Understanding of ACL injuries is still evolving

Concussions may have recently taken the spotlight in lacrosse sports medicine, but anterior cruciate ligament injuries are still a major unanswered issue for the sport. ACL tears are the leading cause of missed game and practice time at both the high school and college levels of play for both males and females.

Concussions may have recently taken the spotlight in lacrosse sports medicine, but anterior cruciate ligament injuries are still a major unanswered issue.


ACL tears are the leading cause of missed game and practice time at both the high school and college levels of play for both males and females. Data from the US Lacrosse membership insurance program shows that knee-related claims —primarily ACL injuries — are greater than all other injury payouts combined. In general, ACL injury rates are on the rise but are particularly high in teenage boys and girls, females of all ages and players with a previous history of ACL tear.

The risk factors for initial injury and failure of return to play are multifaceted and include core athletic abilities, lower-extremity biomechanics, fear of reinjury and access to comprehensive medical care. Although most ACL injures are noncontact in nature, video analysis reveals that these injuries are often related to adjustments such as a quick dodge or awkward landing that players must make in response to unanticipated activities around them.

When appropriately preset, the musculature of the trunk and legs absorbs energy very efficiently. But when left in an awkward or unprotected situation, the ACL alone can quickly fail under stresses commonly seen in high-demand sports such as lacrosse.

Most patients and their families assume that in case of a tear, simple outpatient surgery and a short course of rehabilitation will have them back to their pre-injury level of play in no time. Fueled by the lay press and medical marketing, many patients understandably assume that whatever is broken can be fixed as good as or better than it was. With regard to ACL injuries, however, we need to take a step back and recognize a different reality.

Yes, surgical reconstruction provides the best chance of returning to lacrosse and other high-demand sports. Surgical techniques continue to improve. In general, a torn ACL cannot be repaired but must be reconstructed using other tissues such as the patient's own hamstring or patellar tendons, or even cadaveric tissues in lower-demand athletes.

Surgery must be followed by an intensive, supervised rehabilitation program and a graduated return to sports activities. Readiness for return to play might involve clinical examination as well as high-speed video analysis and computerized strength testing. Nonoperative treatment is best used on patients who are returning to lower-demand activities such as biking, jogging or controlled aerobics.

In the past, surgery was deemed successful if the player had a stable knee and didn't return for further treatment. Today, we are following patients over longer periods of time and more comprehensively. Unfortunately, ACL outcomes are not the slam-dunk we have assumed in the past. Even in the best of hands, many players will develop arthritis, decrease their levels of participation and require up to two years for full recovery.

Lacrosse-specific data is not yet available, but recent research by the highly regarded Multicenter Orthopaedic Outcomes Network found that slightly less than 50 percent of high school football players returned to the same of play after ACL surgery. Other studies on high-level recreational athletes in a variety of sports suggest that less than one-third return to full competitive play within a year of surgery.

Even in the NFL, only two-thirds of players ever play another down after ACL reconstruction. Interestingly, the majority of NFL team physicians mistakenly estimated that more than 90 percent return to play prior to being made aware of this data. About 75 percent of NBA players return to the court, but nearly half will show significant decreases in performance and playing time.

Many factors are involved in a successful return to play. Tears of the reconstructed ACL are not insignificant, and reports vary from 5 percent in professional rugby players to greater than 15 percent in young female soccer players. However, this does not account for the much larger percentage of athletes who do not make a full recovery. Explanations include fear of reinjury, decreased emphasis on sports participation, inadequate rehabilitation and insufficient core athletic abilities.

Recognizing current shortcomings in treatment, the concept of ACL injury prevention is taking on a growing importance. Such programs focus on training the athlete in better mechanics for jumping, landing and turning; developing stronger core and hip musculature; and emphasizing the need to be well-rested and attentive during sports participation. These programs can be instituted on an individual or team basis and can be used to prevent initial injury or as part of a postsurgical rehabilitation program. Such programs have shown some success in decreasing soccer-related ACL injury rates. MedStar Sports Medicine and US Lacrosse are now developing programs specific to lacrosse.

For lacrosse players, having realistic expectations after an ACL injury is important. This is a potentially devastating injury, one without a perfect fix. Successful surgery and rehabilitation, with a full return to the game, are attainable goals, but they require a comprehensive team effort. It is never an option for an athlete to continue playing in the face of recurrent knee instability, and lifelong knee health should always be the first priority.

Dr. Richard Hinton is director of the Sports Medicine Fellowship at Union Memorial Hospital and a team physician for the Towson men's and women's teams as well as the U.S. women's national team. If you have questions for Dr. Hinton, please send them to