Increased occurrence of ACL injuries for football players in teams changing coach and for players going to a higher division

Abstract Purpose To identify football-specific factors associated with ACL injuries that can be targeted for sport-specific injury prevention. Methods A study-specific questionnaire was developed to study the characteristics of ACL injuries in football including intrinsic, extrinsic, and injury specific factors. The questionnaire was available at the Swedish national knee ligament registry’s website for the football players to voluntarily fill out. Data are presented on group level for all football players in total and for females and males separate to examine gender-specific differences. The results are based on answers collected over a 3-year period from 2875 football players, 1762 (61%) males and 1113 (39%) females. Results ACL were more frequently sustained during games 66% than during practices 25%. The injury mechanism was non-contact in 59% and contact in 41%. For the contact injuries during games, no action was taken by the referee in 63% of the situation and a red card was shown in 0.5%. The risk of ACL injury was highest early in the football game with 47% sustained during the first 30 min and 24% in the first 15 min. Players changing to a higher level of play 15% had a higher rate of ACL injuries than players changing to a lower level 8%. This difference was especially seen in female football players with 20% of ACL injuries being sustained by players going to a higher division compared to 7% for those going to a lower division. 15% of the male and 21% of the female ACL injuries occurred in teams with a coach change during the season. Knee control exercises to warm up was used by 31% of the female players and 16% of the males. 40% of the players reported that they did not plan on returning to football. Conclusion Neuromuscular training programs have proven to reduce ACL injuries, but greater adherence to these remains a challenge as only 1 in 5 of the ACL-injured football players report using them. Teams changing coach and players going to a higher division appear to have an increased risk of ACL injury warranting attention and further investigations. Level of evidence IV.

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Neurocognitive and Neurophysiological Functions Related to ACL Injury: A Framework for Neurocognitive Approaches in Rehabilitation and Return-to-Sports Tests

Sports Health A Multidisciplinary Approach ◽

10.1177/19417381211029265 ◽

2021 ◽

pp. 194173812110292

Author(s):

Daghan Piskin ◽

Anne Benjaminse ◽

Panagiotis Dimitrakis ◽

Alli Gokeler

Keyword(s):

Data Extraction ◽

Cruciate Ligament ◽

Injury Rate ◽

Acl Injury ◽

Return To Sports ◽

Level Of Evidence ◽

Acl Injuries ◽

Neurocognitive Functions ◽

Increased Risk ◽

Anterior Cruciate

Context: Only 55% of the athletes return to competitive sports after an anterior cruciate ligament (ACL) injury. Athletes younger than 25 years who return to sports have a second injury rate of 23%. There may be a mismatch between rehabilitation contents and the demands an athlete faces after returning to sports. Current return-to-sports (RTS) tests utilize closed and predictable motor skills; however, demands on the field are different. Neurocognitive functions are essential to manage dynamic sport situations and may fluctuate after peripheral injuries. Most RTS and rehabilitation paradigms appear to lack this aspect, which might be linked to increased risk of second injury. Objective: This systematic and scoping review aims to map existing evidence about neurocognitive and neurophysiological functions in athletes, which could be linked to ACL injury in an integrated fashion and bring an extensive perspective to assessment and rehabilitation approaches. Data Sources: PubMed and Cochrane databases were searched to identify relevant studies published between 2005 and 2020 using the keywords ACL, brain, cortical, neuroplasticity, cognitive, cognition, neurocognition, and athletes. Study Selection: Studies investigating either neurocognitive or neurophysiological functions in athletes and linking these to ACL injury regardless of their design and technique were included. Study Design: Systematic review. Level of Evidence: Level 3. Data Extraction: The demographic, temporal, neurological, and behavioral data revealing possible injury-related aspects were extracted and summarized. Results: A total of 16 studies were included in this review. Deficits in different neurocognitive domains and changes in neurophysiological functions could be a predisposing risk factor for, or a consequence caused by, ACL injuries. Conclusion: Clinicians should view ACL injuries not only as a musculoskeletal but also as a neural lesion with neurocognitive and neurophysiological aspects. Rehabilitation and RTS paradigms should consider these changes for assessment and interventions after injury.

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Anterior Cruciate Ligament Injury Prevention Exercises: Could a Neuromuscular Warm-Up Improve Muscle Pre-Activation before a Soccer Game? A Proof-of-Principle Study on Professional Football Players

Applied Sciences ◽

10.3390/app11114958 ◽

2021 ◽

Vol 11 (11) ◽

pp. 4958

Author(s):

Alessandro de Sire ◽

Andrea Demeco ◽

Nicola Marotta ◽

Lucrezia Moggio ◽

Arrigo Palumbo ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Cruciate Ligament ◽

Acl Injury ◽

Football Players ◽

Professional Football ◽

Activation Time ◽

Exercise Protocol ◽

Warm Up ◽

Anterior Cruciate ◽

Proof Of Principle

Neuromuscular warm-up has been shown to decrease the risk of anterior cruciate ligament (ACL) injury improving muscular firing patterns. All preventive training programs described in the literature have a duration of several weeks. To date, no studies have explored the immediate effect of a neuromuscular warm-up exercise on pre-activation time of the knee stabilizer muscles. Thus, this proof-of-principle study aimed at evaluating the acute effects of a neuromuscular warm-up exercises on the electromyographic activation of knee stabilizer muscles’ activation pattern. We included 11 professional football players, mean aged 23.2 ± 4.5 years, from a Southern Italy football team. All of them underwent a standard warm-up exercise protocol at the first day of the evaluation. At 1 week, they underwent a structured neuromuscular warm-up exercise protocol. We assessed as outcome measure the pre-activation time (ms) of rectus femoris (RF), vastus medialis (VM), biceps femoris (BF), and medial hamstrings (MH) upon landing. Outcomes were assessed before and after the standard warm-up and neuromuscular warm-up. Pre-activation time of RF, VM, BF and MH significantly improved only after neuromuscular warm-up (p < 0.05); moreover, there was a significant (p < 0.05) between-group difference in pre-activation time of all muscles after the neuromuscular warm-up compared with the standard warm-up. These findings suggested that physical exercise consisting of a structured injury prevention neuromuscular warm-up might have an immediate effect in improving the activation time of the knee stabilizer muscles, thus potentially reducing the risk of ACL injury.

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High rate of second ACL injury following ACL reconstruction in male professional footballers: an updated longitudinal analysis from 118 players in the UEFA Elite Club Injury Study

British Journal of Sports Medicine ◽

10.1136/bjsports-2020-103555 ◽

2021 ◽

pp. bjsports-2020-103555

Author(s):

Francesco Della Villa ◽

Martin Hägglund ◽

Stefano Della Villa ◽

Jan Ekstrand ◽

Markus Waldén

Keyword(s):

Acl Reconstruction ◽

Cox Regression ◽

Injury Rate ◽

Acl Injury ◽

High Rate ◽

Football Players ◽

Professional Football ◽

Cox Regression Analysis ◽

Career Length ◽

Increased Risk

BackgroundStudies on subsequent anterior cruciate ligament (ACL) ruptures and career length in male professional football players after ACL reconstruction (ACLR) are scarce.AimTo investigate the second ACL injury rate, potential predictors of second ACL injury and the career length after ACLR.Study designProspective cohort study.SettingMen’s professional football.Methods118 players with index ACL injury were tracked longitudinally for subsequent ACL injury and career length over 16.9 years. Multivariable Cox regression analysis with HR was carried out to study potential predictors for subsequent ACL injury.ResultsMedian follow-up was 4.3 (IQR 4.6) years after ACLR. The second ACL injury rate after return to training (RTT) was 17.8% (n=21), with 9.3% (n=11) to the ipsilateral and 8.5% (n=10) to the contralateral knee. Significant predictors for second ACL injury were a non-contact index ACL injury (HR 7.16, 95% CI 1.63 to 31.22) and an isolated index ACL injury (HR 2.73, 95% CI 1.06 to 7.07). In total, 11 of 26 players (42%) with a non-contact isolated index ACL injury suffered a second ACL injury. RTT time was not an independent predictor of second ACL injury, even though there was a tendency for a risk reduction with longer time to RTT. Median career length after ACLR was 4.1 (IQR 4.0) years and 60% of players were still playing at preinjury level 5 years after ACLR.ConclusionsAlmost one out of five top-level professional male football players sustained a second ACL injury following ACLR and return to football, with a considerably increased risk for players with a non-contact or isolated index injury.

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A Cam Shaped Femur Might Be A Risk Factor for ACL Injuries

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118s00139 ◽

2018 ◽

Vol 6 (7_suppl4) ◽

pp. 2325967118S0013

Author(s):

Thomas Rudolf Pfeiffer ◽

Jeremy M. Burnham ◽

Ajay C. Kanakamedala ◽

Jonathan Daniel Hughes ◽

James J. Irrgang ◽

...

Keyword(s):

Acl Reconstruction ◽

Injury Risk ◽

Roc Analysis ◽

Femoral Condyle ◽

Academic Medical Center ◽

Acl Injury ◽

Control Group ◽

Acl Injuries ◽

Increased Risk ◽

The Mean

Objectives: Bony morphologic characteristics have been demonstrated to increase the risk of anterior cruciate ligament (ACL) injury. While posterior femoral condyle condylar offset is an aspect of distal femoral bony morphology that has been reported to influence range of motion and other aspects of knee joint kinematics, it remains unclear whether this characteristic influences the risk of ACL injury. The purpose of the study was to examine the relationship between distal femoral morphology and risks of ACL injury, reconstruction failure, and contralateral ACL injury. It was hypothesized that increased posterior femoral condylar depth, quantified as the cam ratio, would correlate with increased risk of primary ACL injuries, ACL reconstruction failures, and contralateral ACL injuries. Methods: Consecutive patients undergoing evaluation for knee complaints at an academic medical center from 2012-2016 with minimum 24-month follow-up were retrospectively reviewed. Subjects were stratified into four groups: a control group consisting of patients with no ACL injuries and three groups of patients with a primary ACL injury, failed ACL reconstruction, or previous ACL injury with subsequent contralateral ACL injury. Using lateral radiographs, the ratio of posterior condylar depth over total condylar distance was defined as the cam ratio. Analysis-of-variance (ANOVA) and post-hoc testing were used to test for differences in the mean tomahawk ratio between study groups (p<0.05). Receiver Operating Characteristic (ROC) analysis was performed to determine the optimal cam ratio cut-off for detecting increased risk for ACL injury. Results: One hundred and seventy-five patients met inclusion criteria. The mean cam ratios in the control, primary ACL injury, failed ACL reconstruction, and contralateral ACL injury groups were 61.1% (± 2.1), 64.2% (± 3.8), 64.4% (± 3.6), and 66.9% (± 4.0), respectively. Patients with a primary ACL injury, failed ACL reconstruction, or contralateral ACL injury had a significantly higher cam ratio compared to the control group (p<0.008). ROC analysis demonstrated a cam ratio of 63% or greater to be associated with an increased risk for ACL injury with a sensitivity of83% and a specificity of 71%. Conclusion: The data from this study show that an increased posterior femoral condylar depth, or cam ratio, might be associated with increased risk of ACL injury, including primary ACL injury, failed ACL reconstruction, and contralateral ACL injury. The data from this study may help clinicians identify patients at greater risk of ACL injury and re-injury. Future prospective studies will be helpful in investigating the mechanism by which an increased cam ratio increases ACL injury risk and potential strategies to mitigate the increased risk posed by this bony characteristic.

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The Effect of The Intercondyler Notch Width Index on Anterior Cruciate Ligament Injuries

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967114s00204 ◽

2014 ◽

Vol 2 (11_suppl3) ◽

pp. 2325967114S0020

Author(s):

Cemile Ayşe Görmeli ◽

Gökay Görmeli ◽

Yağmur Burak Öztürk ◽

Zeynep Özdemir ◽

Ayşegül Kahraman

Keyword(s):

Injury Risk ◽

Acl Injury ◽

Intercondylar Notch ◽

Mr Images ◽

Acl Injuries ◽

Notch Width ◽

Increased Risk ◽

Significant Difference ◽

Intercondylar Notch Width ◽

Notch Width Index

Objectives: To evaluate the relationship of the intercondylar notch width with unilateral and bilateral ACL injury by using MR images. Methods: The intercondylar notch width index was measured on the MR images of 18 patients with a bilateral ACL injury, 38 patients with a unilateral ACL injury and 53 healthy subjects with a normal ACL and the results of all groups were compared with each other. Results: The mean NWI values were 0.227 (±0.008) in bilateral injured; 0.245 (±0.009) in unilateral injured and 0.272 (±0.01) in control groups and 0.251(±0.01) in unaffected side of the unilateral group. There were statistically significant differences in intercondylar notch width index (NWI) values between all groups and there was a significant difference between the affected and the unaffected sides in group with unilateral ACL injury. A cutoff value of 0.25 for NWI gave an odds ratio of 26.5 for bilateral and 3.23 for unilateral ACL injuries. Conclusion: The finding that NWI is significantly narrowed in patients with bilateral and unilateral ACL tears compared with the healthy controls suggest a relationship between a narrow NWI and an increased risk of ACL injury. The patients with a narrow NWI should also be screened contralaterally for assessment of ACL injury risk on the other knee. So, specialized training programmes for the people with narrow NWI can be prepared for preventing ACL injuries.

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Risk of Secondary ACL Injury in Adolescents Prescribed Functional Bracing After ACL Reconstruction

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119879880 ◽

2019 ◽

Vol 7 (11) ◽

pp. 232596711987988

Author(s):

Gabriel S. Perrone ◽

Kate E. Webster ◽

Chris Imbriaco ◽

Gabriela M. Portilla ◽

Amishi Vairagade ◽

...

Keyword(s):

Acl Reconstruction ◽

Case Series ◽

Acl Injury ◽

High Rate ◽

Control Group ◽

Acl Injuries ◽

Injury Rates ◽

Increased Risk ◽

Early Graft ◽

Retear Rate

Background: There is a high incidence of a secondary anterior cruciate ligament (ACL) injury in unbraced adolescent athletes. Little is known about the effect of functional bracing with regard to the risk of secondary ACL injuries among adolescents. Hypothesis: Our primary hypothesis was that adolescents would have a high rate of secondary ACL injury even with brace use. A secondary hypothesis was that the reinjury rate with brace use would be lower than that of a historical control group of unbraced patients. Study Design: Case series; Level of evidence, 4. Methods: A group of 219 patients (age <20 years at surgery) who underwent ACL reconstruction and were prescribed postoperative functional bracing during cutting and pivoting sports for 2 years after surgery completed a survey regarding reinjury to either knee. Rates of knee injuries following ACL reconstruction were calculated and compared with those reported in a similar unbraced cohort. The effect of demographic and anatomic factors on risk of secondary ACL injuries was also investigated. Results: The overall follow-up rate was 65% (142/219) at a mean 5.6 years after surgery. In the braced cohort, the overall graft retear rate was 10%, with the highest retear rates observed in male patients 17 years of age and younger (18%). The overall contralateral ACL injury and combined (graft or contralateral ACL) secondary injury rates were 13% and 23%, respectively, with female patients younger than 18 years having the highest contralateral and combined injury rates (17% and 26%, respectively). Younger age (odds ratio [OR], 0.70; P = .021), family history of ACL injury (OR, 2.81; P = .015), and higher lateral tibial slope (OR, 1.25; P = .016) were associated with increased risk of secondary knee injury in the braced cohort. Compared with the unbraced cohort, the braced cohort had a lower overall graft retear rate ( P = .028), a lower graft retear rate in patients younger than 18 years ( P = .012), lower early graft retear rate (within the first year after surgery) ( P = .011), and lower early graft retear rate in subjects younger than 18 years ( P = .003). Conclusion: Postoperative use of functional bracing can result in reduced risk of graft retear and no change in contralateral injury rates. Clinicians may want to consider the use of postoperative functional bracing in adolescent patients.

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Sagittal Plane Hip, Knee, and Ankle Biomechanics and the Risk of Anterior Cruciate Ligament Injury: A Prospective Study

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967117745487 ◽

2017 ◽

Vol 5 (12) ◽

pp. 232596711774548 ◽

Cited By ~ 24

Author(s):

Mari Leppänen ◽

Kati Pasanen ◽

Tron Krosshaug ◽

Pekka Kannus ◽

Tommi Vasankari ◽

...

Keyword(s):

Knee Flexion ◽

Sagittal Plane ◽

Cruciate Ligament ◽

Acl Injury ◽

Young Female ◽

Roc Curve Analysis ◽

Acl Injuries ◽

Increased Risk ◽

Flexion Moment ◽

Hip Flexion

Background: Stiff landings with less knee flexion and high vertical ground-reaction forces have been shown to be associated with an increased risk of anterior cruciate ligament (ACL) injury. The literature on the association between other sagittal plane measures and the risk of ACL injuries with a prospective study design is lacking. Purpose: To investigate the relationship between selected sagittal plane hip, knee, and ankle biomechanics and the risk of ACL injury in young female team-sport athletes. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 171 female basketball and floorball athletes (age range, 12-21 years) participated in a vertical drop jump test using 3-dimensional motion analysis. All new ACL injuries, as well as match and training exposure data, were recorded for 1 to 3 years. Biomechanical variables, including hip and ankle flexion at initial contact (IC), hip and ankle ranges of motion (ROMs), and peak external knee and hip flexion moments, were selected for analysis. Cox regression models were used to calculate hazard ratios (HRs) with 95% CIs. The combined sensitivity and specificity of significant test variables were assessed using a receiver operating characteristic (ROC) curve analysis. Results: A total of 15 noncontact ACL injuries were recorded during follow-up (0.2 injuries/1000 player-hours). Of the variables investigated, landing with less hip flexion ROM (HR for each 10° increase in hip ROM, 0.61 [95% CI, 0.38-0.99]; P < .05) and a greater knee flexion moment (HR for each 10-N·m increase in knee moment, 1.21 [95% CI, 1.04-1.40]; P = .01) was significantly associated with an increased risk of ACL injury. Hip flexion at IC, ankle flexion at IC, ankle flexion ROM, and peak external hip flexion moment were not significantly associated with the risk of ACL injury. ROC curve analysis for significant variables showed an area under the curve of 0.6, indicating a poor combined sensitivity and specificity of the test. Conclusion: Landing with less hip flexion ROM and a greater peak external knee flexion moment was associated with an increased risk of ACL injury in young female team-sport players. Studies with larger populations are needed to confirm these findings and to determine the role of ankle flexion ROM as a risk factor for ACL injury. Increasing knee and hip flexion ROMs to produce soft landings might reduce knee loading and risk of ACL injury in young female athletes.

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Tendency of Driving to the Basket Is Associated With Increased Risk of Anterior Cruciate Ligament Tears in National Basketball Association Players: A Cohort Study

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211052953 ◽

2021 ◽

Vol 9 (11) ◽

pp. 232596712110529

Author(s):

Blake J. Schultz ◽

Kevin A. Thomas ◽

Mark Cinque ◽

Joshua D. Harris ◽

William J. Maloney ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Standard Deviation ◽

Cruciate Ligament ◽

Acl Injury ◽

National Basketball Association ◽

Acl Injuries ◽

Increased Risk ◽

Significant Difference ◽

Anterior Cruciate ◽

Level Performance

Background: Driving to the basket in basketball involves acceleration, deceleration, and lateral movements, which may expose players to increased anterior cruciate ligament (ACL) injury risk. It is unknown whether players who heavily rely on driving have decreased performance on returning to play after ACL reconstruction (ACLR). Hypothesis: Players with a greater tendency to drive to the basket would be more likely to tear their ACL versus noninjured controls and would experience decreased performance when returning to play after ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: Season-level performance statistics and ACL injuries were aggregated for National Basketball Association (NBA) seasons between 1980 and 2017 from publicly available sources. Players’ tendency to drive was calculated using 49 common season-level performance metrics. Each ACL-injured player was matched with 2 noninjured control players by age, league experience, and style of play metrics. Points, playing minutes, driving, and 3-point shooting tendencies were compared between players with ACL injuries and matched controls. Independent-samples t test was utilized for comparisons. Results: Of 86 players with a total of 96 ACL tears identified in the NBA, 50 players were included in the final analysis. Players who experienced an ACL tear had a higher career-average drive tendency than controls ( P = .047). Players with career-average drive tendency ≥1 standard deviation above the mean were more likely to tear their ACL than players with drive tendency <1 standard deviation (5.2% vs 2.7%; P = .026). There was no significant difference in total postinjury career points ( P = .164) or career minutes ( P = .237) between cases and controls. There was also no significant change in drive tendency ( P = .152) or 3-point shooting tendency ( P = .508) after return to sport compared with controls. Conclusion: NBA players with increased drive tendency were more likely to tear their ACL. However, players who were able to return after ACLR did not underperform compared with controls and did not alter their style of play compared with the normal changes seen with age. This information can be used to target players with certain playing styles for ACL injury prevention programs.

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Sexual Dimorphisms in Anterior Cruciate Ligament Injury: A Current Concepts Review

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211025304 ◽

2021 ◽

Vol 9 (12) ◽

pp. 232596712110253

Author(s):

Tayt M. Ellison ◽

Ilexa Flagstaff ◽

Anthony E. Johnson

Keyword(s):

Female Athletes ◽

Cruciate Ligament ◽

Acl Injury ◽

Extrinsic Factors ◽

Male Athletes ◽

Acl Injuries ◽

Sexual Dimorphisms ◽

Increased Risk ◽

Anterior Cruciate ◽

Postsurgical Outcomes

Background: Although most anterior cruciate ligament (ACL) injuries occur in male athletes, female athletes are consistently observed to be at a higher risk for sports-specific ACL injury. Purpose: To provide a thorough review of what is known about the sexual dimorphisms in ACL injury to guide treatment and prevention strategies and future research. Study Design: Narrative review. Methods: We conducted a comprehensive literature search for ACL-related studies published between January 1982 and September 2017 to identify pertinent studies regarding ACL injury epidemiology, prevention strategies, treatment outcomes, and dimorphisms. By performing a broad ACL injury search, we initially identified 11,453 articles. After applying additional qualifiers, we retained articles if they were published in English after 1980 and focused on sex-specific differences in any of 8 different topics: sex-specific reporting, difference in sports, selective training, hormonal effects, genetics, neuromuscular and kinematic control, anatomic differences, and outcomes. Results: A total of 122 articles met the inclusion criteria. In sum, the literature review indicated that female athletes are at significantly higher risk for ACL injuries than are their male counterparts, but the exact reasons for this were not clear. Initial studies focused on intrinsic differences between the sexes, whereas recent studies have shifted to focus on extrinsic factors to explain the increased risk. It is likely both intrinsic and extrinsic factors contribute to this increased risk, but further study is needed. In addition to female patients having an increased risk for ACL injuries, they are less likely than are male patients to undergo reconstructive surgery, and they experience worse postsurgical outcomes. Despite this, reconstructive surgery remains the gold standard when knee stability, return to sports, and high functional outcome scores are the goal, but further research is needed to determine why there is disparity in surgical rates and what surgical techniques optimize postsurgical outcomes for female patients. Conclusion: Male athletes often predominated the research concerning ACL injury and treatment, and although sex-specific reporting is progressing, it has historically been deficient. ACL injuries, prevention techniques, and ACL reconstruction require further research to maximize the health potential of at-risk female athletes.

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Exercise-Based Training Strategies to Reduce the Incidence or Mitigate the Risk Factors of Anterior Cruciate Ligament Injury in Adult Football (Soccer) Players: A Systematic Review

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph182413351 ◽

2021 ◽

Vol 18 (24) ◽

pp. 13351

Author(s):

Jesús Olivares-Jabalera ◽

Alberto Fílter-Ruger ◽

Thomas Dos’Santos ◽

Jose Afonso ◽

Francesco Della Villa ◽

...

Keyword(s):

Risk Factors ◽

Anterior Cruciate Ligament ◽

Cruciate Ligament ◽

Acl Injury ◽

Core Stability ◽

Cochrane Library ◽

Football Players ◽

Injury Incidence ◽

Warm Up ◽

Anterior Cruciate

Anterior cruciate ligament (ACL) is one of the most concerning injuries for football players. The aim of this review is to investigate the effects of exercise-based interventions targeting at reducing ACL injury rate or mitigating risk factors of ACL injury in adult football players. Following PRISMA guidelines, a systematic search was conducted in CINAHL, Cochrane Library, PubMed, Scopus, SPORTDiscus and Web of Science. Studies assessing the effect of exercise-based interventions in ACL injury incidence or modifiable risk factors in adult football players were included. 29 studies evaluating 4502 male and 1589 female players were included (15 RCT, 8 NRCT, 6 single-arm): 14 included warm-up, 7 resistance training, 4 mixed training, 3 balance, 1 core stability and 1 technique modification interventions. 6 out of 29 studies investigated the effect of interventions on ACL injury incidence, while the remaining 23 investigated their effect on risk factors. Only 21% and 13% studies evaluating risk of injury variables reported reliability measures and/or smallest worthwhile change data. Warm-up, core stability, balance and technique modification appear effective and feasible interventions to be included in football teams. However, the use of more ecologically valid tests and individually tailored interventions targeting specific ACL injury mechanisms are required.

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