The American Journal of Sports

Medicine
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Sport Participation and the Risk of Anterior Cruciate Ligament Reconstruction in Adolescents: A
Population-based Prospective Cohort Study (The Young-HUNT Study)
Marianne Bakke Johnsen, Maren Hjelle Guddal, Milada Cvancarova Smstuen, Hvard Moksnes, Lars Engebretsen,
Kjersti Storheim and John-Anker Zwart
Am J Sports Med published online April 27, 2016
DOI: 10.1177/0363546516643807
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AJSM PreView, published on April 27, 2016 as doi:10.1177/0363546516643807

Sport Participation and the

Risk of Anterior Cruciate Ligament
Reconstruction in Adolescents
A Population-based Prospective Cohort Study
(The Young-HUNT Study)
Marianne Bakke Johnsen,*yz MSc, Maren Hjelle Guddal,yz MSc,
Milada Cvancarova Smastuen,y PhD, Havard Moksnes,|| PhD,
Lars Engebretsen,z||{ PhD, Kjersti Storheim,yz PhD, and John-Anker Zwart,yz PhD
Investigation performed at Oslo University Hospital, Oslo, Norway
Background: An anterior cruciate ligament (ACL) injury is a severe injury that may require ACL reconstruction (ACLR) to enable
the return to sport. Risk factors for ACLR have not firmly been established in the general adolescent population.
Purpose: To investigate the incidence and risk factors for ACLR in a population-based cohort of adolescents.
Study Design: Cohort study; Level of evidence, 3.
Methods: We prospectively followed 7644 adolescents from the adolescent part of the Nord-Trndelag Health Study, included
from 2006 to 2008. The main risk factors of interest were the level of sport participation (level I, II, or III) and sport competitions.
The endpoint was primary ACLR recorded in the Norwegian National Knee Ligament Registry between January 2006 and December 2013.
Results: A total of 3808 boys and 3836 girls were included in the analyses. We identified 69 (0.9%) ACLRs with a median of 7.3
years of follow-up, providing an overall ACLR incidence of 38.9 (95% CI, 30.7-49.3) per 100,000 person-years. The hazard ratio
(HR) for ACLR associated with level I sport participation was 3.93 (95% CI, 0.92-16.80) for boys and 3.31 (95% CI, 1.30-8.43) for
girls. There was a stronger association related to participating in sport competitions. Girls had over 5 times a higher risk (HR, 5.42;
95% CI, 2.51-11.70) and boys over 4 times the risk (HR, 4.22; 95% CI, 1.58-11.30) of ACLR compared with those who did not
compete.
Conclusion: Participating in level I sports and sport competitions significantly increased the risk of undergoing primary ACLR.
Preventive strategies should be implemented to reduce the incidence and future burden of ACLR.
Keywords: ACL; epidemiology; injury prevention; sport participation; adolescents; risk factors

*Address correspondence to Marianne Bakke Johnsen, MSc, Communication and Research Unit for Musculoskeletal Disorders, Oslo University Hospital, Building 37, PO Box 4956, Nydalen, Oslo 0424,
Norway (email: m.b.johnsen@medisin.uio.no).
y
Communication and Research Unit for Musculoskeletal Disorders,
Oslo University Hospital, Oslo, Norway.
z
Faculty of Medicine, University of Oslo, Oslo, Norway.

Faculty of Health Sciences, Oslo and Akershus University College of

Applied Sciences, Oslo, Norway.
||
Oslo Sport Trauma Research Center, Department of Sport Medicine,
Norwegian School of Sport Sciences, Oslo, Norway.
{
Department of Orthopaedic Surgery, Oslo University Hospital, Oslo,
Norway.
One or more of the authors has declared the following potential conflict of interest or source of funding: The Norwegian Fund for Postgraduate Training in Physiotherapy supported and funded this project.

It is well documented that regular physical activity improves

physical, psychological, and social health in children and adolescents.11,19 However, there is a concern that participating
in sports exposes youth to a higher risk of musculoskeletal
injuries, which may negatively affect their long-term
health.7,22 Most sports-related injuries among adolescents
occur in the lower extremities, with the knee as a frequent
injury site.5,10 An anterior cruciate ligament (ACL) injury
is a severe knee injury3,6 that may require ACL reconstruction (ACLR) before an athlete is able to return to sports
and competition.40 The population at risk for ACLR in Norway is mainly between 16 and 39 years of age, with an estimated annual incidence of 85 to 120 per 100,000 citizens.14
Risk factors for ACLR in the general adolescent population
have not been firmly established. The only previous population-based study on risk factors found that participating in

The American Journal of Sports Medicine, Vol. XX, No. X

DOI: 10.1177/0363546516643807
2016 The Author(s)

1
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Johnsen et al

The American Journal of Sports Medicine

organized sports at least 4 times per week significantly

increased the risk of cruciate ligament injuries in adolescents.33 Other epidemiological studies have predominantly
investigated risk factors for ACL injuries and not for ACLR
in adolescents and have been performed primarily in athlete
populations.21,27 A high rate of ACL injuries has been
reported in sports characterized by jumping, pivoting, and
cutting such as soccer, basketball, and team handball,28,37
and studies have consistently reported a higher incidence
in women than in men.37,41 Additionally, a population-based
nationwide study in Sweden including the incidence of both
cruciate ligament injuries and reconstruction found that
a greater number of female patients underwent reconstructive surgery (48%) and that the proportion of surgery was
highest among the youngest patients (\30 years).30 Grindem
et al16 reported that, in their cohort (aged 13-60 years), the
main reason for undergoing ACLR within 2 years of injury
was the wish to return to sports that place high demand on
the knee joint (level I). Regardless of treatment, adolescents
with ACL injuries tend to withdraw from sport participation
more frequently than those without injuries.22 One of the
long-term consequences of ACL injuries or reconstruction is
the risk of developing osteoarthritis (OA) at a young age.8
Consequently, it is important to examine risk factors to prevent both ACL injuries and subsequent reconstruction and to
reduce the future burden of OA. The aim of this study was,
therefore, to prospectively investigate the incidence of
ACLR and the association between the level of sport or sport
competitions in a general adolescent population and the risk
of subsequent ACLR.

METHODS
Study Population
The Young-HUNT Study (YHUNT) is the adolescent part of
the Nord-Trndelag Health Study (HUNT). The YHUNT
has been described in detail elsewhere.18 In brief, it is
a unique Norwegian database of personal and family medical histories collected in 3 surveys: YHUNT1 (1995-1997),
YHUNT2 (2000-2001), and YHUNT3 (2006-2008). All adolescents between 13 and 19 years old living in the county
of Nord-Trndelag were invited to participate. The YHUNT
database includes 17,820 teenagers. For the purpose of this
study, we included data from the YHUNT3 in which 7716
(74%) adolescents participated in questionnaires and clinical measurements. Of these, 72 participants were excluded
because they had emigrated or died before baseline. The
study population comprised 7644 participants (Figure 1).

Assessment of Sport Level and Competition

Participation in the following activities/sports during the last
12 months was assessed: endurance sports, team sports, aesthetic sports, strength sports, martial arts/combat sports,
technical sports, adrenaline sports, jogging or race walking/
hiking, and other. It was possible to choose multiple
activities/sports. Four alternatives were given for describing
the frequency of each activity/sport: 0, \1, 1, or .1 time

Adolescents invited to participate

in the Young-HUNT 3
N = 10,464
Excluded (n = 2748)
Nonresponders to the
questionnaire (n = 2264)
Nonresponders to the clinical
assessment (n = 484)

Respondents to the questionnaire

and clinical assessment
n = 7716
Lost to follow-up (n = 72)
Moved out of the county (n = 53)
Died (n = 19)

Study population analyzed

n = 7644

Figure 1. Flow chart of the study population in adolescent

part of the Nord-Trndelag Health Study, 2006-2008
(Young-HUNT 3).
per week. Activities/sports with a frequency of 1 time per
week were accounted for in the categorization of sport levels.
The sport levels were categorized as level I, II, or III according to Moksnes et al,26 who modified the original classification of Hefti et al17 to make it suitable for European sports
(Table 1). The second exposure of interest was sport competitions. The adolescents were asked the following: Do you
participate in sport competitions? with response alternatives
yes, no, or I used to compete. The variable was dichotomized, and the latter 2 alternatives were classified as no (current) participation in sport competitions.

Potential Confounders
Potential confounders for ACLR measured at baseline were
age, sex, timing of puberty, socioeconomic status based on
perceived family income (above average, average, or below
average), and alcohol consumption (current use or no use).
Timing of puberty was defined by self-reported pubertal status in boys using the validated Pubertal Development Scale34
and age at menarche in girls. Boys were asked to assess
changes in voice, facial hair growth, and pubic hair growth
and to rate their own growth on a scale ranging from 1
(has not begun) to 4 (development completed). The items
were summed up and divided by 4 to calculate an average.
Boys with scores within the highest quintile were classified
as early matured (.80th percentile). Girls whose menarche
occurred before the age of 12 years were classified as early
matured.4 Height and weight were measured at the clinical
examination at baseline. Body mass index (BMI) was calculated as body weight divided by height squared (kg/m2).
The BMI-derived categorization of overweight was defined
in accordance with the International Obesity Task Force classification described by Cole et al,9 which includes percentile
cutoff points for age and sex.

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AJSM Vol. XX, No. X, XXXX

Sport Participation and ACLR in Adolescents

TABLE 1
Activity Level Classificationa
Level

Sport Activity

I
II

Jumping, cutting, pivoting

Lateral movements, less pivoting than level I

III

Straight-ahead activities, no jumping or pivoting

Sport Activity in the YHUNT3

Team sports: soccer, volleyball, handball
Technical sports: track and field, alpine skiing, snowboarding
Martial arts: judo, karate, boxing
Aesthetic sports: dance, gymnastics
Risk sports: rafting, rock climbing
Endurance sports: running, cycling, swimming
Strength sports: weight lifting, bodybuilding

a
Various sports in the questionnaire from the adolescent part of the Nord-Trndelag Health Study 3 (YHUNT3) are classified according to
the degree of knee joint load, modified to European sport activities.

Outcome
The defined outcome of interest was ACLR after a primary
ACL injury. The Norwegian 11-digit identity number enabled
us to link information from baseline in the YHUNT3 with
data on ACLR from the Norwegian National Knee Ligament
Registry (NKLR). All ACLRs recorded in the NKLR between
January 2006 and December 2013 were included. The NKLR
was established in June 2004 to collect prospective information on all cases of cruciate ligament surgery in Norway.14
All hospitals in Norway have contributed with a compliance
rate of 97%.15,42 The standardized questionnaire that is submitted to the NKLR for each ACLR also includes information
about the activity that caused the ACL injury (eg, soccer,
team handball, snowboarding, alpine skiing, martial arts,
basketball, traffic, work, and other activities). This information was used only to validate a possible association between
the level of sport at baseline and later ACLR and not for the
risk analyses.

Ethics

Student t test for continuous variables to examine the difference in distributions of baseline characteristics by sex. A
Cox proportional hazard regression model was used to calculate hazard ratios (HRs) with 95% CIs. The risk of
ACLR was analyzed separately for sport level (A) and competition (B). Potential confounders were selected based on
previous studies and a priori reasoning and were included
in the model if they were statistically significant and
changed the estimate of sport level or competition substantially (.10%). Timing of puberty, family income, alcohol
consumption, and BMI did not substantially affect the direction or magnitude of the HRs. Testing and visual inspection
of plotted scaled Schoenfeld residuals showed that the proportional hazard assumption was satisfied for all the
included variables, except for sex. Accordingly, the final
regression models included adjustment for age and were
stratified by sex. P \ .05 was considered statistically significant. All statistical analyses were performed using SPSS
version 21 (SPSS Inc) and Stata 13.0/IC (StataCorp LP).

RESULTS

The current study was approved by the Regional Committee for Medical Research Ethics (2013/1887/REK Sr-st
A). The YHUNT and the NKLR have been approved by
the REK and the Data Inspectorate of Norway. Inclusion
in the YHUNT and the NKLR was based on written consent from participants aged 16 years and from the
parents of those aged \16 years, in accordance with Norwegian law. Written consent for the YHUNT and the
NKLR also includes linkage with other registries.

Statistical Analysis
We calculated the incidence rates of ACLR per 100,000
person-years with 95% CIs according to the level of exposure. The date of entry was the date of baseline in the
YHUNT3 (2006-2008). Person-years of follow-up was calculated from the date of birth to the date of injury, date of
death, date of emigration, or end of follow-up on December
31, 2013, whichever came first. Continuous variables were
described as means and SDs when normally distributed
and categorical variables as numbers and percentages. We
used the chi-square test for categorical variables and the

There were 3808 boys and 3836 girls included in the analyses. We identified 69 (0.9%) ACLRs with a median of 7.3
years of follow-up, providing an overall incidence of 38.9
(95% CI, 30.7-49.3) per 100,000 person-years. More boys
than girls reported participating in level I sports and competitions (P \ .001). Girls were significantly younger than
boys (P = .01) at the time of ACLR (Table 2). Further, age
and sex distributions at baseline, at the time of ACL injury,
and at the time of ACLR are depicted in Table 3. Activities
that most frequently caused an ACL injury were soccer
(52%) and team handball (39%) for girls and soccer (60%)
and alpine skiing (8%) for boys. The sex-specific incidence
per 100,000 person-years was 49.5 (95% CI, 36.8-66.5) for
girls and 28.3 (95% CI, 19.1-41.9) for boys (Table 4).

Sport Level (A)

The incidence rate of ACLR was over 3 times higher in
level I sports compared with level II or III sports (Table
4). The increased risk of ACLR associated with level I
sports was also seen in the sex-stratified and age-adjusted

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Johnsen et al

The American Journal of Sports Medicine

TABLE 2
Characteristics of the Study Population at Baseline (N = 7644)a
Characteristic
Age at baseline, mean 6 SD (range), y
Age at surgery, mean 6 SD (range), y
Sport level
Level I
Level II or III
Sport competition
Yes
No
Missing
Overweight
Yes
No
Missing
Alcohol use
Current use
No use
Missing
Timing of puberty
Early
Intermediate/late
Missing
Family income
Above average
Average/below average
Missing

All (N = 7644)

Girls (n = 3836; 50.2%)

Boys (n = 3808; 49.8%)

15.8 6 1.7 (13-21)

18.0 6 2.6 (14-23)

15.8 6 1.7 (13-21)

17.4 6 2.6 (14-23)

15.8 6 1.7 (13-21)

19.0 6 2.5 (15-23)

4595 (71.8)
1804 (28.2)

2242 (69.8)
970 (30.2)

2353 (73.8)
834 (26.2)

3610 (47.2)
3856 (50.5)
178 (2.3)

1734 (45.2)
2027 (52.8)
75 (2.0)

1876 (49.3)
1829 (48.0)
103 (2.7)

1581 (20.7)
6063 (79.3)

823 (21.5)
3013 (78.5)

758 (19.9)
3050 (80.1)

3826 (50.1)
3509 (45.9)
309 (4.0)

2017 (52.6)
1687 (44.0)
132 (3.4)

1809 (47.5)
1822 (47.8)
177 (4.6)

1093 (14.3)
5208 (68.1)
1343 (17.6)

538 (14.0)
2511 (65.5)
787 (20.5)

555 (14.6)
2697 (70.8)
556 (14.6)

1288 (16.8)
5832 (76.3)
524 (6.9)

559 (14.6)
3075 (80.2)
202 (5.3)

729 (19.1)
2757 (72.4)
322 (8.5)

Data are reported as n (%) unless otherwise indicated.

95% CI, 1.58-11.30), which was statistically significant

for both sexes (Table 5). The cumulative incidences of
ACLR for girls and boys competing and not competing
are depicted in Figures 2 and 3, respectively.

TABLE 3
Age and Sex Distributions at Baseline,
Time of ACL Injury, and Time of ACLRa
Age Group, y
Girls
13-14.9
15-16.9
17
Boys
13-14.9
15-16.9
17

Baseline
(N = 7644)

ACL Injuryb
(n = 67)

ACLR
(n = 69)

1440 (37.5)
1245 (32.5)
1151 (30.0)

4 (9.3)
19 (44.2)
20 (46.5)

3 (6.8)
19 (43.2)
22 (50.0)

1393 (36.6)
1341 (35.2)
1074 (28.2)

1 (4.2)
4 (16.7)
19 (79.2)

0 (0.0)
3 (12.0)
22 (88.0)

DISCUSSION
In this population-based study of adolescents, we found an
increased incidence and risk of ACLR related to participating in knee-demanding (level I) sports. There was a stronger
association related to participating in sport competitions,
where the risk of ACLR for girls who competed was 5 times
higher than for girls who did not compete.

Data are reported as n (%). ACL, anterior cruciate ligament;

ACLR, anterior cruciate ligament reconstruction.
b
Date of ACL injury was missing for 2 patients with ACLR.

analyses but was only statistically significant for girls (HR,

3.31; 95% CI, 1.30-8.43) (Table 5).

Sport Competition (B)

The incidence rate of ACLR was over 4 times higher for
those who participated in sport competitions compared
with those who did not compete (Table 4). In the adjusted
analyses, we found an increased risk of ACLR in girls
(HR, 5.42; 95% CI, 2.51-11.70) and in boys (HR, 4.22;

Strengths and Limitations

The main strengths of our study include a large sample
size with a high participation rate (74%) of adolescents
from the general population, the prospective design, and
comprehensive information about sport participation,
including the type and frequency of activities and competitions. This allowed us to not only estimate the risk associated with participation in sports but also to include the
type of activity and the aspect of competition in the risk
assessment. To our knowledge, such comprehensive information of sports and competitions has not previously
been presented in a nonathlete population of adolescents.

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AJSM Vol. XX, No. X, XXXX

Sport Participation and ACLR in Adolescents

TABLE 4
Incidence Rates for ACLR by Level of Exposurea

Sport level
Level I
Level II or III
Sport competition
Yes
No
Sex
Girls
Boys

No. of Persons

Person-Years

No. of ACLRs

Incidence Rate of ACLRb (95% CI)

4595
1804

105,733
42,291

58
7

54.9 (42.4-71.0)
16.5 (7.9-34.7)

3610
3856

82,489
90,793

55
13

66.7 (51.2-86.4)
14.3 (8.3-24.7)

3836
3808

88,956
88,394

44
25

49.5 (36.8-66.5)
28.3 (19.1-41.9)

ACLR, anterior cruciate ligament reconstruction.

Incidence rate of ACLR per 100,000 person-years.

TABLE 5
Age-Adjusted HRs for the Risk of Anterior Cruciate Ligament Reconstruction by Sexa
Girls

Boys
b

P Value

HR (95% CI)

3.31 (1.30-8.43)
1

.01

3.93 (0.92-16.80)
1

.06

5.42 (2.51-11.70)
1

\.001

4.22 (1.58-11.30)
1

.004

HR (95% CI)
A. Sport level
Level I
Level II or III
B. Sport competition
Yes
No

P Value

HR, hazard ratio.

Adjusted for age (as the time scale), A and B were analyzed in separate Cox regression models.

The compliance rate of reporting ACLRs from hospitals to

the NKLR is high (97%).14
There are some limitations that need to be addressed.
Sport level and competition were self-reported, making
these measurements prone to information bias. However,
potential misclassifications of exposures are likely to be
nondifferential, as this information was collected before
the outcome of interest. We had no repetitive follow-up
data on sport level or competition. Thus, some results
may have occurred as a consequence of factors other than
those initially investigated. However, we had individual
information about the type of activity that caused the
ACL injury from the NKLR. This validated the association
that we found between level I sport participation (at baseline) and the risk of ACLR. Unfortunately, we had no information about the frequency with which they participated
in sports or if they competed around the time of injury.
The Swedish nationwide cruciate ligament register
reported that, of all persons aged \30 years with an ACL
injury, approximately 50% were surgically treated between
2001 and 2009.30 There is currently no register in Norway
that contains data on the nonsurgical treatment of persons
with ACL injuries. Thus, the total incidence and burden of
ACL injuries were not available for the present study.
Even though the overall response rate was high in
the YHUNT3,18 we cannot exclude the possibility that
nonresponders had unhealthier lifestyles and minimal

participation in sports.36 This could have influenced the

estimated association between sport levels or sport competitions and the risk of ACLR.
In line with previous literature on athlete populations,35,37 we found that participation in level I sports
increased the risk of ACLR. Based on information in the
NKLR, the activities most frequently reported at the
time of ACL injury were soccer and team handball. These
2 team sports were responsible for 81% of the subsequent
ACLRs. Higher point estimates (HRs) were associated
with level I sports and ACLR in boys, although the association was only significant for girls. However, the power to
detect significant findings was greater for girls, as 44 of 69
ACLRs were performed on girls. This is also reflected in
the wide 95% CIs for boys. We assumed that participation
in sport competitions did not determine the sport level and
vice versa. The risk of ACL injuries differs between training and competitions.41 In the same manner, we expected
the risk of ACLR to differ between sport levels and competitions. In addition, competition may be thought of as an
intermediate effect in the direct pathway between sport
level and the risk of ACLR and should not be adjusted
for in the analyses if we are interested in the total effect.38
We considered sport competitions to be an independent key
exposure for the risk of ACLR. In this study, participating
in sport competitions was more strongly associated with
the risk of ACLR than sport level was, with girls having

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The American Journal of Sports Medicine

95% CI
No competitions

95% CI
Competitions

95% CI
No competitions

95% CI
Competitions

Cumulative proportion with ACLR

0.01
0.02
0.03
0.04
0.05

Johnsen et al

Cumulative proportion with ACLR

0.02
0.03
0.05
0.01
0.04

12

16

20
Age, y

24

12

28

16

20
Age, y

24

28

Figure 2. Cumulative proportion of anterior cruciate ligament

reconstruction among girls competing or not competing.
ACLR, anterior cruciate ligament reconstruction.

Figure 3. Cumulative proportion of anterior cruciate ligament

reconstruction among boys competing or not competing.
ACLR, anterior cruciate ligament reconstruction.

the highest risk. This is comparable with previous studies,

which found that participating in soccer matches resulted
in an increased risk of ACL injuries in female athletes compared with male athletes.41 The risk of cruciate ligament
injuries was also found to be especially high for active girls
in a Finnish population-based study of adolescents33 in
which the strongest association was related to the high frequency of weekly participation in sport clubs (4-5 times/
week). However, the authors had no additional information
on the type of activities or sports that the adolescents participated in.33 Furthermore, age at the time of ACL injury
has been reported to be lower in female patients.41 Potential reasons for girls greater susceptibility to ACL injuries
include sex-based differences in anatomy, structure, and
hormones as well as neuromuscular and biomechanical
factors considered potentially modifiable through training.39 In our study, we found that girls were significantly
younger than boys at the time of ACLR. A large proportion
of girls underwent ACLR both in the age groups of 15 and
16 years (43%) and 17 years of age (50%), while most of
the boys were 17 years of age at the time of ACLR
(88%). Despite girls younger age at the time of ACL injury,
another reason for the sex-related differences in age at
ACLR may be the earlier skeletal maturation among girls,
making them eligible for surgery at a younger age.
The age difference between boys and girls at the time of
ACLR in our study may also reflect the age-dependent incidence that we find in the NKLR. We know from the registry that girls have their highest incidence of ACLR at 10 to
19 years of age, while boys have their highest incidence
when they are between 20 to 29 years old. Furthermore,
the annual incidence of ACLR for boys exceeds the incidence for girls if we compare the age group of 20 to 29 years
old.15 At the end of follow-up in our study, the participants
were, on average, 23 years old, which means that peak
incidence may not yet have occurred for the boys.
One possible explanation for why we found a stronger
association between sport competitions and ACLR than
between sport levels and ACLR may be because of differences
in the setting of a competition and an exercise session. While
competitions often expose the athlete to unpredictable and

risk-taking situations, they are prepared for the activities

involved in an everyday exercise situation. Expectations
related to a competition are also different than those related
to an exercise session. A competition may, to a greater extent,
be a proxy measure of high frequency, duration, and intensity of an activity or sport compared with the measure of
sport level, thus reflecting a more homogeneous group of
active adolescents. As a result, sport level and competition
may represent somewhat different aspects of being active.
It is therefore important to consider both types of exposure
individually when examining the risk of ACL injuries and
ACLR. Even though the associations that we found between
ACLR and level I sports and competitions were strong, the
number of ACLRs in general was small, which resulted in
low precision, reflected in the wide 95% CIs. Thus, we should
be somewhat cautious when interpreting the results.
Our incidence of ACLR was 38.9 (95% CI, 30.7-49.3)
per 100,000 person-years, compared with the Finnish
population-based study33 that reported a cruciate injury
incidence of 60.9 (95% CI, 53.6-68.2) per 100,000 person
years. The difference in incidence may be because of differences in the age distribution between the 2 cohorts, the
definition of outcome, and the policy of surgery versus nonsurgical treatment in the 2 countries. The Finnish study33
included somewhat older adolescents and used hospitalization due to a cruciate ligament injury as an outcome, not
including only ACLRs as we did. If we calculated the
annual incidence per 100,000 inhabitants instead of per
100,000 person-years, the rate would have been 122 per
100,000 inhabitants (aged 14-23 years). Our incidence is
somewhat higher than in the NKLR,14 which reported an
annual incidence of 85 per 100,000 inhabitants; however,
this main population at risk was in the age group of 16
to 39 years at the time of ACLR. Similarly, a Swedish
study reported an annual incidence of 81 per 100,000
inhabitants in the age group of 10 to 64 years; however,
that study reported the incidence of ACL injuries.13 As
studies operate with different populations at risk, it is
challenging to compare incidence directly. Surely, a better
comparison would have been possible if we had used ageand sex-standardized incidence rates.

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AJSM Vol. XX, No. X, XXXX

Sport Participation and ACLR in Adolescents

In Norway, there has been an increased focus on the

benefits of a nonoperative treatment algorithm including
neuromuscular and strength exercises to restore dynamic
knee stability12,16 and for children and adolescents to delay
surgery until they reach skeletal maturity.25 The incidence
rates of ACLR will naturally be higher in countries where
the surgical treatment of ACL injuries is more aggressively
promoted. Therefore, the health systems of countries are
also relevant when comparing ACL surgery rates.23 Incidence rates of ACL injuries and ACLR are dependent on
the population under investigation and are, therefore,
likely to be higher in an athletic population than a general
unselected population.24 Compared with our results, substantially higher incidences are reported in studies of professional athletes (150-3672 per 100,000 person-years).27
This study identified that participating in level I sports
and competitions in a general adolescent population seem
to be important predisposing factors that may lead to an
ACL injury and subsequent ACLR, as previously shown in
athlete populations. Injury prevention programs have shown
good efficacy in terms of reducing ACL injuries among athletes in team sports.1,29 For adolescents participating in level
I sports and competitions, injury prevention programs should
therefore be prioritized to a higher degree. Identifying these
risk factors can help coaches, team leaders, and physical
therapists to reduce the incidence of ACL injuries by educating adolescents and bringing these preventive strategies into
effect. Injury prevention programs have low costs and can be
implemented as part of a warm-up routine. Some of these
programs have also proven to be beneficial by increasing
speed, strength, agility, and dynamic balance.31 As an addition to basic workout routines and exercises, these programs
may improve performance in various sports. Preventing injuries will help ensure continued sport participation throughout adolescence, allowing more people to experience the
benefits of sports. We know that ACL injuries may result
in functional limitations16 and reduced physical activity2 in
the short term and increase the risk of future lifestyle diseases and OA.20,32

CONCLUSION
In this population-based cohort of adolescents, we found
that participating in both level I sports and in sport competitions significantly increased the risk of undergoing primary ACLR. The increased risk was found for both sexes.
Preventive strategies for the management of ACL injuries,
especially in team sports such as soccer and team handball,
should be implemented to reduce the incidence and burden
of ACL injuries.

ACKNOWLEDGMENT
The authors thank the adolescents who participated in the
Nord-Trndelag Health Study (HUNT) and the HUNT
Research Center for their collaboration and support. The
HUNT is a collaboration between the HUNT Research Center (Faculty of Medicine, Norwegian University of Science

and Technology), Nord-Trndelag County Council, Central

Norway Health Authority, and Norwegian Institute of Public
Health. Further, they thank the Norwegian National Knee
Ligament Registry for allowing them to use its data.

REFERENCES
1. Alentorn-Geli E, Myer GD, Silvers HJ, et al. Prevention of non-contact
anterior cruciate ligament injuries in soccer players, part 2: a review of
prevention programs aimed to modify risk factors and to reduce injury
rates. Knee Surg Sports Traumatol Arthrosc. 2009;17(8):859-879.
2. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic
review and meta-analysis of the state of play. Br J Sports Med.
2011;45(7):596-606.
3. Beynnon BD, Johnson RJ, Abate JA, Fleming BC, Nichols CE. Treatment of anterior cruciate ligament injuries, part I. Am J Sports Med.
2005;33(10):1579-1602.
4. Bratberg GH, Nilsen TI, Holmen TL, Vatten LJ. Early sexual maturation, central adiposity and subsequent overweight in late adolescence. A four-year follow-up of 1605 adolescent Norwegian boys
and girls: the Young HUNT study. BMC Public Health. 2007;7:54.
5. Caine D, Caine C, Maffulli N. Incidence and distribution of pediatric
sport-related injuries. Clin J Sport Med. 2006;16(6):500-513.
6. Caine D, Maffulli N, Caine C. Epidemiology of injury in child and adolescent sports: injury rates, risk factors, and prevention. Clin Sports
Med. 2008;27(1):19-50, vii.
7. Caine D, Purcell L, Maffulli N. The child and adolescent athlete:
a review of three potentially serious injuries. BMC Sports Sci Med
Rehabil. 2014;6:22.
8. Caine DJ, Golightly YM. Osteoarthritis as an outcome of paediatric
sport: an epidemiological perspective. Br J Sports Med. 2011;45(4):
298-303.
9. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard
definition for child overweight and obesity worldwide: international
survey. BMJ. 2000;320(7244):1240-1243.
10. Darrow CJ, Collins CL, Yard EE, Comstock RD. Epidemiology of
severe injuries among United States high school athletes: 20052007. Am J Sports Med. 2009;37(9):1798-1805.
11. Eime RM, Young JA, Harvey JT, Charity MJ, Payne WR. A systematic
review of the psychological and social benefits of participation in
sport for children and adolescents: informing development of a conceptual model of health through sport. Int J Behav Nutr Phys Act.
2013;10:98.
12. Eitzen I, Moksnes H, Snyder-Mackler L, Risberg MA. A progressive
5-week exercise therapy program leads to significant improvement
in knee function early after anterior cruciate ligament injury. J Orthop
Sports Phys Ther. 2010;40(11):705-721.
13. Frobell RB, Lohmander LS, Roos HP. Acute rotational trauma to the
knee: poor agreement between clinical assessment and magnetic resonance imaging findings. Scand J Med Sci Sports. 2007;17(2):109-114.
14. Granan LP, Bahr R, Steindal K, Furnes O, Engebretsen L. Development
of a national cruciate ligament surgery registry: the Norwegian National
Knee Ligament Registry. Am J Sports Med. 2008;36(2):308-315.
15. Granan LP, Forssblad M, Lind M, Engebretsen L. The Scandinavian
ACL registries 2004-2007: baseline epidemiology. Acta Orthop.
2009;80(5):563-567.
16. Grindem H, Eitzen I, Engebretsen L, Snyder-Mackler L, Risberg MA.
Nonsurgical or surgical treatment of ACL injuries. Knee function,
sports participation, and knee reinjury: the Delaware-Oslo ACL
Cohort Study. J Bone Joint Surg Am. 2014;96(15):1233-1241.
17. Hefti F, Muller W, Jakob RP, Staubli HU. Evaluation of knee ligament
injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc.
1993;1(3-4):226-234.
18. Holmen TL, Bratberg G, Krokstad S, et al. Cohort profile of the
Young-HUNT Study, Norway: a population-based study of adolescents. Int J Epidemiol. 2014;43(2):536-544.

Downloaded from ajs.sagepub.com at CAL STATE UNIV SAN MARCOS on May 12, 2016

Johnsen et al

The American Journal of Sports Medicine

19. Janssen I, Leblanc AG. Systematic review of the health benefits of

physical activity and fitness in school-aged children and youth. Int
J Behav Nutr Phys Act. 2010;7:40.
20. Lohmander LS, Englund PM, Dahl LL, Roos EM. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med. 2007;35(10):1756-1769.
21. Louw QA, Manilall J, Grimmer KA. Epidemiology of knee injuries
among adolescents: a systematic review. Br J Sports Med.
2008;42(1):2-10.
22. Maffulli N, Longo UG, Gougoulias N, Loppini M, Denaro V. Long-term
health outcomes of youth sports injuries. Br J Sports Med.
2010;44(1):21-25.
23. Magnussen RA, Granan LP, Dunn WR, et al. Cross-cultural comparison of patients undergoing ACL reconstruction in the United States
and Norway. Knee Surg Sports Traumatol Arthrosc. 2010;18(1):98105.
24. Mall NA, Chalmers PN, Moric M, et al. Incidence and trends of anterior cruciate ligament reconstruction in the United States. Am J
Sports Med. 2014;42(10):2363-2370.
25. Moksnes H, Engebretsen L, Risberg MA. Prevalence and incidence
of new meniscus and cartilage injuries after a nonoperative treatment
algorithm for ACL tears in skeletally immature children: a prospective
MRI study. Am J Sports Med. 2013;41(8):1771-1779.
26. Moksnes H, Snyder-Mackler L, Risberg MA. Individuals with an anterior cruciate ligament-deficient knee classified as noncopers may be
candidates for nonsurgical rehabilitation. J Orthop Sports Phys Ther.
2008;38(10):586-595.
27. Moses B, Orchard J, Orchard J. Systematic review: annual incidence
of ACL injury and surgery in various populations. Res Sports Med.
2012;20(3-4):157-179.
28. Mountcastle SB, Posner M, Kragh JF Jr, Taylor DC. Gender differences in anterior cruciate ligament injury vary with activity: epidemiology of anterior cruciate ligament injuries in a young, athletic
population. Am J Sports Med. 2007;35(10):1635-1642.
29. Myklebust G, Engebretsen L, Braekken IH, Skjolberg A, Olsen OE,
Bahr R. Prevention of anterior cruciate ligament injuries in female
team handball players: a prospective intervention study over three
seasons. Clin J Sport Med. 2003;13(2):71-78.
30. Nordenvall R, Bahmanyar S, Adami J, Stenros C, Wredmark T,
Fellander-Tsai L. A population-based nationwide study of cruciate

31.

32.

33.

34.

35.

36.

37.

38.
39.

40.
41.

42.

ligament injury in Sweden, 2001-2009: incidence, treatment, and

sex differences. Am J Sports Med. 2012;40(8):1808-1813.
Noyes FR, Barber Westin SD. Anterior cruciate ligament injury prevention training in female athletes: a systematic review of injury reduction
and results of athletic performance tests. Sports Health. 2012;4(1):36-46.
Oiestad BE, Holm I, Aune AK, et al. Knee function and prevalence of
knee osteoarthritis after anterior cruciate ligament reconstruction:
a prospective study with 10 to 15 years of follow-up. Am J Sports
Med. 2010;38(11):2201-2210.
Parkkari J, Pasanen K, Mattila VM, Kannus P, Rimpela A. The risk for
a cruciate ligament injury of the knee in adolescents and young
adults: a population-based cohort study of 46 500 people with a 9
year follow-up. Br J Sports Med. 2008;42(6):422-426.
Petersen AC, Crockett L, Richards M, Boxer A. A self-report measure
of pubertal status: reliability, validity, and initial norms. J Youth Adolesc. 1988;17(2):117-133.
Prodromos CC, Han Y, Rogowski J, Joyce B, Shi K. A meta-analysis
of the incidence of anterior cruciate ligament tears as a function of
gender, sport, and a knee injury-reduction regimen. Arthroscopy.
2007;23(12):1320-1325.e6.
Rangul V, Holmen TL, Bauman A, Bratberg GH, Kurtze N, Midthjell K.
Factors predicting changes in physical activity through adolescence:
the Young-HUNT Study, Norway. J Adolesc Health. 2011;48(6):616-624.
Renstrom P, Ljungqvist A, Arendt E, et al. Non-contact ACL injuries in
female athletes: an International Olympic Committee current concepts statement. Br J Sports Med. 2008;42(6):394-412.
Rothman KJ. Epidemiology: An Introduction. Oxford: Oxford University Press; 2012.
Shultz SJ, Schmitz RJ, Benjaminse A, Chaudhari AM, Collins M,
Padua DA. ACL Research Retreat VI: an update on ACL injury risk
and prevention. J Athl Train. 2012;47(5):591-603.
Spindler KP, Wright RW. Clinical practice: anterior cruciate ligament
tear. N Engl J Med. 2008;359(20):2135-2142.
Walden M, Hagglund M, Werner J, Ekstrand J. The epidemiology of
anterior cruciate ligament injury in football (soccer): a review of the
literature from a gender-related perspective. Knee Surg Sports Traumatol Arthrosc. 2011;19(1):3-10.
Ytterstad K, Granan LP, Engebretsen L. [The Norwegian Cruciate
Ligament Registry has a high degree of completeness]. Tidsskr Nor
Laegeforen. 2011;131(3):248-250.

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