April 2026 | Beyond the Operating Table:

The Surgeon’s Role in Injury Prevention and Education

By Diego Pérez-Salazar M., M.D., FAANA Member, AANA Communications and Technology Committee

 

In the traditional orthopaedic landscape, the surgeon’s success was measured by the precision of a tunnel placement or the tension of a suture anchor. However, given the rising incidence of ligamentous injuries and complex overuse pathologies in young athletes, our responsibility has fundamentally evolved and is redefining clinical excellence beyond the operating room. The sports surgeon must bridge toptier evidence and onfield implementation – championing education and prevention to protect longterm function and quality of life becoming a primary architect of public health and athletic longevity1

 

The Biomechanical Basis of Prevention: Leading the NMT Revolution 

 

Injury prevention is no longer a peripheral concern; it is a biological imperative. Neuromuscular training (NMT) programs, such as the FIFA 11+ or PEP program, are often viewed by coaches as purely "warm-up" routines. These programs are high-yield biomechanical interventions that retrain highrisk mechanics (dynamic valgus, stiff landings) through strength, plyometrics, balance and movement retraining with programmed neuromuscular adaptations, specifically targeting the "ligament-dominant" landing patterns prevalent in female athletes2. 

 

Such programs (e.g., FIFA 11+) reduce overall and lowerextremity injuries by about 20–50%, with adherence as the key mediator1,3. Metaanalyses show knee injury risk reduction (~22%) and ACL risk reduction (~50%), optimized with ≥15minute sessions, 2-3 times per week and compliance ≥75%4. Biomechanics improve toward lowerrisk landing profiles after FIFA 11+5. 

 

The surgeon’s unique authority provides a "credibility bridge" that physical therapists or athletic trainers may lack in high-stakes environments. There is data suggesting that when a surgeon explains the specific relationship between hip abductor activation and the reduction of ACL strain during a pivot, compliance rates among elite programs increase significantly. We can conclude that "the surgeon’s role is to provide the 'biological rationale' for these exercises. We are the advocates who turn dry statistical data into daily, habit-forming practice on the training ground. 

 

Surgeon endorsement reframes NMT as “medical prescription,” increasing adoption and consistency3, our role is to translate complex biomechanical strain into actionable training habits. In this same example, explicitly linking hip abductor recruitment to the reduction of ACL graft strain allows the athlete to internalize the "why" behind their training, transforming compliance into proactive engagement2. 

 

Workload Management: The Surgeon as a "Biological Accountant" 

 

A profound challenge in 2026 is the epidemic of overuse injuries in youth sports. Many catastrophic tissue failures and chronic overuse injuries are not "accidents" but the predictable results of workload spikes or insufficient recovery. The acute:chronic workload ratio (ACWR) helps contextualize risk; ratios around 0.8–1.3 tend to align with lower injury risk, whereas spikes >1.4–1.5 associate with higher injury odds – though methods and thresholds vary by sport and metric6,7,8. As surgeons, we possess the unique clinical authority to mediate the "toxic triangle" of athlete, parent and coach. This metric compares the workload performed in the current week to the average of the previous four weeks to identify "spikes" in loading that precede tissue failure. 

 

The surgeon is often the only stakeholder capable of enforcing "mandatory rest periods," leading education on pitch counts and the dangers of year-round specialization. It is known that this modality has a direct correlation with decreased rates of injury, for example medial epicondyle avulsions and ulnar collateral ligament (UCL) attrition in throwers. The most successful surgery in a 13-year-old pitcher is the one that never has to happen because the surgeon intervened in the workload cycle before the point of catastrophic tissue failure.  

 

Exponentially weighted models may improve sensitivity but have limitations; ACWR should sit within a broader, multifactorial monitoring approach and be applied cautiously6,9. Teamlevel work suggests keeping chronic distance adequate and avoiding ACWR surges for accelerations (>1.4) reduces event likelihood8. By monitoring ACWR, the surgeon acts as a biological guardian, identifying when an athlete’s mechanical demand exceeds their physiological capacity, thereby preventing catastrophic tissue attrition before it requires surgical intervention. Our role then as surgeons is to emphasize that performance is built on a foundation of recovery, and that "more" is rarely "better" if it outpaces tissue adaptation.  

 

The ReturntoPlay (RTP) Continuum: A Multifactorial Mandate  

 

Clearance must go beyond time or a “stable exam.” Target a Limb Symmetry Index (LSI) ≥90% in strength and hop tests plus high subjective function; integrating psychological readiness (e.g., ACLRSI) improves prediction of return and safety10,11. Psychological recovery and physical recovery are related but distinct; at ~9 months, ACLRSI correlates weakly with strength/power, underscoring the need to measure and treat both domains. Early quadriceps recovery relates to better ACLRSI at nine months12. After revision ACLR, lower ACLRSI and delayed clearance highlight fear and confidence as major barriers13,14. Delaying return to highdemand sport to around nine months while meeting objective and psychological criteria lowers reinjury risk10. 

 

Knowledge Translation and Public Policy 

 

The final frontier of the sports surgeon is Knowledge Translation. The surgeon is the most trusted voice in the sports community. This clinical weight should be used to advocate for policy changes, such as mandatory NMT in high school curriculums. Furthermore, surgeon-led webinars for community coaches, aiming to reduce the incidence of noncontact injuries in youth soccer. 

 

Our responsibility extends beyond individual patients to the athletic community at large; by leading knowledge translation efforts, surgeons can implement systemic changes that protect entire populations of athletes. 

 

[PRACTICAL TOOLKIT: CLINICAL ACTIONABLES] 

 

To seamlessly integrate this educational model into your high-volume practice, utilize these three targeted strategies: 

 

1. The "Prevention Prescription" (NMT) 

  • Formalize prevention by providing a one-page visual handout of validated neuromuscular control exercises (e.g., PEP or FIFA 11+). 
  • Mechanism: Focus on "soft" landings, knee-over-toe alignment, and core stability. 
  • Outcome: Active surgeon advocacy for NMT is a proven factor in reducing non-contact injury rates across athletic populations. 

2. The "10% Rule" for Families and Coaches 

  • Provide written guidance advising against increasing total weekly training volume or intensity by more than 10%. 
  • Mandatory Recovery: Advocate for at least 1-2 days of total rest per week to prevent "creeping" microtrauma and facilitate biological remodeling. 

3. Standardized RTP Milestone Checklist 

  • Symmetry: Aim for >90% Limb Symmetry Index (LSI) in dedicated strength and functional hop testing. 
  • Quality: Confirm lumbopelvic and knee stability during fatigue-simulated functional tasks. 
  • Psychology: Utilize the ACL-RSI or similar tools to ensure the athlete is mentally prepared for the rigors of competition. 
  • Biology: Honor the "ligamentization" phase by targeting nine months as the minimum threshold for high-demand sports return. 

Biological maturation and psychological confidence are as critical as mechanical stability; surgeons must ensure that the timeline of the sports calendar does not override the non-negotiable timeline of biological healing. We must educate our patients that returning to contact sports before achieving both biological maturation and psychological "readiness" significantly elevates the risk of secondary ruptures and contralateral injuries 

 

Conclusion: From Treating Injuries to Caring for Individuals. The Future of the AANA’s Mission 

 

Historically, medical education has been anchored in a reactive, disease-centric model – trained primarily to "cure" a structural failure once it has occurred. However, the essence of the physician must always transcend the technical procedure. As sports surgeons, our care must be integrative and person-centered, considering not only the injury but the individual's entire physical, psychological and functional environment. 

 

We must recognize that athletes are patients first, and their health is a continuum where prevention is as critical as the reconstruction itself. Modern orthopaedic evidence supports the transition from a purely biomechanical model to a biopsicosocial approach, where maximum well being is the ultimate clinical outcome. This requires us to adapt to new athletic realities and digital environments without losing our focus: embracing person centered excellence. The modern sports surgeon harmonizes technical mastery with prevention, load stewardship and psychologically informed RTP. This Surgeon Educator model measurably lowers injury rates and safeguards athletes’ long term health and performance1,4,7. 

 

REFERENCES 

  1. Tariq, M.B., Jones, M.H., Strnad, G., Sosic, E.; Cleveland Clinic OME Sports Health; Spindler, KP. A Last-Ditch Effort and Personalized Surgeon Letter Improves PROMs Follow-Up Rate in Sports Medicine Patients: A Crossover Randomized Controlled Trial. The Journal of Knee Surgery. 2021 Jan;34(2):130-136. doi: 10.1055/s-0039-1694057. Epub 2019 Aug 7. PMID: 31390674. 
  2. Brophy, R.H., Lowry, K.J. American Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary: Management of Anterior Cruciate Ligament Injuries. The Journal of the American Academy of Orthopaedic Surgeons. 2023;31(11):531–537.  
  3. Huang, Y.L., Jung, J., Mulligan, C.M.S., Oh, J., Norcross, M.F. A Majority of Anterior Cruciate Ligament Injuries Can Be Prevented by Injury Prevention Programs: A Systematic Review of Randomized Controlled Trials and Cluster-Randomized Controlled Trials With Meta-analysis. American Journal of Sports Medicine. 2020 May;48(6):1505-1515. doi: 10.1177/0363546519870175. Epub 2019 Aug 30. PMID: 31469584. 
  4. Thorborg, K., Krommes, K.K., Esteve, E., Clausen, M.B., Bartels, E.M., Rathleff, M.S. Effect of Specific Exercise-Based Football Injury Prevention Programmes on the Overall Injury Rate in Football: A Systematic Review and Meta-Analysis of the FIFA 11 and 11+ Programmes. British Journal of Sports Medicine. 2017 Apr;51(7):562-571. doi: 10.1136/bjsports-2016-097066. Epub 2017 Jan 13. PMID: 28087568. 
  5. Sadigursky, D., Braid, J.A., De Lira, D.N.L., Machado, B.A.B., Carneiro, R.J.F., Colavolpe, P.O. The FIFA 11+ Injury Prevention Program for Soccer Players: A Systematic Review. BMC Sports Science, Medicine & Rehabilitation. 2017 Nov 28;9:18. doi: 10.1186/s13102-017-0083-z. PMID: 29209504; PMCID: PMC5704377. 
  6. Sadoghi, P., von Keudell, A., Vavken, P. Effectiveness of Anterior Cruciate Ligament Injury Prevention Training Programs. Journal of Bone and Joint Surgery, American. 2012 May 2;94(9):769-76. doi: 10.2106/JBJS.K.00467. PMID: 22456856. 
  7. Taylor, J.B., Waxman, J.P., Richter, S.J., Shultz, S.J. Evaluation of the Effectiveness of Anterior Cruciate Ligament Injury Prevention Programme Training Components: A Systematic Review and Meta-Analysis. British Journal of Sports Medicine. 2015 Jan;49(2):79-87. doi: 10.1136/bjsports-2013-092358. Epub 2013 Aug 6. PMID: 23922282. 
  8. Mehl, J., Diermeier, T., Herbst, E., Imhoff, A.B., Stoffels, T., Zantop, T., Petersen, W., Achtnich, A. Evidence-Based Concepts for Prevention of Knee and ACL Injuries. 2017 Guidelines of the Ligament Committee of the German Knee Society (DKG).  
    Archives of Orthopaedic and Trauma Surgery. 2018 Jan;138(1):51-61. doi: 10.1007/s00402-017-2809-5. Epub 2017 Oct 5. PMID: 28983841. 
  9. Renström, P.A. Eight Clinical Conundrums Relating to Anterior Cruciate Ligament (ACL) Injury in Sport: Recent Evidence and a Personal Reflection. British Journal of Sports Medicine. 2013 Apr;47(6):367-72. doi: 10.1136/bjsports-2012-091623. Epub 2012 Aug 31. PMID: 22942168. 
  10. Obërtinca, R., Hoxha, I., Meha, R., Lama, A., Bimbashi, A., Kuqi, D., Shabani, B., Meyer, T., der Fünten, K.A. Efficacy of Multi-Component Exercise-Based Injury Prevention Programs on Injury Risk Among Footballers of All Age Groups: A Systematic Review and Meta-analysis. Sports Medicine. 2023 Apr;53(4):837-848. doi: 10.1007/s40279-022-01797-7. Epub 2023 Feb 8. PMID: 36752977; PMCID: PMC10036279. 
  11. Yang, J., Wang, Y., Chen, J., Yang, J., Li, N., Wang, C., Liao, Y. Effects of the "FIFA11+ Kids" Program on Injury Prevention in Children: A Systematic Review and Meta-Analysis. International Journal of Environmental Research and Public Health. 2022 Sep 23;19(19):12044. doi: 10.3390/ijerph191912044. PMID: 36231344; PMCID: PMC9566496. 
  12. Majid, N., Lee, S., Plummer, V. The Effectiveness of Orthopedic Patient Education in Improving Patient Outcomes: A Systematic Review Protocol. JBI Database of Systematic Reviews and Implementation Reports. 2015 Jan;13(1):122-33. doi: 10.11124/jbisrir-2015-1950. PMID: 26447013. 
  13. Furdock, R., Alejo, A., Hoffa, M., Vergon, A., Romeo, N.M., Vallier, H.A. Improving Patient Recall Following Operative Orthopaedic Trauma. Journal of Bone and Joint Surgery, American. 2024 Nov 20;106(22):2136-2143. doi: 10.2106/JBJS.23.01366. Epub 2024 Aug 27. PMID: 39190689. 

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  2. Game Utilization and Performance Following RTP From ACL Reconstruction Does Not Influence a Subsequent Second ACL Injury in National Football League Players https://arthroscopyjournals.onlinelibrary.wiley.com/doi/10.1016/j.asmr.2021.07.002 Lafi S. Khalil, M.D., Kevin G. Lindsay-Rivera, M.D., Muhammad J. Abbas, B.S., Sabin Shah, M.D., Marissa Tandron, M.D., Albert Ferris, B.S., Kelechi R. Okoroha, M.D. 
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  4. Prevention and Rehabilitation of the Athletic Hamstring Injury Adriana Geraci, P.T., D.P.T., Delaney Mahon, P.T., D.P.T., Eric Hu, B.S., Jesus E. Cervantes, B.S., Shane J. Nho, M.D., M.S. 
  5. Rehabilitation Using a Systematic and Holistic Approach for the Injured Athlete Returning to Sport Ethan Paster, P.T., D.P.T., S.C.S., C.S.C.S., Alfredo Sayeg, P.T., D.P.T., Scott Armistead, M.S., L.A.T., A.T.C., Michael D. Feldman, M.D. 
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