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Background The FIFA 11+ injury prevention program has been shown to decrease the risk of soccer injuries in men and women. The program has also been shown to decrease time loss resulting from injury. However, previous studies have not specifically investigated how the program might impact the rate of anterior cruciate ligament (ACL) injury in male soccer players. Questions/purposes The purpose of this study was to examine if the FIFA 11+ injury prevention program can (1) reduce the overall number of ACL injuries in men who play competitive college soccer and whether any potential reduction in rate of ACL injuries differed based on (2) game versus practice setting; (3) player position; (4) level of play (Division I or II); or (5) field type. Methods This study was a prospective cluster randomized controlled trial, which was conducted in 61 Division I and Division II National Collegiate Athletic Association men’s soccer teams over the course of one competitive soccer season. The FIFA 11+ is a 15- to 20-minute on-the-field dynamic warm-up program used before training and games and was utilized as the intervention throughout the entire competitive season. Sixty-five teams were randomized: 34 to the control group (850 players) and 31 to the intervention group (675 players). Four intervention teams did not complete the study and did not submit their data, noting insufficient time to complete the program, reducing the number for per-protocol analysis to 61. Compliance to the FIFA 11+ program, athletic exposures, specific injuries, ACL injuries, and time loss resulting from injury were collected and recorded using a secure Internet-based system. At the end of the season, the data in the injury surveillance system were crosshatched with each individual institution’s internal database. At that time, the certified athletic trainer signed off on the injury collection data to confirm their accuracy and completeness. Results A lower proportion of athletes in the intervention group experienced knee injuries (25% [34 of 136]) compared with the control group (75% [102 of 136]; relative risk [RR], 0.42; 95% confidence interval [CI], 0.29-0.61; p < 0.001). When the data were stratified for ACL injury, fewer ACL injuries were reported in the intervention group (16% [three of 19]) compared with the control group (84% [16 of 19]), accounting for a 4.25-fold reduction in the likelihood of incurring ACL injury (RR, 0.236; 95% CI, 0.193–0.93; number needed to treat = 70; p < 0.001). With the numbers available, there was no difference between the ACL injury rate within the FIFA 11+ group and the control group with respect to game and practice sessions (games—intervention: 1.055% [three of 15] versus control: 1.80% [12 of 15]; RR, 0.31; 95% CI, 0.09–1.11; p = 0.073 and practices—intervention: 0% [zero of four] versus control: 0.60% [four of four]; RR, 0.14; 95% CI, 0.01–2.59; p = 0.186). With the data that were available, there were no differences in incidence rate (IR) or injury by player position for forwards (IR control = 0.339 versus IR intervention = 0), midfielders (IR control = 0.54 versus IR intervention = 0.227), defenders (IR control = 0.339 versus IR intervention = 0.085), and goalkeepers (IR control = 0.0 versus IR intervention = 0.0) (p = 0.327). There were no differences in the number of ACL injuries for the Division I intervention group (0.70% [two of nine]) compared with the control group (1.05% [seven of nine]; RR, 0.30; CI, 0.06–1.45; p = 0.136). However, there were fewer ACL injuries incurred in the Division II intervention group (0.35% [one of 10]) compared with the control group (1.35% [nine of 10]; RR, 0.12; CI, 0.02–0.93; p = 0.042). There was no difference between the number of ACL injuries in the control group versus in the intervention group that occurred on grass versus turf (Wald chi square [ 1 ] = 0.473, b = 0.147, SE = 0.21, p = 0.492). However, there were more ACL injuries that occurred on artificial turf identified in the control group (1.35% [nine of 10]) versus the intervention group (0.35% [one of 10]; RR, 0.14; 95% CI, 0.02–1.10; p = 0.049). Conclusions This program, if implemented correctly, has the potential to decrease the rate of ACL injury in competitive soccer players. In addition, this may also enhance the development and dissemination of injury prevention protocols and may mitigate risk to athletes who utilize the program consistently. Further studies are necessary to analyze the cost-effectiveness of the program implementation and to analyze the efficacy of the FIFA 11+ in the female collegiate soccer cohort. Level of Evidence Level I, therapeutic study.

The relationships of gender, age and training to the incidence of anterior cruciate ligament (ACL) injury are pivotal to developing a comprehensive neuromuscular and proprioceptive training programme to decrease ACL injuries in female athletes. A prophylactic neuromuscular and proprioceptive training programme may have direct benefit in decreasing the number of ACL injuries in female athletes. This research foundation endorses further epidemiological and biomechanical studies to determine the exact mechanism of ACL injury and the most effective intervention for decreasing ACL injuries in this high-risk population.

Purpose The 11+ injury prevention program has been shown to decrease injury rate. However, few studies have investigated compliance and if it is correlated to time loss. The purpose of this study was to (1) analyze how differences in compliance may impact injury rate and (2) if compliance may impact time loss due to injury. Methods This study was a Level 1 prospective cluster randomized controlled trial conducted in NCAA men’s football (soccer) teams that examined the efficacy of the 11+ injury prevention program. The two outcome variables examined were number of injuries and number of days missed from competition. Twenty-seven teams ( n  = 675 players) used the 11+ program. Compliance, injuries and time loss were recorded. There were three compliance categories, low (LC, 1–19 doses/season), moderate (MC, 20–39 doses/season), and high (HC, > 40 doses/season). Results There was a significant difference among the groups for injuries, p  = 0.04, p η 2  = 0.23. The LC group [mean ( M ) = 13.25, 95% confidence interval (CI) 9.82–16.68, injury rate (IR) = 10.35 ± 2.21] had a significantly higher injury rate than the HC group ( M  = 8.33, 95%CI 6.05–10.62, IR = 10.35 ± 2.21), p  = 0.02. The MC group ( M  = 11.21, 95%CI 9.38–13.05, IR = 8.55 ± 2.46) was not significantly different than the LC group, p  = 0.29, but was significantly greater than the HC group, p  = 0.05. When examined as a continuous variable, compliance was significantly negatively related to injury rate ( p  = 0.004). It was also significantly negatively related to number of days missed ( p  = 0.012). Conclusions When compliance was high, there was a significant reduction in injury and time loss. This evidence reinforces the importance of consistent injury prevention program utilization. Clinically, these findings have important implications when discussing the importance of consistent utilization of an injury prevention protocol in sport. Level of evidence Level 1—Randomized controlled trial (RCT).

Background: Despite an abundance of injury research focusing on European professional soccer athletes, there are limited injury data on professional soccer players in the United States. Purpose: To describe the epidemiology of injury across multiple years in Major League Soccer (MLS) players. Study Design: Descriptive epidemiology study. Methods: A web-based health management platform was used to prospectively collect injury data from all MLS teams between 2014 and 2019. An injury was defined as an incident that required medical attention and was recorded into the health management platform anytime over the course of the 2014-2019 seasons. Injuries and exposure data were recorded in training and match settings to calculate injury incidence. Results: A total of 9713 injuries were recorded between 2014 and 2019. A mean 1.1 injuries per year per player were identified, with midfielders sustaining the largest number of injuries. The most common injuries were hamstring strains (12.3%), ankle sprains (8.5%), and adductor strains (7.6%). The mean time missed per injury was 15.8 days, with 44.2% of injuries resulting in no days missed. Overall injury incidence was 8.7 per 1000 hours of exposure, declining over the course of the investigation, with a 4.1-times greater mean incidence during matches (14.0/1000 h) than training (3.4/1000 h). Conclusion: Between 2014 and 2019, the most commonly reported injuries in MLS players were hamstring strains, ankle sprains, and adductor strains. Injury incidence during matches was 4.1 times greater when compared with training, while overall injury incidence was found to decline during the course of the study period.

Objective This study intends to look at the role of leg dominance in anterior cruciate ligament (ACL) injury risk among soccer (football) athletes. The purpose of this study was to test the hypothesis that soccer players rupture the ACL of their preferred support leg more frequently than the ACL in their preferred kicking leg, particularly in non-contact injuries, despite differences in gender. Design Retrospective observational study. Setting Outpatient orthopaedic practice. Patients Subjects who had sustained an ACL injury due to direct participation in soccer. N=93 (41 male, 52 female). Interventions These noncontact injuries were sustained while playing soccer. Results For non-contact injuries, roughly half of the injuries occurred in the preferred kicking leg (30) and the contralateral leg (28). However, by gender, there was a significant difference in the distribution of non-contact injury, as 74.1% of males (20/27) were injured on the dominant kicking leg compared with 32% (10/31) of females (p<0.002). Conclusions When limited to a non-contact injury mechanism, females are more likely to injure the ACL in their supporting leg, whereas males tend to injure their kicking leg. This research suggests that limb dominance does serve as an aetiological factor with regard to ACL injuries sustained while playing soccer. If follow-up studies confirm that females are more likely to injure their preferred supporting leg, future research should investigate the cause for this discrepancy, which could result from underlying gender-based anatomical differences as well as differences in neuromuscular patterns during cutting manoeuvres or kicking.

Purpose of Review Discoid lateral meniscus (DLM) is a well-known meniscus variant, and comprises excess and thickened meniscal tissue, altered collagen ultrastructure, and peripheral instability. This article presents a comprehensive review on current knowledge of DLM, focusing on pathology in parallel with surgical techniques and outcomes. Recent Findings A paradigm shift in surgical management of DLM is taking place as knee surgeons are seeing more patients with long-term sequelae of partial lateral meniscectomy, the standard treatment for DLM for many years. Surgical treatment has evolved alongside the understanding of DLM pathology. A new classification system has been proposed and optimal surgical techniques described in recent years. This article highlights up-to-date evidence and techniques in management of both acute DLM tears and joint restoration following subtotal meniscectomy for DLM. Summary Surgical management of DLM must be tailored to individual pathology, which is variable within the diagnosis of DLM. We present an algorithm for management of DLM and discuss future directions for the understanding and treatment of this debilitating condition.

Background: Surveillance programs are vital to analyze the cause and nature of lesions and ultimately establish protocols of action to lower injury rates. Purpose: To evaluate the adherence of team doctors to an electronic surveillance system and determine the incidence and characteristics of injuries among soccer players participating in the 2017 Gold Cup. Study Design: Descriptive epidemiological study. Methods: All data were collected from the electronic medical reports submitted during each match of the 2017 Gold Cup. Twelve teams participated in the tournament (each with 23 players), for a total of 276 players. A 19-question online survey was filled out by the team physician after each injury. Each report contained the player’s number, the exact time of injury (minute of play), the location and diagnosis of injury as indicated by a previously defined code, and its severity in terms of the number of days of absence from training and match play. Results: The electronic reporting system had a response rate of 100.0%, with 97.2% of questions answered completely. The mean age of injured players was 27 years (range, 21-35 years) and was not statistically significantly different from the overall mean player age (P > .05). There were no significant differences in the frequency of injuries when analyzed by player position (P = .743). The overall rate of injuries was 1.04 per match, with the most common injuries being contusions (42.3%), sprains (7.7%), strains (7.7%), and fractures (7.7%). These injuries were more commonly the result of contact (75.0%) than noncontact (25.0%) mechanisms (P < .001). Injuries most commonly occurred between the 60th and 75th minute of play when comparing all 15-minute time intervals (P = .004). Conclusion: This study supports the use of electronic injury reporting, which demonstrated a high level of adherence among an international cohort of team physicians and has significant potential for improving injury surveillance and tracking responses to prevention programs. Injury rates in the Gold Cup were similar to those in previous studies and demonstrated the highest rates late in the second half of the game, specifically between the 60th and 75th minute of play.

Purpose of ReviewCellular therapies, also known as “stem cell” interventions (SCI), have undergone a rapid popularization in the USA and worldwide. The current review aimed at outlining (1) the ethical challenges facing the implementation of SCI; (2) the applicability of the currently available SCI; and (3) recommendations to achieve ethical, well-regulated incorporation of SCI in the clinical setting.Recent FindingsConcerns regarding the inadequate characterization, poor adverse effects disclosure, and unorthodox, often inappropriate, market practices have engendered a genuine concern regarding the SCI compliance with ethical standards. Six instances of litigation on the basis of misrepresentation or inappropriate informed consent were recorded between 2012 and 2018. Such concerns have been furthered by the loopholes in the regulatory aspect governing the use of SCI coupled with the unclear literature-reported efficacy and diverse spectrum of profess indications. Similarly, the application of SCI in the clinical field is yet to prove its value. The uncertain efficacy, coupled with obscure true-costs of utilization, impedes a value-based assessment.SummaryA multidisciplinary approach involving legislative and medical professional societies should continue to advance regulations that govern SCI. A well-regulated system that allows for the ethical integration of SCI with appositely evidenced-based described benefits and risks should be sought.

By compelling data, this means randomized controlled trials and prospective cohorts to document efficacy, safety and the personalized treatment based on individual patient and injury factors. [...]when a surgeon is confronted with options for new implants for ACL repair, they should ask themselves three questions: * What is the best evidenced-based literature? Perhaps at the American Orthopaedic Society for Sports Medicine Annual Meeting some compelling data will be presented. [...]BEAR meets the expectations of evidence for use in patients with an ACL injury, in my opinion, in an age group where graft choice has not been shown to be a differentiator of outcome. The evidence will ideally be more generalizable to the ACL tear population and provide data for the individual surgeon and patient for shared decision-making.