ACL Injury Significance

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ACL Injury Significance

• Season ending injury 6-9 mo recovery time
• Disability and increased osteoarthritis risk
• Costly

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Background

• 75 000 to 250 000 ACL injuries/yr in USA
• 1.7 billion annual cost
• 1/100 highschool girls 1/10 college girls
• 80 - 90 return to previous level of play
• Typical recovery 6-9 mo
• gt 70 ACL injuries are NON-contact

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ACL Anatomy
PCL
ACL
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ACL Function

• Keep tibia from sliding forward on the femur

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Becky Hammond ACL Injury

• http//www.youtube.com/watch?vEEO77EY3Jbg

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Injury Mechanism Pivot

• Deceleration change of direction, foot planted
• Causes twisting injury of knee
• Traction at shoe/playing surface interface
• Often close to another player

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Mechanism landing

• Knee slightly flexed on landing
• Quad pulls tibia forward

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Injury Mechanism Pivot

• Deceleration change of direction, foot planted
• Causes twisting injury of knee
• Traction at shoe/playing surface interface
• Often close to another player

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Mechanism landing

• Knee slightly flexed on landing
• Quad pulls tibia forward

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Risk Factors

• Poor landing pivot style
• Stronger quads than hamstrings
• Shoe / playing surface interface

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Risk Factors

• 1. Landing / Pivoting with knee straight or
  slightly bent
• Places ACL in vulnerable position
• Additional torsion/twisting can ? injury

Boden 2000 Physsportsmed
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Risk Factors

• Hamstring/Quadriceps imbalance
• Poor hamstring strength
• Hamstrings protect ACL
• Quads stretch/stress ACL
• Slow activation of hamstring muscles with pivot /
  landing

Hewett AJSM 1999, Crosier AJSM 2002, Huston 1996
AJSM, Orchard AJSM 1997, Baratta AJSM 1988
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Risk Factors

• Female Gender
• 2-8x more common in girls
• Poor hamquad strength
• Activate hams more slowly
• Land with knees slightly bent
• Boys land with knees more bent

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Female Gender

• Hormonal Influences
• ACL has estrogen receptors
• Estrogen can ? ligament looseness
• Estrogen levels ? in girls compared to boys
• Estrogen ?d at specific times in menstrual cycle
• Studies VERY inconsistent
• Every phase of cycle has been implicated in at
  least 1 study

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Female Gender

• Knee anatomy
• Smaller intercondylar notch
• ACL may get stretched across bone and torn
• Athletes with bilateral ACL injuries have smaller
  ICN

Harner 1994 AJSM, Anderson 1999 AOSSM
www.hughston.com
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Female Gender

• Lower extremity alignment
• Women more valgus
• May allow quad to exert more stress on ACL
• Data not great

Female Pelvis
Male Pelvis
http//www.preventaclinjury.com/
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Prevention Strategies

• Shoe wear / field surface
• Bracing
• Exercise Programs
• Change muscle strength activation
• Change landing / Pivoting patterns
• Sportmetrics
• PEP

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• PEP (Prevent Injury Enhance Performance)
• Mandelbaum, Holly Silvers
• Santa Monica Orthopedic and Sports Medicine
  Research Foundation
• http//www.aclprevent.com/index.htm
• Sportmetrics
• Timothy Hewett, Gregory Myer
• Cincinnati Sportsmedicine Research and Education
  Foundation

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Results of the PEP Study

• Data collection for two years on the incidence of
  knee injuries in female soccer players in the USA
  Coast Soccer League.
• 52 teams and 1041 female soccer players between
  the ages of 14 and 18 years were enrolled into
  the PEP program
• The players from the remaining 112 teams and 1091
  players acted as a control group to compare the
  PEP program group against.

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Results of the PEP Study

• We thought that a neuromuscular training
  program, such as PEP, would have a beneficial
  effect on ACL injuries but we didnt realize that
  our results would yield quite such dramatic
  improvements.
• Year 1 2 ACL tears in the PEP program (1041
  athletes) compared to 32 ACL tears in the control
  group (1091 athletes) 88 reduction in ACL
  tears for the season in the PEP athletes.
• Year 2 4 ACL tears in the PEP group (844
  athletes) compared to 35 ACL tears (1913) in the
  control group. 74 reduction in ACL tears.

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Results of the PEP Study Collegiate population

• Collegiate population (ages 18 to 22) in
  sixty-one NCAA Division I Womens soccer programs
  in the 2002 season.
• 72 overall decrease in non-contact ACL injuries
  compared to the control group.
• 100 decrease in contact and non-contact ACL
  injury during games and practice sessions in the
  last six weeks of the season.
• Athletes that had previously sustained an ACL
  injury and had since successfully returned to
  play experienced an 80 decrease in the
  recurrence of contact ACL injury and a 100
  decrease in the recurrence of non-contact ACL
  injury.

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Performance Enhancement

• ? vertical jump
• 10 ? jump height
• ? strength
• 44 ? hamstring strength
• ? sprint speed
• Improved power endurance
• Improved running economy

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Decreased Injury

• ?d non-contact injuries in trained groups

0.47
UT Untrained T Trained MC Male Control
0.35
0.09
0.05
0
Sportsmetrics Hewett 1999 AJSM
PEP Mandelbaum 2005 AJSM
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Athletic Starting Position

• Knees comfortably flexed
• Shoulders back, eyes up, feet approximately
  shoulder-width apart and body mass balanced over
  the balls of the feet.
• The knees should be over the balls of the feet
• The chest over the knees.

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Correct Jump/land techniques

• Land on balls of feet
• Soft landing
• Toe-to-heel rocking of the foot
• ? ground reactive forces
• Knees flexed
• Knees forward
• Discourage inward buckling of knees (knock-kneed
  landing)
• Chest over knees

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The PEPP ProgramPrevent injury and Enhance
Performance Penticton

• This prevention program consists mainly of a
  warm-up, stretching, strengthening, plyometrics,
  and sport specific agilities to address potential
  deficits in the strength and coordination of the
  stabilizing muscles around the knee joint. It is
  important to use proper technique during all of
  the exercises. The coaches and trainers need to
  emphasize
• correct posture
• straight up and down jumps
• limited side-to-side movement
• reinforce soft landings.
•  

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The PEPP ProgramPrevent injury and Enhance
Performance Penticton

• This program should be completed 2-3 times a week
  and ideally should run for 6 weeks leading up to
  the start of competitive games. It should take
  approximately 20 minutes to complete and will
  serve as a routine warm-up and strengthening
  drill that can precede any training throughout
  the regular season.
•  
• The field or gym area should be set up 10 minutes
  prior to the warm-up to allow for a smooth
  transition between the activities.

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WARM-UP Warming up and cooling down are a
crucial part of a training program. The purpose
of the warm-up section is to allow the athlete to
prepare for activity. By warming up your muscles
properly, you greatly reduce the risk of
injury.   A. Jog line to line (between markers)
30 seconds This allows the athletes to
slowly prepare themselves for the training
session while minimizing the risk for injury.
Educate athletes on good running technique keep
the hip/knee/ankle in straight alignment without
the knee caving in or the feet whipping out to
the side. Instruction Complete a slow jog from
line to line.   B. Shuttle Run (between
markers) 30 seconds This exercise engages the
inner and outer hip and thigh muscles to promote
increased speed. Discourage inward caving of the
knee joint. Instruction Start in an athletic
stance with a slight bend at the knee. Leading
with the right foot, sidestep pushing off with
the left foot (back leg). When you drive off with
the back leg, be sure the hip/knee/ankle are in a
straight line. Switch sides at half field.   C.
Backward Running (between markers) 30
seconds Make sure the athlete maintains a forward
leaning athletic stance even though they are
traveling backwards. As the athlete brings their
foot back, make sure they maintain a slight bend
at the knee and land on their toes. Be sure to
watch for and discourage locking of the knee
joint. Instruction Run backwards from sideline
to sideline. Land on your toes without snapping
the knee back. Stay on your toes and keep the
knees slightly bent at all times.
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• 1. Walking Quadriceps Stretch- Same leg (30
  secs)
• Start Position
• Standing
• Procedure
• Grab right ankle with the right hand and pull
  heel to glute as the left hip and ankle extend
• Step forward with right foot and repeat stretch
  on other side
• Coaching Keys
• Keep knee pointed to ground
• Keep gluts contracted during stretch
• Do not hyperextend low back

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• 2. Straight Leg March (30 secs)
• Start Position
• Standing
• Procedure
• Lift straight leg in front of body as opposite
  arm swings forward
• Pull heel back down to ground underneath hip as
  you step forward, repeating with other leg
• Continue for prescribed number of repetitions or
  distance
• Coaching Keys
• Keep chest up
• Keep toes pulled to shins
• Pull foot down to ground with hip going to full
  extension
• Keep bottom leg straight

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• 3. Leg Cradle (30 secs)
• Start Position
• Standing
• Procedure
• Lift right knee to chest and place the right hand
  under the knee, and left hand under ankle
• Pull right leg to chest into a gentle stretch
  while contracting left glute
• Step forward with right foot
• Alternate feet and repeat for prescribed number
  of repetitions
• Coaching Keys
• Keep chest up
• Contract glute of the leg you are standing on

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• 4. Lateral Slide Squat (30 secs)
• Start Position
• Standing in a very wide squat stance
• Procedure
• Shift your weight to the right, bending your
  right knee and keeping your left knee straight,
  and hold stretch for two seconds
• Keeping your hips in squat position, slide hips
  to the left side and repeat stretch with right
  leg straight
• Continue for prescribed number of repetitions
• Coaching Keys Keep knee on squatting side behind
  toes
• Keep weight on midfoot to heel
• Keep chest up and back flat
• Keep hips low throughout movement

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• 5. Standing Trunk Rotation (30 secs)
• Start Position
• Standing, feet shoulder-width apart, knees
  slightly bent, arms raised laterally at shoulder
  level
• Procedure
• Rotate torso about 90 degrees to the right and
  return rotating to the left
• Coaching Keys
• Keep chest up
• Keep hips pointed forward

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• 6. Leg swings Flexion- Extension (30 secs)
• Position
• Standing opposite player at arms length, right
  hand of each player on the right shoulder of the
  opposite
• Procedure
• Swing extended leg forwards and backwards
• Coaches Tips
• Do not hyperextend or hyperflex the lower back

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• 7. Leg swings Abduction Adduction (30 secs)
• Position
• Standing opposite player at arms length, right
  hand of each player on the right shoulder of the
  opposite
• Procedure
• Swing extended leg across the front of the body
  and behind
• Coaches Tips
• Do not rotate the lower back

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STRENGTHENING This portion of the program
focuses on increasing leg strength. This will
lead to increased leg strength and a more stable
knee joint. Technique is everything Close
attention must be paid to the performance of
these exercises in order to avoid injury.
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Walking Lunges 3 sets 5 bronze, 8 silver, 10
gold60 seconds

• Instruction
• Lunge forward leading with your right leg.
• Push off with your right leg and lunge forward
  with your left leg.
• Drop the back knee straight down.
• Make sure that your keep your front knee over
  your ankle.
• Control the motion and try to avoid you front
  knee from caving inward.
• If you can't see your toes on your leading leg,
  you are doing the exercise incorrectly.

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Russian Hamstrings 3 sets 5 bronze, 8 silver,
10 gold 60 seconds

• Instruction
• Kneel on the ground facing another kneeling team
  member at a distance whereby the hand of 1 player
  reaches the elbow of the opposite. Both kneeling
  players should be supported by someone at their
  ankles.
• With a straight back, lean forward leading with
  your hips until your hands have contacted your
  opposite team members palms. Push yourself back
  to the upright starting position with your hands,
  helping with your hamstring muscles. Repeat the
  exercise 10 times before switching to the
  opposite player.
• Your knee, hip and shoulder should be in a
  straight line as you lean toward the ground. Do
  not bend at the waist. You should feel the
  hamstrings in the back of your thigh working.

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Single Toe Raises2 sets 10 bronze, 15 silver,
20 gold 60 seconds

• Instruction
• Standing feet together with your arms at your
  side
• Slowly rise up on your toes. Staying on your
  toes, lift your left foot off the ground so that
  you are balanced on your right foot.
• Slowly lower yourself down onto your right heel.
  Slowly repeat X times and switch to the other
  side.
• Coaching tips
• You may hold your arms out ahead of you to help
• As you get stronger, you may need to add
  additional repetitions or rise up and down on 1
  foot to continue the strengthening effect of the
  exercise.

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Bridging with walkins and walkouts 1 set 10
bronze, 15 silver, 20 gold 60 seconds

• Instruction
• Lie on the ground with your knees bent at right
  angles and feet on the ground.
• Raise your butt up off the ground and squeeze.
• Slowly straighten the right knee so that your
  right leg is now straight. Make sure that your
  right hip does not dip down.
• Lower your right foot and now lift your left foot
  making sure your left hip does not dip down.
  Repeat X times on each side.
• As you get stronger, you can A) place your feet
  on top of a ball and repeat the exercise or B)
  walk your feet out from your hips and back again
  taking small steps on your heels

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PLYOMETRICS

• These exercises are explosive and help to build,
  power, strength and speed. The most important
  element when considering performance technique is
  the landing. It must be a soft landing!
• When landing from a jump
• softly accept your weight on the balls of your
  feet slowly rolling back to the heel
• land with a bent knee and a straight hip
• ensure your knees stay over your ankles and cave
  in
• Although these exercises are basic, it is
  critical to perform them correctly.
• Please take the time to ensure safe and correct
  completion of these exercises.

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Vertical Jumps with Headers 1 set 10 bronze,
15 silver, 20 gold 30 seconds

• Instruction
• Stand in an athletic stance
• Push off jumping straight up.
• Remember the proper landing technique accept the
  weight on the balls of your feet with a slight
  bend at the knee. Repeat 20 times and switch
  sides.

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b) Lateral Hops over Cone 1 set 10 bronze, 15
silver, 20 gold 30 seconds

• Instruction
• Stand with a 6" cone to your left.
• Hop to the left over the cone softly landing on
  the balls of your feet land bending at the knee.
• Repeat this exercise hopping to the right.

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c) Forward/Backward Hops over cone 1 set 10
bronze, 15 silver, 20 gold 30 seconds

• Instruction
• Hop over the cone/ball softly landing on the
  balls of your feet and bending at the knee.
• Hop backwards over the ball using the same
  landing technique.
• Be careful not to snap your knee back to
  straighten it.
• Maintain a slight bend to the knee.

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d) Single Leg hops over cone 1 set 10
bronze, 15 silver, 20 gold 30 seconds

• Instruction
• Hop over the cone/ball landing on the ball of
  your foot bending at the knee.
• Hop backwards over the ball using the same
  landing technique.
• Be careful not to snap your knee back to
  straighten it.
• Maintain a slight bend to the knee. Repeat for X
  reps. Stand on the left leg and repeat the
  exercise.
• Increase the number of repetitions as needed.

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e) Scissors Jump 1 set 10 bronze, 15 silver, 20
gold 30 seconds

• Instruction
• Lunge forward leading with your right leg.
• Keep your knee over your ankle.
• Push off with your right foot and propel your
  left leg forward into a lunge position.
• Be sure your knee does not cave in or out. It
  should be stable and directly over the ankle.
• Remember the proper landing technique accept the
  weight on the ball of your foot with a slight
  bend to the knee.

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AGILITIES. 1

• Shuttle run with forward/backward running
• 60 seconds
• Instruction
• Starting at the first cone, sprint forward to the
  second cone, run backward to the third cone,
  forward to the fourth cone (etc).
• Return to first cone and repeat laps

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AGILITIES. 2

• Diagonal runs
• 60 seconds
• Instruction
• Face forward and run to the first cone.
• Pivot off the outside (left) foot and run to the
  second cone.
• Now pivot off the outside (right) foot and
  continue onto the third cone.
• Make sure that the outside leg does not cave in.
  Keep a slight bend to the knee and make sure the
  knee stays over the ankle joint.

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AGILITIES. 3

• Bounding run
• 60 seconds
• Instruction
• The athlete begins this jump by bounding in
  place.
• Once proper rhythm and form is attained, the
  vertical component of the bound is maintained
  while adding some horizontal distance to each
  jump.
• When coaching this jump, encourage the athlete to
  maintain maximum bounding height