain’s role in noncontact anterior cruciate ligament injuries. J Athl Train. 2015;50(10):1100–2.

    PubMed  Article  Google Scholar 

  14. Swanik CB, Covassin T, Stearne DJ, Schatz P. The relationship between neurocognitive function and noncontact anterior cruciate ligament injuries. Am J Sports Med. 2007;35(6):943–8.

    PubMed  Article  Google Scholar 

  15. Zazulak BT, Hewett TE, Reeves NP, Goldberg B, Cholewicki J. The effects of core proprioception on knee injury: a prospective biomechanical-epidemiological study. Am J Sports Med. 2007;35(3):368–73.

    PubMed  Article  Google Scholar 

  16. Mall NA, Chalmers PN, Moric M, Tanaka MJ, Cole BJ, Bach BR Jr, et al. Incidence and trends of anterior cruciate ligament reconstruction in the United States. Am J Sports Med. 2014;42(10):2363–70.

    PubMed  Article  Google Scholar 

  17. Herzog MM, Marshall SW, Lund JL, Pate V, Spang JT. Cost of outpatient arthroscopic anterior cruciate ligament reconstruction among commercially insured patients in the United States, 2005–2013. Orthop J Sports Med. 2017;5(1):2325967116684776.

    PubMed  PubMed Central  Article  Google Scholar 

  18. Tator CH. Concussions and their consequences: current diagnosis, management and prevention. CMAJ. 2013;185(11):975–9.

    PubMed  PubMed Central  Article  Google Scholar 

  19. Brooks MA, Peterson K, Biese K, Sanfilippo J, Heiderscheit BC, Bell DR. Concussion increases odds of sustaining a lower extremity musculoskeletal injury after return to play among collegiate athletes. Am J Sports Med. 2016;44(3):742–7.

    PubMed  Article  Google Scholar 

  20. Burman E, Lysholm J, Shahim P, Malm C, Tegner Y. Concussed athletes are more prone to injury both before and after their index concussion: a data base analysis of 699 concussed contact sports athletes. BMJ Open Sport Exer Med. 2016;2(1):e000092.

    Article  Google Scholar 

  21. Cross M, Kemp S, Smith A, Trewartha G, Stokes K. Professional Rugby Union players have a 60% greater risk of time loss injury after concussion: a 2-season prospective study of clinical outcomes. Br J Sports Med. 2016;50(15):926–31.

    PubMed  Article  Google Scholar 

  22. Fino PC, Becker LN, Fino NF, Griesemer B, Goforth M, Brolinson PG. Effects of recent concussion and injury history on instantaneous relative risk of lower extremity injury in division I collegiate athletes. Clin J Sport Med. 2017;29(3):218–23.

    Article  Google Scholar 

  23. Herman DC, Jones D, Harrison A, Moser M, Tillman S, Farmer K, et al. Concussion may increase the risk of subsequent lower extremity musculoskeletal injury in collegiate athletes. Sports Med. 2017;47(5):1003–10.

    PubMed  PubMed Central  Article  Google Scholar 

  24. Lynall RC, Mauntel TC, Padua DA, Mihalik JP. Acute lower extremity injury rates increase after concussion in college athletes. Med Sci Sports Exerc. 2015;47(12):2487–92.

    PubMed  Article  Google Scholar 

  25. Lynall RC, Mauntel TC, Pohlig RT, Kerr ZY, Dompier TP, Hall EE, et al. Lower extremity musculoskeletal injury risk after concussion recovery in high school athletes. J Athl Train. 2017;52(11):1028–34.

    PubMed  PubMed Central  Article  Google Scholar 

  26. Makdissi M, McCrory P, Ugoni A, Darby D, Brukner P. A prospective study of postconcussive outcomes after return to play in Australian football. Am J Sports Med. 2009;37(5):877–83.

    PubMed  Article  Google Scholar 

  27. Nordström A, Nordström P, Ekstrand J. Sports-related concussion increases the risk of subsequent injury by about 50% in elite male football players. Br J Sports Med. 2014;48(19):1447–50.

    PubMed  Article  Google Scholar 

  28. Nyberg G, Mossberg KH, Tegner Y, Lysholm J. Subsequent traumatic injuries after a concussion in elite ice hockey: a study over 28 years. Curr Res Concussion. 2015;2(3):109–12.

    Google Scholar 

  29. St Sauver JL, Grossardt BR, Leibson CL, Yawn BP, Melton LJ 3rd, Rocca WA. Generalizability of epidemiological findings and public health decisions: an illustration from the Rochester Epidemiology Project. Mayo Clin Proc. 2012;87(2):151–60.

    PubMed  PubMed Central  Article  Google Scholar 

  30. Rocca WA, Yawn BP, St Sauver JL, Grossardt BR, Melton LJ 3rd. History of the Rochester Epidemiology Project: half a century of medical records linkage in a US population. Mayo Clin Proc. 2012;87(12):1202–13.

    PubMed  PubMed Central  Article  Google Scholar 

  31. St Sauver JL, Grossardt BR, Yawn BP, Melton LJ 3rd, Pankratz JJ, Brue SM, et al. Data resource profile: the Rochester Epidemiology Project (REP) medical records-linkage system. Int J Epidemiol. 2012;41(6):1614–24.

    PubMed  PubMed Central  Article  Google Scholar 

  32. St Sauver JL, Grossardt BR, Yawn BP, Melton LJ 3rd, Rocca WA. Use of a medical records linkage system to enumerate a dynamic population over time: the Rochester epidemiology project. Am J Epidemiol. 2011;173(9):1059–68.

    PubMed  PubMed Central  Article  Google Scholar 

  33. Schilaty ND, Nagelli C, Bates NA, Sanders TL, Krych AJ, Stuart MJ, et al. Incidence of second anterior cruciate ligament tears and identification of associated risk factors from 2001 to 2010 using a geographic database. Orthop J Sports Med. 2017;5(8):2325967117724196.

    PubMed  PubMed Central  Article  Google Scholar 

  34. Schilaty ND, Bates NA, Sanders TL, Krych AJ, Stuart MJ, Hewett TE. Incidence of second anterior cruciate ligament tears (1990–2000) and associated factors in a specific geographic locale. Am J Sports Med. 2017;45(7):1567–73.

    PubMed  PubMed Central  Article  Google Scholar 

  35. Hennessy S, Bilker WB, Berlin JA, Strom BL. Factors influencing the optimal control-to-case ratio in matched case–control studies. Am J Epidemiol. 1999;149(2):195–7.

    CAS  PubMed  Article  Google Scholar 

  36. McCrory P, Meeuwisse W, Dvorak J, Aubry M, Bailes J, Broglio S, et al. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838–47.

    PubMed  Google Scholar 

  37. Boden BP, Sheehan FT, Torg JS, Hewett TE. Non-contact ACL injuries: mechanisms and risk factors. J Am Acad Orthop Surg. 2010;18(9):520.

    PubMed  PubMed Central  Article  Google Scholar 

  38. Griffin LY, Agel J, Albohm MJ, Arendt EA, Dick RW, Garrett WE, et al. Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg. 2000;8(3):141–50.

    CAS  PubMed  Article  Google Scholar 

  39. Ingersoll CD, Grindstaff TL, Pietrosimone BG, Hart JM. Neuromuscular consequences of anterior cruciate ligament injury. Clin Sports Med. 2008;27(3):383–404 (vii).

    PubMed  Article  Google Scholar 

  40. Howell DR, Lynall RC, Buckley TA, Herman DC. Neuromuscular control deficits and the risk of subsequent injury after a concussion: a scoping review. Sports Med. 2018;48(5):1097–115.

    PubMed  PubMed Central  Article  Google Scholar 

  41. Asplund CA, McKeag DB, Olsen CH. Sport-related concussion: factors associated with prolonged return to play. Clin J Sport Med. 2004;14(6):339–43.

    PubMed  Article  Google Scholar 

  42. Cantu RC. Posttraumatic retrograde and anterograde amnesia: pathophysiology and implications in grading and safe return to play. J Athl Train. 2001;36(3):244.

    PubMed  PubMed Central  Google Scholar 

  43. Cantu RC. Return to play guidelines after a head injury. Clin Sports Med. 1998;17(1):45–60.

    CAS  PubMed  Article  Google Scholar 

  44. Collins M, Lovell MR, Iverson GL, Ide T, Maroon J. Examining concussion rates and return to play in high school football players wearing newer helmet technology: a 3-year prospective cohort study. Neurosurgery. 2006;58(2):275–86.

    PubMed  Article  Google Scholar 

  45. Lovell M, Collins M, Bradley J. Return to play following sports-related concussion. Clin Sports Med. 2004;23(3):421–41.

    PubMed  Article  Google Scholar 

  46. Sye G, Sullivan SJ, McCrory P. High school rugby players’ understanding of concussion and return to play guidelines. Br J Sports Med. 2006;40(12):1003–5.

    PubMed  PubMed Central  Article  Google Scholar 

  47. Wasserman EB, Kerr ZY, Zuckerman SL, Covassin T. Epidemiology of sports-related concussions in National Collegiate Athletic Association athletes from 2009–2010 to 2013–2014: symptom prevalence, symptom resolution time, and return-to-play time. Am J Sports Med. 2016;44(1):226–33.

    PubMed  Article  Google Scholar 

  48. Meehan WP 3rd, d’Hemecourt P, Collins CL, Taylor AM, Comstock RD. Computerized neurocognitive testing for the management of sport-related concussions. Pediatrics. 2012;129(1):38–44.

    PubMed  PubMed Central  Article  Google Scholar 

  49. Echemendia RJ, Meeuwisse W, McCrory P, Davis GA, Putukian M, Leddy J, et al. The Sport Concussion Assessment Tool 5th Edition (SCAT5): background and rationale. Br J Sports Med. 2017;51(11):848–50.

    PubMed  Article  Google Scholar 

  50. McCrea M. Standardized mental status testing on the sideline after sport-related concussion. J Athl Train. 2001;36(3):274–9.

    PubMed  PubMed Central  Google Scholar 

  51. Farnsworth JL 2nd, Dargo L, Ragan BG, Kang M. Reliability of computerized neurocognitive tests for concussion assessment: a meta-analysis. J Athl Train. 2017;52(9):826–33.

    PubMed  PubMed Central  Article  Google Scholar 

  52. Eagle SR, Kontos AP, Pepping GJ, et al. Increased risk of musculoskeletal injury following sport-related concussion: a perception-action coupling approach. Sports Med. 2020;50(1):15–23. https://doi.org/10.1007/s40279-019-01144-3.

    Article  PubMed  Google Scholar 

  53. Kamins J, Bigler E, Covassin T, Henry L, Kemp S, Leddy JJ, et al. What is the physiological time to recovery after concussion? A systematic review. Br J Sports Med. 2017;51(12):935–40.

    PubMed  Article  Google Scholar 

  54. Howell DR, Buckley TA, Lynall RC, Meehan WP 3rd. Worsening dual-task gait costs after concussion and their association with subsequent sport-related injury. J Neurotrauma. 2018;35(14):1630–6.

    PubMed  Article  Google Scholar 

  55. Register-Mihalik JK, Littleton AC, Guskiewicz KM. Are divided attention tasks useful in the assessment and management of sport-related concussion? Neuropsychol Rev. 2013;23(4):300–13.

    PubMed  Article  Google Scholar 

  56. Dubose DF, Herman DC, Jones DL, Tillman SM, Clugston JR, Pass A, et al. Lower extremity stiffness changes after concussion in collegiate football players. Med Sci Sports Exerc. 2017;49(1):167–72.

    PubMed  PubMed Central  Article  Google Scholar 

  57. Howell DR, Myer GD, Grooms D, Diekfuss J, Yuan W, Meehan WP 3rd. Examining motor tasks of differing complexity after concussion in adolescents. Arch Phys Med Rehabil. 2018;100:613–9.

    PubMed  Article  Google Scholar 

  58. Lynall RC, Blackburn JT, Guskiewicz KM, Marshall SW, Plummer P, Mihalik JP. Functional balance assessment in recreational college-aged individuals with a concussion history. J Sci Med Sport. 2018;22:503–8.

    PubMed  Article  Google Scholar 

  59. Murray NG, Szekely B, Moran R, Ryan G, Powell D, Munkasy BA, et al. Concussion history associated with increased postural control deficits after subsequent injury. Physiol Meas. 2019;40(2):024001.

    CAS  PubMed  Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Nathan D. Schilaty.

Ethics declarations

Funding

Fellowship funding was provided by the Mayo Clinic Graduate School of Biomedical Sciences [ALM]. Funding for this research was received from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01AR55563 [TEH] and L30AR070273 [NDS]) and the National Institute of Children and Human Development (K12HD065987 [NDS]). This study was also made possible using the resources of the Rochester Epidemiology Project, which is supported by the National Institute on Aging of the National Institutes of Health under Award R01AG034676.

Conflict of interest

All authors have no conflicts of interest to declare.

Ethical approval

Institutional review board approval was obtained from both the Mayo Clinic (IRB# 18-001196) and the Olmsted Medical Center (005-OMC-18) and the study complied with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with human participants performed by any of the authors. All patients provided general research authorization for use of their medical records at the time of medical care.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

McPherson, A.L., Shirley, M.B., Schilaty, N.D. et al. Effect of a Concussion on Anterior Cruciate Ligament Injury Risk in a General Population. Sports Med 50, 1203–1210 (2020). https://doi.org/10.1007/s40279-020-01262-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40279-020-01262-3