AAP Guidelines Address ACL Tear Management in Adolescents‏

Laurie Barclay, MD

April 28, 2014

The American Academy of Pediatrics (AAP) has issued new clinical guidelines on diagnosing, treating, and preventing anterior cruciate ligament (ACL) tears in adolescents‏. The recommendations were published online April 28 in Pediatrics.

"The number of ACL injuries in young athletes has increased over the past 2 decades, coincident with the growing number of children and adolescents participating in organized sports, intensive sports training at an earlier age, and greater rate of diagnosis because of increased awareness and greater use of advanced medical imaging," write Cynthia R. LaBella, MD, and colleagues from the AAP Council on Sports Medicine and Fitness and Section on Orthopaedics. "Intrinsic risk factors for ACL injury include higher [body mass index], subtalar joint overpronation, generalized ligamentous laxity, and decreased neuromuscular control of the trunk and lower extremities."

Girls have higher rates of ACL injuries than do boys participating in similar sports. Overall, ACL injury rates are low in young children and increase sharply during puberty, the committee notes. High school athletes have lower rates of ACL injury than do college athletes (5.5 vs 15 per 100,000 athlete exposures), with a similar distribution of injury across sports. Girls' soccer and boys' football appear to have the highest rates of ACL injury.

In terms of ACL injury prevention, the guidelines emphasize the importance of clinicians recognizing and educating patients and parents about the benefits of neuromuscular training.

Several Management Options Available

Specific recommendations include the following:

  • Neuromuscular control may be the most important and most modifiable factor underlying the differences in noncontact ACL injury rates in male and female athletes, although multiple factors are likely to play a role.

  • Surgery and/or many months of rehabilitation are often needed for treatment of ACL injuries, which often result in significant time missed from school and from sports.

  • The Lachman test is the best physical examination test to detect an ACL tear.

  • For the young patient in whom pain, swelling, and lack of cooperation hinder physical examination, magnetic resonance imaging may be needed to diagnose ACL tears and associated meniscal and chondral injury.

  • In a pediatric athlete, an ACL tear is not a surgical emergency. The clinician should have multiple discussions with the patient and parents to understand their goals and expectations and to educate them regarding treatment options.

  • For an athlete who is skeletally immature, measurement of skeletal age using an anteroposterior radiograph of the left hand and wrist and Tanner stage may help determine optimal treatment of an ACL tear.

  • Regardless of treatment regimen, young people with ACL tears are at increased risk for early-onset osteoarthritis in the injured knee. Clinicians should counsel them regarding this risk and document these discussions in the medical record.

  • Neuromuscular training interventions begun in early to middle adolescence, when neuromuscular risk factors for ACL injury first develop, may help reduce musculoskeletal changes that decrease dynamic joint stability in high-risk female athletes and potentially increase injury rates.

  • In adolescent female athletes, neuromuscular training may reduce risk for injury by 72%. The most effective prevention training includes plyometric and strengthening exercises and feedback regarding proper technique.

  • Pediatricians and orthopedic surgeons should refer patients at highest risk for ACL injuries to suitable resources to help prevent injury and should document these discussions in the medical record. Such patients include adolescent female athletes and patients with personal or family history of ACL injury and/or generalized ligamentous laxity.

  • Pediatricians and orthopedic surgeons involved with schools and sports organizations should help educate athletes, parents, coaches, and sports administrators regarding the benefits of neuromuscular training in reducing ACL injuries and inform them of suitable and available resources.

All guidelines authors filed conflict of interest statements with the AAP, and any conflicts were resolved through a process approved by the Board of Directors. The AAP neither solicited nor accepted any commercial involvement in the development of the content of these guidelines.

Pediatrics. Published online April 28, 2014.

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