Knee Injury Prevention in Football

Knee Injury Prevention in Football

Knee injuries constitute a serious problem in many team field based sports but are especially common in football due to the 360 degree nature of the sport. In Football the sport involves sudden change of directions, pivoting/cutting, accelerations/decelerations and jumping/landing which are all common mechanisms for knee injuries. 

Knee injuries such as anterior cruciate ligament (ACL) tears are a common injury in football and represent a large problem. Treatment for these injuries is costly (often involving surgery) and often takes 12 months or more to return to sport. These injuries can prevent an athlete reaching their full potential or sometimes cause a player to end their career prematurely. 

Long term after ACL injuries a high percentage of athletes will develop longer term complications such as knee osteoarthritis 15-20 years later in life. 

Many of the ACL non-contact (pivoting on knee without contact from opposing players) injuries are preventable. Therefore applying programs to prevent these injuries from occurring is key.  In this blog we will cover how to reduce the risk of sustaining a knee injury with the focus on reducing ACL injury risk. 

 

Mechanisms

An ACL injury will commonly occur without contact between players and typically will involve an uncontrolled knee twisting/pivoting incident with the foot fixed to the ground or landing on one leg and the knee is forced into knee valgus and/or hyper extension¹. Knee valgus (when the knee drops inwards to “knee knocked position”-see picture below) has been associated in research studies to be a factor in ACL injuries. Therefore avoiding knee valgus positions when cutting and landing is an important principle to follow for injury prevention. 

Risk Factors

As for any injury, a previous history of knee ligament injury is a pre-dominant risk factor for subsequent re-injury. After an ACL reconstruction surgery the same knee that has had the ACL reconstructed is at higher risk but interestingly the opposite side is also at an much higher risk of a ACL injury. There number of reasons why the opposite side is at higher risk including non-optimal movement patterns, deconditioning of the leg while rehabilitating from the surgery and that the athlete on returning will generally choose to use the non-surgically repaired leg to jump/land and plant off to try and protect the surgical side.

ACL injuries are significantly more common in females than males. Females are 3.5 times at more risk of sustaining a non-contact ACL injury². Research studies have suggested that hormonal, anatomy, cross sectional size of ligament, neuromuscular (jumping/landing strategies) differences as reasons for the large gap in ACL injury rates between genders³. Therefore for female football players/athletes it is highly essential that they are participating in an ACL injury prevention program. 

A family history of ACL injury has been also been found to be a risk factor for ACL injury ^4. Therefore for those with immediate family members (mother and father) that have had sustained an ACL injury it is key they are diligent with an injury prevention program. 

Prevention

Prevention is always better than being reactive to these costly and high time loss injuries. There a variety of injury specific/sport specific neuromuscular preventative programs out there. These programs have been developed to reduce the risk of knee and lower limb injuries in general with focus targeted on reducing ACL injuries. The studies show when these neuromuscular programs are set up as standard team warm up programs and are completed well with good compliance they can reduce the risk of all knee injuries by as much as 50% and lower limb injuries by 22% ⁴. 

Examples of these knee specific injury prevention programs are the FIFA 11+, Netball KNEE program and PEP program which are available freely online. A physiotherapist is well placed to be implementing these programs in sporting teams in collaboration with coaches. 

Typically these programmes consist of neuromuscular exercises focusing on:

• Lower limb muscle strength
• Trunk stability
• Retraining of optimal jumping/landing and cutting mechanics
• Co-ordination/balance
• Dynamic control with plyometric exercises.

Practical Applications

What type of exercises?

We know ACL injury prevention program when implemented well works. One single type of exercise will not be effective alone in isolation but a combination of strength, dynamic Balance/proprioception, plyometric and agility exercises are the most effective. The primary goal is to be able to teach the athlete to be able to maintain good lower limb and trunk control in dynamic jumping/landing and cutting tasks. 

The exercises in the injury prevention program should be specific to the age group of the athletes and be specific to the movements and demands of the sport played. 

 

When should these programs start?

Injury prevention should start early, as soon as the athlete starts participating in organised sports. Starting to teach motor learning exercises early on in the child’s development can create “good habits” in mechanics and therefore will be less susceptible to injury as these less vulnerable movement patterns become second nature to them. 

Who should be targeted?

 There is no sufficient evidence that there are screening tests (e.g. jump/land, hopping tests) are able to reliably detect who is at risk of ACL injury. Therefore everyone participating in team field sport should be participating in a form of injury prevention program. 

However there are certain populations where injury prevention programs should non-negotiable. In the age range of 14 to 18 years old for females and 18 to 25 years old for males who are at higher risk for ACL injury and have the highest ACL injury rates, in comparison to other age groups. Female athletes, past history of ACL injury, athletes with hypermobility (more available joint motion than normal) and athletes with family history of ACL injury we know are at more risk so they need to be educated on their higher risk and have comprehensive injury prevention programs in place. 

How long and how often should these programs be completed?

The evidence suggests that injury prevention programs should be used as team warm up lasting between 15-30 minutes before each training session (at least 2 times per week) and before every game. 

The FIFA 11+ has been tailored specifically to football and there are two versions developed . One is specific for kids under 14 years of age and another version for adolescents/adults over the age of 14 years old. The efficacy of FIFA 11+ to prevent non-contact injuries  by 50% has been proven in young male and female amateur football players if performed consistently at least two times per week⁵.

 

In summary:

• Knee injuries in particular ACL injuries represent a large problem in football and team based sports for young male and female athletes. 
• These injuries come with a high cost and longer term consequences.
• Neuromuscular Injury prevention programs lasting up to 30 minutes tailored to the sport played and performed consistently at least 2 times per week are very effective in reducing non-contact knee and lower limb injury risk.

A sports physiotherapist experienced in ACL prevention/rehabilitation can put together a comprehensive individualised injury prevention program based off a thorough assessment to address impairments/modifiable risk factors specific to the athlete and sport they play to reduce the risk of sustaining a knee/ ACL injury.

 

References

1. Olsen OE, Myklebust G, Engebretsen L, Bahr R. Injury mechanisms for anterior cruciate ligament injuries in team handball: a systematic video analysis. Am J Sports Med 2004; 32:1002-1012
2. Voskanian, N. (2013). ACL Injury prevention in female athletes: review of the literature and practical considerations in implementing an ACL prevention program. Current Reviews in Musculoskeletal Medicine, 6(2), 158–163. http://doi.org/10.1007/s12178-013-9158-y
3. Renström P, Ljungqvist A, Arendt E, Beynnon B, Fukbayashi T, Garrett W et al. Non-contact ACL injuries in female athletes: an International Olympic Committee current concepts statement. Br J Sports Med 2008; 42:394-412
4. Mandelbaum BR, Silvers HJ, Watanabe DS, Knarr JF, Thomas SD, Griffin LY et al. 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 2005; 33:1003-1010
5. Bizzini M, Dvorak J FIFA 11+: an effective programme to prevent football injuries in various player groups worldwide—a narrative review Br J Sports Med 2015;49:577-579