ACL Injuries Among Football Players

Abstract

Anterior Cruciate Ligament (ACL) injuries may arguably be the most prevalent of all knee injuries among football players. The ACL is a cruciate ligament located within the knee that helps stabilize the entire leg. Also, this ligament serves to protect the knee from awkward flexion or extension. The purpose of this issue brief is to explain why this injury occurs among football players and which positions are more susceptible to this injury. Additionally, this research paper will provide a thorough description of risk factors that may lead to this horrible injury.

This information could be useful for athletic trainers as well as physical therapists in working toward the prevention of this type of injury. Moreover, this issue brief will prove how important it is for all athletes, not just football players, to take the recovery process seriously in order to keep their bodies performing at an elite level. Finally, this research essay will address roughly how long the recovery process takes and how the advancement of technology plays a part in this ordeal.

Keywords: Anterior Cruciate Ligament, football, male athletes, return to play, injury, confidence interval, chop block

ACL Injuries Among Football Players

An anterior cruciate ligament (ACL) injury can be considered one of the most prevalent injuries in football. This sensitive ligament is crossed in the front of the knee and is attached to the femur bone of the leg. The ACL can be severely damaged due to the high rate of play and high intensity of football. Furthermore, there are many quick changes of movement and direction during football plays which could lead to an uncomfortable sensation in the knee. Not only can change of direction affect this ligament, direct contact can also lead to injury. A direct hit or force inhibited among the knee could potentially lead to this injury. Due to the prevalence of this injury in football, it is important to learn who is involved and affected, how this injury can be prevented, and how long the recovery process takes.

Stakeholders

There are a multitude of populations that can ultimately be affected by this particular injury. First and foremost are the athletes and individuals dedicated to the game who are highest risk of being affected. They are the ones who have to undergo the extensive healing process and this injury could affect their chances of playing again. Any athlete who falls victim to this injury is faced with possible life changing outcomes.The average healing process after an ACL injury could range from six to nine months. The chances of returning to play at a high level in the National Football League (NFL) are severely reduced after sustaining an ACL injury.

Secondly, General Managers of professional football teams would be devastated if a player on their team is ineligible to play due to this injury. General Managers normally hold the role of overseeing the players of the team. In line with this position, the president of football operations would be someone that focuses on all other parts of the organization and making sure that the company is successful and generating revenue. When a player gets severely injured this could negatively affect ticket sales, therefore resulting in the decline of game attendance.

Furthermore, coaches of the team would be directly affected in the instance of injury. Once one of their starting players gets injured they will have to resort to the second string, meaning a player who is not as skilled in the game would take the place of the injured player. This implementation of the second string player to play the game could affect the teams overall dynamics and thus change the teams standings within the league.

Another population that may be affected by this horrible injury is Private Equity or Venture Capital firms who directly invest money in a professional football team. These prestigious firms have the luxury of setting aside a portion of money to help the professional team in any way they feel is necessary. If a single player, or multiple players, are sitting out due to injury, this may result in the team not performing to their highest potential. Unfortunately, this could then be considered a bad investment for the private equity or venture capital firms if the football team is not succeeding during the regular season.

Issue History

Emergence and Chronology

Cruciate ligament injuries have a rich history that can date back as far as the Egyptian times. In the early years, the citizens were searching for a successful way of reconstructing the knee. During the Roman era males were very active and held their physique to a high standard. Injury was quite common, thus the need for rehabilitation was crucial. “Claudius Galen, a Greek physician in the Roman Empire, was the first to describe the true nature of the ACL” (Davarinos, O’Neill, & Curtin, 2014, pg 1). The ACL is one of the most important ligaments located within the knee to prevent abnormal movements. By analyzing the actions and way of living of those in ancient times and by researching more about this injury, there has become an increased awareness of this injury. The first ACL reconstruction surgery was eventually performed in 1900. The results of this procedure were adequate, however no other information was given post operation. Three years later, in 1903, a 41-year old miner was diagnosed with both an ACL and posterior cruciate ligament rupture. After a full repair, which consisted of fixing the cruciate ligament, the patient was directed to spend a few weeks of immobilization. By following the doctor’s recommendation, the patient experienced a full recovery. As more research has been conducted and with the advancement of technology, many surgeons have been able to brainstorm new ways of rehabilitation. There are nine different types of ACL reconstruction but only a few are noteworthy, due to whether or not the procedure was successful or not.

Due to the prevalence of this injury in football there has been various steps in order to prevent ACL injuries from happening in the future. There have been added restrictions on what plays and certain movements are acceptable. The chop block is a football maneuver where one offensive player blocks an opponent around the thigh while another offensive player drives toward the same opponent above the waist. During the 2016-17 season the National Football League(NFL) declared the chop block illegal. Chop blocks have been analyzed and have been questioned for the cause of injury among offensive and defensive linemen (Baker, Varelas, Shi, Terry, & Tjong, 2018). However, with the installation of this new rule, there has been a notable decrease in ACL injuries among these athletes.

Trends

Due to the increase of ACL injuries, there has inevitably been an increase of public awareness. Two hundred and nineteen football players have experienced an ACL injury from 2010-2013 (Secrist, Bhat, & Dodson, 2016). Due to the number of players injured, athletic trainers, coaches, teams, stakeholders, and fans are all becoming more aware of this awful injury. With the development of new media, information regarding the status of athletes’ injuries are is always readily available. Social media has become the most popular way to receive information about professional athletes alongside the news and television. Broadcasting this information allows the public to stay up to date not only about their favorite teams, but the injury and anatomy behind it. There are various grades when it comes to the ACL injury. It can range from a grade 1 to grade 3. A grade 1 injury is less severe when compared to a grade 3 which would require surgery to repair the entire tear of the ligament. This information is useful for up and coming athletes to know that this injury is a threat and it will be useful for physical therapists to know how long the athletes recovery process will take. There is continuous research being conducted to this day in order to differentiate the grades of the injury as well as prevention of the injury all together.

According to Verstegen, Falsone, Orr, and Smith, (2012) they emphasize the importance of taking the recovery process seriously post operation. Some of the key symptoms that show an athlete is close to being ready to return to play is absence of pain, and swelling of the knee (Verstegen et al., 2012). This study also concludes that the athlete must not experience any pain before activity as well as after. Additionally, by strengthening the quadriceps and hamstrings may lead to the gradual recovery of the entire leg and knee. In doing so, the knee stability will increase (Verstegen et al., 2012). By taking the necessary steps and following the recovery protocol from a given doctor or team trainer, this could lead to a full recovery post ACL surgery.

With the advancement of technology it has become increasingly easier to try different tests on the athletes to detect the injury. Likewise, with new technology this may help in the forms of rehabilitation. The Magnetic Resonance Imaging (MRI) is the most common way to detect an ACL injury because it is more reliable than a normal x-ray. An MRI has the capability to take a detailed image of all ligaments, bones, cartilage and tendons within the knee. However, there is more research that needs to be conducted in order to solve this ongoing issue of injury among football players.

Issue Defined

Problem

ACL injuries are a possible threat to many athletes. Specifically in football, there are a few factors that can lead to this type of injury. Two of these risk factors include the playing surface and quick change of direction during performance. The first risk factor is the playing surface, which plays a crucial role when it comes to an ACL tear. A solid, pristine, well maintenanced field is important for athletes to reduce their risk of any injury during a game. Most documented injuries occur on grass surfaces when compared to artificial turf. Although most NFL teams have turf fields, grass creates more friction and athletes have a higher chance of their cleats getting stuck in the ground during play. Quick change of direction, the second risk factor, is where most injuries are obtained. ACL injuries have been most documented during games because of the high intensity and high pace in which movements are performed. Furthermore, these risk factors can affect which players among the roster experience the injury more than others. The players who are more prone to suffer from this common injury are defensive and offensive linemen. “These athletes are particularly susceptible to sustaining an ACL tear due to the demands and risks of their position, such as twisting of the knee, getting pushed forcefully to the ground, and getting rolled up on from behind.” (Cinque, Hannon, Bohl, Erickson, Verma, Cole & Bach, 2017, p. 2). The positions that may be considered more demanding are the ones who may experience this injury more than others. Although there is a significant amount of information about the injury, there is little research available on ACL injury prevention.

Extent

Football, along with basketball and soccer, is one of the most popular sports among male athletes. The NFL may be well known nationwide due to the media attention that it receives. Unfortunately, each year there are more than 200,000 ACL injuries in the United States (Cinque et al., 2017). The risk of sustaining an ACL tear is significant for athletes who play high-level contact sports that require cutting and pivoting. Specifically in the NFL, ACL injuries account for 2% of all injuries that the athletes undergo in a season (Cinque et al, 2017).

Due to the increased participation in the NFL, it is recorded that 8% of all football players at the NFL combine have a history of an ACL injury (Einstein, Rawicki, Rensing, Kusnezov & Lanzi, 2016). Research has been conducted to speculate whether or not most NFL injuries occur at the beginning of the season or further into the season. Einstein et al. (2016) conducted a study to show the distribution of when players were injured. The methods of this research were conducted by analyzing a total of 92 NFL players who were injured between 2013-2015. The results of the study show that “80.4% sustained ACL injuries requiring ACL reconstruction early in the season, which was defined as the preseason through week 8 of the NFL season” (Einstein et al., 2016, p. 2). However, only “19.6% sustained ACL injuries late in the season, defined as week 9 through the end of the NFL playoffs” (Einstein et al., 2016, p. 2). The research conducted for this study show that those recurring knee injuries were seen in 17 players, while the other 75 NFL players were reported as having only one ACL injury. This study concludes that return to play could be reliant on the time of the injury which may affect the alloted time necessary for recovery. This study also concludes that there is a lower chance of returning to play in the NFL when compared to other professional sports.

To build upon the previous study, Yang, Hodax, Machan, Secrist, Durand, Owens, Eltorai and Dodson, (2017) were able to explain the differentiation of the various positions in football. The positions were separated into two categories based on the demands required of each position. The researchers were able to characterize “skilled” positions as running backs, fullbacks, wide receivers, quarterbacks, tight ends, cornerbacks, linebackers, and safeties (Yang et al., 2017). The researchers were then able to characterize “unskilled” positions as offensive tackles, guards, centers, defensive tackles, and defensive ends (Yang et al., 2017). The methods of this data were conducted by observing the athletes who experienced ACL tears between 2010-2013. The results of the study show that offensive and defensive lineman who were drafted earlier had a lower return to play rate when compared to the skilled players who were drafted early (Yang et al., 2017).

Along with the time frame of when the players experienced an injury, it is important to understand which players are more susceptible to this injury. The methods of this research were conducted by maximizing the number of athletes observed to increase the range of data collected. The results of the study reflect that 81 offensive and defensive NFL linemen who tore their ACL also underwent an ACL reconstruction between 1980 and 2015 (Cinque et al., 2017). This study also mentions the relationship between body mass index (BMI) and the chances of experiencing an ACL injury. NFL linemen who have a higher BMI are more susceptible to an ACL injury while also taking into consideration the physical demands of their position (Cinque et al., 2017) This study concludes that the offensive and defensive lineman played significantly less games after experiencing an ACL injury.

Although offensive and defensive lineman may be more susceptible to this injury, any player could have this tragedy happen to them during competition. Dragoo, Braun, Durham, Chen, and Harris, (2012) found that the ACL injury rate during games (95% CI) was significantly greater than the rate during practice. During competition, adrenaline is pumping and there is more of a chance of something going wrong because of the high pace of play. By looking at the methods of this research they were able to conclude that players were approximately 10 times more likely to sustain an ACL injury in competition when compared with practices. Furthermore, ACL injuries could be caused due to the surface that the players are on. Dragoo et al. (2012) concluded that there was an incidence rate of 1.73 ACL injuries on artificial playing surfaces compared with a rate of 1.24 on natural grass.

Players and organizations must be aware of the many risk factors that lead to an ACL injury. Although many researchers are finding ways to prevent this injury, the recovery time is still extensive. This injury is severe and can negatively impact any professional team. The previously stated results prove how significant ACL injuries are and that there is an urge for change.

Policy Implications

There are many changes that need to be made within the league itself to prevent this tragic injury from happening so often. However, the decision to create the rule in order to ban the chop block was one step in the right direction to prevent the ACL injury from happening. In doing so, less players, whom are offensive or defensive positions experienced an injury. When these particular players suffer this injury they must either get tested to determine if they need surgery or sit out from playing. This affects the dynamics of the team and overall standings. However, there must be more research done on whether or not the chop block was in fact tied to ACL injuries. There is some speculation that this rule was to ban concussions from occuring in football.

Discussion

ACL injuries are common among many sports, but football has been affected the most. Offensive and defensive lineman have suffered this injury the most due to the requirements of their position. There are several risk factors that can lead to this injury ranging from playing surface as well as performing during high intensity competition. Moreover, there are specific players that may be more susceptible to this type of injury. There are various ways of rehabilitation to repair this potentially career ending injury. Athletes must take the recovery process seriously in order to increase their return to play rate. With the installation of new rules and regulations within the National Football League, as well as athletic trainers working diligently, there is a higher chance they can prevent this injury from being so prevalent.

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