educate OBJECTIVES AND TAKE-HOME ACL INJURY BY THE NUMBERS 12/4/2011 LIVE ON-SCREEN DEMONSTRATION

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1 LIVE ON-SCREEN DEMONSTRATION Derek Hirai, MS, ATC Gina Biviano, MA, ATC PRE-EMPTIVE STRIKE: ACL Injury Prevention Techniques OBJECTIVES AND TAKE-HOME Identify risk factors In-office testing/evaluation Recommend changes Prevention program ACL INJURY PREVENTION TECHNIQUES educate assess train ACL INJURY BY THE NUMBERS 80, ,000 ACL injuries annually in U.S.A. 50% are young athletes years of age (Griffin, 2006) 100,000 ACL reconstructions performed annually in U.S.A. (CDC, 1996) $1 Billion in medical costs annually in the U.S. $17,000 per injury (CDC, 2006; Parkkari, 2008) FEMALE ATHLETE STATISTICS High school female athlete: 1/100 chance of ACL injury Collegiate female athlete: 1/10 chance of ACL injury (Wilk, 1998) Female soccer players: 6x more ACL injuries than men (Lindenfeld,1994) 1

2 ACL INJURY CONSEQUENCES Consequences include: Temporary disability Permanent disability Posttraumatic DJD Discontinuation from athletics Re-injury Emotional difficulties Academic problems Scholarship / contract loss ACL INJURY MECHANISM Over 60% occur with non-contact mechanism (Wilk, 1999) The most common high-risk situations appear to be deceleration, changing direction, or landing from a jump (Griffin, 2006) ACL INJURY RISK FACTORS Non-Modifiable Anatomical BMI Femoral Notch Index Genu recurvatum General joint laxity Family history Developmental Sex Pubertal or maturation status Menstrual status ACL tensile strength Modifiable Biomechanical Knee abduction Anterior Tibial shear Lateral trunk motion Tibial rotation Dynamic foot pronation Fatigue resistance Ground reaction forces Neuromuscular Relative HS recruitment Hip abduction strength Trunk proprioception ACL INJURY RISK FACTORS- Modifiable Point of No Return Trunk forward flexed, rotated to opposite side Hips adducted and internally rotated Minimally flexed, valgus Tibial external rotation Landing on one foot and is out of control Weight forward on balls of feet (Ireland, 1999) 2

3 Non-Contact ACL injury ACL INJURY PREVENTION TECHNIQUES Assess in the office In-Office Testing/Evaluation What to look for Single Leg Step Down 2. Single Leg Hop 3. Drop Jump 4. Tuck Jump CORE/TRUNK CONTROL JUMP MECHANICS & LOWER LIMB CONTROL DYNAMIC BALANCE LEG DOMINANCE 3 4 3

4 1. SINGLE LEG STEP DOWN Test: Six inch step down repeated 10 times Evaluation: Balance Knee valgus Hip internal rotation Leg Dominance 2. SINGLE LEG HOP Test: Single leg hop for distance Evaluation: Jump Distance Knee Valgus Hip Internal Rotation Landing Control 3. DROP JUMP + REBOUND 3. DROP JUMP + REBOUND Test: Double leg drop with a max vertical rebound Evaluation: Landing Mechanics Knee valgus Hip internal rotation Hip and knee flexion Landing Noise 4

5 3. DROP JUMP + REBOUND 4. TUCK JUMP TEST Test: Double leg tuck jump for 10 sec Evaluation: Core Control Balance Jump Mechanics 4. TUCK JUMP CONT Hewett TE, Ford KR, Hoogenboom BJ, et al. Understanding and preventing ACL injuries: current Biomechanical and Epidemiologic Consideration- update 2010 N Am J Sports Phys Ther. 2010; 5(4):

6 ACL INJURY PREVENTION TECHNIQUES ACL PREVENTION PROGRAM train Program should address all modifiable risk factors through focused training Trunk strength and stability Plyometrics Dynamic Balance/ Proprioception FOUR QUADRANT APPROACH 1 CORE/TRUNK CONTROL 1. CORE CONTROL Dead Bugs Find pelvic neutral Raise legs to 90 Alternate lowering one leg at a time, touching heel to table. KEY: maintain pelvic neutral during exercise 3 sets, 60 sec 6

7 1. CORE CONTROL 1. CORE CONTROL Uni-bridge Find pelvic neutral Raise hips Straighten one leg, hold for 10 sec Alternate legs KEY: maintain pelvic neutral during exercise 3 sets, 60 sec Russian Eccentrics Have partner hold ankles Stabilize trunk Slowly lower body forward Hold 3 sec Return to starting position KEY: maintain pelvic neutral during exercise 3 sets 10 reps FOUR QUADRANT APPROACH 2 DYNAMIC BALANCE 2. DYNAMIC BALANCE Dynadisc Stand on one leg Slightly bent knee Maintain upright posture KEY: Focus on using lower extremity to control balance 3 set, 60 sec 7

8 2. DYNAMIC BALANCE 2. DYNAMIC BALANCE Single Leg Squat Stand on one leg Slowly bend knee to 45 Hold 3 sec Return to start position Increase difficulty by standing on foam mat or dynadisc 3 sets, 15 reps Tipping Bird Stand on one leg Stabilize trunk Lower trunk towards the floor Slowly return to starting position 3 sets, 15 reps FOUR QUADRANT APPROACH JUMP MECHANICS & LOWER LIMB CONTROL 3 3. JUMP MECHANICS + LOWER LIMB CONTROL Grid Jumps Place two strips of tape on the floor Jump on 2 feet side to side Maintain good jump mechanics Gradually increase jump distance 3 sets, sec 8

9 3. JUMP MECHANICS + LOWER LIMB CONTROL Box Jumps Double leg jumps 1) Jump up on the box 2) Jump off the box Gradually increase box height 3 sets, 10 reps 3. JUMP MECHANICS + LOWER LIMB CONTROL Lateral Box Jumps Stand next to a box Jump onto it with two feet Jump off the other side Progression: Increase height of step/box Jump over box 3 sets, 10 reps 3. JUMP MECHANICS + LOWER LIMB CONTROL Broad Jumps Stand evenly on both legs Jump forward 80% max Regain balance and repeat Progression: Increase jump distance and shorten time between jumps 3 sets, 10 reps FOUR QUADRANT APPROACH LEG DOMINANCE 4 9

10 4. LEG DOMINANCE 4. LEG DOMINANCE Lateral Bounds Stand on one leg Jump laterally Regain balance and repeat 3 sets, 10 reps Single Leg Hop Stand on one leg Jump forward Maintain balance and repeat 3 sets, 10 reps 4. LEG DOMINANCE Single Leg Drops Stand on box on one leg Hop down onto opposite leg Focus on landing mechanics 3 sets, 10 reps PREVENTION PROGRAMS Sportsmetrics minute work-out sessions 6 week preseason training program Developed by Cincinnati Sportsmedicine Research and Education Foundation PEP (Prevent injury Enhance Performance) 15 minute workout Used as a pre-practice warm-up 3d/wk Developed by Santa Monica Orthopedic and Sports Medicine Research Foundation 10

11 PREVENTION PROGRAMS Sportsmetrics Warm-up Stretching Series of jumping tasks that progress thru 6 weeks Upper and lower body weight training PREVENTION PROGRAMS PEP Warm-up Stretching exercises Plyometics Strengthening Agility PREVENTION PROGRAMS TAKE-HOME Outcomes Decrease ACL and knee ligament injury Increased vertical jump and strength Increased speed and endurance Improved landing technique and mechanics Hewett TE, Lindenfelt TN, Riccobene JV, et al. The effects of neuromuscular training on the incidence of knee injury in female athletes. Am J Sports Med. 1999:27(6) Identify risk factors In-office testing/evaluation Recommend changes Prevention program Mandelbaum BR, Silvers HJ, Watanabe DS. Effectivenss of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: a 2 year follow-up. Am J Sports Med. 2005: 33(7)

12 REFERENCES THANK YOU! Centers for Disease Control and Prevention, National Center for Injury Prevention & Control. Injury Research Agenda [monograph on the Internet]. Atlanta, GA: Centers for Disease Control and Prevention; 2002 [cited 2006 Sep 07]. Available from: Centers for Disease Control and Prevention, National Center for Health Statistics. National hospital discharge survey: annual summary, 1996 [monograph on the Internet]. Atlanta, GA: Centers for Disease Control and Prevention; 1996 [cited 2008 Mar 11]. Available from: Griffin LY, Albohm MJ, Arendt EA, Bahr R. Understanding and preventing noncontact anterior cruciate ligament injuries: a review of the Hunt Valley II meeting. Am J Sports Med ; 34(9). Hewett TE, Myer GD, Ford KR, Colosimo AJ, McLean SG. Cruciate Ligament Injury Risk in Female Athletes : A Prospective Study. Am J Sports Med 2005 ; 33: 492. Hewett TE, Lindenfeld TN, Riccobene JV, et al. The effect of neuromuscular training on the incidence of knee injury in female athletes: A prospective study. Am J Sports Med. 1999;27: Lohmander LS, Englund PM, Dahl LL, Roos EM. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med Oct;35(10): Schmitt DJ, Hendy MP, Mangine RE, Noyes FR. Incidence of injury in indoor soccer. Am J Sports Med. 1994; 22(3): Hewett TE, Ford KR, Hoogenboom BJ, et al. Understanding and preventing ACL injuries: current Biomechanical and Epidemiologic Consideration- update 2010 N Am J Sports Phys Ther. 2010; 5(4): Alentorn_Geli E, Myer GD, Silvers HJ et al. Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 2: A reiew of prevention programs aimed to modify risk factors and to reduce injury rates. Knee Surg Traumtol Arthrosc. 2009; 17: