Can We Prevent ACL Injuries? Texas Girls Coaches Association 2011 Summer Clinic

1. Can We Prevent ACL Injuries?Texas Girls Coaches Association 2011 Summer Clinic Randy Brewer MS, PES, CES rbrewer413@hotmail.com 817-368-3578

2. One Mother’s Perspective

3. Our Situation? • Female athletes are injuring knees at an alarming rate. • We have been aware of the ACL issue for close to 20 years but have yet to make a big dent in the injury rate. • Lack of “coach friendly” assessment tools in the field that could be used to potentially identify “at risk” athletes. • Haven’t implemented a wide scale program for training female athletes to reduce ACL injury rate.

4. Female Athletes • As they mature: • Up to 8 more times likely to tear their ACL’s • Changes during pubertal process negatively effect neuromuscular control (Hewett et al, JBJS 2004) • Land differently from a jump than boys (Hewlett, et al, JBJS 2004) • Increase quadriceps strength greater than hamstring strength (Ahmad et al, AJSM 2005) • Exhibit less muscular protection of knee ligaments during external loading (Wojtys et al, JBJS 2003) • Aggressive quadriceps loading with the knee in slight flexion can produce significant anterior tibial translation ie. ACL injury! (De Morat et al, AJSM 2004)

5. Background • Musculoskeletal growth during puberty, in the absence of corresponding neuromuscular adaptation, may facilitate the development of certain intrinsic ACL injury risk factors. • Lack of core proprioception and decrease lumbo-pelvic strength has been implicated as a major risk factor for the female athlete. • Core stabilization appears to be just as much about neuromuscular control as it is about strength. • Up to 80% of ACL injuries are “non-contact” in nature and many may be preventable.

6. Why the Concern? • How does the ACL get stressed • Lack of proprioception and kinesthesia lead to increased stress on the ACL during functional loading activities

7. Non Contact Mechanism • Mechanism of injury • NonContact (80%) vs Contact (20%) • Non contact forceful valgus collapse in near full extension with rotation of the tibia (internal or external) • Deceleration plant and twist with foot fixed • Higher risk with turf • High risk sports: • Soccer • Basketball • Football

8. Etiological Theories • Anatomical • Q-angle • Narrow Intercondylar notch • Thigh length • Hormonal • Collagen strength • Joint laxity • Neuromuscular • Ligament Dominance • Quadriceps Dominance • Leg Dominance • Trunk Dominance “Core” Dysfunction

9. Neuromuscular Issues • Ligament Dominance • Imbalance between neuromuscular and ligamentous control of dynamic knee stability (lack of shock absorption) • Quadriceps Dominance • Imbalance between quad and hamstring strength, recruitment and coordination • Leg Dominance • Imbalance between the two legs with respect to strength, coordination and control (many times from previous injury) • Trunk Dominance “Core” Dysfunction • Imbalance between the inertial demands of the trunk and control and coordination to resist it. • Knee is “dumb joint” stuck in the middle of the hip and ankle (“It’s not my fault!)

10. What does the research say? • Decrease in Neuromuscular Control with Pubertal Growth Spurt (Hewett et al, JBJS 2004) • Core Stability Measures as Risk Factors for Lower Extremity Injury in Athletes (Leetun et al, MSSE 2004) • Deficits in Neuromuscular Control of the Trunk Predict Knee Injury Risk (Zazulak et al, AJSM 2007) • The Drop-Jump Video Screening Test: Retention of Improvement in Neuromuscular Control in Female Volleyball Players (Barber-Westin et al, JSCR 2010) • A Training Program to Improve Neuromuscular Indices in Female High School Volleyball Players (Noyes et al, JSCR 2011)

11. What does the research say about screening? • Biomechanical Measures Predict ACL Risk in Female Athletes (Hewett et al, AJSM 2005) • Two Dimensional Analysis Screening and Evaluation Tool (McLean et al, BJSM 2005) • Correlation Between two-dimensional Video Analysis and Subjective Assessment in Evaluating Knee Control Among Elite Female Team Handball Players (Stensrud et al, BJSM 2010) • Real-Time Assessment and Neuromuscular Training Feedback Techniques to Prevent Anterior Cruciate Ligament Injury in Female Athletes (Myer et al, Strength and Conditioning Journal 2011)

12. Three Pronged Approach to Preventing ACL Injuries • Injury Risk Screening • Intervention • Dynamic Neuromuscular Training

13. Recommendations • Implement Wide Spread Injury Prevention Programs for Female Athletes • Focus on ages 12 and up • Injury Risk Increases at onset of Puberty • Individual Orthopedic and Functional Injury Risk Assessments • Identify “at risk” athletes • Injury History Review • Implement injury prevention warm-up • Implement “functional” strength program (in-season and off-season) designed to • Correct biomechanical dysfunction • Strengthen and improve core function • Improve overall performance and athleticism • Improve neuromuscular control

14. Recommendations • Injury History Review (previous injury is a big predictor of future injury) – Smoke Alarm!! • Low Back Pain • Ankle Sprains • Knee Pain • Unilateral hip pain/discomfort or muscle pulls • Perform Orthopedic and Functional Injury Risk Assessments • Performance Enhancement Specialists • Athletic Trainers • Physical Therapists • “Every Nerve and Fiber” • When your determination changes, everything will begin to move in the direction you desire. The moment you resolve to be victorious, every nerve and fiber in your being will immediately orient itself toward your success. • Daisaku Ikeda

15. Functional Screen • Bi-Lateral Squat technique • Single leg squat technique • Balance reach tests • Lower quarter • Upper quarter • Vertical Drop Jump • Repeat Tuck Jumps

16. Bi-Lateral Squat

17. Single Leg Squat

18. Vertical Drop Jump

19. Tuck Jump Screen

20. Orthopedic Screen - Intervention • Previous Injuries • Screen for biomechanical deficiencies • SI dysfunction • Ankle mobility • Hip mobility • Knee Pain • Back Pain • Muscular Injuries

21. Training Program • Corrective Soft Tissue Work • Core Activation • Core Strength • Dynamic Warm-Up • Injury Prevention – Neuromuscular Control • Performance Training – Vertical Jump, Agility, Speed, Explosion • Strength – Multi-Planar Strength • Flexibility

22. Core Activation - Strength

23. Core Activation - Strength

24. Core Activation - Strength

25. Warm-Up

26. Neuromuscular Control

27. Neuromuscular Control

28. Workout

29. The FutureThe ACL Prevention Program Must Correct Poor Functional Movement • Neuromuscular Control • Dynamic Joint Stabilization • Rate of Force Production • Eccentric Strength • Dynamic Flexibility • Postural Control • Previous Injuries

30. The FutureThe ACL Prevention Program “Must-Haves” • Prevention efforts should be included in overall performance enhancement training program • Prevention efforts should be “user/coach friendly” and easily implemented in the field • All athletes should complete functional injury risk assessments • “At Risk” athletes may need medical intervention followed by corrective exercise program

31. The FutureBiggest Areas “in the field” That Can Impact ACL Injury Rates • Education and Awareness efforts for parents, athletes, and coaches • Appreciate the significance of previous ankle sprains, knee and back pain, and muscle injuries • Can’t “power-through” dysfunction • Piling training on a dysfunctional athlete creates bigger injury risk • Creating dysfunction with poor training

32. The FutureImplementation • Train the Trainer • DVD training program • Monthly TGCA Newsletter • E-Learning Options