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Pediatricians recommend training to prevent ACL tears

By Andrew M. Seaman

NEW YORK (Reuters Health) - Doctors who work with schools and sports organizations should encourage training to reduce the risk of anterior cruciate ligament tears, according to a leading group of U.S. pediatricians.

The clinical report from the American Academy of Pediatrics (AAP) also includes information for doctors to diagnose and treat the ligament tears, which have been increasing among young athletes - especially girls.

"The Academy wanted to put together a clinical report that updates pediatricians and the general public about all three of these issues," Dr. Cynthia LaBella told Reuters Health.

LaBella is the lead author of the report published in the AAP's journal Pediatrics. She is an expert in sports medicine at the Ann & Robert H. Lurie Children's Hospital of Chicago.

The anterior cruciate ligament (ACL) is one of four key ligaments that hold the bones of the knee together. The ligaments also work to stabilize the knee during movement.

The ACL can tear when athletes quickly change direction, land on their leg incorrectly, stop suddenly or collide with each other.

Soccer, football, lacrosse, basketball and gymnastics are among some of the most common sports in which high school athletes experience ACL tears.

Girls are especially at risk for ACL tears through their college years, the committee writes. It's thought that growth during puberty puts more force on kids' joints, and while boys gain muscular strength and coordination at the same time, girls typically do not.

The report says neuromuscular training programs that strengthen leg muscles, improve stability and teach people how to safely move should be encouraged.

The authors write that the components of training programs that have effectively reduced the risk of ACL tears include plyometric or jump training and tailored feedback for individual athletes.

Programs that also include strength training have been among the most successful in reducing ACL injury rates, they add.

Dr. Lyle Micheli said it makes sense that the neuromuscular training described in the new report works. It's the type of training doctors use within the Division of Sports Medicine at Boston Children's Hospital, where he is director.

"In ballet in most parts of the world, little girls or boys start when they're four, five or six (years old)," he said. "They learn to jump and land. We don't get many ACL injuries from the ballet."

Micheli, who is also the founder of The Micheli Center for Sports Injury Prevention, was not involved with the creation of the new report.

According to one paper cited in the report, training was tied to a 72 percent reduced risk of ACL injuries among female athletes younger than 18 years old. The risk was decreased by about 16 percent among those 18 years old and older.

The report says there is not enough evidence to support the use of braces to prevent ACL injuries.

"There is no good research to show that bracing as a primary prevention strategy is effective," LaBella said.

Many, but not all, children who tear their ACL will need surgery.

For those children, the report says it's reasonable to wait until they mature to the age when the surgery will not disturb the growth of their leg. Surgical techniques do exist to repair the ACL without disturbing the leg's growth plate, however.

"Everybody is a little different with their needs and goals," LaBella said. "It's definitely an individualized decision."

Regardless of treatment choice, the report says doctors should advise their patients that they will be at an increased risk of early-onset osteoarthritis, which is caused by wear-and-tear of the knee.

As for diagnosis, LaBella said people - especially athletes, parents and coaches - should be aware of the warning signs of an ACL tear.

"Most athletes will feel their knee give out and feel a pop," she said, adding that the knee may also swell.

Whether the increase in ACL tears is due to kids playing sports at a younger age, taking part in more intense training or some other factor, Micheli said he agrees with the report's recommendations.

"We definitely think this is the way we've got to go as a nation," he said.

The AAP has several resources, including instructional videos, on its website (aap.org/cosmf), according to LaBella.

SOURCE: http://bit.ly/uFc4g2 Pediatrics, online April 28, 2014.

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