NFL ACL Tears: A Critical Review of the Trends

Over the past five years, I have been closely reviewing the number of ACL injuries requiring surgery in the National Football League. In many ways, this examination has been for the purpose of determining the efficacy of off-season training protocols in keeping athletes healthy, with the ACL being the “canary in the coal mine,” so to speak. Much of this has been connected to the changes in the collective bargaining agreements (CBAs) in professional sports, which now often don’t require athletes to train with the team staff. Of course, we must consider many factors when it comes to the causes behind these types of injuries, but the data can be helpful when cross-referenced with both situational and environmental changes occurring over time.

I have accumulated the following unofficial data by watching injury reports through conventional media, examining posts on NFL Fantasy Football websites, reviewing posts on social media, and talking to people close to the data. Interestingly enough, fantasy football reporting has been one of the more expedient and accurate means of tracking injuries and man games lost to injury in recent years. Whenever money is on the line, people will find the information that they need to make an informed decision.

The accuracy of the data is only as good as the sources, but at least it gives us a rough idea of the injury numbers each year. Table 1 outlines the observed data for the last 10 years, including an incomplete number for the current NFL season, showing some interesting trends since the introduction of the new CBA in March 2011. Although it was introduced in 2011, it was followed by a lockout that ended in late July 2011, so the effects of the new CBA rules were not fully realized until the following years.

 

1. Improved Physical Preparation in the Off-Season

It is important to start off on a positive note and give credit where credit may very well be due. I have been involved in a number of professional development events with the NFL in the past few years, including a number of NFL Combine gatherings. I have been included among a broad range of elite experts and professionals brought in to provide insight into injury prevention and athlete resiliency. Both medical staff and physical preparation staff have been the audience, and a good deal of practical information was exchanged.

I would like to think that much of this information has been passed on and implemented in both the off-season and in-season environments to give players a better chance to perform at a high level and stay healthy. This could very well be one of the reasons the pre-season ACL injury numbers are significantly lower than previous years. Professional sport requires that all employees retain a mindset of eternal optimism as an effective mental health strategy.

The difficult part of this situation is that team staff members have not been given any additional time to implement these specific strategies. The NFL Collective Bargaining Agreement is not due to be altered until 2021, and teams are still bound by the current agreement, limiting off-season work with players. Perhaps teams are simply getting smarter and more efficient with the limited time they have with players, such as the five weeks of dedicated strength and conditioning time.

One year of reduced NFL pre-season injuries is just a blip on the radar, and we must continue to monitor the situation, especially as we transition into a new CBA era, says @DerekMHansen. Share on X

My own work with teams has been focused on being more effective and efficient in a shorter period of time in order to effect sustainable adaptations and strategies for players. Trimming the fat has been a prime objective with no wasted effort, accounting for every minute of training time. However, this approach has significant limitations if players are non-compliant once they leave the training facility.

Let us assume that team staff members have been able to make inroads on the issue of injury prevention. Time will tell as we move forward this season and next, and beyond. One year of reduced pre-season injuries is simply a blip on the radar, and we must continue to monitor the situation, particularly as we transition into a new CBA era.

2. Risk Avoidance for Older Players

The recent lessons of the NBA have been front and center for NFL coaches and executives. Having your top players go down with a catastrophic injury at the worst possible time is not a solution for success. The term “load management” has made its way through professional sports, and sitting players on the bench seems to be a viable solution to all of the teams’ injury woes. And, seemingly, the waters of the “anti-fragile” swamp have drained away in recent years, as making players more resilient in the off-season just does not seem to be viable strategy in the minds of many. Resting players is easier to implement and label as a “sports science” intervention, regardless of what technology tells us.

We must ask ourselves if the top players in the NFL are being “load managed” more than ever in the pre-season and not being given the opportunity to rupture a ligament or tendon in games that are considered worthless. The better players have also had a few more years in the league and may not be considered as youthfully durable. Thus, the bulk of the pre-season game load is being shouldered by players who have just completed 3–4 years in college under a strength and conditioning program that requires them to be in attendance for more than six months outside of the season.

It does seem that we see fewer and fewer appearances by each team’s top players in pre-season games. Has this trend influenced the ACL injury totals this year? asks @DerekMHansen. Share on X

While sitting out stars makes sense, this is not a new development, as starters have often been held back in pre-season games to not only preserve their health, but also evaluate new talent for the roster selection process. However, it does seem that we are seeing fewer and fewer appearances by each team’s top players in pre-season games. Has this trend influenced the ACL injury totals this year? It is difficult to make this connection without tracking the minutes of all players in the pre-season over the last 10 years and comparing them against regular season playing minutes.

It still remains a compelling discussion, as more and more teams and players are complaining that the pre-season games are worthless and detrimental to the health and longevity of players, as well as the fortunes of individual teams in the regular season. It will be interesting to see how the pre-season is handled in the upcoming 2021 Collective Bargaining Agreement, as team owners will likely not choose to give up the revenues earned from those games. Only a move to the 18-game regular season model, with two pre-season games, may be attractive to owners. However, the injury implications of such an arrangement could make it even more costly for star players.

3. Rule Changes and Enhanced Enforcement

Some may attribute the reduction in pre-season ACL injuries to a change in rules and the way NFL officials are calling penalties, particularly those of the “targeting” variety. Are defensive players changing their approach to tackling and hitting their opponents, resulting in fewer catastrophic injuries? While this may be the case, the opposing argument has been that since NFL officials are trying to minimize traumatic brain injuries on the field, defensive players have decided to tackle and place hits below the waist, resulting in an increase in knee injuries. In addition, the expansion of instant-replay reviews by officials may make players adjust their behavior on the field, resulting in fewer serious injuries.

While rule changes may be part of the recent shift in pre-season ACL injuries, a longer-term evaluation of the effect of rule changes must be performed to truly understand the impact of on-field officials on injury patterns. Players don’t change behaviors that have been developed over their entire football careers in four games. Often, making players overtly think about their on-field movement strategies can create more coordination problems and apprehension that can lead to injury.

While we can be in favor of rule changes that minimize serious injury risk, it is difficult to ‘legislate’ fewer injuries in a game that is inherently dangerous, says @DerekMHansen. Share on X

While we can be in favor of rule changes that minimize serious injury risk, it is difficult to “legislate” fewer injuries in a game that is inherently dangerous. This can be observed with the changes to both the “kick-off” rules and the rules around “defenseless players” implemented in the last 10 years. The pre-season total for ACL injuries has shown a general increase over this same time period, despite the shift toward rule changes intended to reduce injuries.

Sports leagues often make rule changes to give the impression that they are trying to improve the health of the players and the safety of the game. Whether or not the rule changes actually improve safety remains to be seen. For every penalty that is issued for a hit to the head, will there be an unintended consequence experienced years later? Will excessive stoppages due to instant replay reviews allow the players to cool down and stiffen up more during a game in cold weather? In any event, more data must be collected to determine the true causes of injuries, as well as determine if new interventions are rightfully improving the situation.

4. Dumb Luck

In a pre-season when “Smart Luck” decided to end his NFL career and move on to other aspects of life, “Dumb Luck” may be the reason that fewer players have torn their ACL so far this season. As was mentioned earlier, a positive outcome this year may simply be a blip on the radar that comes and goes due to factors out of control of the players and the staff around them. Injuries can rarely be explained by a single variable. The problem with declaring the current reduction in pre-season ACL injuries a “victory” is that if this year is actually a “dumb luck” anomaly, teams and players may start to relax on the key prevention measures that have kept the injuries from exploding beyond current levels.

In a sport such as American football, the need to be vigilant on all aspects of biomechanics, tactical preparation, and physical training is as important as ever to maintain the health and well-being of all players. Recent statistics show that the number of high school boys playing football continues to fall, with participation in 11-player football dropping by 30,829 participants to 1,006,013—the lowest mark in almost 20 years. The influence of injuries and the long-term health implications reported among NFL players have trickled down to the youth sport level, making parents and kids think twice about participation. Everyone in football—especially the NFL—has a stake in making the sport safer, but also in changing perceptions of the sport.

Another recent study showed that more individuals suffer concussions from recreational activities such as cycling, skateboarding, and horseback riding when compared to competitive sport, but we haven’t seen Will Smith examining brain slices from Shaun White yet. While we all want to celebrate victories around injury reductions from year to year, we should also be taking a more global approach to improving all aspects of professionalism, planning, and preparation around the sport to minimize bad luck and maximize good luck.

Moving into the Regular Season

As we start the 2019–20 NFL regular season, many of us will be watching closely to see if there is a spike in injuries—particularly those of the ACL variety—when the games count and full starting rosters are put on the field. Additionally, as players accumulate training and competition load week to week, exacerbated by travel demands, inclement weather, and field surface variability, we may get a more accurate indication of their resiliency and durability. I would love to see the current pre-season ACL injury total result in fewer than 25 cases for the season. However, I am much too pragmatic to believe that this is a sign of things to come, given the lack of change in physical preparation time, the complications around cleat-field interaction, and the nature of the sport itself.

At some point, the NFL and its teams will begin to seriously examine the trends and start making connections with key variables that can fall under their control, says @DerekMHansen. Share on X

At some point, the League and its teams will begin to seriously examine the trends and start making connections with key variables that can fall under their control. A clear and comprehensive evaluation of what is required and permissible in the off-season must be undertaken. Everyone is making significant sums of money—much more than ever before in the history of the League—so moving in the direction of improving game safety will only improve the public perception of the sport. If more star players are removed from the picture with serious injuries, particularly after being shelved for most of the pre-season, teams will falter, and fan followings will decline. Factor in the trickle-down impact of these injuries on youth participation, and now you have a serious problem around your sport over the long term.

Unfortunately, collective bargaining tends to become more about power, control, deal-making, and perceived victories than what is best for everyone. If injuries are simply written off as the cost of doing business or an occupational hazard, the problem will persist and perhaps even grow in magnitude.

Burying your head in the sand and hoping that ‘load management’ will be the solution is akin to giving Chernobyl clean-up crews longer coffee breaks on the job site, says @DerekMHansen. Share on X

A simple examination of injury statistics around other industries such as mining or construction demonstrates a significant downward trend in injuries and fatalities in the last 20­–30 years due to acknowledgement of the problem, organizational changes, and cooperation between business owners, management, and employees. Professional sports should be no different. Burying your head in the sand and hoping that “load management” will be the solution is akin to giving Chernobyl clean-up crews longer coffee breaks on the job site. The risk has not been reduced. The inevitable has simply been delayed.

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