ArticleKnee surgery, sports traumatology, arthroscopy : official journal of the ESSKA2026
Knee injury mechanism varies by injury category: Video analysis of multi-ligament knee injuries in the National Football League.
Article in Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
purposeThis study aims to characterize the mechanism of multi-ligament knee injury (MLKI) sustained during a National Football League (NFL) game through video analysis.
methodsA retrospective video analysis of official NFL game footage spanning 1997-2022 was performed. Players with MLKIs were identified from publicly available injury surveillance data. Player and game demographic information was collected. Athletes were categorized based on ligament injury patterns. Videos including MLKI were analyzed to categorize injuries based on non-contact, indirect or direct contact mechanisms and determine the hip, knee and ankle position at the time of injury. Differences across MLKI groups were identified by Fisher's exact test.
resultsThirty-five MLKIs were identified. MLKIs most commonly occurred from direct contact to the limb (80%), with the second most common injury mechanism being indirect contact (14.3%). The most common MLKI was injury to the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) (65%), while the second most common was the ACL and lateral collateral ligament (LCL) (15%). Direct contact MLKI most often resulted in a valgus and external rotational force about a flexed knee (58%). There were statistically significant differences when comparing the direction of contact, hip and knee position between injury MLKI groups. Combined ACL and MCL injury commonly occurs with knee flexion, valgus and external rotation. Combined ACL/posterior cruciate ligament (PCL) or ACL/LCL injuries occurred most commonly with varus and internal rotational forces on an extended knee. Multiligament injuries involving three ligaments occurred only from direct contact mechanisms.
conclusionVarious injury mechanisms and characteristics result in different types of MLKI in NFL athletes, though the vast majority of MLKIs occur from direct contact forces to the knee. Combined ACL and MCL injury occurred most frequently, resembling the mechanism and lower extremity position for isolated ACL injury, though it frequently occurs due to direct contact with the knee. LEVEL OF EVIDENCE: Level IV.
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