Published Rates of Reinjury After ACL Reconstruction Show Need for Advanced Neuromuscular Retraining

Sue Barber-Westin

Despite advances in ACL reconstruction techniques and the use of early rehabilitation principles such as immediate knee motion and quadriceps strengthening exercises, some recent studies have reported high failure rates when patients resume athletics after surgery. This problem has been especially noted in athletes under 25 years of age who return to sports that involve jumping, pivoting, and cutting. For instance, one study2 reported that 30% of patients sustained noncontact reinjuries and tore either their ACL graft or the ACL in the contralateral knee within 2 years of surgery. These patients had a 6 x greater ACL injury incidence compared with a healthy control group. Even more concerning was the finding that the rate of a contralateral ACL injury was significantly higher than the rate of ACL graft injury (20.5% and 9%, respectively). Another study4 that involved 788 ACL autograft and 228 ACL allograft patients reported a significant difference in the reinjury rates in patients under the age of 25 (9% and 25%, respectively; p < .0001). This study was the first to show such poor results in young, highly active patients who received allografts and questioned this graft choice for primary ACL reconstruction. A third study3 followed 878 patients who were less that 25 years of age at the time of their ACL autograft reconstruction. These investigators reported that ACL reinjuries occurred to either knee in 62% of men (289 of 465) and 40% of women (167 of 413) after the patients had resumed sports activities.

None of these studies reported on the program of rehabilitation that was followed after surgery, or if the patients underwent advanced neuromuscular retraining and demonstrated a return of normal muscle strength, balance, proprioception, and other athletic indices. There is currently a lack of consensus in the medical community regarding objective criteria that is required before athletes are released to full sports participation after ACL reconstruction. We performed a systematic review1 of 264 studies and found that only 13% discussed objective criteria – such as muscle strength and lower limb symmetry – required for return to athletics. We highly recommend that athletes who wish to resume high-risk sports complete a course of Sportsmetrics neuromuscular retraining and demonstrate normal values on single-leg hop tests (< 15% deficit distance hopped between legs), the video drop-jump test (> 60% normalized knee separation distance), isokinetic strength testing (< 10% deficit), and knee stability (< 3 mm increased anteroposterior displacement on Lachman testing) before they are released to unrestricted activities.


  1. Barber-Westin SD, Noyes FR. Factors used to determine return to unrestricted sports activities after anterior cruciate ligament reconstruction. Arthroscopy. 2011;27(12):1697-1705.
  2. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of Second ACL Injuries 2 Years After Primary ACL Reconstruction and Return to Sport. Am J Sports Med. 2014;42(7):1567-1573.
  3. Shelbourne KD, Gray T, Haro M. Incidence of subsequent injury to either knee within 5 years after anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med. 2009;37(2):246-251.
  4. Wasserstein D, Sheth U, Cabrera A, Spindler KP. A Systematic Review of Failed Anterior Cruciate Ligament Reconstruction With Autograft Compared With Allograft in Young Patients. Sports Health. 2015;7(3):207-216.

ACL Injuries in the Female Athletes Textbook

…Over 15,000 Chapters Downloaded and Counting

Dr. Noyes has many research interests and one of the most prominent is the prevention of anterior cruciate ligament injuries in female athletes. ACL injuries can cause long-term problems in the knee joint, including the early onset of osteoarthritis. It has been evident for some time that a gender disparity exists in noncontact ACL injuries, with female athletes suffering 2 to 6 times the injury rate as male athletes in sports such as soccer and basketball. In response to this problem, Dr. Noyes and researchers at his institute developed an ACL injury prevention training program (Sportsmetrics) that has been successful in reducing the injury incidence in female athletes.

In 2012, Dr. Noyes and co-editor Sue Barber-Westin published an extensive, 22-chapter textbook (ACL Injuries in the Female Athlete: Causes, Impacts, and Conditioning Programs) on this topic designed for orthopedic surgeons, physical therapists, athletic trainers, sports medicine primary care physicians, and strength and conditioning specialists. The 500+ page textbook examines the short- and long-term impacts of ACL tears and gender-related risk factors for this injury. Neuromuscular training programs, including Sportsmetrics, are provided in detail. Dr. Noyes and researchers at his institute have also published 20 articles in peer-reviewed orthopaedic journals on this topic.

From its online publication in November 2012 through 2014, over 15,00 chapters from the textbook were accessed from the publisher’s website. This large number indicates the relevance and interest in this topic and makes this book the most widely read on this topic. Dr. Noyes and researchers at the Noyes Knee Institute remain dedicated to continued research and training efforts to reduce the incidence of ACL injuries in female athletes.  Visit for more information.

July Certification Course

Our July certification class…25 new certified instructors traveling from as far as Alaska to New York! Many of our sites have shown their ongoing commitment to the program by sending multiple staff members to get certified throughout the years. Thanks to Hulst Jepsen Physical Therapy, Therapeutic Associates, ATI Physical Therapy, Kenyon College and Inova Sports Medicine Institute. We welcome all of our new instructors and thank you for your commitment to female athlete injury prevention! See who got certified…

Fabrizio Apodaca, MS, ATC:  Henry Mayo Physical Therapy & Sports Rehab, Santa Clarita, CA

Karen Asekomeh, DPT, COMT:  Hulst Jepsen Physical Therapy, Rockford, MI

Fokion Avgerinos, DC:  Millennium Physical Therapy, Little Neck, NY

Colin Barich: Therapeutic Associates- Cedar Hills, Portland, OR

Allee Enderle, ATC:  The Orthopedic Hospital, Fort Wayne, IN

Roxanne Faison, MAT, ATC:  Covanent Health System, Lubbock, TX

Kathia France, BS, MA:  Millennium Physical Therapy, Little Neck, NY

Katie Hamberg, ATC:  Mother of Mercy High School, Cincinnati, OH

Ryan Hassick:  Cincinnati SportsMedicine Physical Therapy Clinical, Cincinnati, OH

Chris Henke, BS, PTA, CES, CKTP:  Memorial Hospital & Health Care Center, Jasper, IN

Daile Jackson, DPT:  Rehabilitation Specialists, Jamestown, NY

David Kaufman, ATC:  Millennium Physical Therapy, Little Neck, NY

April Dawn Kent, DPT:  Platte Valley Medical Center, Brighton, CO

Jim Kimbal, ATC, CSCS, LMT:  Fairbanks, AK

David Kock, MS, ATC:  ATI Physical Therapy, Naperville, IL

Elizabeth Murdock:  Cincinnati SportsMedicine Physical Therapy Student Clinical, Cincinnati, OH

Zachary Olivarez, ATC:  Fremont Therapy Group, Rawlins, WY

Camille Riddering, MD:  Grand Rapids Medical Education Partners Family Medicine Residency Program, Grand Rapids, MI

Amanda Rodriquez, DPT, OCS:  Physical Therapy Today, Lubbock, TX

Jenifer Shoultz, ATC:  Kenyon College, Gambier, OH

Sharon Strizak, DPT:  Cincinnati SportsMedicine, Cincinnati, OH

Roselyn Vassilatos, BS:  Millennium Physical Therapy, Little Neck, NY

Amelia Wiggins, DO:  Wellington Orthopaedics, Cincinnati, OH

Steve Wolak, BS:  West Springfield, MA

Christopher Young, MAT, ATC, ITAT:  Inova Sports Medicine Institute, Fairfax, VA

Sportsmetrics Course in Hilton Head

We always look forward to our annual course in Hilton Head, SC for many reasons… the weather, the beach scene, an appearance from the one and only George Davies.  There is something about palm trees and blue skies that brings out the best in everyone and this year was no exception.  Our course of 26 was filled with sports medicine healthcare professionals eager to learn and contribute to the field of injury prevention.  We welcome our 26 new certified instructors and look forward to working with you to keep your athletes healthy and strong for years to come!

Kellie Barber, PTA:  First Health of the Carolinas, Pinehurst, NC

Carolina Elisabeth Bockelman, PT:  Kauniainen, Finland

Brandi Bossinger, DPT:  First Health of the Carolinas, Pinehurst, NC

Ennea Dailey, MPT, DPT:  Air Force Special Operations Command, Fayetteville, NC

George Davies, DPT, MEd, PT, SCS, ATC, CSCS, PAPTA:  Armstrong Atlantic State University, Savannah, GA

Tom Davis, MPT, CSCS:  Fremont Therapy Group, Lander, WY

Ryan Dulling, DPT:  Tennessee Sports Medicine Group, Knoxville, TN

Cheryl Ellis, ATC:  Peak Rehabilitation Fitness & Performance Center LLC, Evans, GA

Christi Ewing, MPT:  Casa Colina Hospital & Centers for Healthcare, Azusa Center, Azusa, CA

Cozette Hanegan, DPT:  Frisco Physical Therapy, Frisco, TX

Cheryl Hochstein, MS, PT, ATC:  Mercy Clinics, Des Moines, IA

Mark Howard, DPT, OCS:  Howard Physical Therapy, Depew, NY

Miranda Huffman, DPT:  Bone and Joint Center, Bismarck, ND

Lauren Klemowicz, DPT:  PhysioFocus Orthopedic & Sports Therapy LLC, Charlotte, NC

Linda Leva-Schrank, PT, C/NDT, PCS:  NYU Rusk at Hospital for Joint Disease- Pediatrics, New York City, NY

Eric Lytle, PTA:  Novant Health Martinet Rehabilitation, Winston Salem, NC

Heather MacMillan, DPT:  First Health of the Carolinas, Pinehurst, NC

Philip Malloy, DPT, OCS: Pottsville Area Physical Therapy Services, Pottsville, PA

Fred McAlpin, DO:  Premier Orthopedics, Vineland, NJ

Debbie McGuire, PT, OCS:  Cape FearOrthopedic Clinic, Fayetteville, NC

Dan Roble, ATC, PTA:  Carolinas Rehabilitation- Mount Island Lake, Charlotte, NC

Michelle Rodriguez, PTA:  First Health of the Carolinas, PInehurst, NC

Marianna Spero, MS, ATC:  Charlotte Latin School, Charlotte, NC

Thierry Urbain, PT:  Associates in Orthopedics & Sports Medicine, Dalton, GA

Heather Ward, PTA:  OrthoCarolina, Lincolnton, NC

Gavin Weber, DPT, ATC:  Brookings Health System, Brookings, SD

Sportsmetrics Course at LSU- Lafayette

On May 9th and 10th, we traveled to Louisiana State University- Lafayette, LA.  The course was hosted by Tiina Garrison, PhD, MS, CSCS, who has been certified with the Sportsmetrics program since March of 2008.  Tiina was kind enough to get me acquainted with local tradition on arrival including a swamp tour and introduction to the region’s friendliest gator, Sheree.  The Ragin’ Cajuns know how to welcome their visitors!  The course roster included PT’s, ATCs and coaches from the region as well as Kala Kuhlmann from the University of Nebraska Medical Center and Shelby Cedotal from Mid-Tennessee Bone and Joint PT.  We are happy to welcome our 13 new certified instructors to the Sportsmetrics family!

Bob Austin, Head Women’s Basketball Coach:  Louisiana State University- Alexandria, LA

Shelby Cedotal, PTA:  Mid-Tennessee Bone & Joint PT, Murfreesboro, TN

Dustin Chadwick, CSCS/USAW:  Northwestern State University, Natchitoches, LA

Jason Drury, ATC:  Northwestern State University, Natchitoches, LA

Jean Hall, LAT, CSCS:  Physical & Occupational Therapy of Alegent, Alexandria, LA

Austin James, PTA:  Physical & Occupational Therapy of Alegent, Alexandria, LA

Troy James, PT, MS, SCS:  Physical & Occupational Therapy of Alegent, Alexandria, LA

Anna Kubiczki, Head ATC:  Louisiana State University- Alexandria, LA

Kala Kuhlmann, DPT:  University of Nebraska Medical Center, Omaha, NE

Mandy Guilliams, ATC:  Mid-State Orthopedics, Alexandria, LA

Tyler Martinez, Grad Student:  Louisiana State University- Lafayette, LA

Michael Poropat, Head Men’s & Women’s Soccer Coach:  Louisiana State University- Alexandria, LA

Gage Trahan, ATC:  Mid-State/Pineville High School, Pineville, LA

Sportsmetrics Tennis Paper Published

Read Full Article


Objective: Tennis requires speed, agility, and explosive power. Few studies have assessed the effects of a training program in junior players who are not on an elite or national level. We evaluated the impact of a program that combined components of a knee ligament injury prevention program with other exercises to improve athletic performance indicators. We hypothesized that this program would significantly improve dynamic single-leg balance and function, correct lower limb asymmetry, enhance speed and agility, and improve core endurance.

Methods: Forty-two players (31 females, 11 males; mean age, 14 ± 2 years) participated in the 6-week program conducted by a tennis professional and certified trainers. Each training session included a dynamic warm-up, jump training, strength training, and tennis- specific agility and hitting drills. Two single-leg hop tests, baseline and service box speed and agility tests, a 1-court suicide run, and an abdominal endurance test were conducted at baseline and 3 days after the last session. Fifteen athletes participated in more than one training program a mean of 9 months apart.

Results: In all 42 players, statistically significant improvements and large-moderate effect sizes were measured for speed, agility, dynamic single-leg balance, and abdominal endurance. Players who participated in multiple programs continued to improve, although the magnitude of the improvements was smaller than those obtained from the first training program. There were no differences in the percent of improvement in any of the tests between genders.

Conclusions: The program improved neuromuscular and athletic performance indicators in junior tennis players. Repeated training for continued improvements is justified as required or desired by the player. The program is appropriate for pre-season training for high school players or before the initiation of seasonal tournament play.

Sportsmetrics April Course

On April 18-19, we certified 18 new instructors from across the country.  Healthcare professionals traveled from as far as Ottawa to become experts in knee injury prevention training.  We welcome our new certified sites and thank you for your dedication to the Sportsmetrics program!

Lindsay Aarseth, MS, ATC, NSCA-CPT:  Black Hills Surgical Hospital, Rapid City, SD

Cole Abernathy, ATR:  OSR Physical Therapy, Chanhassen, SD

Justin Bobby, DPT, CSCS:  AspireFIT, Harrisburg, PA

Ryan Cummings:  Cincinnati SportsMedicine PT Student

Jackie Esguerra:  Mercy HealthPlex, Cincinnati, OH

Sarah Gerichs: Cincinnati SportsMedicine PT Student

Hannah Jones, ATC:  Fremont Health, Fremont, OH

Samantha Jones, ATC:  Wise Physical Therapy & Sports Medicine, Slippery Rock, PA

Ryan Koepp, DPT, ATR:  OSR Physical Therapy, Eden Prairie, MN

Jessica Lawson, ATC:  Memorial Orthopaedic Associates, Jasper, IN

Jenna Maag, DPT:  Northwest Physical Therapy/FAST Ohio, Elida, OH

Amanda McKibben, ATC:  Dayton Children’s Sports Medicine, Dayton, OH

Nicole Roether, ATC:  Cincinnati SportsMedicine, Cincinnati, OH

Lauren Sabatini:  Cincinnati SportsMedicine PT Student

Megan Saunders, ATC:  Excel Sports Medicine, Springfield, OH

Allison Shoemaker, ATC:  Excel Sports Medicine, Springfield, OH

Steven Shroyer, ATC:  Genesis HealthCare System, Zanesville, OH

Jacob Stryker, MA, ATC:  Avera St. Anthony’s Hospital, O’Neill, NE

Dana Thompson:  Lantana, TX

Sportsmetrics March Course

On March 21-22, we certified 19 new health care professionals in Sportsmetrics training.  Our class traveled from Michigan, Nebraska, Mississippi, Colorado, Wyoming, Montana and Wyoming.  We were happy to certify 6 individuals in our own healthcare system and look forward to seeing Sportsmetrics grow throughout our community and the country.  We welcome our newly certified instructors and thank you for taking time out of your weekend to help prevent ACL injuries:

Gretchen Aberg:  Mercy HealthPlex, Cincinnati, OH

Nic Baston:  Mercy HealthPlex, Cincinnati, OH

Karen Bearce, ATC: MedSport Dominos Farms, Ann Arbor, MI

Eric Bock, PTA: Orthopedic Associates of Lake County

Gerald Breedlove, PT: Orthopedic Associates of Lake County

Thomas Buehler, ATC: Catholic Health Initiatives/Millard West HS

Emily Campbell, ATC: MedSport Dominos Farms, Ann Arbor, MI

Danny Clifford, MS, ATC, CSCS: Cincinnati SportsMedicine, Cincinnati, OH

Chris Dobrowolski, ATC:  Wellington Orthopaedic, Cincinnati, OH

Chris Farrell:  Mercy HealthPlex, Cincinnati, Oh

Don Harrison Jr, MS, ATC: Performance Physical Therapy, Booneville, MS

Danielle Jolliff, PT: Orthopedic Associates of Lake County

Charles King, PT: Orthopedic Associates of Lake County

Asdrubal Lopez, DC: Summit Chiropractic and Sports Institute

Heather Mathis, PT, MS: Children’s Therapy Group, Cheyenne, WY

April Nierman, ATC: Wellington Orthopaedic, Cincinnati, OH

Matt Noe: Mercy HealthPlex, Cincinnati, OH

Brittany Schiager, DPT: Children’s Therapy Group, Cheyenne, WY

Ted Wells, MS, ATC: Ortho-Montana

Interpreting ACL Injury Prevention Program Results: Understanding Injury Incidence Rates and Athlete-Exposures

Sue Barber-Westin

Since the first publication of a knee ligament injury prevention training program appeared in the sports medicine literature for female high school athletes in 1996 – Sportsmetrics – [1], at least 50 have followed that focused on female athletes. To date, 9 of these studies have reported ACL injury rates in female athletes according to athlete-exposures. An athlete-exposure is usually defined as one athlete participating in a practice or game in which there is the possibility of sustaining an injury. There have been a few studies on intervention programs that did not provide ACL injury rates according to athlete-exposures. Instead, these investigations provided the number of injuries divided by the number of athletes participating, which is not considered accurate according to modern epidemiology methods. One must instead use athlete-exposures to calculate injury incidence rates.

Athlete-exposures are usually determined using one of two methods. The first, which is the most accurate but difficult to collect, is the actual number of hours a player participates in practices and games throughout the season. The second method defines 1 athlete-exposure as one athlete participating in a practice or game. Therefore, if an athlete participates in 3 practices a week for 16 weeks and a total of 10 games during the season, the athlete-exposures would equal 58 for that player.

Injury incidence rates are calculated as the number of injuries divided by the total number of athlete-exposures. They may be calculated separately for practices and games, or all combined for an entire season.

To date, 3 ACL injury prevention programs have significantly reduced the rate of noncontact ACL injuries in female adolescent athletes. These include Sportsmetrics [2], Prevent Injury and Enhance Performance Program (PEP) [3], and Knee Injury Prevention Program (KIPP) [4]. The Sportsmetrics program had 700 trained athletes with 36,724 exposures and 1,120 control athletes with 61,244 exposures. There were 13 noncontact ACL injuries in the control group and just 1 in the trained group, for incidence rates of .21 and .03, respectively (p = .03). These numbers included athletes who participated in the original Sportsmetrics program and those that participated in the more recent sports-specific programs of Sportsmetrics Volleyball, Sportsmetrics Basketball, and Sportsmetrics Soccer.

It is important to note that other programs have been successful in reducing the rate of other types of lower limb injuries. For instance, the HarmoKnee program reduced the incidence of all types of acute knee injuries and all noncontact knee injuries [5]. When noncontact ACL injuries were sorted from the other knee injuries, the data did not reach statistical significance. A program from Sweden significantly reduced the incidence of ACL injuries when contact and noncontact injuries were combined [6] .

So, for medical professionals, when you hear of a claim that a program “reduced the rate of ACL injuries”, it is important to carefully study the methods used to calculate the injury rates and if contact and noncontact injuries were combined. ACL injury prevention programs are designed to prevent noncontact injuries and are especially relevant for high-risk sports such as soccer and basketball.


  1. Hewett, T.E.; Stroupe, A.L.; Nance, T.A.; Noyes, F.R. Plyometric training in female athletes. Decreased impact forces and increased hamstring torques. Am J Sports Med 1996, 24, 765-773.
  2. Noyes, F.R.; Barber-Westin, S.D. Neuromuscular retraining intervention programs: Do they reduce noncontact anterior cruciate ligament injury rates in adolescent female athletes? Arthroscopy 2014, 30, 245-255.
  3. Mandelbaum, B.R.; Silvers, H.J.; Watanabe, D.S.; Knarr, J.F.; Thomas, S.D.; Griffin, L.Y.; Kirkendall, D.T.; Garrett, W., Jr. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med 2005, 33, 1003-1010.
  4. Labella, C.R.; Huxford, M.R.; Grissom, J.; Kim, K.Y.; Peng, J.; Christoffel, K.K. Effect of neuromuscular warm-up on injuries in female soccer and basketball athletes in urban public high schools: Cluster randomized controlled trial. Arch Pediatr Adolesc Med 2011, 165, 1033-1040.
  5. Kiani, A.; Hellquist, E.; Ahlqvist, K.; Gedeborg, R.; Michaelsson, K.; Byberg, L. Prevention of soccer-related knee injuries in teenaged girls. Arch Intern Med 2010, 170, 43-49.
  6. Walden, M.; Atroshi, I.; Magnusson, H.; Wagner, P.; Hagglund, M. Prevention of acute knee injuries in adolescent female football players: Cluster randomised controlled trial. BMJ 2012, 344, e3042.

First Course to Kick Off 2015

We kicked off our 1st certification course of 2015 with 5-8 inches of snow! Remarkably all of our course participants made it safely without delays or cancellations, traveling from Pennsylvania, New York, Wisconsin, Nebraska, Minnesota and New Mexico!  Perhaps the most difficult trip came for the two traveling the shortest distance…Erich Koenig and Ashley Stanko from Dayton Children’s Hospital drove through snow and ice early Saturday morning and made it on time! Thanks to all of you for your dedication and commitment to Sportsmetrics and injury prevention!  We welcome 12 new members to the Sportsmetrics team:

Craig Allen, ATC:  OSR Physical Therapy, Chaska, MN

Katelyn Dahl, DPT:  OSR Physical Therapy, Minnetonka, MN

Megan Freeman, DPT:  Proformance Physical Therapy, Lincoln, NE

Kurt Jacobson, ATC:  Mayo Clinic Health System, Eau Claire, WI

Erich Koenig, ATC:  Dayton Children’s Hospital, Dayton, OH

Jeffrey Lasko, PT, CSCS:  ACMH Hospital, Sarver, PA

Felipe Mares, PT:  PT First, Albuquerque, NM

Nicole Nolan, DPT:  Sports Physical Therapy of New York, Rochester, NY

Amy Postupack, PT:  ACMH Hospital, Lower Burrell, PA

Allison Pulvino, PT:  Sports Physical Therapy of New York, Rochester, NY

Ashley Stanko, ATC, MBA:  Dayton Children’s Hospital, Dayton, OH

David Webster, ATC:  Mayo Clinic Health System, Eau Claire, WI