The Female Athlete: Train Like a Girl Sarah DoBroka Wilson, PT, SCS Ron Weathers, PT, DPT, ATC, LAT
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The Female Athlete: Train Like a Girl Sarah DoBroka Wilson PT, SCS Ron Weathers PT, DPT, ATC/L I. Contributing Intrinsic Risk Factors to ACL Injury A. Anatomical and Structural Factors 1. Female ACL is smaller in length, cross sectional area and volume 2. Female ACL is less stiff and fails at lower load level 3. 25-35% greater frontal and transverse plane knee laxity 4. Greater genu recurvatum anterior knee laxity B. Hormonal Factors 1. Sex hormones (ie. estrogen, relaxin, testosterone) receptors are present on the human ACL 2. Risk of ACL injury greater during preovulatory phase of cycle (safest is 3-7 days post mensus) C. Cognitive, Behavioral, and Socioeconomic D. Risk Factor Screening and Prevention 1. Prior history of ACL injury increases risk for another ACL injury on same or opposite side 2. Family history may increase risk 3. The ideal ACL injury prevention program has yet to be identified E. Neuromuscular and Biomechanical Factors 1. Fatigue compromises central processing and control 2. Four common motor performance components during ACL injury: a. During landing, the knee buckles inward, knee is relatively straight, most of the weight is on a single LE, trunk tilted laterally b. same mechanisms in both sexes, but more exaggerated in women OUR GOAL: Identify faulty movement patterns and develop specific interventions targeted at prevention (neuromuscular control is the most modifiable factor) II. Four Neuromuscular Imbalances A. Ligament Dominance 1. Definition: Muscles do not sufficiently absorb the ground reaction forces, so the joint and ligaments must absorb high amounts of force over a brief time period 2. Contribution to ACL injury: High amounts of force sustained over a short period of time results in ligament rupture a. Knee collapses into valgus during landing b. Foot placement not shoulder width apart with landing Page 2 of 6
4. Intervention a. Train for proper landing technique b. Train muscle of posterior chain (glutes, hamstring, calves) c. Train core stability B. Quadriceps Dominance 1. Definition: The tendency to stabilize the knee joint by primarily using the quad muscle 2. Contribution to ACL injury: Quad contraction pulls the tibia anterior relative to the femur creating an anterior shear stress to ACL. Also, you are relying on a single muscle with a single tendinous insertion for knee stability and control. WOMEN ARE HIGHLY QUAD DOMINANT, while men activate hamstrings first a. Decreased knee flexion angle during landing b. Excessive landing contact noise 4. Intervention a. Train posterior chain (esp hamstrings) -squat jump sequence -russian hamstring curl (eccentric and concentric) -dynamic core stab with hamstring curl on swiss ball -SL calf raises C. Leg Dominance 1. Definition: Difference between limbs in muscle recruitment patterns, muscle strength and muscle flexibility 2. Contribution to ACL injury: Most, if not all weight is on a single leg when ACL is torn a. Muscle asymmetry b. Foot contact time not equal c. Foot placement not parallel (front to back) with landing d. Thighs not equal side to side during flight with tuck jump 4. Intervention a. Single leg balance b. Single leg hopping D. Trunk Dominance 1. Definition: Inability to precisely control the trunk in three-dimensional space, or allowing greater trunk movement following a perturbation or disturbance 2. Contribution to ACL injury: Female center of mass is higher off the ground than the male, making it harder to control and balance the body. This results in excessive lateral trunk motion, moves the center of mass lateral to the knee jt, and forces the knee into a valgus position a. Pelvis deviates into rotated or ant/post tilted positions during bridge Page 3 of 6
b. Pause between jumps with consecutive jumps c. Does not land in same footprint with tuck jump 4. Intervention a. Train local musculature (transverse abdominus, multifidus) b. Train pelvic and hip stabilizers (esp abductors and HIP ER) c. Perturbation training in all planes (ex. stand on BOSU) III. Tuck Jump A. Clinician friendly landing technique assessment tool that evaluates all 4 neuromuscular techniques B. Specifics 1. Athlete performs repeated tuck jumps for 10 sec 2. Standard video camera can be used in frontal and sagittal planes 3. Clinician subjectively rates athlete as having apparent deficit or not 4. Intervention program designed based on observed neuro deficits 5. Reasses as athlete progresses through training IV. Key Points When Designing Programs for Females A. Greater focus on dynamic trunk training (esp hip ER and abd, TA, multifidus B. Greater focus on posterior kinetic chain training C. Teach these concepts for correct control during athletic tasks: 1. Trunk shouldn t swing side to side during motion 2. Knee shouldn t collapse medially 3. Posterior chain muscles must be turned on so the knee is in controlled flexion and she uses correct muscles to absorb forces. 4. Use lower extremities equally D. Adolescents perform athletic tasks differently than adults. Consider growth spurts and how that affects motor programs and neuromuscular strategies E. Ground based dynamic testing. Ground based dynamic training References: 1. Shultz SJ, Schmitz RJ, Nguyen AD, Chaudhari AM, Padua DA, McLean SG, Sigward SM. ACL research retreat V: An update on ACL injury risk and prevention, March 25-27, 2010, Greensboro, NC. J of Athletic Training. 2010;45(5):499-508. 2. Hewett TE, Ford KR, Hoogenboom BJ, Myer GD. Understanding and preventing ACL injuries: Current biomechanical and epidemiologic considerations-update 2010. North American Journal of Sports Physical Therapy. 2010;5(4):234-251. Page 4 of 6
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