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The Emerging Crisis of ACL Injuries in High School Sports

 

Nicholas A. Corso MS, CPT, CES, PES

Legendary Athletes, LLC

 

Abstract

In the world of high school athletics, there appears to be an increasing trend in the volume of Anterior Cruciate Ligament (ACL) injuries.  In this paper, the author examined this disturbing trend and discusses the problem, possible reasons for the problem, and potential solutions to ameliorate this unfortunate direction of this injury in youth sports.

The Emerging Crisis of ACL Injuries in High School Sports

A recent study, conducted by the Sports Medicine and Performance Center at Children’s Hospital of Philadelphia, and published online in Pediatrics, begins to shed some light on one of the most disturbing trends in youth sports today.   Young athletes (and parents of young athletes) who are (or have young athletes) who wish to compete in high intensity level athletics, and possibly even compete for a spot in their sport at the next level of college athletics, should sit up and take notice.

This study outlines the alarming rate at which ACL injuries are becoming one of the most predominant injuries currently in youth sports.  This study has confirmed that ACL injuries in children and adolescents are on the rise. The study authors found a 2.3 percent annual increase from 1994 to 2013 in the number of ACL tears in patients 6 to 18 years old. Females had significantly higher rates of injury in the younger ages, while males demonstrated higher incidence in the 17-to 18-year-old age group (Ganley, 2017).

This may or may not become a problem for some student athletes unless it derails their plans to compete in their sport at the next level of collegiate competition.  As we have said many times at Legendary Athletes, the business of recruiting, in high school to college athletics, has exploded.  One merely needs to take a look at the proliferation of websites, services, mentors, coaches, trainers, tournaments and camps dedicated to gaining exposure for college-bound high school athletes and listen, even not so closely, to the conversations of parents in the stands at local high school sporting events.

In Division I schools alone, nearly 350 colleges and universities field more than 6,000 athletic teams, and provide opportunities for more than 170,000 student-athletes to compete in NCAA sports each year (NCAA, 2015). Couple this opportunity with the costs of a college education ranging between $24,061 per year, for a moderate in-state college budget, and $47, 831 per year, for a moderate private college budget, and no wonder the conversations of parents with high school aged children are so focused on the subject (Collegedata, 2016).

Many young male and female student-athletes grow up dreaming of playing sports in college and the pro ranks. But, of the nearly 8 million students currently participating in high school athletics in the United States, only 480,000 of them will compete at NCAA schools. And of that group, only a fraction will realize their goal of becoming a professional athlete.

The world of youth sports today is more competitive than at any time in the past and this direction certainly shows absolutely no signs of abating. Athletes today are bigger and stronger than they have ever been before and the proliferation of strength training programs for youth and high school students has literally exploded in order to allow our young athletes to gain a competitive advantage.

However, here’s the problem: In the rush to remain competitive and to get our young athletes bigger and stronger, high schools across the country have unknowingly begun implementing one dimensional, strength training programs.  These programs are most often focused on high intensity, hypertrophy-based training regimes built to create as much muscle mass, strength, and power as possible, within the shortest amount of time.  While the visible results of such strength programs look good on the surface (high school athletes now look like Division 1 college athletes), the problem is that these programs circumvent crucial components of what it takes to properly train elite, high intensity athletes. These one-dimensional programs are quite likely a major contributor in the creation of mechanical or neuromuscular imbalances that are known to increase the risk of injury.  In many instances, these injuries can prove to be career altering, if not ultimately, career ending.  Unfortunately, when it comes to the world of athletic recruiting in high school sports, these injuries can cause college recruiters to reevaluate what otherwise might have once been an easy decision. This type of one-dimensional, maximal strength and power training tends to create two major problems:

  1. Without coaches having the proper training, expertise, and education, they quite likely lack the ability to evaluate, identify and quantify the mechanical and neuromuscular imbalances that are potentially developing. The sole use of traditional strength and power training models highly likely to continue to create new inefficiencies and compensations – while simultaneously continuing to exacerbate existing inefficiencies and imbalances.
  2. It will build and strengthen skeletal muscle at a much faster rate than the connective tissue can support.

Both of these scenarios will lead to greater risk of injury which can ultimately lead to career altering consequences for high school athletes.

According to Dr. Michael Clark, team physical therapist for the NBA’s Phoenix Suns, former CEO of the National Academy of Sports Medicine, and current founder of Fusionetics Health Science, there is a proper progression that must be followed when training athletes who compete at high intensity levels of athletic competition.  Shortcutting or circumvention of this progression puts athletes at significant risk of injury.

“The body must progress through progressive stages of adaptation to ensure that all of the necessary tissues are developed properly to meet the desired goal.  Connective tissue adapts much more slowly than muscle but also must be strong in order for muscles to generate high levels of tension.  If emphasis is placed on training muscles to get big, strong, or both, the absence of prior training that will also allow connective tissue to increase in strength, will increase risk of injury.

Remember that type I muscle fibers, which are vitally important to postural stabilization, function differently than type II muscle fibers.  In order to train with higher intensities, proper postural stabilization is a necessity.  Therefore, both fiber types need to be trained specifically to prepare them to support higher levels of training. (Clark & Lucett, 2010, p. 258)”.

While we ultimately seem to be gaining a much better understanding of the “scientific” (mechanical and neuromuscular) causes of ACL injuries, recent figures presented by the National Strength and Conditioning Association (NSCA), in combination with the experience and findings of Dr. Michael Clark, may have inadvertently shed some light on what we will refer to as the “societal” cause to the rise in ACL injuries in youth and high school sports.

Although data on the issue is still in its infancy, according to one estimate by the National Strength and Conditioning Association, “there are approximately 1000 certified strength and conditioning coaches currently training student athletes at the high school level – a fairly meager figure considering there are close to 25,000 high schools in the United States. (Steinbach, 2017).

As if this statistic isn’t troublesome enough, it is further complicated by the fact that just because a high school’s strength coach is certified by an accrediting body, it doesn’t mean they possess the specific knowledge on how to train youth athletes.  “Working with student-athletes, who are going through growth spurts, is not the same as working with a college or elite-level athlete who has finished growing. The coach must take into consideration that a growth spurt will cause the limbs to get longer, which means balance, coordination and movement patterns will be affected” says Patrick McHenry, head strength coach at Castle View High School in Castle Rock, Colorado.

To complicate these findings further, like most things in a competitive world, success breeds imitation. In the rush for competing high school programs to proclaim that they too offer a strength training curriculum, they may very well be continuing to exacerbate the disservice done to student athletes.  This is particularly notable in cases where a school’s trainer, or coach, does not possess complete or correct knowledge, training, and understanding of the entire fitness continuum or progressions required to properly train high intensity athletes. In such instances, many high school programs will seek an alternative solution. Many schools have no other option than to seek to level the competitive playing field by shifting strength training responsibilities to either an untrained PE coach, a team assistant coach, an un-certified trainer (who may have some personal experience in strength training), or perhaps even shift this responsibility altogether to an off-campus/outsourced trainer.

Laine Blyn, head Olympic sports strength and conditioning coach at Appalachian State University, identifies the problems created when such an option is pursued.  “A sport coach knows how to coach their respective sport – soccer, field hockey, football, not necessarily how to enhance athletic performance through speed, strength and conditioning programming” or worse yet, “Just because a coach or teacher has lifted does not mean they understand pediatric exercise physiology and can apply it to their students.” (Steinbach, 2017).

As the world of high school athletics has grown over the years, the requirement for athletic programs to remain competitive drives them to offer strength training programs whose primary metric is outward appearance; this is, of course the most easily observed result – building bigger and stronger athletes in the shortest amount of time possible (and quite possibly during one of the most vulnerable period of time in their lives; puberty).  The cost we are asking our young athletes to pay, while succumbing to these “societal” pressures of competition, may be greater than we realize.
To illustrate this point further, while writing this paper, the author came across the following program offered to 6-8 graders by a major high school powerhouse football program:

Description: Open to 6-8 graders, Jr. High weight room camp teaches the fundamentals and proper techniques of power lifting necessary to gain a competitive advantage at the high school level.”

This example serves as direct testament to the fact that there are both “scientific” causes and “societal” causes at play when it comes to injuries caused by the lack of understanding or ability to implement proper training progressions for training young athletes.

In a personal conversation the author of this paper had with Jon Lee, head strength and conditioning coach of the World Champion Toronto Raptors, Jon made the statement that “power lifting is a sport, in and of itself, for which athletes train.”  Unfortunately, in many high school programs, powerlifting has now become the defacto training regimen upon which they rely with a primary (and reckless) focus on getting their athletes as big and strong as possible within the shortest amount of time.

The fact is that our young athletes are being subjected to one-dimensional strength training programs for a multitude of problematic reasons:

  1. They produce the most visible results in the shortest period of time
  2. There has been such a high premium placed on securing athletic scholarships
  3. Programs simply just don’t know any better.
  4. Trainers who possess the knowledge to deliver correct programming are expensive and in short supply.

Solution

As Allen M. Joseph at the Center for Injury Research and Policy at Children’s Hospital in Columbus, Ohio points out

“Coaches and Athletic Trainers, in sports with high rates of ACL injury, should take special care to teach sport-specific skills (e.g. planting and changing direction, jumping and landing) and address potential deficits in the neuromuscular strength and coordination of the stabilizing muscles around the knee joint through stretching, plyometrics, and strength training drills.” And most importantly, “Effective targeted prevention programs must be evidence based to address modifiable risk factors.” (Joseph & Collins, 2013).

The road to proper training for our young athletes takes time and should integrate a comprehensive performance training progression that will train athletes properly; thereby reducing the risk injury.  In most instances, athletic injuries are caused by mechanical and/or neuromuscular inefficiencies and compensations brought on by improper or incomplete training programs and the lack of available evidence-based programming aimed at identifying and correcting these inefficiencies BEFORE they sideline an athlete with an injury.

The proper off season or pre-season training should systematically progress through the phases of stabilization training and balance training (designed to strengthen the core stabilizers and connective tissues), and hypertrophy training PRIOR to jumping head-first into an immediate focus of maximizing strength or power.  Properly designed programs should provide for integrated multiplanar movements that include acceleration, deceleration, and stabilization training as opposed to, and in conjunction with, traditional strength training which focuses primarily on absolute or maximal strength gains in isolated muscles (chiefly the prime movers) throughout single planes of motion. It should make sense to any athlete, trainer, or athletic coach that normal human functional movements occurs naturally in multiple planes of motion, not in a single plane of motion, and training should be based on such.  According to Clark and Lucett,

“The central nervous system (CNS) is designed to optimize the selection of muscle synergies to perform integrated movement patterns in all three planes of motions.  Therefore, if the human movement system is designed to move in all three planes of motion, isolated training (in a single plane of motion and focused on prime movers) does little to improve over-all athletic performance” (Clark & Lucett, 2010, p. 4).

At Legendary Athletes, we understand the importance of how a proper progressive training program helps our young athletes improve and, more importantly, what it helps to avoid.  Because of this, we have very selectively chosen to partner with world class companies who only deliver evidence-based programs in the areas of sports nutrition, biomechanical movement, and speed training.  We believe that, when it comes down to the business of athlete development, and high school to college athletic recruiting, EVERY competitive edge that an athlete can integrate into his/her training should be implemented.  We believe that proper nutrition can make a good athlete great and a great athlete better.  We believe that an athlete who trains across a complete and progressive spectrum will be a better over-all athlete and more importantly, an injury averse athlete.  We also believe that speed is one of the most highly coveted skills an athlete can possess in the world of competitive sports and, as a skill, speed can be taught, learned, and developed.

To that end, Legendary Athletes provides solutions to young athletes, high school coaches, and college coaches that are aimed at building better athletes and, in turn, better college recruits.  Recently, Legendary Athletes has added the National Academy of Sports Medicine (NASM) to its hand-picked list of strategic partnerships.  Through this partnership, youth and high school athletes, high school coaches, and college coaches can actively search for certified trainers who are skilled in training athletes at all levels, from youth to the pros. This functionality is located within the Legendary Athletes website (legendaryathletes.com) under the “Train” Like the Pros tab.  Access to this service requires the athlete, parent or coach to register at LegendaryAthletes.com.

In addition to the partnership with NASM, Legendary Athletes also brings a strategic partnership with Dr. Mike Clark and Fusionetics Health Systems.  In this part of the website, under the “Move” Like the Pros tab, athletes can access two levels of biomechanical assessment that will assist them in identifying and correcting movement inefficiencies and compensations.

The first level of this assessment is FREE to all of Legendary Athletes’ registered users.  In this digital assessment, users are asked to complete a comprehensive and confidential biomechanical health questionnaire.  The result of this questionnaire will deliver to each athlete a personalized corrective exercise program designed to Inhibit, Lengthen, Strengthen and Integrate overactive and underactive muscles/muscle groups targeted at helping each athlete to address compensations caused by previous injuries, and will also suggest corrective measures.  The deliverable at this FREE level of access is a color coded, numerical scoring system which identifies likely areas of inefficiency in the body and an individualized corrective exercise program – complete with video instruction.

The second level of access to this program under the ”Move” Like the Pros tab, provides Legendary Athletes’ registered users with the optional upgrade (purchase required if the user chooses to take advantage of this upgrade) to a personalized, practitioner driven, biomechanical assessment utilizing the latest in artificial intelligence, motion capture and body mapping. The result of this practitioner driven movement assessment will deliver to each athlete a personalized corrective exercise program designed to Inhibit, Lengthen, Strengthen and Integrate overactive and underactive muscles/muscle groups helping each athlete to address compensations caused by current muscular and neuromuscular inefficiencies.  The deliverable at this level of access is a color coded, numerical scoring system which identifies current inefficiencies and compensations in the body, and an individualized corrective exercise program – complete with video instruction.  See example below.

Legendary Athletes utilizes the latest in evidence-based science with one thought in mind, the health and betterment of our young athletes.  We provide solutions that help young athletes, high school coaches, and college coaches in the hopes of building stronger and healthier athletes; and athletic programs that educate, build, and protect their athletes to the greatest extent possible.

References

Ganley, T. J. (2017, April 27). What are the Odds of Tearing Your ACL in the Sports You Play? Retrieved from http://www.chop.edu/news/what-are-odds-tearing-your-acl-sports-you-play

Clark, M. A., & Lucett, S. C. (Eds.). (2010). NASM Essentials of Sports Performance Training (p. 258). Baltimore: Lippincott, Williams & Wilkins.

Clark, M. A., & Lucett, S. C. (Eds.). (2010). NASM Essentials of Sports Performance Training (p. 4). Baltimore: Lippincott, Williams & Wilkins.

Steinbach, P. (2017, May 1). The Case for High School Strength Coach Hires. Retrieved from http://www.athleticbusiness.com/high-school/the-case-for-high-school-strength-coach-hires.html

Joseph, A. M., & Collins, C. L. (2013). A Multisport Epidemiologic Comparison of Anterior Cruciate Ligament Injuries in High School Athletics. Journal of Athletic training.

* Image above courtesy NASM (National Academy of Sports Medicine)