How to avoid ligament injuries in children

Are we doing enough to prevent children sustaining serious injuries whilst on the sports pitch or ski slope?

Seeing children running about a sports pitch, or enjoying ski school is a great sight, and one we all actively encourage, both as parents, teachers or one of the army of volunteer coaches. However, increasing numbers of children are sustaining serious knee injuries, which could have long term consequences on their future activity levels. Whilst several sports bodies around the world have introduced simple injury prevention exercises to try and mitigate this problem, here in the UK we are behind the curve and need to do more.

In this article, Specialist Orthopaedic Knee Surgeon, Professor Adrian Wilson, who has treated serious complex ligament injuries in both adults and children, gives his views on how we can all help to ensure our young people enjoy a lifelong relationship with sport and exercise. His own daughter suffered an anterior cruciate ligament (ACL) rupture whilst on a family ski holiday a number of years ago. Whilst she is now able to participate in many activities, she unfortunately no longer skies, due to the risk of further damage.

So, what’s causing the increase in injuries?

Our children in the UK are incredibly active, with 88% of 5-15 year olds taking part in sport at least once a month₁. However, it is the increasingly competitive nature of school and local sports teams and the enthusiasm post 2012 for growing the next generation of Olympic medal winners, which I believe could be having an impact on children’s bodies and leading to injury.

A greater understanding of the impact on their knees of specific activities and the application of simple warm up exercises could make a real difference, as it is starting to do in other parts of the world.

What is the most common knee injury in children?

Damage to the anterior cruciate ligament (ACL) is the most frequently seen injury and is increasingly common in young people. The ACL is the largest ligament in the knee and controls the back and forth motion of your knee, along with the less commonly injured posterior cruciate ligament (PCL), which is the largest ligament in the knee and helps give stability.

If the ACL is torn or ruptured, the knee becomes unstable when it is twisted and can give way, as well as losing its full range of movement. As the knee gives way, the delicate structures inside it, as well as the joint surface and meniscal cartilages, may also be damaged.

A study in the US found that the number of ACL injuries in 6-18 year olds has increased by over 2% a year for the last 20 years2. Whilst I don’t have exact figures for the number of children being affected in the UK, I would estimate it to be growing at around 15% a year. The US study found that just under half of pre-teens and 65% of adolescents being seen for a swollen knee had suffered an ACL rupture.

As well as children playing more sport and competing at a younger age, better detection via MRI scans and greater patient awareness have meant that more children and young people are being diagnosed with ligament damage, hence greater numbers being referred on to knee specialists.

How does ACL injury in children occur?

As children’s bones and ligaments are not yet fully developed, they are at greater risk of damage.

An ACL injury is most likely to occur when children are taking part in sports involving twisting and pivoting and jumping, such as football, netball, tennis and rugby, which are all played regularly in UK schools. Skiing, due to the pressure on the knee, whilst the ankle is kept in a fixed position, is also one of the sports with a higher than average occurrence of ACL tears.

It can also occur with certain movements, such as a child jumping and landing hard on their feet. If the quadriceps muscles aren’t strong enough, a movement can suddenly put too much pressure on the knee joint, causing the ACL, a rope-like band of tissue, to tear or rupture.

Teenage girls are between two and ten times more likely than boys to tear an ACL, due to their body shape, limb alignment, neuromuscular control, and the presence of hormones which might loosen the ligament.

What should I look out for?

Usually with an ACL injury, there will be a popping sound. The child may also use their hands to demonstrate a severe twist of their knee or describe it as feeling wobbly or loose.

They will definitely feel pain when the ACL tear happens, however afterwards, they might have symptoms, depending on the severity of the injury. Often there is pain, which can be intense, and swelling of the knee joint, which can happen within 24 hours of the injury occurring.

Most will have no problems walking. But if they try to go back to sport, they may have some instability, or be unable to bear weight on the affected knee.

What should I do if I suspect my child or pupil has torn their ACL?

For any knee injury or following a ski fall or collision on the football or netball field, it is important to stop activity straight away. If the knee is swollen, ice should be applied for at least 20 minutes at a time, and the knee should be kept elevated.

A trip to A & E or a local minor injuries clinic is the first port of call, or to your GP, whichever is available soonest. If weight bearing is painful, your child should be kept off their feet until you can get them assessed.

If your child has any of the symptoms of a ligament injury mentioned above, you must insist on getting a referral to a knee specialist, who is an expert in ligament injuries. Your consultant will need an MRI scan to confirm the diagnosis, so request that your child is referred for a scan at the same time.

While an X-ray might be taken at A & E, this will only show bone damage, so will be used to rule out a fracture or break. An MRI scan, which assesses ligaments and muscles can confirm a partial or complete ACL tear so you really need one to confirm diagnosis.

I cannot stress enough how important it is to see a knee specialist early. The average time from knee ligament injury to fixing the problem is four weeks in Australia, the US and many European countries. Unfortunately, it can take 18 months in the UK by which time there is usually significant secondary damage to the joint surface and meniscus shock absorbers which is bad news. This is why our outcomes are less than ideal and lagging behind the rest of the world.

What’s the treatment?

Once your child has had an MRI scan and been referred to a consultant orthopaedic knee surgeon and ideally a specialist in ligament repair and reconstruction, they will review the MRI scan and carry out a full assessment.

The consultant will discuss your child’s symptoms and examine the knee to check for tenderness, stiffness, swelling and any other problems. They may also ask them to move their knee into different positions to assess the range of movement and the function of the joint. Depending on your child’s age and the severity of the injury, there are two treatment routes for a torn ACL.

Non-surgical treatment: involves physiotherapy and additional support – such as a knee brace – when playing sport.
Surgery: if the knee regularly gives way during normal everyday activities, or prevents your child taking part in sport, they may require ACL surgery. Traditionally, this surgery involved a long recovery period of around a year; however, new procedures for treating ACL injuries, which I have pioneered, have reduced this to around four months.

If an adult is injured and damages their anterior cruciate ligament, the tear usually occurs in the upper or middle part of the ligament. However, in children and young people, the attachment of the ligament to the bone is a weak point and the ligament can become completely separated from the bone, possibly with a fragment of bone still attached.

In some cases, it may be possible to re-attach the bone fragment along with the ligament using keyhole surgery. However, ligament re-attachment can only be carried out in the first few weeks after an injury. In some cases, I might also advise carrying out the All-Inside reconstruction technique and anterolateral ligament (ALL) reconstruction alongside ACL surgery to improve the outcome.

Anterior cruciate ligament (ACL) reconstruction in children using a parent’s hamstring as a donor graft

I saw this procedure, pioneered by Dr Leo Pinczewski in Sydney, Australia, and its exceptional results during my fellowship. When I returned to the UK, I decided to set up a service to provide this innovative technique.

While hamstrings grow in length, they don’t thicken and can remain very thin, especially in small children. However, using a parent’s hamstring to repair an ACL injury has been shown to reduce the failure rate from 30% to less than 10%. During the six years that I have been carrying out this procedure on children, surgery has been 100% successful.

How long is the recovery?

After surgery, your child will need to walk with the assistance of crutches initially, limit physical activity and wear a full-leg brace for 4 to 6 weeks. Painkillers and anti-inflammatories are prescribed initially to ensure they remain pain free.

Recovery from ACL surgery can take as little as 4 months using the more innovative techniques which I use. Physiotherapy is a bit part of this to restore the range of motion, regain strength and stability and reduce swelling.

Will they be able to get back to sport after injury?

Getting back to sport is a definite possibility. I operated on an 18 year old elite hockey player who was back on the pitch within 4 months.

More usually, I recommend children get back to more gentle activity such as swimming, cycling before progressing to running. Contact sports may remain off limits for a number of years, however I always review patients regularly and advise on activities which can be safely enjoyed.

What has been successful in reducing knee injuries in children and young people?

There are some great of examples of how specific warm up exercises and activities can protect children from sustaining ACL injuries.

Professor Lars Engebretsen, a consultant orthopaedic surgeon in Norway, identified the value of pre-exercise warm up to reducing the incidence of ACL injury in young people through programmes implemented with the Norwegian national handball team4. Subsequent research concluded that injury can be reduced by up to 50%. The research found that that pre-sport exercise programmes need to include a combination of balance/co-ordination, strength, plyometric and technique exercises. These ideas have subsequently been included in schools across the country. Children can quickly learn how to avoid the movements that are associated with an ACL tear.

In response to the growth in ACL injuries, Netball Australia has developed ‘The KNEE Program’, which is an on court warm up programme, which has a target of reducing ACL injuries by 40-70%. It has been designed to educate athletes, coaches and support staff of the benefits of warming up and provides a different set of exercises for junior players.

The International Federation of Association Football (FIFA), have introduced FIFA 11+, a simple, and easy to implement, sports injury prevention programme, which consists of 10 warm up exercises. A study reviewing the impact of implementing the programme₃, found that there was a 30-70% decrease in the incidence of injuries amongst amateur teams which had used the exercises.

How can I protect my child or my pupils from injuring their knee?

In the absence of a national programme for individual sports in the UK, I would draw on the resources available online from other countries.

Take advice from knee specialists, both surgeons and physiotherapists when you come into contact with them. They can give you expert advice and point you in the right direction.

About Professor Adrian Wilson:
Professor Adrian Wilson is a world-leading Knee and Sports Injury Specialist who practises privately in Harley Street, London, Basingstoke and Windsor. His patients travel to him from all over the world.

Adrian has a global reputation in carrying out knee realignment (osteotomy) surgery and has developed pioneering techniques for sports injury repair. He is also a leading authority in diagnosing and treating children’s knee problems. He has developed a number of evidence-based techniques which include new, minimally invasive procedures for knee realignment (osteotomy) and anterior cruciate ligament (ACL) repair. Among other innovations, he has developed a minimally invasive technique to treat anterior cruciate ligament (ACL) injuries in children that has a fast recovery time and excellent long-term results. Most recently, Adrian has introduced adipose tissue therapy to the UK. Often used alongside other surgery, it harnesses the body’s own natural repair cells to help reduce pain and increase activity levels for patients with arthritis. A true innovator, Adrian is acknowledged for his work by his fellow surgeons, many of whom he trains to perform these procedures. His colleagues also trust him to operate on members of their own families, as well as themselves. Most importantly for Adrian is the fact patients benefit from and appreciate his skills as a knee surgeon.

For more information:
Telephone: 020 3397 7779

1 Taking Part 2016/17: annual child release, Department for Digital, Culture, Media & Sport, published 28 September 2017.
2 Prevention, treatment, and rehabilitation of anterior cruciate ligament injuries in children, Open Access Journal of Sports Medicine, published 12 June 2017.
3 The Impact of the FIFA 11+ Training Program on Injury Prevention in Football Players: A Systematic Review, International Journal of Environmental Research and Public Health, published 19 November 2014. 4 ACL prevention in female handball, published ASPETAR Sports Medicine Journal.


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