Is Fatigue a Risk Factor for Anterior Cruciate Ligament Rupture?
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CURRENT OPINION
Is Fatigue a Risk Factor for Anterior Cruciate Ligament Rupture? Matthew N. Bourne1 · Kate E. Webster2 · Timothy E. Hewett3
© Springer Nature Switzerland AG 2019
Abstract Neuromuscular fatigue is a commonly accepted risk factor for anterior cruciate ligament (ACL) injury. It has been proposed that fatigue leads to transient reductions in muscle strength, and deleterious changes in lower limb kinematics and kinetics, during potentially hazardous tasks such as cutting or landing. The purpose of this clinical commentary is to (1) highlight the complexity of fatigue; (2) discuss the theoretical basis by which it is thought to contribute to ACL injury; and (3) critically discuss the evidence underpinning this hypothesis. Despite a significant amount of research, none of the published fatigue protocols appear to have any consistent effect on any lower limb kinematic or kinetic variables known to increase ACL injury risk. On the contrary, fatigued athletes appear to land with greater peak knee and hip flexion angles, and lower landing forces than unfatigued athletes—all of which are considered favourable movement strategies for reducing ACL loading. These data support recent analyses demonstrating no relationship between player workload in training and competition and the occurrence of ACL injury in sport.
Key Points
1 Introduction
The broad scope with which the term ‘fatigue’ is used causes confusion and there is a lack of interdisciplinary consensus on what it encompasses.
Anterior cruciate ligament (ACL) ruptures are among the most debilitating injuries in landing-, pivoting- and jumpingbased sports [1, 2]. It is well-recognised that the aetiology of ACL injury is multifactorial and likely results from the interaction of several modifiable and non-modifiable risk factors [3]. One potentially modifiable factor that has received considerable attention in recent years is the role of neuromuscular fatigue [4, 5]. Proponents of the ‘fatigue theory’ [6, 7] argue that fatigue leads to acute reductions in muscle strength, altered patterns of lower limb muscle activation, changes in hip and knee kinematics, and increased ground reaction forces during landing or cutting—all of which are hypothesised to increase the likelihood of non-contact ACL injury. However, despite its near universal acceptance, few prospective studies have quantified fatigue in any meaningful way and there are few to no data to indicate that fatigue is indeed a risk factor for ACL injury [4, 5]. Furthermore, none of the neuromuscular training interventions that have proven successful in reduction of ACL injury rates [8] target fatigue-resistance, and there is no evidence to suggest that these ACL injury reduction programmes should be altered to focus on this parameter. This clinical commentary aims to (1) highlight the complexity of fatigue; (2) discuss the theoretical basis by which it is thought to contribute to ACL injury; and (3) critically discuss the evidence underpinning this hypothesis.
Fatigue is a commonly cited risk fac
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