Tuesday Tips: ACL Injury Prevention In Ultimate [Pt. 1]

The data is clear: we can substantially lower the risk of tearing an ACL with a proper prevention program.

Too many ultimate players have direct or indirect experience with ACL injuries. Photo: Rodney Chen -- UltiPhotos.com
Too many ultimate players have direct or indirect experience with ACL injuries. Photo: Rodney Chen — UltiPhotos.com

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In the dialogue of orthopedic surgery, ultimate is underrepresented. The inverse is true too — there aren’t widely available resources for ultimate players on the medical and surgical aspects of the injuries we sustain. Ultimate has the most high-speed changes of direction of any sport, both within a single game and especially over the course of a weekend. Those cuts put huge stresses on the joints, making injuries an obvious part of the sport (Hess 2020). Clearly, ultimate players deserve resources providing knowledge about musculoskeletal injuries.

The best starting point is ACL injury prevention. Athletes and orthopedic sports medicine surgeons alike have a huge focus on ACL tears because, 1) they’re quite common, 2) they have a long recovery period, and 3) they’re associated with future injury. We’ve all had teammates or personal experiences with them and know how impactful they are on an athlete.

The good news: ACL injuries are partially preventable. At the least, we can substantially lower the risk of tearing an ACL. The data in the orthopedic surgery/physical therapy/athletic training literature supporting prevention programs is excellent. Yet these programs aren’t performed widely.

ACL injury prevention is best achieved by training programs that combine multiple elements – plyometrics, balance, strengthening, neuromuscular training, and coaching to improve form. Most often they take 15-20 minutes, to be done 2-3 times weekly (more in preseason, less in season), for at least 2-3 months but ideally all season.

The Data

Here’s a deeper dive into the data, but, in short, these programs work. Meta-analyses (studies of many studies combined) show a 50-60% reduction in ACL tears by using an ACL injury prevention program (Myer 2013, Webster 2018). A landmark paper on prevention showed the biggest reduction, with rates of ACL tears 4-9 times lower among teenage female soccer players doing a prevention program (Mandelbaum AJSM 2005). The ‘number needed to treat,’ or the number of people that need to do the program in one season to prevent one ACL tear, has been shown to be 70-120 (Silvers-Granelli 2015, Sugimoto 2012). That means about three ultimate teams need to do a program to prevent an ACL tear in a single season. That number shrinks dramatically if you look at an entire college or club career.

A quick primer on why these programs work: ACL injuries occur from the tibia (leg bone) moving forward and rotating inwards relative to your femur, alongside the knee caving inwards (valgus collapse). This can be prevented by strengthening stabilizing muscles (e.g. your hamstrings, which pull the tibia backwards), training your neuromuscular system to fire those muscles appropriately, and teaching good body mechanics that prevent your knee from falling into at-risk positions like caving inwards. The only way to train these things is to do exercises consistently over a period of time while reinforcing good form.

Injury prevention programs can address more than just the ACL. They’ve shown success preventing hamstring, ankle, and other knee injuries — even better than preventing ACL injuries, given that those other injuries are much more common. Looking at the reduction of all injuries, the FIFA 11+ program led to a decrease from 20 injuries per team to 11 injuries per team in a single men’s NCAA soccer season, and the number needed to treat was three (Silvers-Granelli 2015). For every three athletes doing the program, an injury was prevented that season. As further evidence, Nordic hamstring exercises alone decrease the risk of hamstring tears by 50-70% in both amateur and elite soccer players (Al Attar 2017, van der Horst 2015).

Implementing Injury Prevention Programs

If the data is so clear, why aren’t these programs used more widely? It’s a key question. The primary barriers to implementation are buy-in from athletes and coaches, time, a lack of training expertise or form coaching, and cost. Compliance from athletes and teams is the biggest one — in order to warrant the time and energy that it takes to commit to these programs, they need to highly value the benefits they offer.

The next question is how to overcome those barriers. First is teaching ultimate players and coaches the benefits of these programs. In my eyes, the data above speaks for itself. While lifting and running sprints logically help athletes with their game and often receive our focus as players, an argument can be made that avoiding injury is the single most impactful physical thing a player can do for their team. Next, time is a substantial factor. I get it — we all have stretching or rolling or PT exercises that we could be doing more often but don’t, whether due to time or motivation. We need to find a time to do a prevention program. Lack of expertise and cost are lesser obstacles. We can give you free guidance to do these programs well. They’re no substitute for trained in-person coaching, but these programs are a good start.

In my mind, the best way to make injury prevention programs happen is to make them routine. Making them part of a warmup, something that most ultimate players do multiple times a week regardless of what the warmup is, can ensure that players build in time for them. This is slightly more challenging because the routine must double as an appropriate warmup that gets athletes ready to play without overtaxing them. Therefore, it may not be the perfect prevention program or the perfect warmup. But it can do a very good job of both of them.

Good Form

A large part of why ACL injury prevention programs work is because they teach athletes how to jump, land, and take off with good form. Therefore, the athlete must deliberately perfect their form every time they do the program, especially with all jumping and cutting exercises.

Likely the most important part of good form is preventing the knee from caving inwards. The cue here is ‘knee over toes’ or ‘knee over ankle.’ The error is most often seen when landing from a jump or when cutting. This is a very high-risk position for the knee during a high-stress activity.

Other important pieces of good form are to ‘land softly’ on the ball of your foot before the rest of your foot comes down. This greatly cushions the landing, leading to decreased forces through the knee joint. Landing with a bent knee and slightly bent hip also protect the ACL. The feet or foot should land between your shoulders; wider than this has been shown to put more strain on the ACL.

Take-away cues: Knee over toes, not caving in. Land softly on the ball of the foot. Land with a bent knee and hip.

Next week: the foundation of a good ACL injury prevention program.

  1. Ian Engler
    Ian Engler

    Ian Engler is an orthopedic surgery sports medicine fellow at the University of Pittsburgh. He plays ultimate with Boston Wild Card and the Boston Glory.

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