Rethinking anterior cruciate ligament injury prevention

Listen to Andrew Duckworth, Iain Murray and Fares Haddad discuss the editorial 'Rethinking anterior cruciate ligament injury prevention' published in the April 2026 issue of The Bone & Joint Journal and the annotation 'Anterior cruciate ligament injury prevention: who is responsible for implementation and what are the challenges?' in the April 2026 issue of Bone & Joint Open.

Papers discussed:

Rethinking anterior cruciate ligament injury prevention

Anterior cruciate ligament injury prevention: who is responsible for implementation and what are the challenges?

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Transcript

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[00:00:00] Welcome everyone to our BJJ podcast series. I'm Andrew Duckworth, and a warm welcome back to you all for your team here at The Bone & Joint Journal. As always, we'd like to thank you all for your continued comments and support, as well as a big gra-gratitude to our many authors and colleagues who take part in the series that highlights just some of the great work published by our authors each month.

So today for our podcast, I have the pleasure of being joined by two authors from both an editorial and an annotation that's been published in the April editions of the BJJ and BJO respectively, looking at how we approach ACL injury prevention. Now, before I introduce our guests, I do have a quick message from our sponsor for this episode, the International Hip Preservation Society.

The ISHA will be holding its annual scientific meeting in Bruges, Belgium on the 8th to 10th of October this year, and the early registration deadline is coming up on the 31st of July. This is a great place to meet with other hip preservation experts and learn about the latest research and techniques in the field.

Registration can be a-accessed via ishasoc.net and is open to member and non-member physicians, trainees, residents and fellows, physiotherapists, sports clinicians, and any other allied health [00:01:00] care professionals with an interest in the hip. So back to today. Firstly, I have the pleasure of being joined by my colleague and friend here in Edinburgh, Mr Iain Murray, who's a sports knee surgeon at the University of Edinburgh, who's driving much of this work in Scotland and with partners across the UK.

Iain, great to have you with us. Thanks, Andrew. Happy to be here. Joining in, we're delighted to welcome back our awesome Editor-in-Chief of the BJJ, Professor Fares Haddad. Prof, great to have you back with us as always. Dux, thank you. Great to be here. So s- both today we're gonna talk about ACL injuries, and in particular how we prevent them.

W- as you both know, these are common injuries and the burden is rising, especially amongst younger people, and there's been a huge amount of really good work in this area both in the UK and elsewhere worldwide on how to prevent them. But what these editorials do is really take a step forward talking about implementation.

So Iain, if you could maybe kick things off for us. How do these sort of editorials come about, and how have you got involved in this area? Yeah. I think there's been a growing realization by a number of groups here in the UK and internationally about the real burden of these injuries, as you've highlighted.

And for ACLs in particular, [00:02:00] that burden that we've historically thought of as a year out of sport is actually far more impactful than that. You have rates of up to 50% of osteoarthritis in people who've had ACL injuries, and what I think is even almost more important is you're taking our young people out of sport, particularly our young girls, during these formative years where they're lear- really developing health behaviours.

And so this paradox where you have rising injuries, you have better ways of treating them, but actually we're not able to reduce the number of them, and this growing realization that prevention actually works. And so we're not in an issue here of trying to prove that prevention works, it's really about how are we implementing it and why haven't we been able to reduce those, these rates?

So this editorial and these articles came together by shared minds across the UK who are really feeling strongly on this matter, and really trying to shape how that might look as we start to build a bit of momentum. [00:03:00] There's groups in England and up here in Scotland who are r- really trying to move this forward, and coming together, bringing all these stakeholders together and interested parties really helps to align views.

Yeah, absolutely. That, I think that's a really nice background to th- this sort of area of work and why it has I think, like you say the frame shift that you're really trying to bring across in these, th- these bits of work. And Prof, that sort of brings me to you. We're talking about, Iain talks about the current evidence in the area of ACL injury prevention.

What is that and is, and what is the level of that? Is that good evidence that we have in terms of these injury prevention strategies that are available? Yes, I think it's an interesting area because I think most people don't realize, first and foremost, that we as practitioners, this is probably the most powerful thing we can do for ACL injuries because once a knee's ACL injured, the die is cast.

That knee is never normal again, regardless of the most skillful intervention, be that physio-based or surgical. There are actually a large number of studies generally focused on, largely [00:04:00] focused on collegiate athletes, for example in certain subgroups, but essentially of interventions where the, neuromuscular retraining, strength work, balance work have been put in place, and then compared, often in a randomized fashion, without, with the absence of these interventions, and shown to reduce re-injury rates.

So I think the evidence is clearly there. It's often level one evidence. It just isn't widely known, and it has not been translated to the wider population, as Iain has said, anywhere near as well as any of us would have liked. And this is not, this is not just an ACL issue. The ACL's a huge burden that makes the press because of its prominence in elite sport and it's if you like, the personality of an ACL injury resonates with the public.

But in reality, hamstring injuries, other soft-tissue injuries all benefit and are influenced equally by having these training programmes put in place. Generally, these are multi-component training methods, [00:05:00] centred around primarily neuromuscular control, but often improving lower limb biomechanics, targeting functional-specific performance metrics, and working on strength and power, and those make a difference to soft-tissue injuries.

They make a difference to ACL injuries, to lots of other injuries. So that's all out there, and perhaps that's one of the opportunities is that we shouldn't just be targeting the ACL, important though it is. We could be targeting a lot of other things at the same time, including improved performance. But that's interesting, Prof, and y- you do mention that in the these articles and though this concept of whole limb injury prevention.

And is, and just to clarify, there is evidence for that there as well, now this concept that we're not just trying to maybe prevent one type of injury, it's just trying to prevent injury in, i- in general. Is that right? That's, that, that's absolutely right. And I think, if we move aside from this editorial and this paper for two minutes, in my world we are, we've seen an epidemic of hamstring injuries- in elite sport for the last decade and a half. And, I think a lot of that could be managed, [00:06:00] prevented by appropriate strategies, so I think we're gonna see more and more of that. So I think looking at the bigger picture, or if you like, the knock-on benefits of what we're talking about here today, they could go well beyond the very important issue of ACL injury.

That's really interesting. And that sort of b- nicely brings me back to yourself. Prof's gone through a lot of the good evidence that there, not only just ACL but also this whole limb injury prevention concept. So why are we still seeing these rising number of injuries, and where have potentially maybe we've not, maybe we've gone wrong in, in some context?

Yeah I think the first thing I really want to emphasize is that there is some amazing, really good work that's being done out there, particularly here in the UK we've got some great groups like the Power Up to Play group with Kate Jackson and Will Jackson and their network of people that are really showing that they can make a difference.

The challenge is to have a joined-up programme that can really make a difference at a national level, and I do think that the editorial in [00:07:00] particular raises some issues that where we perhaps have become slightly undone and Professor Haddad has raised one of those first ones, which is that this is not an ACL problem.

These are injuries, they're other injuries that are affecting things, and when we're considering implementation, we have to be practical. Yes. So if we say to a group of coaches or whoever we're really trying to move this forward, "Today we're doing an ACL injury prevention, and next week we're gonna add in a shoulder prevention or a hamstrings or an ankle," it really h- it, it isn't practical.

And so I think that we have to be very practical to our target audience, and one is I think we've been slightly perhaps a bit narrow in, in our target. The second thing is as we've also discussed, is the high-profile athletes often hit the newspapers, but actually the real people that we're trying to target are grassroots.

Yeah. And for a long time we've tried to design interventions that have been designed around elite athletes, and they're really not practical [00:08:00] for our grassroots chil- kids who are maybe having one hour of coaching per week. And so we have to really target our interventions to the group that's most important.

And a- and another point is that we have to be very careful with the messaging for this. Yeah. And so as we are trying to highlight the importance of it, I think it's important that we do have to raise awareness of the injuries and the negative impact, but we have to be careful with our young people because we don't want to have a fear-based messaging that might actually inadvertently restrict their participation in sport.

So there's a number of challenges, and I think we might get onto it later, but the other is taking ownership for it and that is something in terms of who's responsible for implementation that has been a big challenge, and again, one thing that we've really tried to address through the articles. No, absolutely.

And I think it was really interesting, particularly in the editorial when you talk about, that concept of performance not fear as the primary driver, and actually rather than maybe [00:09:00] preaching avoidance, it's actually we want people to take part in these sports, but it's just how we do it safely, and that's a really important concept, isn't it?

Yeah. It's these inadvertent effects, that the FIFA 11+, which was originally set up as an ACL injury prevention, reduced hamstrings injuries in one trial by 63%. And there's data to show that these injury prevention that teams who have undertaken these injury prevention programmes- actually improve their performance and results, and it makes sense because they're improving neuromuscular strength. They're improving all these metrics that not only reduce injury, but imp- improve athletic performance. Yeah and just before we move on to how these changes may be implemented, you talk a little, like you've mentioned it already, but it's really focusing on those high risk, the bit, the people at greatest risk, isn't it?

And actually, as you say in your tutorial, adolescent female athletes have constantly been identified as the high risk for ACL injuries, but a lot of the preventative strategies aren't really been f- targeted or focused in that area, have they? No, that, that's exactly right. And that will change throughout the world.

So what works in [00:10:00] young people around New York might not work for, people in, in, in Glasgow or people in the South of England. So we really have to target by geography, by age, even by the sport that they're doing. Yeah. There's a number of factors that all really have to be individualized.

So it's about being local, but delivering what is transferable, these core principles, but being local about it. That's great, Iain. So Prof, if I could come back to you. S- we're moving on to it now, I suppose the obvious question is w- where is the clear pathway next? H- you know, this editor- editorial really argues that the next phase needs fundamental look to...

it needs to look fundamentally different about how you reapproach it. So how do you see the initial steps of this all moving forward? L- all, effectively like all public health initiatives you've gotta get top-down support, but you've gotta go broad and involve all the stakeholders.

I think we're in a better place than many other countries 'cause, because for example, we do have a lot of grassroots sports, and actually we've got physical education in schools. There are lots of places that don't have anywhere near as much physical education in [00:11:00] schools as we do, and that's an ideal place to intervene.

So I think in, in, in reality, this is setting up the right influencing groups both nationally, regionally and locally to try and get this message across, to try and... it's a bit like the entire physical activity message. It's the dream of every Olympics to leave a country healthier than it was before, and we all know physical activity is the ultimate pill.

It actually makes m- most chronic diseases better, it will prevent some diseases, and so on. This is a corollary, it's the next step up from that. So I think, Iain and h- and the team have highlighted a number of stakeholders and a number of ways to engage with them. And as Ian has said, that recipe may be different in different areas and in different sports.

I think we can learn from the Norwegians and the Swedes who've implemented national programmes o- of this kind, albeit through sport. Here we've gotta go through sport to go through coaches, we've gotta go through just national recognition of the problem, [00:12:00] and we've gotta go through schools. And just i- if you like, have a multimodal approach at just getting this message across that by getting people better balance, better strength, better coordination, actually will make them better at whatever they wanna do, but also reduce their injury risk.

Totally, Prof. And even if, when we're talking about this sort of implementation, one of the things that obviously comes to mind, I know we've discussed it before, is, you look at other areas of, so injury prevention, and one of the ones that is very well, I think very well known is about concussion.

And that has really exploded in terms of our, I think, everybody's, even out with orthopaedics or whatever specialty about the issue with concussion, that well-known phrase, if in doubt, sit them out is just permeated through all sort of, rugby coaching in for example.

H-how... Is that something we can learn from, do you think, in this sort of area so it becomes more of just common knowledge? Yeah, no, absolutely. I think as Prof was indicating there, we really have to learn from different settings and not reinvent the wheel. So we know that the Norwegians [00:13:00] and other countries have been very successful in, in, in certain areas, and as you point out, there's been other areas of medicine where there's been very similar campaigns targeting similar groups.

So if we take that concussion message, which is now really global- ... that if in doubt, sit them s- sit them out, that started 15 years ago in Scotland, I believe- ... where i- in an environment where there was even less evidence than there is now for ACL injury prevention. And this is now y- a global message that's really making a huge difference.

And what they've successfully been able to do is deliver a very simple and clear message, and know exactly what success looks like. Yeah. And that is a challenge for us because there's so many different injury prevention programmes that, that I think the whole concept can seem so complicated that you can- Yeah

get worked up about getting it perfect. And I really feel that we just need to get something out there to make a difference to these young people that are being that are being injured. And so [00:14:00] success for me really would look like that before organized sport, our our young people do a warm-up or neuromuscular programme for 10 minutes or whatever is convenient for them before organized sport,

so that we still have that same culture change. So if we see our young people going straight on the field and not doing that, we get that same horrible feeling when we see a kid without a cycling helmet. Yeah. Because really the implications are not a huge amount different. These are life-changing events.

So clear messaging, learning the mistakes from others, and really looking broad in terms of gaining expertise. That's really interesting, and I think really nicely put. And just to delve into a little bit more before w- we finish up about y- what you say in your annotation and your editorial, who should really then really be b- responsible for implementing these changes?

And what is already happening already in this area that is trying to develop this change? That's the big golden question that I'm not sure we ever really answered [00:15:00] in the editorial. But the key thing is that I think we need everyone to be involved. I think there has been a bit of a challenge, and the groups that have been working in the UK and Scotland through lots of structured interviews with all the stakeholders, whether that be government, education, national governing bodies, is there is a little bit of fear that if you take responsibility now for implementation, there's this concern that you might be in some way responsible for the injuries that have maybe happened in the past.

So I think we need to draw that to one side- but what we what's, we feel that we're starting to gain a bit of traction in Scotland. We have brought together a a steering group which has been selected on those individuals and who are representing groups that we really feel will make a huge difference.

And for us in Scotland really we, the big participation sports are rugby and football, but we know that we will not get anything achieved without government input and for example, in Scotland, the Scottish [00:16:00] Institute from Sport, and of course bringing in those people who have, who successfully implemented things like the concussion programme.

So bringing all the stakeholders, but it has to be people that can make a change in those organizations whilst also making it local. And one thing I think that's working for us is that we've got some funding now from the Scottish government, and there's nothing like having a meeting in a government building funded by the Scottish government s- to, to make people feel like there's a chance that you'll make a change in policy.

And so- Yeah ... those things have worked for us and hopefully will lead to further success. Yeah, absolutely. And I suppose just a final question on that sort of note, which sort of wraps up, or maybe I'll ask you, Iain, first and then you, Prof, as with all these things, how do we define success?

Is it gonna be, with all due respect people are gonna put both of you slightly out of work? Or is that gonna be too far with the ACL re- ACL injuries? Yeah. I'm not sure what it's like south of the border, but it's [00:17:00] actually very difficult in Scotland to determine how many ACL injuries occur because measuring success ultimately should be a reduced number of ACL injuries and surgeries, but I think we need to be practical and for us success will be seeing our young people warming up or doing these neuromuscular programmes.

We have to celebrate all the successes, so that might be a policy change, it might be that funding is linked to adherence with these programmes. So success, I think we should celebrate even the small wins, but ultimately it'll be that culture change, like they saw in concussion- Yeah ... where people have that kinda gut feeling that they should be doing a warm-up in the same way if they've any doubt that anyone's concussed, they bring them off the field.

No, I totally agree. And then Prof, maybe to finish up, I think, the same question to you, and I think something that you alluded to at the beginning is it's I suppose part of the success is, yes, we can reduce the in- number of injuries and, but actually still getting lots of people to play these really important sports and keeping, keeping active.[00:18:00] 

Yeah, so for my drive has always been participation. I think- Yeah ... we want a healthier nation. So I think success will come at many levels, but what you really want is a high noise level on this- Yeah ... from elite athletes through to influencers, through ultimately to the policymakers, and you want it to percolate through schools and so on.

I don't think this comes down to counting injuries, 'cause actually we don't know the current denominator, we don't know the current instance that well, not everybody gets a scan- Sure ... or sees a s- sees a surgeon. So from that point of view, those things are really tricky. I think what success would be is you listen to sp- watch Sports Personality of the Year at the end of the year, and you get an award for someone introducing this kind of programme- Yeah

to a group of youth sports or young teams or a school. I think that sort of thing will mean success. That'd be pretty cool. I think that's a really n- nice thought to finish on, Prof. Both I'm afraid that's all we have time for today, so thank you so much to you both for taking the time to join us and discussing this really important area of work, and [00:19:00] I look forward to reading more as we move forward.

And to our listeners, we do hope you've enjoyed joining us, and we do encourage you all to share your thoughts and comments on our various platforms. Feel free to post about anything we have discussed here today and thanks again for joining us everyone. Take care.