Background In female athletes, sports-related injuries to the anterior cruciate ligament (ACL) increase during adolescence and peak in incidence during the mid- to late teens. Although biomechanical investigations indicate that a potential window of opportunity exists for optimal timing for the initiation of integrative neuromuscular training (NMT) in young female athletes, the influence of the timing of initiation of these programs on the efficacy of ACL injury reduction has yet to be evaluated. Hypothesis/Purpose The purpose of the current report was to systematically review and synthesize the scientific literature regarding the influence of age of NMT implementation on the effectiveness for reduction of ACL injury incidence. The hypothesis tested was that NMT would show a greater effect in younger populations. Study Design Meta-analysis; Level of evidence 1a. Methods Data were pooled from 14 clinical trials that met the inclusion criteria of (1) number of ACL injuries reported; (2) NMT program used; (3) female participants were included; (4) investigations used prospective, controlled trials; and (5) age of participants was documented or was obtainable upon contact with the authors. A meta-analysis with odds ratio (OR) was used to compare the ratios of ACL injuries between intervention and control groups among differing age categorizations. Results A meta-analysis of the 14 included studies demonstrated significantly greater knee injury reduction in female athletes who were categorized in the preventive NMT group compared with those who were in the control group (OR: 0.54; 95% confidence interval [CI]: 0.35, 0.83). Lower ACL injuries in mid-teens (OR 0.28; CI: 0.18, 0.42) compared with late teens (OR 0.48; CI: 0.21, 1.07) and early adults (OR 1.01; CI: 0.62, 1.64) were found in participants undergoing NMT. Conclusion The findings of this meta-analysis revealed an age-related association between NMT implementation and reduction of ACL incidence. Both biomechanical and the current epidemiological data indicate that the potential window of opportunity for optimized ACL injury risk reduction may be before the onset of neuromuscular deficits and peak knee injury incidence in female athletes. Specifically, it may be optimal to initiate integrative NMT programs during early adolescence, before the period of altered mechanics that increase injury risk.

Self-reported fear of movement/reinjury after ACLR at the time of RTS may be an important measure to incorporate into discharge criteria prior to release to return to pivoting and cutting sports after ACLR.

Participants with higher IKDC scores demonstrated an increased likelihood of presenting with greater involved limb quadriceps strength and better Q-LSI. Based on the results of this study, a patient-reported outcome measure, such as the IKDC, may be able to serve as a valuable screening tool for the identification of quadriceps strength deficits in this population; however, it should not be considered an accurate surrogate for isokinetic dynamometry. Furthermore, a score of ≥94.8 on the IKDC is likely to indicate that a patient's quadriceps strength is at an acceptable RTS level.

Background:Biomechanical predictors of a second anterior cruciate ligament (ACL) injury after ACL reconstruction (ACLR) and return to sport (RTS) have been identified; however, these measures may not be feasible in a standard clinical environment.Purpose/Hypothesis:The purpose of this study was to evaluate whether standard clinical measures predicted the risk of second ACL injuries. The hypothesis tested was that a combination of strength, function, and patient-reported measures at the time of RTS would predict the risk of second ACL injuries with high sensitivity and specificity.Study Design:Case-control study; Level of evidence, 3 and Cohort study (prognosis); Level of evidence, 1.Methods:A total of 163 participants (mean age, 16.7 ± 3.0 years) who underwent primary ACLR and were able to RTS were evaluated. All participants completed an assessment of isokinetic strength, hop testing, balance, and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Participants were tracked for a minimum of 24 months to identify occurrences of a second ACL injury. The initial 120 participants enrolled were used to develop a clinical prediction model that utilized classification and regression tree (CART) analysis, and the remaining 43 participants enrolled were used as a validation dataset. Additional analyses were performed in all 163 participants using Kaplan-Meier analysis and Cox proportional hazards modeling.Results:Approximately 20% (23/114) of the initial subset of the cohort suffered a second ACL injury. CART analysis identified age, sex, knee-related confidence, and performance on the triple hop for distance at the time of RTS as the primary predictors of a second ACL injury. Using these variables, a model was generated from which high-risk (n = 53) and low-risk groups (n = 61) were identified. A total of 22 participants in the high-risk group and 1 participant in the low-risk group suffered a second ACL injury. High-risk participants fit 1 of 2 profiles: (1) age <19 years, triple hop for distance between 1.34 and 1.90 times body height, and triple hop for distance limb symmetry index (LSI) <98.5% (n = 43) or (2) age <19 years, triple hop for distance >1.34 times body height, triple hop for distance LSI >98.5%, female sex, and high knee-related confidence (n = 10). The validation step identified the high-risk group as being 5 times (odds ratio, 5.14 [95% CI, 1.00-26.46]) more likely to suffer a second ACL injury, with a sensitivity of 66.7% and specificity of 72.0%.Conclusion:These findings recognize measures that accurately identify young patients at high risk of sustaining a second ACL injury within 24 months after RTS. The development of a clinical decision algorithm to identify high-risk patients, inclusive of clinically feasible variables such as age, sex, confidence, and performance on the triple hop for distance, can serve as a foundation to re-evaluate appropriate discharge criteria for RTS.

Level II, Prospective cohort study.

Context Early sport specialization, or the participation in 1 sport year-round to the exclusion of all others, is a growing concern in youth athletics because of its possible association with musculoskeletal injury. The underlying injury risk may be the result of coordination differences that sport-specialized athletes have been speculated to exhibit relative to multisport athletes; however, little evidence exists to support or refute this notion. Objective To examine relative hip- and knee-joint angular-motion variability among adolescent sport-specialized and multisport female adolescent athletes to determine how sport specialization may affect coordination. Design Cohort study. Setting Research laboratory. Patients or Other Participants A total of 366 sport-specialized and 366 multisport adolescent female basketball, soccer, and volleyball players. Intervention(s) Drop–vertical-jump (DVJ) assessment. Main Outcome Measure(s) Average coupling-angle variability (CAV) for hip flexion and knee flexion, knee flexion and ankle flexion, hip flexion and knee abduction, knee flexion and knee abduction, knee flexion and knee internal rotation, and knee abduction and knee internal rotation. Results The sport-specialized group exhibited increased coupling variability in dominant-limb hip flexion and knee flexion (P = .015), knee flexion and knee abduction (P = .014), and knee flexion and knee internal rotation (P = .048) while landing during the DVJ, although they had small effect sizes (η2 = 0.010, 0.010, and 0.007, respectively). No differences were present between groups for any of the other CAV measures of the dominant limb, and no differences were found for any CAV measures of the nondominant limb (all P values &gt; .05). Conclusions Sport specialization was associated with increased variability of critical hip- and knee-joint couplings responsible for effective landing during the DVJ. Altered coordination strategies that involve the hip and knee joints may underlie unstable landings, inefficient force-absorption strategies, or greater contact forces that can place the lower extremities at risk for injury (or a combination of these).

Objectives Adolescents with juvenile fibromyalgia (JFM) are typically sedentary despite recommendations for physical exercise, a key component of pain management. Interventions such as cognitive behavioral therapy (CBT) are beneficial but do not improve exercise participation. The objective of this study was to obtain preliminary information about the feasibility, safety, and acceptability of a new intervention - Fibromyalgia Integrative Training for Teens (FIT Teens), which combines CBT with specialized neuromuscular exercise training modified from evidence-based injury prevention protocols. Methods Participants were 17 adolescent females (ages 12–18) with JFM. Of these, 11 completed the 8-week (16-session) FIT Teens program in a small-group format with 3–4 patients per group. Patients provided detailed qualitative feedback via individual semi-structured interviews after treatment. Interview content was coded using thematic analysis. Interventionist feedback about treatment implementation was also obtained. Results The intervention was found to be feasible, well-tolerated, and safe for JFM patients. Barriers to enrollment (50% of those approached) included difficulties with transportation or time conflicts. Treatment completers enjoyed the group format and reported increased self-efficacy, strength, and motivation to exercise. Participants also reported decreased pain and increased energy levels. Feedback from participants and interventionists was incorporated into a final treatment manual to be used in a future trial. Discussion Results of this study provided initial support for the new FIT Teens program. An integrative strategy of combining pain coping skills via CBT enhanced with tailored exercise specifically designed to improve confidence in movement and improving activity participation holds promise in the management of JFM.

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