How Can We Improve ACL Injury Recovery in Females? A few research principles.

Best practices for management of post-rehab training of an ACL injury in females. First, we will focus on making sure the athlete is ready for return to sport (RTS) after the rehab. We need to make sure their body and mind can exceed the capacity and demands needed in their sport. Currently, a metanalysis found that only about 69% of female athletes can return to their previous sport and 79% of elite females return to their sport with literature lacking on reasons for the high rates of those who do not return to sport especially compared to their male counterparts (Figueroa, Figueroa & Figueroa, 2024). One reason why it has been document that the athlete will not return to sport is due to psychosocial factors. For example, fear-avoidance behaviour, fear of reinjury, or lack of confidence in their knee has interfered with RTS outcomes (Figueroa, Figueroa & Figueroa, 2024). Therefore, proper usage of some fear avoidance questionnaires (like the FABQ) might be helpful for understanding the patient’s beliefs and work through them empower the patient to self-efficacy and participation. A cognitive behavior therapist could be recommended.

Soccer has one of the highest rates of female ACL injuries, therefore, the following document referenced is the recent international return to sport consensus for soccer athletes. Below are some of the most important considerations and conclusions by Figueroa et al. (2022) of their consensus regarding goals and criteria for clearing the athlete for RTS in soccer:

·       Create an environment that creates a high level of motivation for the athlete; incorporate them into active goal setting improves self-efficacy. In this report, there was a unanimous agreement that psychological status should be a “critical” decision to clearing the athlete to RTS.

·       Focus on symmetrical strengthening of the hips, hamstrings, adductors, and quadriceps, along evaluation of dynamic control of takeoff, landing and running mechanics to reduce possible recurrence. Goal of creating 90-100% of symmetry compared to unaffected side since association of a second ACL injury is increased when asymmetry of strength and jumping/ landing mechanics are <90% versus uninjured side.

·       Furthermore, there can be false positives for reaching symmetry of performance if the uninjured side has subpar levels of neuromuscular control, strength, and jumping mechanics. Thus, an evaluation should be assessed to ensure the unaffected side is not below the capacity necessary to safely participate in the sport.

·       Progressive strength training is also recommending for increase RTS rates while simultaneously decreasing risk of subsequent ACL injury with goal of reaching strength standards of uninjured players in about 7 months post-injury.

Regarding interventions to reduce ACL injury recurrence would involve both physical training, training/ workload management and considerations of the female cycle. Hayward et al. (2024) explains that in the context of elite female rugby players, ACL tears were more prevalent in the days around their period (i.e. the few days prior to onset or during menses). Multiple mechanisms explain why this phenomenon occurs. According to their study, 87.8% of players reported their training and playing performance is affected during the period part of their cycle. First, the psychological preparedness of the athletes themselves is diminished during this part of their menstrual cycle with athletes reporting to feel more difficult to concentrate, less motivation to train/ play. Physical fatigue and feeling less explosive were reported. Overall, the players subjectively rated their performance as the worst when on their period. Therefore, to prevent recurrence of ACL injuries, we should customize their playing and training loads to be the lowest volume, intensity, and reduce ballistic exposure around the period so stresses on passive tissues, like the ACL, are not risking a failure point. Secondly, studies also suggest that hormone relaxin peaks the few days before the period begins which leads to ligaments, namely the ACL, to increase in laxity, predisposing to injury around this time in the menstrual cycle or shortly after (Berger et al., 2023).

Since statistically females are 2-9x more likely to have an ACL injury vs male in the same sport, therefore effort and precision in training interventions should be a priority when working with female athletes. As previously mentioned, if the athlete is afraid of reinjury or lack of confidence to perform it can affect prognosis. However, it can also pre-dispose to repeat injury since this demographic tends to have stiffer jumping and landing mechanics (Figueroa, Figueroa & Figueroa, 2024). Thus, again we should be evaluating the psychological components of the athlete and comanage if necessary to a therapist or similar professional. Reinforcement of the psychological importance is exemplified as males have higher levels of RTS and male’s self-reported psychological readiness has been found to be the most significant factor in predicting subsequent RTS and athletic performance (Figueroa, Figueroa & Figueroa, 2024).

References:

Berger, G. K., Rockov, Z. A., Byrne, C., Trentacosta, N. E., & Stone, M. A. (2023). The role of relaxin in anterior cruciate ligament injuries: a systematic review. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie, 33(8), 3319–3326. https://doi.org/10.1007/s00590-023-03618-7

Figueroa, D., Figueroa, M. L., & Figueroa, F. (2024). Return to sports in female athletes after anterior cruciate ligament reconstruction: A systematic review and metanalysis. Journal of ISAKOS : joint disorders & orthopaedic sports medicine, 9(3), 378–385. https://doi.org/10.1016/j.jisako.2024.01.008

Figueroa, D., Arce, G., Espregueira-Mendes, J., Maestu, R., Mosquera, M., Williams, A., Parker, D., Cohen, M., Karahan, M., Ochoa Perea, G. A., Zaffagnini, S., Neyret, P., Karlsson, J., Musahl, V., Radice, F., van der Merwe, W. M., Landreau, P., Imhoff, A., Menetrey, J., Ayeni, O. R., … Patnaik, S. (2022). Return to sport soccer after anterior cruciate ligament reconstruction: ISAKOS consensus. Journal of ISAKOS : joint disorders & orthopaedic sports medicine, 7(6), 150–161. https://doi.org/10.1016/j.jisako.2022.08.004

Hayward, E., Akam, L., Hunter, D., & Mastana, S. (2024). Role of the Menstrual Cycle on Performance and Injury Risk: A Survey of Female Professional Rugby Players in the United Kingdom. International journal of environmental research and public health, 21(2), 150. https://doi.org/10.3390/ijerph21020150