The HSS investigators found that the odds of taking human growth hormone therapy were 15 times higher among children who experienced a fracture to the growth plate of the upper shinbone compared with a matched comparison group who experienced midshaft tibia fractures, according to a new study published December 21 in the Journal of Bone and Joint Surgery. 

In children, human growth hormone therapy has been used for decades to treat growth hormone deficiency due to underlying medical conditions such as Turner syndrome, very small weight at birth, Prader-Willi syndrome and chronic renal insufficiency. However, in 2003, its use became more widespread in children, when the U.S. Food and Drug Administration approved it for the treatment of short stature with no known cause, called idiopathic short stature. Since then, an increasing number of children have been taking growth hormone therapy to boost their height.

Fractures to the growth plate at the top end of the shinbone, or tibia, are called proximal tibia physeal avulsion fractures. “We have been seeing more cases of tibia growth plate fractures in our emergency room and outpatient offices,” says senior author Peter D. Fabricant, MD, MPH, a pediatric orthopedic surgeon at HSS. “While kids are still growing, the tibia growth plate is structurally weaker than the patellar tendon. When a child or adolescent lands awkwardly or forcefully contracts their quadriceps muscle, instead of the patellar tendon rupturing, it pulls off a piece of bone from the growth plate because the growth plate is weaker.”

“At HSS, a big part of what our pediatric orthopedic service does is treat children with significant fractures and orthopedic injuries,” says study co-author Daniel W. Green, MD, MS, FAAP, FACS, chief of the Pediatric Orthopedic Service at HSS. “Parents frequently ask our pediatric orthopedic surgeons if human growth hormone caused their children’s fractures. Given the volume of patients we treat, we were able to investigate the relationship between tibia growth plate fractures and growth hormone therapy in pediatric patients.”

The study is the first to formally quantify this concerning relationship. The researchers analyzed hospital records for two groups of pediatric patients treated at HSS between February 2016 and May 2023—66 patients who experienced proximal tibia physeal avulsion fractures and a comparison group of 66 patients who had midshaft tibia fractures, which involve the same bone but not the growth plate area. Patients in both groups were 13 years of age on average, with similar body mass indices. The percentage of males in each group was 82 percent.

The analysis revealed that seven, or 11 percent, of patients with a proximal tibia physeal avulsion fracture reported taking human growth hormone, whereas zero patients in the comparison group were taking growth hormone. Therefore, the odds of taking growth hormone therapy were 15 times higher among patients with proximal tibia physeal avulsion fractures than the comparison group. Most patients, 86 percent, were taking growth hormone for increasing stature.  

“Tibia growth plate fractures are rare but serious injuries. They account for less than 3 percent of pediatric fractures, but more than 40 percent of patients with these fractures require surgical repair,” says Dr. Fabricant. “Moreover, whether a patient requires surgery or not, these fractures require a long recovery period—12 weeks for healing the break and regaining range of motion, plus several more weeks to months to recover strength and endurance before resuming normal activities.”

“We hope families deciding whether their children should start or continue growth hormone therapy consider our new evidence as they carefully weigh the pros and cons of therapy in consultation with their pediatric endocrinologists,” Dr. Green says. “Further research is required to tease out whether limiting specific high-impact sports will mitigate the risk of tibia growth plate fractures in active children and adolescents.”

Dr. Mayman will succeed Mathias P. Bostrom, MD, who, along with sports medicine surgeon Answorth A. Allen, MD, was recently appointed Associate Surgeon-in-Chief at HSS after serving as ARJR chief for the past four years. Dr. Green will succeed Roger F. Widmann, MD, who has led the Pediatric Surgical Service since 2004. Dr. Widmann will continue to care for pediatric patients with spine and limb deformities and will lead a new center of excellence dedicated to robotic-assisted surgery at HSS. Both appointments will go into effect September 5.

“We are grateful to Drs. Bostrom and Widmann for their steadfast leadership over the years,” said Bryan T. Kelly, MD, MBA, president, surgeon-in-chief and medical director of HSS. “Drs. Mayman and Green are not only talented surgeons, they are collaborative leaders who bring a wealth of expertise and experience to their new roles. These appointments will allow us to continue to advance excellence for our joint replacement and pediatric surgical patients.”

In their new roles, Drs. Mayman and Green will each lead highly integrated multidisciplinary teams. The ARJR service is comprised of programs focused on hip and knee osteoarthritis and other problems requiring joint replacement in adults, while Pediatrics covers the spectrum of conditions requiring orthopedic surgery in children, ranging from sports medicine injuries and trauma to congenital issues of the spine and hip.

David Mayman

David J. Mayman, MD, is an orthopedic surgeon specializing in hip and knee replacements. A member of the Hip and Knee Societies, Dr. Mayman is a leader in the field of robotic and navigated joint replacement surgery. His primary research interest lies in incorporating new technologies into arthroplasty, with the goal of achieving more favorable outcomes for patients.

“I’m honored to take on this new role, leading and collaborating with a deeply talented team of surgeons in order to deliver scientific breakthroughs and address joint pain challenges,” said Dr. Mayman. “HSS is recognized as the leader in joint replacement, and by harnessing the power of our musculoskeletal expertise, we will advance the overall health and wellness of generations to come.” 

Daniel Green

Daniel W. Green, MD, MS, is a pediatric orthopedic surgeon specializing in knee surgery.

A holder of the Mary Kathryn and Alexander Navab Chair for Pediatric Orthopedic Research at HSS, Dr. Green’s clinical research has focused on surgical outcomes and techniques used to treat patella dislocation, osteochondritis dissecans, discoid meniscus and pediatric ACL tears.

“I am honored to be asked to represent such a talented group of pediatric orthopedic surgeon leaders dedicated to taking care of children at the hospital ranked no. 1 in the world for orthopedics,” said Dr. Green. “We are positioned to maintain our leadership position as national and international thought leaders and dedicated to increasing access to our care.”

“HSS is home to an unparalleled number of talented and knowledgeable experts who specialize in caring for patients with various conditions throughout the lifespan,” said Louis A. Shapiro, CEO of HSS. “These appointments highlight the depth of leadership and experience across each area of the organization.”
 

“Surgery to utilize the implant for graft fixation is more efficient and effective than previous methods and has been shown to result in more successful outcomes,” said Frank A. Cordasco, MD, MS, a sports medicine surgeon at Hospital for Special Surgery (HSS) in New York City. Dr. Cordasco and an HSS colleague, pediatric orthopedic surgeon Daniel W. Green, MD, MS, FAAP, FACS, have partnered in this effort and are among the nation’s leaders in using the approach in the operating room. These physicians, who are dedicated to improving outcomes for pediatric and young adolescent athletes with ACL tears both clinically and through research and education, helped evaluate the clinical effectiveness of the device through a collaboration with Arthrex that started approximately 15 years ago. Drs. Cordasco and Green also developed pediatric- and young-adolescent-specific instrumentation guides to address an increasing population of injured high-risk young athletes. Previously, only adult instrumentation guides were available for use and are inadequate in the surgical management of this cohort of pediatric and young adolescent athletes.

Tears of the ACL, a structure that is essential for knee stability during lateral movement, have become increasingly common in children and young adolescents over the past two decades, largely as a result of greater participation of both boys and girls in competitive team sports.

Until relatively recently, however, surgeons were reluctant to operate on children whose growth plates in the legs had not fused. Doing so carries the risk of permanent deformities to the long bones (femur and tibia) that meet at the knee, explained Dr. Green. Historically, the solution for most of these patients was to treat them with a brace and hope for the best until their bones had matured. But in the majority of cases, the non-operative approach led to serious problems, including further damage to the joint, as well as psychosocial effects by limiting the young athletes’ participation in sports until they reached skeletal maturity a few years later.¹

The Cordasco-Green technique of all-epiphyseal ACL reconstruction was developed in collaboration with Arthrex for use in the youngest athletes with more than three years of remaining growth.² This approach involves the use of pediatric-specific instrumentation guides to drill sockets for the ACL graft and avoid the growth plate and thereby diminish the potential for growth disturbance.^2,3,4

The complete transphyseal technique is indicated in young adolescent athletes who are approaching skeletal maturity. This approach drills across the growth plates with a small socket to perform an ACL reconstruction using a quadriceps autograft (taken from a piece of the athlete’s quadriceps tendon). Based upon their research, Drs. Cordasco and Green have found that of the two all-soft tissue autografts available for ACL reconstruction, quadriceps autografts have superior outcomes compared to hamstring autografts in this high-risk young adolescent athletic population.^5,6,7

Unlike previous iterations of the approach, the newly cleared technique uses Adjustable- rather than Fixed-Loop buttons. This feature improves surgeons’ ability to adequately tension the quadriceps autograft tendon while the patient is on the operating table and to reduce “creep,” slack in the tissue that leads to residual instability in the knee. “The stronger and greater the fixation at the time of surgery, the better the outcome for the athletes,” said Dr. Cordasco. In addition, the implant eliminates the need for ligament interference screw fixation, which may increase the potential for growth plate injury and growth disturbance.

These techniques have also provided superior outcomes in terms of the need for revision surgery and return to sports. “Our research has demonstrated that more than 90 percent of children who have undergone the surgery with this implant at HSS have returned successfully to sports without the need for additional surgery,” said Dr. Cordasco.^5,6,7

“The ideal patient for the procedure is, in general, a child between the ages of 12 and 15 to 16, depending upon the athletes’ skeletal maturity, at which point the growth plates are effectively closed,” said Dr. Green. This group has seen an “epidemic” of ACL tears over the last 20 years, he added.

Dr. Green concluded that the youngest children may not good candidates for this approach, because their bones are not large enough to hold the sockets. The youngest children benefit from a different physeal-sparing approach using a combined intra- and extra-articular surgery utilizing the iliotibial band as a graft.

References:

1.       James EW, Dawkins BJ, Schachne JM, Ganley TJ, Kocher MS; PLUTO Study Group; Early Operative Versus Delayed Operative Versus Nonoperative Treatment of Pediatric and Adolescent Anterior Cruciate Ligament Injuries: A Systematic Review and Meta-analysis. Am J Sports Med. 2021 Dec;49(14):4008-4017. doi: 10.1177/0363546521990817. Epub 2021 Mar 15.PMID: 33720764

2.       Fabricant PD, Jones KJ, Delos D, Cordasco FA, et al: Reconstruction of the Anterior Cruciate Ligament in the Skeletally Immature Athlete: A Review of Current Concepts: AAOS Exhibit Selection. J Bone Joint Surg 2013, 95:e28(1-13). PMID: 23467876.

3.       McCarthy MM, Graziano J, Green DW, Cordasco FA: All-Epiphyseal, All-Inside Anterior Cruciate Ligament Reconstruction Technique for Skeletally Immature Patients. Arthrosc Tech 2012, 1(2):e231-e239. PMID: 23767001

4.       Cordasco FA, Mayer SW, Green DW: All-Inside, All-Epiphyseal ACL Reconstruction in Skeletally Immature Athletes: Return to Sport, Incidence of Second Surgery and Two-Year Clinical Outcomes. Am J Sports Med. 2016 Dec 1:363546516677723. doi: 10.1177/0363546516677723. [Epub ahead of print] PMID: 28027452

5.       Cordasco FA, Black SR, Price M, Wixted C, Asaro L, Heller M, Nguyen J, Green DW: Return to Sport and Re-Operation Rates in Athletes Under the Age of 20 Following Primary Anterior Cruciate Ligament Reconstruction: Risk Profile Comparing Three Patient Groups Predicated Upon Skeletal Age.  Am J Sports Med. 2019 Jan 15:363546518819217. Doi:10.1177/036354651882917. [Epub ahead of print] PMID: 20645948

6.       Aitchison AH, Schlichte LM, Green DW, Cordasco FA. Open Full-Thickness Quadriceps Tendon Autograft Harvest With Repair for Anterior Cruciate Ligament Reconstruction. Arthrosc Tech. 2020 Sep 15;9(10):e1459-e1465. doi: 10.1016/j.eats.2020.06.006. eCollection 2020 Oct.PMID: 33134047

7.       Aitchison AH, Alcoloumbre D, Mintz DN, Hidalgo Perea S, Nguyen JT, Cordasco FA, Green DW. MRI Signal Intensity of Quadriceps Tendon Autograft and Hamstring Tendon Autograft 1 Year After Anterior Cruciate Ligament Reconstruction in Adolescent Athletes. Am J Sports Med. 2021 Nov;49(13):3502-3507. doi: 10.1177/03635465211040472. Epub 2021 Oct 6.PMID: 34612708

The study evaluated the safety and efficacy of performing a lateral extra-articular tenodesis (LET) using a modified Lemaire technique (MLT) in conjunction with an ACL reconstruction in children and adolescents who are at an increased risk for a failed ACL reconstruction. Findings revealed the technique was associated with favorable patient-reported outcomes, high return to sports participation and low ACL re-tear rate.

Research has long demonstrated that young adolescents (typically in eighth and ninth grades) who return to a pivoting or high-risk high school sport have the highest re-tear rate after an ACL reconstruction.

In the New York City metro area alone, over 80 percent of ACL injuries in adolescents stem from participation in sports such as basketball, soccer, lacrosse, skiing and football.

The ACL, one of four major ligaments in the knee joint, helps maintain the knee’s rotational stability and prevent the shinbone (tibia) from slipping in front of the thighbone (femur). It is especially vulnerable to injury from impact or athletic activities.

Currently, the standard-of-care surgical treatment for ACL tears is reconstruction. This involves placing a graft in the knee using a minimally invasive incision. Approximately 300,000 ACL reconstructions are performed annually in the United States. If the surgery fails, a revision procedure is necessary, which may result in higher rates of failure and lower rates of return to sport.

“Reconstruction alone has not been sufficient for kids who haven’t finished growing yet and want to stay active in sports,” said Daniel W. Green, MD, MS, FAAP, FACS, senior author and pediatric orthopedic surgeon at HSS.

“The risk of re-injury has been too high, leading to devastating consequences for a young athlete,” added Frank A. Cordasco, MD, MS, lead author and sports medicine surgeon at HSS, who noted that this continues to be an important area of clinical research for sports medicine surgeons worldwide.

About a decade ago, surgeons in France innovated on the standard ACL reconstruction procedure after identifying elite soccer players as high risk for re-tear. They added the LET to the reconstruction and successfully demonstrated that this combination decreased the re-tear rate in adult soccer players by nearly 50 percent.

Drs. Cordasco and Green are two of the first physicians to apply this European technique to teenage athletes in North America. The physicians are dedicated to improving outcomes for adolescent athletes with ACL tears both clinically and through research.

“We are proud to have published one of the first surgical-technique papers describing how this procedure can be safely performed in young patients who still have open growth plates,” said Dr. Green, who explained that this study is also unique in that it reports on two-year clinical outcomes in children who underwent this particular procedure.

“Not only does this technique not disturb children’s growth plates or cause post-operative stiffness, but we also found that this demonstrates a remarkably low re-tear rate in this high-risk group,” said Dr. Cordasco.

The study followed 61 patients between 11 and 19 years old who underwent simultaneous ACL reconstruction and LET with a minimum two-year follow-up; 97 percent of the patients participated in organized sports, with soccer being the most popular. These patients were identified as high risk when one or more of the following factors occurred: the patient participated in high-risk competitive sports such as football, lacrosse, soccer or basketball or that involved grade 3 pivot shift; had hyperlaxity; recurvatum; revision ACL reconstruction; contralateral ACL reconstruction; or chronic ACL insufficiency.

Depending on the patient’s skeletal maturity, the ACL reconstruction was performed either by using full-thickness quadriceps tendon, bone-patellar tendon-bone autograft, all-epiphyseal or complete transphyseal techniques.

At a minimum two-year follow-up, the researchers looked at patient-reported outcome measures as well as data on returning to sports and any potential additional surgeries. The results were overwhelmingly positive, with a median Single Assessment Numeric Evaluation (SANE) score of 95%, where 100% represents normal function. The mean Pediatric International Knee Documentation Committee (Pedi-IKDC) score was 91, where 100 is interpreted to mean no limitations on daily living or sports activities. Patients also reported a median score of 27/30 on the HSS Functional Activity Brief Scale (HSS Pedi-FABS), which is a validated eight-item instrument to quantify the activity of children.  

Nearly 92 percent of patients were able to return to sport. One patient had a revision ACL surgery and three had subsequent contralateral ACL reconstructions.

This study expanded upon work that Drs. Cordasco and Green published in 2020 that showed LET can be performed safely in skeletally immature athletes who underwent a quadriceps autograft ACL reconstruction.

These results, from 28 patients under age 20, are the first to emerge from a larger study currently in progress. This study is available online as part of the AAOS 2020 Virtual Education Experience.

“An ACL re-injury in the young adolescent athlete, who has undergone an ACL reconstruction and nine to 12 months of rehabilitation, is a devastating clinical problem that sports medicine orthopedic surgeons continue to confront in the United States and around the world,” says Frank Cordasco, MD, MS, a sports medicine surgeon at HSS and the study’s first author. “Our goal is to reduce the risk of re-injury as these athletes return to sports and prevent additional surgery involving the same knee or the uninjured knee to the extent that is possible.”

The ACL is one of the major ligaments that stabilizes the knee joint. Adolescents under age 20 who play field or court sports that involve jumping and pivoting motions or high-energy impacts to the knee, such as soccer, lacrosse, football, basketball or rugby, may tear the ACL. The goals of ACL surgery are to reconstruct a torn ACL to help stabilize the knee and to allow athletes to return to their former level of sports activity after recovery.

The additional surgical technique is called a modified Lemaire IT band tenodesis, named after Marcel Lemaire, a surgeon in France who originally described it in 1975. It is performed at the end of an ACL reconstruction. It involves using an 8-cm-by-1-cm strip of the iliotibial (IT) band, which is the long strap of connective tissue that extends from the hip to the knee on the outer side of the leg. This requires an additional, small, 5 cm incision. Surgeons pass the strip deep under the lateral collateral ligament, another large stabilizing ligament in the knee, and secure it in place, creating a tether or checkrein that limits the potential for recurrent rotational instability.

The method has been used in Europe for many years. “The biggest study so far has been from Europe, where studies have demonstrated the modified Lemaire IT band tenodesis has been proven successful in professional or semi-professional soccer players,” says Daniel Green, MD, MS, FAAP, FACS, a pediatric orthopedic surgeon at HSS and senior study author. “At HSS, we’re proud to be one of the first groups to use this technique in high-risk teenage athletes in North America.”

Dr. Cordasco and Dr. Green recently described the technique and their rationale for using it to treat athletes under the age of 20 years with a high risk of re-injury in a paper published in Arthroscopy Techniques. They identified that patients who had an ACL reconstruction and were in the eighth and ninth grade had a higher risk of re-injury and lower rates of returning to sports compared to those who were in the seventh grade and younger, and those who were in the tenth grade and older. They speculated that among the multiple risk factors, athletes in the eighth and ninth grades had a higher risk of re-injury because they return to play with athletes in the tenth grade who are skeletally mature and did not lose a year of physical and sports-specific development. The results were published in the American Journal of Sports Medicine.

The new data looks at results in patients from this higher-risk age group who received an ACL reconstruction with modified Lemaire IT band tenodesis, returned to sport for at least one season and were followed for a minimum of two years. Patients were 14.9 years old, on average, with a range of 11.1 to 19.1 years. Dr. Green and Dr. Cordasco performed the surgeries at HSS, starting in 2015.

To date, patient-reported outcomes have been highly positive, with all patients giving their injured joint a Single Assessment Numeric Evaluation (SANE) score higher than 90% on a scale from 0% to 100%, where 100% represents normal function. “We now have more than 100 patients in our database. We are continuing to track outcomes and plan to publish a larger report on results for this patient population in the future,” Dr. Cordasco says.

“We are excited about our preliminary results and plan to follow patients for at least five years until they reach skeletal maturity, around the age of 20,” Dr. Green says. “We anticipate there will be some failures, but we hope to see far fewer than if we had not supplemented the ACL reconstruction with this additional surgical method.”

Dr. Green explains that 6 to 16-year-old girls have higher rates of tears than boys because of "more flexible ligaments" and a greater "tendency to have knock knees". He believes that this trend can be stopped if athletes can be taught how to move differently. 

NY1 also visits an HSS Sports Safety event which focuses on ACL prevention.

"It's really important and we're not just talking about knees. So if a kid has better posture they're going to grow in a healthier way. If a kid has better control of their core they're going to be a better athlete. And if a kid has more stable legs they're going to be able to jump higher so be more controlled when they land," said Jimmy Russomano, manager, HSS Sports Safety, who helps train coaches and their teams at these events.

"ACL prevention programs can really be effective in decreasing the rate of ACL tears in the 30-40 percent range," said Dr. Green.

One year post-surgery, Danielle is back on the soccer field. "I feel much more secure about everything. I know how to control things now," she said.

Watch the full segment at NY1.com.

View the first part here.

HSS pediatric orthopedic surgeon Daniel W. Green, MD, MS, FAAP, FACS, said "20 years ago, maybe we saw one child a year under 12 years old with an ACL tear. It was really a rare event, an uncommon event."

He added that he currently sees teen and younger patients with ACL tears weekly.

"The younger athletes are getting more opportunities to play sports at a higher level. More opportunities in terms of hours per week, in terms of months per year, in terms of sports specific camps. Their neuromuscular skills are still in development. They cannot run, jump, even squat as effectively and safely as they can when they are 18, 19," Dr. Green explained.

According to Dr. Green's study, published in the American Journal of Sports Medicine, operating on children shortly after injury shows a high rate of success.

The segment reported that Nicole Svantner, patient of Dr. Green and HSS sports medicine surgeon Frank A. Cordasco, MD, MS, injured her leg during a soccer game a year ago and had surgery. Today, she is healed and playing golf.

Nicole's mother, Josephine, said she would like schools to teach sports safety and injury prevention tips for athletes.

Watch the full segment at ny1.com. This segment aired during the June 20, 2018 broadcast.

View the second segment here.

Over 300 HSS patients were assessed in three groups based on the amount of skeletal growth remaining:

• Group 1 patients were mainly comprised of elementary and middle school athletes up to 7th grade (3-6 years left of growth).
• Group 2 patients were predominantly 8th and 9th graders (2-3 years left of growth).
• Group 3 patients included high school and young collegiate athletes (fully grown).

This prospective study evaluated two year clinical outcomes from these adolescent patients who underwent primary ACL reconstruction. It found that the rate of revision ACL reconstruction was higher and the return to sport rate was lower in Group 2.

The successful Group 1 cohort saw a 6 percent rate of revision and a perfect 100 percent return to sport. The Group 3 numbers were similar (6 percent revision rate, 94 percent return to sport) while the Group 2 segment saw a much higher 20 percent revision rate and only a 86 percent return to sport rate.

"There could be multiple factors associated with the less successful outcomes we observed in the Group 2 athletes," said Frank Cordasco, MD, MS, sports medicine surgeon at HSS and senior study author. "This Group 2 cohort bridges the divide between middle school and high school. At this age, when you miss a season and re-join your teammates in a competitive high school athletic environment, you have not developed the same sports-specific skills that this non-injured group did during the gap year, which can lead to another injury."

The ACL reconstructions in Groups 1 and 2 used the same hamstring graft, while Groups 2 and 3 utilized the same surgical technique. One size does not fit all for ACL injuries, and different techniques and materials are used based on age and type of tear. There has not been one widely-agreed upon method for patients who aren’t yet fully grown.

"We are continually evaluating our techniques to improve our outcomes and lower this revision rate for Group 2 patients. They are too young to use the traditional patella tendon graft that we prefer with athletic young adults," said Dr. Cordasco. "We are assessing modifications in our technique which include the addition of a lateral ligament augmentation performed at the time of the ACL reconstruction, changing the graft choice from hamstring to quadriceps tendon which we believe may be a better choice for this high risk cohort of young athletes, and utilizing implant mediated guided growth when indicated."

Group 1 patients underwent an all-epiphyseal hamstring autograft ACL reconstruction, which was developed by Dr. Cordasco and Daniel Green, MD, MS, FAAP, FACS. This technique uses sockets instead of tunnels and provides improved graft incorporation and tendon-to-bone healing as a safer alternative for young patients.

"This study shows that our all-epiphyseal technique is successful in treating young athletes who are not yet skeletally mature," said Dr. Green, pediatric orthopedic surgeon at HSS and senior study author. "These patients used to be denied surgery because of their age, but we have developed an effective reconstruction technique to get them back in the game."

This study also illustrates the need for stronger communication to parents, coaches, PTs and athletic trainers about the risk of ACL injuries in this age group.

"If an 8th or 9th grader walks into a doctor’s office with a torn ACL, the high risk needs to be communicated to the family," said Dr. Green. "Conversely, if it’s a younger middle school athlete, the success rate is pretty good."

The recovery period is just as important when looking at preventing re-tears and returning to sport.

"To achieve optimal results after surgery, we counsel our patients to complete an ACL prevention injury program," added Dr. Green. "It’s very important that these athletes only return to sports after they have regained great physical shape and learned prevention techniques."

HSS established the HSS Sports Safety Program in 2015 which launched the first ACL program customizable by skill level and sport type in 2016.

This study was presented today at this year’s annual meeting for the American Academy of Orthopaedic Surgeons (AAOS).