Knee Injury Prevention. Knee Injury Prevention

Transcription

1 ACSM TPC Part 2 Miami, Florida February 9, 2013 Knee Injury Prevention Associate Professor Dept. of Orthopaedic Surgery & Sports Medicine University of Kentucky Lexington, Kentucky ACSM TPC Part 2 February 9,

2 Knee Injury Prevention: MAIN MENU Introduction Risk Factors Mechanisms of Injury Prevention Programs Core Conclusions Quit 2 ACSM TPC Part 2 February 9,

3 27 Years of Observation has led to many research ideas 80 males, 64 females Knee injuries: Number (% of gender) Males, 11 (13%); Females 34 (53%) p< (18%) underwent surgery Males 6 (7.5%); Females 20 (31%) 21 surgeries p=.0007 ACL reconstructions: 2 males, 8 females M. L. Ireland, C. Wall, Epidemiology and Comparison of Knee Injuries in Elite Male and Female United States Basketball Athletes ACSM TPC Part 2 February 9,

4 Sports-Related Injuries Among High School Athletes United States, School Year Title story in MMWR (CDC) : : 4 million 7.2 million 1.4 million injuries Rate 2.4 injuries per 1000 athletic exposures 425 Schools, 9 sports No statistical significant difference in sex, soccer vs. basketball (p<0.05) High School Overall Injuries, 34 Years Increased from 4 million to 7.2 million ACSM TPC Part 2 February 9,

5 Sports-Related Injuries Among High School Athletes United States, School Year MMWR (CDC) Sept. 29, 2006 p Study by Comstock, RD Ratio C:P Competition MUCH greater risk than practice ACSM TPC Part 2 February 9,

6 Women s Participation High school: Pre-Title IX, 1972: 300, : 3,000,000 10x increase College: Pre-Title IX: 30, : 205,000 7x increase Increase in Women s Participation over 36 Years: High School: 10X College: 7X ACSM TPC Part 2 February 9,

7 Basketball ACL Injury Rates NCAA Avg. For Women Ratio of Average Rates Women: Men Avg. For Men AVG. * Rates Given are per 1000 Athlete-Exposures. Data from NCAA Injury Surveillance System, season through season. ACSM TPC Part 2 February 9,

8 Soccer ACL Injury Rates NCAA Avg. For Women DATA NOT YET AVAILABLE Ratio of Average Rates Women: Men Avg. For Men Avg. * Rates Given are per 1000 Athlete-Exposures. Data from NCAA Injury Surveillance System, season through season. ACSM TPC Part 2 February 9,

9 Basketball ACSM TPC Part 2 February 9,

10 VROOM... Valgus Rotation Out Of control Movement It takes 70 milliseconds to tear the ACL ACSM TPC Part 2 February 9,

11 Observation of ACL Injury Patterns Allow us to develop hypotheses in the lab for computer modeling Bring lab studies back out to the training room Joint position and muscle activation is critical to knee stability Strength is not as important as timing of activation Best: hamstrings firing on flexed knee-hip Worst: quadriceps dominance in extended hip-knee ACSM TPC Part 2 February 9,

12 What I Have Observed Mechanism of Injury High risk vs. low risk landing position ACSM TPC Part 2 February 9,

13 Ireland, ML. Anterior Cruciate Injury in Female Athletes: Epidemiology, in J Athletic Training 1999;34(2), ACSM TPC Part 2 February 9,

14 Tire with a sudden blowout is like a mop-end tear of ACL ACSM TPC Part 2 February 9,

15 Knee: Cone of Stability ACSM TPC Part 2 February 9,

16 NonContact ACL Tear Anterior Dislocation Weight Bearing Pivot Shift ACSM TPC Part 2 February 9,

17 Basketball: non-contact, unexpected, not thinking ACSM TPC Part 2 February 9,

18 Position of No Return Is it really knee valgus? Seen from frontal plane, YES, but NOT from sagittal plane Injury Landing Pivot Shift Knee: Anterior subluxation of tibia Hip: Internal Rotation and Adduction Femoral rotation first internal, then external Anterior tibial translation = valgus collapse ACSM TPC Part 2 February 9,

19 ACSM TPC Part 2 February 9,

20 Alignment Proximal control / Core stability POSITION OF SAFETY Neutral HEAD NECK Forward POSITI ON OF NO RETURN Neutral Neutral LUMBAR SPINE PELVIS Hyp erlordotic Anteri orly rotated FEMUR KNEE 2001 Mary Lloyd Ireland, M.D. ACSM TPC Part 2 February 9,

21 ACSM TPC Part 2 February 9,

22 GOOD BAD ACSM TPC Part 2 February 9,

23 ACSM TPC Part 2 February 9,

24 Core Stability Defined as the lumbopelvic-hip complex where a person s center of gravity is located and all movement begins Provides a stable base to allow optimal kinetic chain function Weak core does not allow for production of efficient movements leading to possible injury ACSM TPC Part 2 February 9,

25 Core Stability Exercise Principles Spine stability system Panjabi: Clinical instability is loss of spine s ability to maintain its patterns of displacement under physiologic loads so there is no initial or additional neurologic deficit, no major deformity, no incapacitating pain. Venu Akuthota, et. al., Core Stability Exercise Principles, in Current Sports Medicine Reports [ACSM] Vol. 7, No. 1 (Jan.-Feb. 2008), ACSM TPC Part 2 February 9,

26 Core Stability Exercise Principles Spine stability system: Neuromuscular control (Neural elements) Passive subsystem (osseous and ligamentous elements) Active subsystem (muscular elements) Core stability Improves efficacy and musculoskeletal conditions Reduces low back and lower extremity injuries Venu Akuthota, et. al., Core Stability Exercise Principles, in Current Sports Medicine Reports [ACSM] Vol. 7, No. 1 (Jan.-Feb. 2008), ACSM TPC Part 2 February 9,

27 Single-Leg Squat is the best assessment of altered core stability and neuromuscular activity Ireland ML, Durbin T, Bolgla Lori. Gender Differences in Core Strength and Lower Extremity Function During Single Leg Squat. In: ACL Injuries in the Female Athlete: Causes, Impacts, and Conditioning Programs, Noyes F, Barber-Westin S Eds. (Submitted to Springer 3/14/2012). ACSM TPC Part 2 February 9,

28 Ireland ML, Durbin T, Bolgla Lori. Gender Differences in Core Strength and Lower Extremity Function During Single Leg Squat. In: ACL Injuries in the Female Athlete: Causes, Impacts, and Conditioning Programs, Noyes F, Barber-Westin S Eds. (Submitted to Springer 3/14/2012). ACSM TPC Part 2 February 9,

29 Multiple Factors Resulting in ACL Injuries NOT modifiable: Anatomic/Structural Hormonal Modifiable: Neuromuscular/biomechanical Expert think tanks agree that modifiable factors are most important Emphasize modifiable factors for return-to-play and prevention programs Ireland ML, Durbin T, Bolgla Lori. Gender Differences in Core Strength and Lower Extremity Function During Single Leg Squat. In: ACL Injuries in the Female Athlete: Causes, Impacts, and Conditioning Programs, Noyes F, Barber-Westin S Eds. (Submitted to Springer 3/14/2012). ACSM TPC Part 2 February 9,

30 Simple Single-Leg Squat Give clinicians information on neuromuscular control Plank Test Measures lumbar and pelvic control in side or sagittal plane Can see excessive lumbar lordosis Observe in Fatigue and Non-fatigue states Ireland ML, Durbin T, Bolgla Lori. Gender Differences in Core Strength and Lower Extremity Function During Single Leg Squat. In: ACL Injuries in the Female Athlete: Causes, Impacts, and Conditioning Programs, Noyes F, Barber-Westin S Eds. (Submitted to Springer 3/14/2012). ACSM TPC Part 2 February 9,

31 Core Stability Exercise Principles Spine stability system Panjabi: Clinical instability is loss of spine s ability to maintain its patterns of displacement under physiologic loads so there is no initial or additional neurologic deficit, no major deformity, no incapacitating pain. Venu Akuthota, et. al., Core Stability Exercise Principles, in Current Sports Medicine Reports [ACSM] Vol. 7, No. 1 (Jan.-Feb. 2008), ACSM TPC Part 2 February 9,

32 Ireland ML, Willson JD, Ballantyne BT, and Davis IM, Hip Strength in Females With and Without Patellofemoral Pain. In J Orthop Sports Phys Therapy 33;2003, Willson JD, Ireland ML, Davis I, Core strength and lower extremity alignment during single leg squats, Med Sci Sports Exerc 2006 May;38(5): Leetun DT, Ireland ML, Ballantyne B, McClay IS, Core Stability Measures as Risk Factors for Lower Extremity Injury in Athletes. In Med Sci Sports Exer 36(6);2004, ACSM TPC Part 2 February 9,

33 Ireland ML, Willson JD, Ballantyne BT, and Davis IM, Hip Strength in Females With and Without Patellofemoral Pain. In J Orthop Sports Phys Therapy 33;2003, female subjects with and without patellofemoral joint pain Symptomatic females demonstrated weakness in hip abduction and ER compared to age-matched controls ACSM TPC Part 2 February 9,

34 Core Stability Measures 80 females, 60 males Intercollegiate basketball and track athletes Measurements of core stability were made prior to the season Injury records were kept Leetun DT, Ireland ML, Ballantyne B, McClay IS, Core Stability Measures as Risk Factors for Lower Extremity Injury in Athletes. In Med Sci Sports Exer 36(6);2004, ACSM TPC Part 2 February 9,

35 Methods: Isometric strength Trunk Hip Thigh (Average force/bw) * lever arm (m) ACSM TPC Part 2 February 9,

36 Straight Leg Lowering Test 9 º / second Angle at which low back raises off the testers hand Side Bridge Test Time in seconds athlete able to maintain side bridge with hips & knees off the table ACSM TPC Part 2 February 9,

37 RESULTS & CONCLUSIONS: Hip external rotation strength was the only useful predictor of injury status Males produced greater hip ABD, ER, and lumbar spine stability measures Uninjured athletes were significantly stronger in hip ABD and ER ACSM TPC Part 2 February 9,

38 Methods: TF Valgus (projection) Single leg stance Single leg squat (45 ) Average projection angle (degrees) ACSM TPC Part 2 February 9,

39 Conclusions Simple clinical measures allow testing of athletes in training room setting Increase in TF valgus moderately explained by core strength ACSM TPC Part 2 February 9,

40 Ongoing ACL Research at the University of Kentucky ACSM TPC Part 2 February 9,

41 Risk Factors Contributing to ACL Injuries Intrinsic Alignment Hyperextension Physiologic Rotatory Laxity ACL Size Notch Size/Shape Hormonal Influences Inherited Skills/Coordination ACSM TPC Part 2 February 9,

42 Risk Factors Contributing to ACL Injuries Extrinsic Combined (potentially changeable) Strength Proprioception Conditioning (Position Sense/Balance) Shoes Neuromuscular Motivation Order of Firing Acquired Skills ACSM TPC Part 2 February 9,

43 Risk Factor Categories (Murphy et. al.) ACL Risk Intrinsic 1. Age 2. Sex (Male / Female) 3. Phase of menstrual cycle 4. Previous injury and Inadequate Rehabilitation 5. Aerobic fitness 6. Body size 7. Limb dominance 8. Flexibility 9. Muscle strength imbalance 10. Reaction time 11. Limb girth (Wide / Narrow notch) 12. Postural stability 13. Anatomic alignment 14. Foot morphology Extrinsic 1. Level of competition Games / Practice 2. Skill level 3. Shoe type Edge-Cleats Other Cleats 4. Ankle bracing 5. Playing surface 5 Significant ACL Factors Murphy DF. Connolly DAJ, Beynnon BD, Risk factors for lower extremity injury: a review of the literature, Br J Sports Med 2003, 37: ACSM TPC Part 2 February 9,

44 Risk Factors, Noncontact ACL Being female Not hormonal levels during cycle Previous injury and inadequate rehab Narrow notch, therefore smaller ACL size Games 1 st degree relative Younger age in females Landing patterns valgus extended knee Core dysfunction / weakness ACSM TPC Part 2 February 9,

45 Risk Factors for Lower Extremity Injuries Fatigue Previous injury Shoe- surface interface Game situation Awkward landing Combination ACSM TPC Part 2 February 9,

46 Family History Risk Factor 742 subjects with a family history of ACL tear Including only first-degree relatives, participants with ACL tear were more than twice as likely to have a first degree relative with an ACL tear, compared to participants without an ACL tear. Flynn RK, Pedersen CL, Birmingham TB, Kirkley A, Jackowski D, and Fowler PJ, The Familial Predisposition Toward Tearing the Anterior Cruciate Ligament: A Case Control Study, AJSM 33:1 (January, 2005), ACSM TPC Part 2 February 9,

47 Does age, level of play increase ACL Risk? Soccer athletes <16 who move up are more likely to be injured than seniors Soderman K, et. al.: Anterior cruciate ligament injuries in young females playing soccer at senior levels. Scan J Med Sci Sports 12(2):68-68, ACSM TPC Part 2 February 9,

48 ACL Reconstructions KSM Experience Females are younger than males by 5 years Ott SO, Ireland ML, et. al.: Comparison of outcomes between males and females after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 11:75-80, ACSM TPC Part 2 February 9,

49 Hewett, TE, and Myer GD, The Mechanistic Connection Between the Trunk, Hip, Knee, and Anterior Cruciate Ligament Injury, Exer Sport Sci Reviews, Vol. 39, No. 4, pp , Fig. 1. Theory linking growth, neuromuscular (NM) adaptation, trunk NMC, dynamic valgus, and knee joint load to anterior cruciate ligament (ACL) injury risk. ACSM TPC Part 2 February 9,

50 Hewett, TE, and Myer GD, The Mechanistic Connection Between the Trunk, Hip, Knee, and Anterior Cruciate Ligament Injury, Exer Sport Sci Reviews, Vol. 39, No. 4, pp , Fig. 2. Mechanical model linking 1) lateral trunk motion to change in direction of the ground reaction force vector ( GRFv), 2) hip adductor torque, and 3) knee load during cutting and landing anterior cruciate ligament (ACL) injuries. ACSM TPC Part 2 February 9,

51 Hewett, TE, and Myer GD, The Mechanistic Connection Between the Trunk, Hip, Knee, and Anterior Cruciate Ligament Injury, Exer Sport Sci Reviews, Vol. 39, No. 4, pp , Fig. 3. Conceptual model of lateral trunk motion leading to increased ground reaction force vector ( GRFv) and hip adductor torque and knee load. ACSM TPC Part 2 February 9,

52 Development of probability of high knee abduction moment (pkam) Myer GD, Ford KR, Hewett TE. New method to identify athletes at high risk of ACL injury using clinic-based measurements and freeware computer analysis. Br J Sports Med 2011;45(4): Myer GD, Ford KR, Khoury J, Succop P, Hewett TE. Biomechanics laboratorybased prediction algorithm to identify female athletes with high knee loads that increase risk of ACL Injury. Br J Sports Med 2011;45(4): Myer GD, Ford KR, Khoury J, Succop P, Hewett TE. Clinical correlates to laboratory measures for use in non-contact anterior cruciate ligament injury risk reduction prediction algorithm. Cin Biomech 2010;25(7): Myer GD, Ford KR, Khoury J, Succop P, Hewett TE. Development and validation of a clinic-based prediction tool to identify female athletes at high risk for anterior cruciate ligament injury. Am J Sports Med. 2010;38(10): ACSM TPC Part 2 February 9,

53 SUMMARY: 4 articles: development of probability of high knee abduction moment (pkam) Clinical-based algorithm developed to predict probability of a high pkam based on 2-dimensional video data as a measurement tool to mass screen for injury risk 15/16-year-old female soccer/basketball athletes pkam values ranged between 0 and 1, with 84% sensitivity, 64% specificity, and C statistic.85 ACSM TPC Part 2 February 9,

54 Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes. Pre-screened female athletes will demonstrate neuromuscular control and increased valgus joint loading predicting ACL injury risk 205 female athletes: soccer/basketball/volleyball 3D joint angles and joint loads during jumping/loading task: 9 athletes: ACL tear 2.5X greater knee abduction moment, 20% higher ground reaction force Knee Abduction Moment predicted ACL Injury Status 73% specificity, 78% sensitivity Hewett TE et. al., Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes. Am J Sports Med 2005:33(4); ACSM TPC Part 2 February 9,

55 Goetschius J, et. Al, (University of Vermont), Application of a Clinic-Based Algorithm as a Tool to Identify Female Athletes at Risk for Anterior Cruciate Ligament Injury: A Prospective Cohort Study With a Nested, Matched Case-Control Analysis, AJSM Vol. 40, No. 9, 2012, ACSM TPC Part 2 February 9,

56 High knee abduction moment (pkam) Based on analysis of 2D video data with standard video cameras to provide measurement tool that has capacity for larger populations for mass screening of injury risk Based on work by: Hewett TE, Ford KR, Myer GD, Khoury J, Succop P. In British Journal of Sports Medicine 2011 (45;4) Goetschius J, et. Al, Application of a Clinic-Based Algorithm as a Tool to Identify Female Athletes at Risk for Anterior Cruciate Ligament Injury: A Prospective Cohort Study With a Nested, Matched Case-Control Analysis, AJSM Vol. 40, No. 9, 2012, ACSM TPC Part 2 February 9,

57 Hypothesis Clinic-based algorithm would predict athletes at increased risk for ACL injury 1885 Female athletes Recruited Soccer / Field hockey / Basketball / Gymnastics / Lacrosse / Rugby / Ultimate Frisbee / Volleyball 20 ACL tears, 45 controls Goetschius J, et. Al, Application of a Clinic-Based Algorithm as a Tool to Identify Female Athletes at Risk for Anterior Cruciate Ligament Injury: A Prospective Cohort Study With a Nested, Matched Case-Control Analysis, AJSM Vol. 40, No. 9, 2012, ACSM TPC Part 2 February 9,

58 Goetschius J, et. al, Application of a Clinic-Based Algorithm as a Tool to Identify Female Athletes at Risk for Anterior Cruciate Ligament Injury: A Prospective Cohort Study With a Nested, Matched Case-Control Analysis, AJSM Vol. 40, No. 9, 2012, ACSM TPC Part 2 February 9,

59 Goetschius J, et. al, Application of a Clinic-Based Algorithm as a Tool to Identify Female Athletes at Risk for Anterior Cruciate Ligament Injury: A Prospective Cohort Study With a Nested, Matched Case-Control Analysis, AJSM Vol. 40, No. 9, 2012, ACSM TPC Part 2 February 9,

60 Results No relationship between risk of suffering ACL injury and pkam as determined by clinic-based algorithm Conditional logistic regression analyses did not reveal statistically-significant relationships Conclusions The pkam was not associated with non-contact ACL injury in our group of injured athletes and matched controls Goetschius J, et. Al, Application of a Clinic-Based Algorithm as a Tool to Identify Female Athletes at Risk for Anterior Cruciate Ligament Injury: A Prospective Cohort Study With a Nested, Matched Case-Control Analysis, AJSM Vol. 40, No. 9, 2012, ACSM TPC Part 2 February 9,

61 Conclusion Additional research is needed to develop alternative clinic-based algorithms for prediction of ACL injury risk that can be applied in an efficient manner to large groups of participants involved in activities that are associated with an increased risk of suffering ACL injury In other words... If we don t know the factors causing increased risk of injuries, we can t predict why prevention programs are working Goetschius J, et. Al, Application of a Clinic-Based Algorithm as a Tool to Identify Female Athletes at Risk for Anterior Cruciate Ligament Injury: A Prospective Cohort Study With a Nested, Matched Case-Control Analysis, AJSM Vol. 40, No. 9, 2012, ACSM TPC Part 2 February 9,

62 Prevention Programs Griffin, LY., ed., Prevention of Noncontact ACL Injuries. AAOS, ACSM TPC Part 2 February 9,

63 Injury Prevention-ACL Tear Simple as: ABC s Agility Balance Core Strength ACSM TPC Part 2 February 9,

64 What the programs have in common Emphasize safe landing positions Neuromuscular recruitment Should be sport-specific Program must be done properly and participation documented Look at all lower extremity injury rates, not just ACL tears ACSM TPC Part 2 February 9,

65 Prevention Programs Published results: do reduce risk of injury Adolescent Females (Tim Hewett, Ohio) Soccer (Bert Mandelbaum, Santa Monica, CA) Team Handball (Grete Myklebust, Norway) ACSM TPC Part 2 February 9,

66 Prevention Program Websites Cincinnati Children s Hospital PEP Program ACL Prevent Soccer program Santa Monica, California ACSM TPC Part 2 February 9,

67 67 ACSM TPC Part 2 February 9,

68 Sports Injury (ACL) Prevention Timothy E. Hewett, Ph.D ACSM TPC Part 2 February 9,

69 Prevent injury and Enhance Performance Soccer athletes, years of age Study design cohort Level of Evidence Female subjects, 52 teams 2 to 3 times per week Not on game days 20 minute program Performed throughout the season, not just 6 weeks Mandelbaum BR, et. al., Effectiveness of a Neuromuscular and Proprioceptive Training Program in Preventing Anterior Cruciate Ligament Injuries in Female Athletes: 2 Year Follow-up, AJSM 33(7) ACSM TPC Part 2 February 9,

70 PEP emphasizes correct form: 70 ACSM TPC Part 2 February 9,

71 ACL tear reduction 88% in 2000 and 74% in 2001 Rate per player (trained-untrained)/rate x 100 Mandelbaum BR, et. al., Effectiveness of a Neuromuscular and Proprioceptive Training Program in Preventing Anterior Cruciate Ligament Injuries in Female Athletes: 2 Year Follow-up, AJSM 33(7) ACSM TPC Part 2 February 9,

72 Lower Extremity Injury Prevention Program Sheri McNew, ATC Director of Athletic Training Services University of Kentucky Dept. of Orthopaedic Surgery & Sports Medicine Lexington, Kentucky USA Tel. (859) SPECIAL THANK YOU James E. Ireland Foundation Post-Time Productions Athletic Trainers, Certified: Aaron MacDonald, Amy Waugh, Michelle Meeks, Jantzen Merrimen ACSM TPC Part 2 February 9,

73 Lower Extremity Injury Prehab Program Message: Performance enhancement, not injury prevention ACSM TPC Part 2 February 9,

74 ACL Injury Prevention Mental preparation Physical training Coaches cries Land Softly Light as a feather Like a spring Get Down More bent hip/bent knee position 74 ACSM TPC Part 2 February 9,

75 Return to Play after ACL Reconstruction? Months or Years? Question is: how to test by objective measures Jumping / landing Treadmill Functional Assessment in PT Fatigue Confidence in Landing ACSM TPC Part 2 February 9,

76 Functional Assessment ACSM TPC Part 2 February 9,

77 Remember the Core! 77 ACSM TPC Part 2 February 9,

78 Landing is EVERYTHING! 78 ACSM TPC Part 2 February 9,

79 Not all injuries are preventable. Things happen! Determine and rank order of importance of risk factors. Injury Prevention Strategies Harder to sell than performance enhancement to coaches, parents Key to ACL Injury Prevention Understanding and ranking importance of risk factors: Intrinsic Extrinsic ACSM TPC Part 2 February 9,

80 You Never See It Coming... ACSM TPC Part 2 February 9,

81 Bottom Line Question with long-term results of ACL reconstruction: Can we prevent arthritis? Can we restore normal knee function? Evidence based results: unknown Experience driven: known ACSM TPC Part 2 February 9,

82 36YO Female Professional basketball athlete Allograft ACL reconstruction Injured PF Osteoarthritis ACSM TPC Part 2 February 9,

83 2 Years Post ACL recon Injured PF Osteoarthritis ACSM TPC Part 2 February 9,

84 3.5 years postop increasing knee pain Injured PF Osteoarthritis ACSM TPC Part 2 February 9,

85 ACSM TPC Part 2 February 9,

86 ACSM TPC Part 2 February 9,

87 Knee pack-years as in smoking: Additive effects of years of participation in basketball... Pack-years of smoking on lungs Pack-years of activity on knees? Too many pack years of basketball? ACSM TPC Part 2 February 9,

88 National Cruciate Ligament Registry in Norway Established June 12, 2004 Overview: Matt Hasson, Scandinavian ACL registries could serve as models for large European database, ORTHOPAEDICS TODAY INTERNATIONAL 2006; 9:25 Study presented at ISAKOS Congress in Florence, May 2007 Authors: Granan LP, Engebretsen L, Bahr R, Oslo Sports Trauma Research Center, Ullevaal University Hospital, Oslo, Norway ACSM TPC Part 2 February 9,

89 Sports Multicenter Outcomes Studies MOON ACLR, MARS & MeTeOR NIH Funded 1. Original ACLR (Spindler) SHOULDER (Kuhn) The only prospective longitudinal outcome cohort to identify features that predict success with non operative treatment of full thickness rotator cuff tears. Design and sites based on original MOON platform. 3. MARS with AOSSM (Wright) Collaborative multicenter cohort (offered to all AOSSM members) to identify causes and modifiable risk factors for worse outcomes in Revision ACLR. Design based on original platform, but grew to include 83 surgeons (the number needed to accrue enough revision surgeries), with nearly half the sites in private practice. 4. MeTeO R (Katz) Randomized controlled trial to establish efficacy of surgery compared with nonoperative therapy in patients with symptomatic meniscal tear and osteoarthritis. Six of seven study sites were MOON or MARS participants. ACSM TPC Part 2 February 9,

90 ACSM TPC Part 2 February 9,

91 The Uneven Playing Field By Michael Sokolov New York Times, May 11, 2008 Janelle Pierson High school soccer player Multiple ACL injuries, both knees Mindset: after surgeries, multiple knee injuries Rehab hard Get back on the field Compete fiercely Hope not to be injured ACSM TPC Part 2 February 9,

92 Establish Risk Factors Prioritize Order of Risk Document what factors are changed by intervention programs ACSM TPC Part 2 February 9,

93 We must choose the correct risk factors and implement programs at multiple centers to study the impact of those programs. If you pick the wrong risk factor(s) or a poor study design, you may be out of a ride to work. For example ACSM TPC Part 2 February 9,

94 94 ACSM TPC Part 2 February 9,

95 Knee Injury Prevention Thank You! University of Kentucky Dept. of Orthopaedic Surgery & Sports Medicine Lexington, Kentucky ACSM TPC Part 2 February 9,

96 KNEE INJURY PREVENTION Mary Lloyd Ireland, M.D. ACSM TPC II UK Healthcare - Orthopaedics Miami, Florida & Sports Medicine February 9, Perimeter Drive #200 Lexington, KY (859) Fax: (859) BIBLIOGRAPHY Baltaci G et al. The effect of prophylactic knee bracing on performance balance, proprioception, coordination, and muscular power. Knee Surg Sports Traumatol Arthrosc 2011;19(10): Benjaminse A, Otten E. ACL injury prevention, more effective with a different way of motor learning? Knee Surg Sports Traumatol Arthrosc 2011;19(4): Bien DP. Rationale and implementation of anterior cruciate ligament injury prevention warm-up programs in female athletes. J Strength Cond Res 2011;25(1): DiStefano LJ et al. Effects of an age-specific anterior cruciate ligament injury prevention program on lower extremity biomechanics in children. Am J Sports Med 2011;39(5): Donnelly CJ et al. Optimizing whole-body kinematics to minimize valgus knee loading during sidestepping: implications for ACL injury risk. J Biomech 2012;45(8): Dowling, AV et al. A wearable system to assess risk for anterior cruciate ligament injury during jump landing: measurements of temporal events, jump height, and sagittal plane kinematics. J Biomech Eng 2011;133(7): Check page # Dowling AV et all. intertial sensor-based feedback can reduce key risk metrics for anterior cruciate ligament injury during jump landings. Am J Sports Med 2012;40(5): Flynn RK, Pedersen CL. Birmingham TB, Kirkley A, Jackowski D. and Fowler PJ. The familial predisposition toward tearing the anterior cruciate ligament: A case control study. AJSM 2005; 33 (1):

97 KNEE INJURY PREVENTION 2 Franklin CC, Weiss JM. Stopping sports injuries in kids: an overview of the last year in publications. Curr Opin Pediatr 2012;24(1): Goetschius J et al. Application of a clinic-based algorithm as a tool to identify female athletes at risk for anterior cruciate ligament injury: A prospective cohort study with a nested, matched case-control analysis. AJSM 2012;40(9): Granan LP, Engebretsen L, Bahr R. Study presented at ISAKOS Congress in Florence, May 2007, Oslo Sports Trauma Research Center, Ullevaal University Hospital, Oslo, Norway. Griffin LY., ed. Prevention of noncontact ACL injuries. AAOS, Hewett TE. Hewett TE et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes. Am J Sports Med 2005;3394): Hewett TE, Myer GD. The mechanistic connection between the trunk, hip, knee, and anterior ligament injury. Exer Sports Sci Reviews 2011;39(4): Hewett TE, Myer GD and Ford KR. Decrease in neuromuscular control about the knee with maturation in female athletes. JBJS 2004;86-A; Hurd WJ, Axe MJ, Snyder-Mackler L. A 10-year prospective trial of a patient management algorithm and screening examination for highly active individuals with anterior cruciate ligament injury: Part 2, determinants of dynamic knee stability. Am J Sports Med 2008;36(1): Ireland ML. Anterior cruciate ligament injuries in young women athletes. Your Patient & Fitness 1996;10(5): Ireland ML. Anterior cruciate ligament injury in female athletes: Epidemiology. Journal of Athletic Training 1999;34(2):

98 KNEE INJURY PREVENTION 3 Ireland ML et al. A radiographic analysis of the relationship between the size and shape of the intercondylar notch and anterior cruciate ligament injury. Knee Surgery Sports Traumatol Arthrosc 2001;9: Ireland ML, Durbin T,Bolgla L. Gender differences in core strength and lower extremity function during single leg squat. In: Noyes F, Barber-Westin S Eds. ACL injuries in the female athlete: Causes, impacts, and conditioning programs. (Submitted to Springer 3/14/2012). Ireland ML, Wall, C. Epidemiology and Comparison of Knee Injuries in Elite Male and Female Basketball Athletes. Medicine & Science in Sports & Exercise 1990;22(2) S582. Ireland ML, Willson JD, Ballantyne BT, Davis IM. Hip strength in females with and without patellofemoral pain. J Orthop Sports Phys Ther 2003;(Nov)33(11): Leetun DT, Ireland ML, Ballantyne B, McClay IS. Core stability measures as risk factors for lower extremity injury in athletes. Med Sci Sports Exer 2004;36(6): Mandelbaum BR, Silvers HJ, Watanabe DS, Knarr JF, Thomas SD et al. Effectiveness of a neuromuscular and proprioception training program in preventing anterior cruciate ligament injuries in female athletes: 2 year follow-up. AJSM 2005;33(7): Milner CE et al. Simple verbal instruction improves knee biomechanics during landing in female athletes. Knee 2012;19(4): Myer GD, Ford KR, Hewett TE. New method to identify athletes at high risk of ACL injury using clinic-based measurements and freeware computer analysis. Br J Sports Med 2011;45(5): Myer GD, Ford KR, Khoury J, Succop P, Hewett TE. Biomechanics laboratory-based prediction algorithm to identify female athletes with high knee loads that increase risk of ACL injury. Br J Sports Med 2011;45(4): Myer GD, Ford KR, Khoury J, Succop P, Hewett TE. Clinical correlates to laboratory measures for use in non-contact anterior cruciate ligament injury risk reduction prediction algorithm. Cin Biomech 2010;25(7): Myer GD, Ford KR, Khoury J, Succop P, Hewett TE. Development and validation of a clinic-based prediction tool to identify female athletes at high risk for anterior cruciate ligament injury. Am J Sports Med 2010;38(10):

99 KNEE INJURY PREVENTION 4 Myer GD, Ford KR, Paterno MV, Nick TG, and Hewett TE. The effects of generalized joint laxity on risk of anterior cruciate ligament injury in young female athletes. Am J Sports Med 2008;36(6): Oliver GD et al. A kinematic and kinetic analysis of drop landings in military boots. J R Army Med Corps 2011;157(3): Olson TJ et al. Comparison of 2D and 3D kinematic changes during a single leg step down following neuromuscular training. Phys Ther Sport 2011;12(2): Olsen TJ et al. Injury mechanisms for anterior cruciate ligament injuries in team handball: A systematic video analysis. Am J Sports Med 2004;32(4): Ott SM, Ireland ML, Ballantyne B, Willson JD, McClay I. Comparison of outcomes between males and females after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2003;11: Padua DA et al. Retention of movement pattern changes after a lower extremity injury prevention program is affected by program duration. Am J Sports Med 2012;40(2): Sadoghi P et al. Effectiveness of anterior cruciate ligament injury prevention training programs. J Bone Joint Surg Am 2012;94(9): Sanders MS et al. Knee injuries and the use of prophylactic knee bracing in off-road motorcycling: results of a large-scale epidemiological study. Am J Sports Med 2011;39(7): Soderman K et al. Anterior cruciate ligament injuries in young females playing soccer at senior levels. Scan J Med Sci Sports 2002;12(2):68. Sokolov M. The uneven playing field. New York Times, May 11, Willson JD, Dougherty CP, Ireland ML, Davis IM. Core stability and its relationship to lower extremity function and injury. JAAOS 2005;13(5): Zazulak BT et al. The effects of core proprioception on knee injury: a prospecrtive biomechanical-epidemiology study. Am J Sports Med 35(3):

100 KNEE INJURY PREVENTION 5 Prevention Programs Adolescent Females (Tim Hewett, Ohio) s.org/svc/alpha/s/sports-med/acl.htm Soccer (Bert Mandelbaum, Santa Monica, CA) Team Handball (Grete Myklebust, Norway) Teran-Yengle P et al. Efficacy of gait training with real-time biofeedback in correcting knee hyperextension patterns in young women. J Orthop Sports Phys Ther 2011;41(12) van Beijsterveldt AM et al. Effectiveness and cost-effectiveness of an injury prevention programme for adult male amateur soccer players: design of a cluster-randomised controlled trial. Inj Prev 2011;17(1):e2 Venu Akuthota et al. Core stability exercise principles. In: Current Sports Medicine Reports [ACSM] 2008;7(1): Wagner M. Functional anatomy of the posterolateral structures of the knee. Arthroscopy 1993;9(1): Wagner M. Functional anatomy of the posterolateral structures of the knee. Arthroscopy 1993;9(1): Willson JD, Ireland ML, Davis I. Core strength and lower extremity alignment during single leg squats. Med Sci Sports Exerc 2006 May;38(5): Yeow CH et al. Shod landing provides enhanced energy dissipation at the knee joint relative to barefoot landing from different heights. Knee 2011;18(6):