Anterior cruciate ligament injury occurrence, return to sport and subsequent injury in the Australian High Performance Sports System: A 5-year retrospective analysis

Joshua D. Rigg*, Nirmala Kanthi Panagodage Perera, Liam A. Toohey, Jennifer Cooke, David Hughes

*Corresponding author for this work

    Research output: Contribution to journalArticlepeer-review

    Original languageEnglish
    Pages (from-to)140-146
    Number of pages7
    JournalPhysical Therapy in Sport
    Publication statusPublished (VoR) - Nov 2023


    This case series included athletes within the Australian High Performance Sports System who had an ACL injury recorded in the centralised Athlete Management System (AMS) database (Smartabase, Fusion Sport Pty Ltd., Brisbane, Australia) between January 1, 2015 and May 31,2020. The Australian High Performance Sport System has iteratively changed over time, but now comprises of National Sporting Organisations, who receive federal funding through government agencies, as well as state funded and officially endorsed Olympic, Paralympic and Commonwealth Games training centers within the National Institute Network of Australia (Sheehy et al., 2022; Weissensteiner, 2023). A national athlete categorisation framework is used by the Australian High-Performance Sport System to identify talented athletes most likely to achieve performance outcomes linked to Australia's high performance sport targets. Specific athlete categorisation criteria are set by each National Sporting Organisation and the number of athletes categorised at any one time can vary according to funding, the stage of a season and performance outcomes achieved (Australian Sports Commission, 2021). Athletes supported by National Sporting Organisations, or training within the National Institute Network, have a profile on the AMS, which is used as a central repository for athlete data inclusive of injury surveillance data and clinical notes. The number of athletes with an active AMS profile changes throughout the year as developing athletes are added to state and national level squads and other athletes are removed due retirement and deselection.All injury and medical record data were entered by the treating doctor or physiotherapist into the AMS at the point of care (following initial assessment and throughout rehabilitation). A four-character Orchard Sports Injury Classification System 10 (OSICS-10.1) injury diagnosis code (Rae & Orchard, 2007) was assigned to the injury record. The number of days for which the athlete was unavailable, and days to RTS were calculated. RTS was defined as the date the athlete was cleared by the treating practitioner for full participation in training and competition with no medical restrictions related to the primary mode of training (Australian Institute of Sport, 2020). A subsequent ACL injury was defined as an athlete's second or later ACL injury (whether ipsilateral or contralateral to the initial injury). All definitions and uses comply with the Australian Institute of Sport data dictionary (Australian Institute of Sport, 2020) and the International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (Bahr et al., 2020). Ethics approval for the study was granted by the Australian Institute of Sport Human Research Ethics Committee (Approval number: 20200501) and all eligible athletes were contacted via generic email and provided the opportunity to opt-out of the study.Two out of three ACL injuries reported were in female athletes, and a higher proportion of female athletes with a knee injury sustained an ACL injury compared to male athletes. Anatomical (e.g., decreased femoral notch width), physiological (e.g., increased joint laxity), hormonal (e.g., the effect of oestrogen on ACL injury incidence) and biomechanical (e.g., variations in kinematics during cutting maneuvers) factors are all proposed to increase the risk of ACL injuries in female athletes despite contrasting findings across the literature (Devana et al., 2022; Gans et al., 2018; Hewett et al., 2006; Shelbourne et al., 1998; Söderman et al., 2001; Sutton & Bullock, 2013; Tan et al., 2016; Webster, 2021). Socio-cultural factors such as between-gender differences in access to development pathways, high performance training facilities, coaching staff and performance support practitioners, and athlete income also likely contribute to the established higher rates of ACL injury in female athletes (Bruder et al., 2023; Parsons et al., 2021). Limitations of our data made direct comparisons of injury incidence rates between sexes not possible, however our results support previous findings that female athletes represent a key target group for primary ACL injury prevention strategies (Mattu et al., 2022; Montalvo, Schneider, Yut, et al., 2019; Petushek et al., 2019; Sugimoto et al., 2015).Our data represents a five-and-a-half year review of ACL injuries in high-performance athletes from across the spectrum of Olympic, Paralympic and Commonwealth games sports. Given that all Australian High Performance Sports System sports utilise the AMS for clinical records, it is likely that relatively few ACL injuries were not reported. A further strength is that each injury was prospectively entered into the AMS by the treating clinician and assigned an OSICS-10.1 code at the time of assessment. However, the AMS is not universally used within the Australian High Performance Sports System as a repository for exposure information meaning we were unable to accurately calculate ACL injury incidence rates. This prevents accurate comparison of risk between athlete sex and sport, which future research should address. To ensure consistency of reporting, a data dictionary (Australian Institute of Sport, 2020) is available to all AMS users in the Australian High Performance Sports System, though ensuring consistent data entry across a widespread system is difficult. Some data was incomplete as not all athletes were followed to RTS within the AMS, and as a result we were unable to calculate RTS rates for this cohort. Furthermore, the management (conservative/surgical) of ACL injuries was not able to be reported as this is not captured as a structured data point within the surveillance system, and the ethical approval granted for this study did not extend to reviewing all the associated clinical management notes linked to the structured injury surveillance fields. The breadth of sports and age ranges of athletes included in this research may enable extrapolation of our findings to other multi-sport high-performance environments, however, inference made to specific sport cohorts should occur with caution given the heterogeneity of athletes and likely risk factors that exist within multisport athlete cohorts.

    FundersFunder number
    Australian High Performance Sport System
    Australian High Performance Sports System
    Australian High-Performance Sport System
    Australian Institute of Sport Human Research Ethics Committee20200501
    Australian Institute of Sport data dictionary
    Fusion Sport Pty Ltd.
    Administration for Community Living
    Australian Institute of Sport
    Australian Sports CommissionOSICS-10.1
    International Olympic Committee


      • Athletes
      • Cruciate
      • Knee
      • ligaments
      • Rupture


      Dive into the research topics of 'Anterior cruciate ligament injury occurrence, return to sport and subsequent injury in the Australian High Performance Sports System: A 5-year retrospective analysis'. Together they form a unique fingerprint.

      Cite this