ANTERIOR CRUCIATE LIGAMENT TEAR RECOVERY IN

COLLEGIATE FOOTBALL CLINICAL SETTINGS

REBECCA RAQUEL LARSON

______________________

A Thesis Submitted to The Honors College

In Partial Fulfillment of the Bachelors Degree

With Honors in

Physiology & Medical Sciences

THE UNIVERSITY OF ARIZONA

MAY 2023

Approved by:

_______________________

Dr. Lucinda Rankin, Ph.D.

Department of Physiology

_______________________

Paul Smith, MK, ATC, CSCS

University of Arizona Athletics: Football

Abstract
In collegiate football athletics, anterior cruciate ligament injuries have the ability to cause

premature ending of a career and sustained disability. Advanced technology targeting more

efficient and effective methods of recovery has provided various conductive modalities that work

to decrease the pain and swelling associated with recovery, as well as improve athletes’ strength

and performance. Student athletes across the country are experiencing higher instances of

anterior cruciate ligament tears which may culminate from weaknesses in surrounding muscles,

field material, or cleat design. Addressing these complications, furthering research, and

encouraging continuing education will help student athletes, athletic trainers, and collegiate

football teams to thrive without such considerable effects from ACL tears.
Table of Contents
Introduction 1
Purpose of Review 1
Anatomy of the Knee Joint 2
The Synovial Joint 2
Bone Structures 2
Muscles of the Knee 2
The Anterior Cruciate Ligament 3
Surgical Reconstruction 4
Recovery Modalities 6
Laser Therapy 6
Hydroworx Therapy 8
Electrical Stimulation 10
Deep Oscillation Therapy (HIVAMAT) 12
Dry Needling 13
Compression Therapy 13
Recovery Techniques 15
Cupping 15
Blood Flow Restriction (BFR) 15
Instrument Assisted Soft Tissue Mobilization (IASTM) 16
External Factors 17
Field Material 17
Cleat Design 18
Return To Play 19
University of Arizona Football 20
Conclusion 23
Acknowledgements 23
References 24
Introduction

Anterior cruciate ligament tears are amongst the most common injuries seen within collegiate

level football. The knee is a prime synovial joint within the body allowing for multiplanar

movement, and the anterior cruciate ligament is a key component in the stabilization of the joint,

connecting the upper and lower leg, which can be injured during play or practice in football

settings. Collegiate football student athletes are subject to increasingly high workloads and

exposure to contact, putting them at higher risk for injury. The high demand for athletes to return

to their sport following injury has brought advancements in technology working to accelerate

recovery time and improve full movement potential. These recovery modalities and techniques

are comprised of various conductive treatments that are able to target muscle swelling, range of

motion, and pain. Continued use of these modalities has allowed a high percentage of collegiate

football student athletes to return to play in quicker time. External factors such as field material

and cleat design also have the potential to increase the rate of occurrence of ACL injuries. In

examining such factors, clinical sites are able to establish the safest environment for athletes at

high risk.

Purpose of Review

Anterior cruciate ligament (ACL) injuries have the ability to cause premature ending of an

athletic career and sustained disability. The purpose of this review is to assess current recovery

modalities and techniques used in the treatment of ACL injuries in hopes to minimize sustained

injury in collegiate football student athletes.

Anatomy of the Knee Joint

The Synovial Joint

The knee joint is the largest and most complex synovial joint. Synovial joints, also known as

diarthrodial joints, are free-moving and contain synovial fluid. Due to the free movement of the

joint, the knee remains one of the most unprotected joints making it subject to acute and chronic

injuries. The knee contains four bursae, fluid filled cavities within the tissue that assist in

movements of tendons over the joint. These bursae contain synovial fluid to reduce friction

amongst adjacent moving structures, and are located in the anterior and medial sides of the joint

(Kumar et al, 2020).

Bone Structure

The major bones which assist in the formation of the knee

joint include the distal end of the femur, and the superior

surfaces of the tibia and posterior surface of the patella as

seen in Figure 1. These form the three major articulation

points within the knee joint, two located between the tibial

and femoral condyles and the third between the patella and Figure 1: Bone Structure of the Knee (RL)

femur. The intercondylar notch of the femur and intercondylar eminence of the tibia provide

additional support for the joint (Kumar et al, 2020).

Muscles of the Knee

Muscles surrounding the knee, including hip and gastrocnemius muscles, act primarily to

mobilize and stabilize the knee. Motion of the joint can occur about the sagittal plane through
flexion and extension, about the frontal plane through varus and valgus rotation, about the

transverse plane through medial rotation and lateral rotation at the terminal motions of knee

flexion and extension. The freedom of the joint allows for six degrees of motion also requiring

neuromuscular coordination for knee movement. The anterior aspect of the knee consists of the

rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius that function in extension

of the knee. The posterior aspect of the knee consists of the biceps femoris, semimembranosus,

semitendinosus, along with the gastrocnemius to function in knee flexion (Abulhasan, Grey,

2017).

The Anterior Cruciate Ligament

Ligaments are fibrous tissue bands that connect bone to bone to provide support to the joints.

The cruciate ligaments within the knee consist of a pair of strong bands connecting the tibia to

the femur. The ACL within the synovial membrane is composed of soft connective tissue

surrounding collagen fibrils. The attachment points of the

ACL into both the tibia and femur are approximately three

times larger than the midsubstance cross-sectional area,

made to minimize stresses on ligament-bone interfaces

(Harner et al, 1999). The femoral attachment is oriented

along the longitudinal axis of the femur and the tibial

attachment lays in the anteroposterior axis of the tibia. Due

to its orientation, the ligament undergoes a lateral spiral

within the joint to reach its bony attachments as depicted in

Figure 2.

Figure 2: Lateral Spiral of the ACL (RL)

This supportive ligament is essential to knee stability, divided into two complex components, the

anteromedial (AM) and posterolateral (PL) bundles, which differentiate in their orientation and

tension patterns during movement (Siegel et al, 2012). Fibers in the AM bundle originate from

the proximal portion of the femoral origin and insert at the AM tibial insertion. PL bundles

contrastingly originate in the distal portion of the femoral origin and insert on the PL portion of

tibial insertion. While these two bundles compose the ACL, there is no definite spatial separation

occurring between them, only differences in range of motion. As the knee is extended, the PL

bundle tightens and the AM bundle is comparatively lax. In knee flexion, the AM bundle

tightens and PL loosens up. In terms of anatomical operations, the PL bundle has a more

significant role in knee stabilization and rotary load. The ACL primarily functions to resist

anterior and rotational displacement of the tibia relative to the femur, responsible for

approximately 85% of knee stabilization (Zantop et al, 2006).

Surgical Reconstruction

For athletes who want to remain active in football, surgery is the most common treatment of

choice. Reconstructive surgery typically takes place within four weeks post initial injury,

allowing at least two weeks for swelling to go down, for range of motion to improve, and for

strength to continue building (P. Smith, personal communication, March 1, 2023). This surgical

reconstruction time span also depends on the time of year in which the injury occurs for an

athlete. A typical recovery time for these student athletes is estimated at 10-12 months (P. Smith,

personal communication, March 1, 2023), in order to return to full playing potential. If the injury

takes place later in season, earlier in the calendar year, they would not want to delay the surgery,

in hopes of returning in time for the next season. However if the injury takes place in the spring,
later in the calendar year, the surgery can be delayed with no immediate rush as the athlete will

not be returning for the following season (P. Smith,

personal communication, March 1, 2023).

During reconstructive surgery, there is typically a

section of ruptured ACL, seen in image 1 to the right,

that can either be left in place, to promote

mechanoreceptor reinnervation, or taken out to limit

the impact of visualization and quality of

reconstruction. Surgeons will then place a graft to Image 1: Arthroscopic View of Ruptured ACL (Arizona Athletics)

reconstruct the torn or damaged portion of the ACL.

A graft portion can be selected from the patellar

tendon (PT) or the hamstring tendon (HT), which

contains the gracilis and semitendinosus tendons

(Siegel et al, 2012). PT graphs are readily accessible

and have shown to have good structural fixation

properties in healing, however, it could lessen the

strength of the patellar and quadricep muscles.

Image 2: Arthroscopic View of ACL Repair (Arizona Athletics) PT graphs can also be associated with greater

incidences of chronic knee pain. HT graphs have highly desirable tension strains but graphs are

greatly linked to reduced hamstring strength and endurance months after the reconstruction.

While both graft sites have disadvantages associated with them, an additional option would be

taking a graft from the quadriceps tendon. This is a bilaminar graft, stemming from the vastus

medialis, vastus intermedius, and rectus femoris. In this selection, the quadricep muscle power is
not diminished and there is ease of excision due to the graft size when compared to PT and HT

forms (Siegel et al, 2012). Placement of the grafts in ACLR patients is the determining factor of

the outcome of reconstruction in athletes. Attention to the vertical degree when the graft is

placed is necessary to limit the high tension causing graft stretch during flexion post-operatively.

Reconstructions can be performed in single-bundle and double-bundle manners. Single-bundle

reconstructions restore knee stability but do not permanently allow the knee to resist combined

rotatory loads and rotational kinematics which would be extremely disadvantageous for athletes

wanting to return to play. Double bundle reconstructions provide knees with a better resistance to

extrinsic forces, but are significantly more challenging to perform surgically and have higher

chances at failure (Siegel et al, 2012). Athletes needing recurring reconstruction is often

attributed to weakness in surrounding tissues that provide stabilization. The combination of

surgical techniques, graft selection, fixation methods, and rehabilitation programs postoperative

can determine the success or failure of the reconstruction.

Recovery Modalities

Laser Therapy

Laser therapy is a non-invasive, fast acting, light treatment that

stimulates the photobio-modulation processes within the body

with the goal of preventing and reducing muscle fatigue. During

this process, photons will enter the mitochondrial rich muscle

tissues of the targeted area to increase the membrane potential of

mitochondria, increasing the enzymatic activity of the Image 3: Laser Therapy (Arizona Athletics)
respiratory chain. This change enables increased levels of respiration within the mitochondrial

electron transport chain, leading to greater production of ATP (Ferraresi et al, 2012).

As a result of this cascade, satellite cells are stimulated within the target tissues, leading to

proliferation of myoblasts and differentiation into myofibrils. These steps of myogenesis enable

regeneration and recovery within the injured muscle (Ferraresi et al, 2012). Athletes will

experience a decreased sensation of pain, reduction in inflammation, reactive oxygen species,

and muscle spasms, along with improved microcirculation to the tissue. The improvement in

muscle fatigue and performance overall benefits muscle repair.

Class IV lasers, most used within collegiate football, differ

from other laser classes in their maximum power output,

dosage, treatment strategies, and wavelength. With a power

range from 0.5W-40W (P. Smith, personal communication,

March 1, 2023), practitioners are able to treat larger areas

in a smaller period of time administering therapeutic doses

to the targeted tissues. While Class III lasers are used

Image 4: Laser Machine (Arizona Athletics) to treat small areas, Class IV lasers are more beneficial

when used on larger areas of the body including back, shoulders, and legs. Typical wavelengths

of these lasers remain between 700 and 980 nm (P. Smith, personal communication, March 1,

2023), in which practitioners must consider melanin and water retention in the athlete to ensure

correct dosage. A typical laser machine set up, as shown in Image 4, allows for adjustment of

time, skin pigment, and wavelength in an easy manner.

Clinically, laser therapy can be used for joint swelling, muscle strain, tendinopathy, myofascial

pain, acute or chronic injuries, delayed onset muscle soreness, and additionally optimizes muscle

performance and post activity recovery (Ferraresi et al, 2012). Laser therapy is increasing in its

usage as a replacement for prescription drugs to treat postoperative pain.

Hydrotherapy

Hydrotherapy provides an aquatic environment for recovery that alters the properties of density,

specific gravity, hydrostatic pressure, buoyancy, and viscosity. The environmental changes allow

athletes to experience a reduction of pain and swelling while allowing for greater joint range of

motion in gradual progression activity. Hydrotherapy allows weight bearing activities to be

introduced to athletes earlier than what would

be appropriate on land, and at higher intensity

levels, accelerating the recovery process and

potentially reducing the recovery time overall.

Following an ACL reconstruction surgery,

there are many ways that hydrotherapy can

help target recovery. When an athlete is

submerged in water, they are subjected to

hydrostatic pressure which is proportional to

the density of the liquid, meaning the deeper

the submersion the greater the pressure they

experience. Image 5: Hydrotherapy Pool (Arizona Athletics)

When hydrostatic pressure is experienced at levels higher than that of the diastolic blood

pressure, it counteracts gravity and allows the movement of fluid, shifting fluid out of the joints

and back into venous return and lymphatic drainage. This process causes the resolution in joint

inflammation and swelling which in effect allows increased range of motion for both active and

passive movements (Buckthorpe et al, 2019). Hydrotherapy pools, such as that shown in Image

5, are often kept cold to induce vasoconstriction within the body to centralize circulation.

Additionally, when the athletes are subject to immersion, the pain perception within the body is

diminished, or desensitized with the associated elevated pain threshold. When movement begins,

the stimulation of nerve endings causes sensory overflow that allow the athlete to have greater

range of motion than they would on land (Buckthorpe et al, 2019).

A typical ACLR student athlete may not be fully weight bearing for up to four weeks (P. Smith,

personal communication, March 1, 2023), resulting in compensatory movements within normal

giat to protect the injured joint. Over these weeks, joints can become weaker, and athletes may

experience a decrease in performance that has the potential to result in post-operative

complications and osteoarthritis. Hydrotherapy allows density and buoyancy to reduce the effect

of normal gravity allowing for normal lower body weight distribution and joint load (Buckthorpe

et al, 2019). Over the recovery process, the athletes can gradually move from deeper to shallower

levels to slowly add a proportion of body weight and facilitate normal walking. Balance,

strength, and coordination are all targets that can be optimized within hydrotherapy as an athlete

transitions into more dynamic movements requiring force.

The musculoskeletal system is not the only important factor to consider when looking at ACL

recovery in collegiate and professional athletes. These athletes, hoping to soon return to play,

must also maintain their cardiovascular fitness. Hydrotherapy is a method for athletes to identify

deficits in aerobic condition in the months following the reconstruction. When jogging, running,

or sprinting underwater, there is an increased resistance due to the dynamic viscosity which

makes it as efficient as running on land. It is safe for these athletes to train in higher intensities in

hydrotherapy to maintain cardiovascular fitness as long as the increase in cardiac output and

stroke volume stay within healthy limits (Buckthorpe et al, 2019).

The HydroWorx© therapy pool has become a key component in post-surgical recovery within

collegiate football, and leagues across the globe. Its benefits in reduction of pain and swelling,

support of the recovery of the giat, and maintenance of cardiovascular fitness promote it as one

of the standardized recovery modalities for ACLR patients.

Electrical Simulation

Electrical stimulation is one of the most popular modalities used to target muscle recovery in

surgical and non-surgical patients. Contractile activity in the muscle is due to electrical activation

signals in the motor units that travel from the nervous system to the muscle. The motor unit is a

set of distinct muscle fibers that react in response to action potential generation in motor neurons

(Moran et al, 2019). Electrical stimulation allows for activation of the action potential pathways

to generate involuntary contractions within the targeted muscle. Typically, two conductive pads

are placed over the targeted muscle and an electric current will be sent between them to generate

action potentials. Activation of the targeted muscle prevents decay of cell density over the time
of recovery. The electrical stimulation units provide control over the force produced, meaning

greater force produces greater currents from an increased number in activated motor neurons

(Moran et al, 2019).

Post reconstruction, neuromuscular electrical stimulation is applied to the quadricep muscles of

ACLR patients with the goal to restore and improve muscle function. By placing electrodes over

the vastus medialis and over the vastus lateralis on the proximal thigh, there will be stimulation

of the quadricep muscle, done in 30 minute treatment durations.

There are many different electrical stimulation systems that can be used including Compex©,

Biowave©, and Marcpro©. While they all have the same

overarching purpose, each system targets the muscle in a

different way. Compex© electrical stimulation systems,set

up shown in Image 6, work to maximize muscular effort by

engaging a higher percentage of muscle fibers. It can target

Type 1 slow twitch muscles which contribute to endurance

factors, and Type 2 fast twitch muscle fibers which

correlate to power (“Compex© Stimulation,” 2023).

Biowave© systems are different from other electrical

stimulation units with the focus being primarily on deep

pain relief. Biowave technology uses high frequency Image 6: Compex© Electrical Stimulation (Arizona Athletics)

wave signals summed together to be delivered into the deep tissue. The stimulation of this path

affects all polarized tissues including nociceptive pain fibers, providing deep pain relief of the
targeted muscle (“How Biowave© Works,” 2023). Another popular stimulation unit, the Marc

Pro©, uses signals to contract muscles in a comfortable manner and slowly release over a period

of time. In allowing proper contraction and relaxation of the muscle fibers, fluids are able to

move through the area, promoting circulation and preventing fatigue. This system promotes the

highest recruitment ratio of fibers within the tissues, optimizing recovery without discomfort in

the muscle (“Marc Pro© Technology,” 2023). The benefits of this system include improved

conditioning and endurance of muscles, enhanced performance post-recovery, maximizing

strength training gains and promoting a faster recovery (Enoka et al, 2020).

Deep Oscillation Therapy (HIVAMAT ©)

Hivamat©, histological variable manual technique, is a deep oscillation modality that works to

treat pain and swelling. This treatment uses intermittent electrostatic fields to create deep

oscillations, or wave movements, within the tissue. The electrostatic waves produce a kneading

effect that travels deep into damaged tissues,

rapidly relaxing them to alleviate pain, reduce

swelling, and restore blood supply. Hivamat

oscillations work by freeing the lymphatic

blockages in the injured tissue causing excessive

pain and swelling, allowing optimal healing in

the tissue (McCall, Koenig, 2019). Having the

ability to reduce inflammation and pain rapidly,

this modality can be used at an abundance of

injury sites including sprains, strains, tendonitis, Image 7: Hivamat© Technology (Cale, 2021)
muscle tension and spasms, and pre- and post-operative care. Hivamat is extremely advantageous

in postoperative therapy as it can be used extremely early in the recovery process of the injury to

reduce redness, swelling, and edema (McCall, Koenig, 2019).

Dry Needling

Dry needling (DN) therapy involves the insertion of fine needles into the muscle and moving

them in various directions without fully extracting the needle to reduce muscle tension and pain.

Most commonly, DN is used on myofascial trigger points (MTrP). MTrP are points in taut bands

of skeletal muscle and fascia that cause tenderness and referred pain when they are compressed

(Ortega-Cebrian et al, 2016). Microtraumas from the needle normalized both electrical and

chemical changes from inflammation restoring the function of tissue and relieving pain. Trigger

point dry needling can also assist in increasing joint range of motion after ACL reconstruction

(Velázquez-Saornil et al, 2017).

Compression Therapy

The combination of conductive compression therapies have

incredible benefits in both pre- and post-surgical patients.

Together, the techniques function to alleviate pain, reduce

swelling, and promote recovery of speed functioning. The

more commonly used forms of compression, Normatec©

Compression boots and ACE© compression wraps function

to improve circulation, reduce water accumulation, accelerate

recovery and reduce inflammation Image 8: Normatec© Boots (Arizona Athletics)

(P. Smith, personal communication, November 1, 2022). When compression is conducted in a

intermittent pattern such as in Normatec© therapy, it assists in removing toxins from the targeted

muscles by flushing lymphatic fluids and lactic acids. ACE© wraps have the same ability to

reduce discomfort and improve recovery through restraining the injured area and reduce swelling

of injured tissue. Athletes can continue to wear compression sleeves long term, promoting

stability and continued blood flow to the area for healing (P. Smith, personal communication,

November 1, 2022).

Cold compression devices such as the Game Ready©, have

become an essential part of the surgical recovery process.

The Game Ready© shown in Image 9, demonstrates how

cryotherapy and compression are combined through a dual

action wrap around the targeted tissue repair. Blood vessels

constrict and reduce fluid outflow into the interstitial space

of the muscles (P. Smith, personal communication,

November 1, 2022). In the preliminary stages of healing, Image 9: Game Ready© Device (Arizona Athletics)

the athlete will experience increased swelling in which cold modalities are beneficial. Once the

primary inflammation calms, providers can decrease the amount of ice to the injury site, keeping

inflammation processes and allowing for the natural process of healing. Typically on the back

end of rehabilitation efforts, providers can implement heat modalities that increase range of

motion. Heat is not applied towards the start of rehabilitation following surgery (P. Smith,

personal communication, November 1, 2022).

Recovery Techniques

Cupping

Cupping therapy is an additional treatment technique targeting muscular healing and pain

reduction. The goal of the therapy is to promote peripheral blood circulation by creating a

subatmospheric pressure suction. As blood flow is increased towards the surface, there are

improvements in anaerobic metabolism, and reductions

in inflammation and pain. Additionally, there is a

controlling influence over the cellular immune system

by stimulating blood flow and metabolism

(Aboushanab, AlSanad, 2018). Post ACLR operation,

cupping can be applied to the quadriceps to reduce pain

around the knee area. There are five different

categories that classify cupping therapy including

technical type, power of suction, method of suction, Image 10: Cupping Technique for ACL Recovery (Arizona Athletics)

materials inside cup, and area treated. There are many different materials that can compose

cupping sets including: plastic, glass rubber, metal, silicone, ceramic, and bamboo (Aboushanab,

AlSanad, 2018). Cupping is never applied to open wounds, fractures, or deep vein thrombosis, so

it is used only after the incision site is fully healed (P. Smith, personal communication,

November 1, 2022).

Blood-Flow Restriction (BFR)

BFR has become a more commonly used rehabilitation therapy for postoperative ACLR patients.

The technique revolves around strengthening and hypertrophy of the muscle while the athlete
remains under a low-load environment completing high repetition cycles. A tourniquet cuff,

shown in Image 11, will be placed above the target muscle group and the athlete will perform

weight or non-weight-bearing exercises using minimal resistance. The extremity cuff will inflate

to occlude venous outflow to reduce oxygen delivery and promote

hypertrophy (DePhillipo et al, 2018). Muscle atrophy in the knee

following surgery can diminish overall outcomes of recovery and

bring pain and muscle weakness. BFR allows student athletes to

regain muscle mass, strength, and volume that they may have lost

during the recovery process (DePhillipo et al, 2018).

Image 11: BFR Cuff and Machine Set Up (Arizona Athletics)

Instrument Assisted Soft Tissue Mobilization (IASTM)

Soft tissue work can greatly promote recovery during the

ACLR process. IASTM is a technique that involves the use

of stainless steel instruments, depicted in image 12, in

massaging patterns to remove scar tissue from injured soft

tissue promoting the healing process. This treatment can

benefit student athletes by increasing the activity and

number of fibroblasts and synthesis of collagen in the

extracellular matrix to help heal soft tissue damage (Kim et

al, 2017). Athletes can experience a reduction of pain Image 12: IASTM Scraper Placement (Arizona Athletics)

and improvement of joint range of motion. IASTM treatments done consistently can increase

blood flow to remove swelling to injured tissues, fighting chronic inflammation.

External Factors

Field Material

Widespread use of new generation turf as opposed to natural grass has drawn speculation for

being a possible factor for increased injuries within football. Installation of turf fields have

become more popular for their ability to handle climatic differences where grass may not be

suitable for year-round usage. The artificial

turf installed in the Arizona Stadium is

pictured in Image 13. While studies are

limited, researchers have used a surveillance

system within the NCAA to compare the

incidences and cause of injuries within

football (Fuller et al, 2007). Previous

knowledge led people to believe that there

would be a much higher risk of lower limb

injuries, specifically

non-bone/ligament/cartilage, on artificial turf

than natural grass. Data noted that while

abrasions were much more common Image 13: Arizona Stadium Turf (Arizona Athletics)

on artificial turf, there was in fact no major difference in the risk or cause of injuries associated

with artificial turf and grass. Both groups presented with around a 35% chance of sustaining an

ACL tear on either field material (Fuller et al, 2007). Any increase that was found in the

incidence of lower limb injuries on artificial surfaces could be contributed by the increase in

surface hardness and shoe-surface traction produced from the turf.

Cleat Design

Further attention has been given to cleat design used amongst different football teams. Studies

looked at four main cleat designs including Edge, Flat, Screw-in, and Pivot disk to draw

conclusions on if cleat design could have an effect on ACL injuries (Lambson et al, 1996).

These cleat designs are all very different and can alter the movement patterns of athletes during

play. For reference, all four cleat designs are shown

below in Image 14. A major factor in ACL injuries is

foot fixation which occurs when the foot can not be freed

from the surface in time to avoid injury. During play,

torsional forces are transmitted through the knee when

players make sudden directional changes with a planted

foot in deceleration. When contact is made or the knee

fails to adjust to the forces put on the joint, Image 14: Four Primary Cleat Designs (Lambson et al, 1996)

ACL tears are very likely to occur. Traction plays an additional factor that is necessary to

prohibit falls of athletes. However, this also puts the joint at risk of further injury when excessive

loads are placed on it and it cannot be freed. To test this further, Rick Lambson and his team used

a Vermont Release Calibrator torque wrench, shown to the

right in Image 15, which placed a prosthetic foot into each

cleat design to evaluate its impact with the artificial turf mat.

The torque wrench moved 90 degrees in 1 second with a

load of 45.5 kg to measure the shoe-to-turf torque resistance

(Lambson et al, 1996). Image 15: Vermont Release Calibrator (Lambson et al, 1996)
Results displayed that the Edge cleat design produces significantly greater torsional resistance

than the other three cleat designs when tested on artificial turf. While there can be many factors

contributing to the occurrence of ACL tears, the cleat design has proven to play a part in

contribution to ACL injuries (Lambson et al, 1996).

Return To Play Statistics

Studies conducted within the NCAA have examined the impact of anterior cruciate ligament

reconstruction (ACLR) by comparing pre-injury controls with their return to play statistics. By

gathering data between 2010 and 2015, the study examined 349 football players sustaining ACL

tears (Wise, Gallo, 2019). These athletes spread over every position group, and played at least

four games prior to injury and after returning to play. It should be noted that 67.33% of the ACL

injuries occurred within the first three months of the season in August, September, and October

and of the athletes 84.91% returned to play post ACLR (Wise, Gallo, 2019).

The data showed that while the majority of NCAA football players did return to compete after

undergoing ACLR, the performance upon return was highly dependent on position group.

Offensive skill positions focusing on wide receivers and running backs showed the greatest

decrease in performance, while defensive players showed very similar performance in preinjury

and return. Data is consistent with the conclusion that qualities that contribute to improved

performance may be the biggest risk factors for ACL injuries. Running backs and receivers

typically participate in more plays per game, carry the ball for longer periods of time in each play

and attract defensive attention in execution of duties.

Of all position groups, it was found the offensive lineman had the lowest percentage of return to

play, potentially due to the intensity of contact leading to more complex sustained injuries.

Running backs had a significant decrease in carries per game, yards per game, and receptions per

game in comparison to controls. Receivers, including tight ends, showed significant decreases in

number of touchdowns per game, along with decreases in number of receptions and receiving

yards (Wise, Gallo, 2019). Defensive backs also demonstrated a decrease in total tackles and

sacks compared with controls, but did not have as significant of deficits in comparison to

offensive positions. Defensive lineman demonstrated no significant changes. Defensive positions

followed a trend of performing closer to prinjury standards, while offensive positions were not

able match performance standards.

University of Arizona Football

Looking specifically into the football clinical setting at the University of Arizona, the patterns

both support and vary from the ACL statistics stated above. Many of the researched factors were

considered in this clinical setting including field material, position group, and cleat structure. No

information was gained using human subjects or personal information from the program.

Athletic training staff in this clinical setting anecdotally found there were similar amounts of

ACL injuries on artificial turf fields in comparison to grass fields. The majority of fields are

transitioning to turf leading to higher number of injuries based on exposures. With that being

said it brings the question whether more injuries occur on home or away fields where materials

may differ than what is typically practiced on. While prior research has shown that home and

away fields remain equal in injury occurrences, differences may spike when comparing a home
turf field and an away grass field, and vice versa. One topic not yet to be researched is the

correlation between sleep and injury rates that occur when teams travel to different time zones.

This could be associated with increased injury rates occurring during away settings.

While athletic training staff observed there was no main difference in away vs. home injury

occurrence, there is a much larger difference in exposures that occur during a practice in

comparison to a game. The number of players in a practice, roughly 110, is double the amount

that usually play in a game. Thus, there is a higher probability of injuries taking place in a

practice setting. Trends were seen that there is usually more repetitions of drills completed in

practice, while game repetitions are not nearly as high. However game scenarios are not always

the safest spot for players, as contact is uncontrolled during a game, but may be generally limited

during practices (P. Smith, personal communication, March 1, 2023). So while there are

differences, injuries can be split between both practice and game settings.

There is a notable correlation in position group and injury however, clinical site observations do

vary from the data found in the study discussed above. The distinction remains not only between

the offensive and defensive skill groups, but in the high contact job of both offensive and

defensive lineman. While skill players face the challenges of cutting and planting with twisting

motions that can cause instability within the joint, lineman endure a higher rate of contact

including hits from behind, people falling onto them and other blunt movements putting their

joints at higher risk (P. Smith, personal communication, March 1, 2023). While data had

suggested that offensive lineman were most at risk for ACL injuries, it could also be said that
these players are being asked to be more mobile and do more than they have historically been

asked to do.
Conclusion

Collegiate football student athletes across the country are experiencing higher instances of

anterior cruciate ligament tears. In order to ensure that these student athletes are able to return to

football, advanced modalities and techniques have been developed to assist in speedy recovery

and increased range of motion. Current research discussed throughout this review has attended to

recovery methods and external factors currently impacting football student athletes. However,

future research will soon turn to examine patterns suggesting that those who experienced ACL

tears have higher rates of experiencing additional injuries that weaken the joint’s stability.

Athletes are not necessarily predisposed to ligament tears, rather student athletes will have

experienced other weakening injuries such as hamstring strains, ankle sprains, or concussions

that increase their chances for experiencing lower extremity injuries. The projection of this

research will allow collegiate football student athletes to hopefully have the precautionary

measures set in place by coaches, strength staff, and athletic trainers, to prevent them from

experiencing the potential career ending injury.

Acknowledgements

I would like to thank my mentor, Paul Smith (University of Arizona Department of Sports

Medicine, Assistant Head Football Athletic Trainer) for his support and guidance throughout this

entire project. It would have been impossible to complete this project successfully without him. I

would also like to thank University of Arizona Football for allowing me to grow my knowledge

and photograph all modalities discussed in the project.

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