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ACL Injury Prevention Programs

ACL Injury Prevention Programs. Michael D. Lee, MD. ACL Tears. 250,000 to 300,000 per year $20,000 to $50,000 per reconstruction $800 to $3000 out of pocket PT: $1000+. ACL Reconstruction. Failure Rate. 6% ipsilateral knee (2-10%) 12% contralateral knee (8-16%)

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ACL Injury Prevention Programs

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  1. ACL Injury Prevention Programs Michael D. Lee, MD

  2. ACL Tears • 250,000 to 300,000 per year • $20,000 to $50,000 per reconstruction • $800 to $3000 out of pocket • PT: $1000+

  3. ACL Reconstruction Failure Rate • 6% ipsilateral knee (2-10%) • 12% contralateral knee (8-16%) • about 1 in 5 will have another ACL tear Wright et al., JBJS, 2011

  4. ACL Revision Failure Rate • 14% Wright et al., JBJS, 2012

  5. ACL Tears • ACL reconstructed knee is not “normal” • lifelong increased risk of OA • best treatment: prevention

  6. Female Risk • 4 - 6 times male risk • Title IX 1972 Act • Female participation 5 times at college level • Female participation 10 times high school level

  7. ACL Injuries • 70% are non-contact injuries • Non-contact injuries are theoretically preventable

  8. Risk Factors • non-modifiable • modifiable basis for prevention

  9. Non-modifiable Risk Factors • anatomic • genetic: COL5 risk in some females • developmental • hormonal • Ge • G

  10. Notch Stenosis • Theory: small notch impinges on ACL • Several studies support this theory

  11. Notch Width Index

  12. Notch Size • Smaller notch = smaller ACL? • + correlation of ACL size and notch width index • Smaller ACL found in ACL injured patients compared to controls

  13. Ligamentous Laxity • Generalized LL a significant risk for ACLI • Studies show knee hyperextension in ♀ soccer and bball players a risk for ACLI

  14. Tibial Slope

  15. Tibial Slope • Increased slope increases ACLI risk • Increased slope increases ACL strain

  16. Hormonal Function • ACL fibroblasts have estrogen receptors • Estrogen affects tensile properties of ligaments • Increased ACLI risk in pre-ovulatory menstrual phase (first 1/2 of cycle)

  17. Hormone Function • Retrospective studies show decreased risk of ACLIs with BCPs • Theory: stabilize hormonal functional through cycle

  18. Neuromuscular Maturation • No ACLI difference in pre-adolescent ♀vs ♂ • 4 -6 x risk for females after maturation • only males have a n-m spurt with increase in power, strength and coordination • post-maturation jump mechanics differ

  19. Modifiable Risk Factors Neuromuscular Imbalance • ligament dominance • quadriceps dominance • leg dominance • trunk dominance

  20. Ligament Dominance • responsible for valgus collapse • supporting ms groups don’t adequately contract to absorb ground reaction forces • this increases the forces placed thru static restraints

  21. Ligament Dominance • all LE muscles contribute to dynamic stability • posterior kinetic chain most important for ACLI prevention (glutes, hamstrings, gastro-soleus) • improper PKC recruitment during landing causes higher knee abd. moments and increases load on ACL

  22. Valgus Collapse

  23. Quadriceps Dominance • ♀ preferentially activate quads in landing • results in stiff-legged, extended landing posture rather than safer flexed position • hamstrings are ACL-agonists, reducing anterior tibial translation • Quads are ACL-antagonists, exerting strain on ACL

  24. Quadriceps Dominance • an erect or extended knee landing posture activates the quads • quadriceps contraction increase anterior shear stress to knee • protective pull of hamstrings is lost • plyometric training can increase HS:Quad torque or strength ratio

  25. Leg Dominance • women rely more on one leg compared to men • leg dominance defined as measurable muscle asymmetry • limited evidence to support LD as a definite risk factor

  26. Trunk Dominance • inability to control trunk in space allows greater movements outside of safe zone • creates larger moments on the LE • ACL injured females in one study had significantly more max. trunk displacement in all directions compared to controls

  27. Environmental • most important is shoe-surface interface • larger (longer) cleats and rubber floors are risk factors in several studies

  28. Fatigue • may decrease dynamic stability • Chappell et al: increased ant shear force and valgus moments, and decreased flexion angles in jump study in fatigued vs non-fatigued state • data support but clinical research lacking to validate this theory

  29. Prevention Focus • balance • strength • proprioception • endurance • plyometrics • stability

  30. Goals Prevention Biomechanics • decrease peak landing forces, knee abduction forces and HS/Quad strength ratio • increase knee flexion with landing • importance of feedback can’t be overemphasized

  31. Clinical Studies • Hewett et al. 1999, 1263 athletes: increased ACLI in untrained group • Mandelbaum “PEP” program: Prevent injury and Enhance Performance. 20 min. soccer program replaces warm-up. Reduced ACLI 74-88% over 2 years

  32. Clinical Studies • Gilchrist et al.: 1435 female Div. I soccer players. Non-contact ACLI rate 3.3 x less in trained group • Caraffa et al.: Proprioceptive training 600 soccer players. ACLI 8 x higher in untrained group

  33. Meta-Analyses of ACL PP • Hewett 2006: 6 studies, concluded that N-M programs have sign. effect on reducing ACLIs • Yoo 2010: ACLI PP best for < 18 y.o., female, and emphasis on plyometric and strength training. • Sadoghi 2012: significant, positive effect of ACLI PP. ♀ RRI = 52%. ♂ RRI = 85%

  34. Screening • Meyer: ♀ separated into hi/low risk groups from motor analysis of drop vertical jump. Significant decrease in knee abduction moments in hi risk group with ACLI PP training. • DiStefano: “LESS”: Landing Error Scoring System. Those with higher risk scores improved most with ACLI PP

  35. Screening • Studies consistently identify at risk athletes • identification methods presently are too labor intensive for large scale implementation.

  36. Compliance • Poor • athletes and coaches prefer to focus on performance rather than injury prevention

  37. Compliance • Performance is usually enhanced with ACLI PP • Improved: LE strength, vertical jump height, • squat strength, single leg hop distance, sprint times

  38. Recommendations Journal of Bone and Joint Surgery 2013 • “ all female athletes should undergo an ACL PP until more reliable methods of identification of at-risk athletes are developed. The training sessions should emphasize proper technique and should be performed year-round.”

  39. Questions?

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