Video Analysis of Anterior Cruciate Ligament Injury Situations in the Women's Australian Football League

Most Anterior Cruciate Ligament Injuries in Professional Athletes Occur Without Contact to the Injured Knee: A Systematic Review of Video Analysis Studies

PURPOSE

To systematically review studies using video analyses to evaluate anterior cruciate ligament (ACL) injury mechanisms in athletes during sport to better understand risk factors and the potential for injury prevention.

METHODS

A literature search was conducted in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines statement using SCOPUS, PubMed, Medline, and the Cochrane Central Register for Controlled Trials from database inception through June 2023. Inclusion criteria included studies reporting on ACL injury mechanisms occurring in athletes based on video analysis. Athlete demographics, injury mechanisms, position of the lower extremity, and activity at the time of injury were recorded.

RESULTS

A total of 13 studies, consisting of 542 athletes, met inclusion criteria. Most athletes competed at the professional level (91%, n = 495/542), with 79% (n = 422/536) of athletes being male. The most common sports were soccer (33%, n = 178/542) and American football (26%, n = 140/542). The most common injury mechanism was noncontact in 42.9% (n = 230/536) of athletes, followed by indirect contact (32.6%, n = 175/536) and direct contact (22.4%, n = 120/536). The most common position of injury was with a planted foot (91.7%, n = 110/120), full or near-full knee extension (84.4%, n = 49/58), and axial loading (81.3%, n = 87/107). Injuries commonly involved a deceleration/shift in momentum (50.4%, n = 123/244) or pivoting maneuver (36.1%, n = 77/213). At the time of injury, the knee commonly fell into valgus (76.8%, n = 225/293) with associated internal (53.5%, n = 46/86) or external tibiofemoral rotation (57.7%, n = 101/175).

CONCLUSIONS

Most ACL injuries, when evaluated by video analysis, involve professional athletes participating in soccer and American football. The most common injury mechanism occurred without contact with the knee in extension during a deceleration or momentum shift, with resultant valgus and rotational force across the knee.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Injury prevention for women and girls playing Australian Football: programme cocreation, dissemination and early adopter coach feedback

Background

Adherence to injury prevention programmes may improve with greater end-user involvement and application of implementation frameworks during development. We describe the cocreation, initial dissemination and feedback from programme early adopters (coaches), to develop the first evidence-informed injury prevention programme for women playing community Australian Football (Prep-to-Play).

Methods

We used a pragmatic seven-step process for developing sports injury prevention programmes to (1) gain organisational support, (2) compile research evidence, (3) consult experts, (4) engage end-users, (5) test programme acceptability, (6) evaluate against theory and (7) gain early adopter feedback. All Australian Football-registered coaches of women's/girls' teams were sent a postseason survey to determine initial awareness, adoption and implementation (steps 5 and 6). Purposively selected coaches were invited to interviews/focus groups (step 7) to identify competency, organisational and leadership implementation drivers with a deductive thematic analysis applied.

Results

Prep-to-Play was cocreated using previous efficacious programmes and expert input (steps 1-4), and disseminated via the national sporting organisation in preseason 2019 to all registered coaches (step 5). 343 coaches (90 women) completed the postseason survey and 22 coaches (5 women) participated in an interview (n=9) or focus group (n=13) (steps 6 and 7). 268 coaches (78%) were aware of Prep-to-Play. Of those aware, 218 (81%) had used (at least one element) Prep-to-Play, and 143 (53%) used it at least twice per week. Competency drivers included local expert-delivered face-to-face workshops complimented by online content and ongoing support. Organisational drivers included coach education integrated into existing league/club. Leadership drivers included compulsory injury prevention education integrated into coach reaccreditation processes or incentivisation via recognition (eg, professional development points).

Conclusions

Cocreation and organisational support resulted in high programme awareness and adoption. However, high fidelity implementation and maintenance may need to be facilitated by competency, organisational and leadership drivers. Responsibility should be shared among all stakeholders.

Relationships between physical fitness characteristics, technical skill attributes, and sports injury in female Australian football players

OBJECTIVES

To explore the relationships between physical fitness and i) technical skills and ii) time-loss from Australian football injury in female players across the talent and participation pathways.

METHODS

This study uses a subset of data from two cross-sectional and one prospective cohort studies. A total of 223 female Australian football players across five competition levels (elite/non-elite senior, high-level junior, and non-elite junior (14-17 years)/(10-13 years)) were included in this study. Comprehensive physical fitness assessments and modified Australian football kicking and handballing tests were conducted in the 2018/19 pre-seasons. During the respective competitive in-season, time-loss injuries were recorded by team personnel. Stepwise multiple linear regressions were performed to determine the relationship between physical fitness and kicking and handballing scores. Cox proportional regressions were conducted to identify physical fitness factors associated with injury.

RESULTS

Increased running vertical jump height, greater hip abduction strength, and faster timed 6 m hop speed demonstrated a relationship with kicking accuracy when adjusted for years of Australian football playing experience (adjusted R2 = 0.522, p < 0.001). Faster agility time and increased lean mass were associated with better handballing accuracy (adjusted R2 = 0.221, p < 0.001). Multivariate Cox regression revealed an increased risk for sustaining a time-loss injury in less agile players (adjusted HR 2.41, 95% CI 1.23, 4.73, p = 0.010). However, this relationship no longer remained when adjusted for age and years of Australian football experience (adjusted HR 1.68, 95% CI 0.81, 3.50, p = 0.166).

CONCLUSIONS

Physical fitness may be a significant factor contributing to development of Australian football technical skills in female players. However, its role is unclear in protecting against injury risk in this athlete population. Further research is needed to explore the multifactorial and complex phenomenon of talent development and injury risk reduction in female Australian football players.

If we build it together, will they use it? A mixed-methods study evaluating the implementation of Prep-to-Play PRO: an injury prevention programme for women's elite Australian Football

OBJECTIVES

We evaluated the implementation of Prep-to-Play PRO, an injury prevention programme for women's elite Australian Football League (AFLW).

METHODS

The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) of Prep-to-Play PRO were assessed based on the proportion of AFLW players and/or staff who: were aware of the programme (R), believed it may reduce anterior cruciate ligament injury (E), attempted to implement any/all programme components (A), implemented all intended components as practically as possible (I) and intended future programme implementation (M). Quantitative and qualitative data were triangulated to assess 58 RE-AIM items (evidence of yes/no/unsure/no evidence) and the 5 RE-AIM dimensions (fully achieved=evidence of yes on >50% dimension items, partially achieved=50% of items evidence of yes and 50% unsure or 50% mix of unsure and unanswered, or not met=evidence of yes on <50% dimension items).

RESULTS

Multiple sources including AFLW training observations (n=7 total), post-implementation surveys (141 players, 25 staff), semistructured interviews (19 players, 13 staff) and internal programme records (9 staff) contributed to the RE-AIM assessment. After the 2019 season, 8 of 10 (80%) AFLW clubs fully met all five RE-AIM dimensions. All 10 clubs participating in the AFLW fully achieved the reach (R) dimension. One club partially achieved the implementation (I) dimension, and one club partially achieved the effectiveness (E) and adoption (A) dimensions.

CONCLUSION

The Prep-to-Play PRO injury prevention programme for the AFLW achieved high implementation, possibly due to the programme's deliberately flexible approach coupled with our pragmatic definition of implementation. Engaging key stakeholders at multiple ecological levels (organisation, coaches, athletes) throughout programme development and implementation likely enhanced programme implementation.

Appraising the Methodological Quality of Sports Injury Video Analysis Studies: The QA-SIVAS Scale

BACKGROUND

Video analysis (VA) is commonly used in the assessment of sports injuries and has received considerable research interest. Until now, no tool has been available for the assessment of study quality. Therefore, the objective of this study was to develop and evaluate a valid instrument that reliably assesses the methodological quality of VA studies.

METHODS

The Quality Appraisal for Sports Injury Video Analysis Studies (QA-SIVAS) scale was developed using a modified Delphi approach including expert consensus and pilot testing. Reliability was examined through intraclass correlation coefficient (ICC3,1) and free-marginal kappa statistics by three independent raters. Construct validity was investigated by comparing QA-SIVAS with expert ratings by using Kendall's tau analysis. Rating time was studied by applying the scale to 21 studies and computing the mean time for rating per study article.

RESULTS

The QA-SIVAS scale consists of an 18-item checklist addressing the study design, data source, conduct, report, and discussion of VA studies in sports injury research. Inter- and intra-rater reliability were excellent with ICCs > 0.97. Expert ratings revealed a high construct validity (0.71; p < 0.001). Mean rating time was 10 ± 2 min per article.

CONCLUSION

QA-SIVAS is a reliable and valid instrument that can be easily applied to sports injury research. Future studies in the field of VA should adhere to standardized methodological criteria and strict quality guidelines.

Anticipatory effects on side-step cutting biomechanics in Women's Australian Football League players

Objectives

Reactive side-step cutting manoeuvres are linked to anterior cruciate ligament (ACL) injuries in Women's Australian Football League (AFLW) matches. We explored knee joint moments and ground reaction forces (GRFs) in AFLW players when performing anticipated and unanticipated side-stepping.

Methods

Sixteen AFLW players (age=25.3±4.2 years; height=1.71±0.06 m; mass=68.4±4.7 kg) completed anticipated and unanticipated side-stepping trials during which full-body three-dimensional kinematics and kinetics were recorded. One-dimensional statistical parametric mapping paired t-tests were used to compare three-dimensional knee moments during weight acceptance and GRFs during the stance phase between anticipated and unanticipated conditions.

Results

Unanticipated side-stepping incurred lower knee flexion (18%-39% of stance, p<0.01) and abduction (11%-24% of stance, p<0.01) moments. Braking and propulsive GRFs were lower and higher, respectively, across the majority of stance phase (6%-90% of stance, p<0.01) in unanticipated side-stepping. Vertical GRFs were lower in unanticipated side-stepping in the early stance phase (14%-29% of stance, p<0.01).

Conclusion

Contrary to existing literature, AFLW players exhibited knee joint moments associated with reduced ACL loading when performing unanticipated side-stepping. Players appeared to adopt a 'cautious' approach to the unanticipated side-step (ie, decelerating at the change of direction), by reducing braking and vertical GRFs in the early stance phase of cutting. This approach may be implausible to employ or detrimental to performance during matches. AFLW ACL injury prevention programmes may be enhanced with greater exposure to scenarios that replicate reactive match-play demands when aiming to improve side-stepping biomechanics.