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ACL Prevention Amanda KW Kelly, MD Case Western Reserve University Rainbow Babies and Childrens Hospital.

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Presentation on theme: "ACL Prevention Amanda KW Kelly, MD Case Western Reserve University Rainbow Babies and Childrens Hospital."— Presentation transcript:

1 ACL Prevention Amanda KW Kelly, MD Case Western Reserve University Rainbow Babies and Childrens Hospital

2 Outline Background Background Injury risk factors Injury risk factors ACL prevention programs ACL prevention programs

3 Background 250,000 ACL injuries/yr in USA 250,000 ACL injuries/yr in USA $1.5 billion annual cost $1.5 billion annual cost % return to previous level of play % return to previous level of play Typical recovery 6-9 mo Typical recovery 6-9 mo > 70% ACL injuries are NON-contact > 70% ACL injuries are NON-contact Boden 2000 Physspportsmed

4 Importance of ACL Injury Season ending injury Season ending injury 6-9 mo recovery time 6-9 mo recovery time Children often must wait several yrs for repair Children often must wait several yrs for repair Costly Costly

5 ACL Anatomy ACL MCL LCL PCL

6 ACL: Function Keep tibia from sliding forward on the femur Keep tibia from sliding forward on the femur

7 Injury Mechanisms Pivot Pivot Landing from jump Landing from jump Contact Contact

8 Injury Mechanism: Pivot Deceleration + change of direction, foot planted Deceleration + change of direction, foot planted Causes twisting injury of knee Causes twisting injury of knee Traction at shoe/playing surface interface Traction at shoe/playing surface interface Often close to another player Often close to another player ACL

9 Mechanism: Pivot Importance of ground-shoe surface interface in pivot mechanism Importance of ground-shoe surface interface in pivot mechanism Shoe surface interface

10 Mechanism: landing Knee slightly flexed on landing Knee slightly flexed on landing Quad pulls tibia forward Quad pulls tibia forward

11 Mechanism: Contact Hit on outside of leg Hit on outside of leg Foot planted Foot planted Twisting of knee Twisting of knee

12 Mechanism Pivoting with knee slightly bent, twisting knee Pivoting with knee slightly bent, twisting knee Landing from jump: knees slightly bent, quads pull tibia forward Landing from jump: knees slightly bent, quads pull tibia forward Too much shoe traction Too much shoe traction Poor balance Poor balance Uneven ground throwing off balance Uneven ground throwing off balance

13 Risk Factors Poor landing + pivot style Poor landing + pivot style Stronger quads than hamstrings Stronger quads than hamstrings Shoe / playing surface interface Shoe / playing surface interface Playing surface quality Playing surface quality Female gender Female gender

14 Risk Factors Landing / Pivoting with knee slightly bent Landing / Pivoting with knee slightly bent Places ACL in vulnerable position Places ACL in vulnerable position Additional torsion/twisting can injury Additional torsion/twisting can injury Boden 2000 Physsportsmed

15 Risk Factors Hamstring/Quadriceps imbalance Hamstring/Quadriceps imbalance Poor hamstring strength Poor hamstring strength Hamstrings protect ACL Hamstrings protect ACL Quads stretch/stress ACL Quads stretch/stress ACL Slow activation of hamstring muscles with pivot / landing Slow activation of hamstring muscles with pivot / landing Hewett AJSM 1999, Crosier AJSM 2002, Huston 1996 AJSM, Orchard AJSM 1997, Baratta AJSM 1988

16 Risk Factors Footwear Footwear Longer cleats at edge of sole with fewer, smaller cleats in the middle of the sole Longer cleats at edge of sole with fewer, smaller cleats in the middle of the sole s torsional resistance s torsional resistance Lambson 1996 AJSM

17 Risk Factor Uneven playing surface Uneven playing surface Unexpected foot position may change muscle activation patterns Unexpected foot position may change muscle activation patterns Balance thrown off Balance thrown off Boden, Orthopedics

18 Risk Factors Female Gender Female Gender 2-8x more common in girls 2-8x more common in girls Poor ham:quad strength Poor ham:quad strength Activate hams more slowly Activate hams more slowly Land with knees sl bent Land with knees sl bent Boys land with knees more bent Boys land with knees more bent

19 Female Gender Hormonal Influences Hormonal Influences ACL has estrogen receptors ACL has estrogen receptors Estrogen can ligament looseness Estrogen can ligament looseness Estrogen levels in girls compared to boys Estrogen levels in girls compared to boys Estrogen d at specific times in menstrual cycle Estrogen d at specific times in menstrual cycle Studies VERY inconsistent Studies VERY inconsistent Every phase of cycle has been implicated in at least 1 study Every phase of cycle has been implicated in at least 1 study

20 Female Gender Knee anatomy Knee anatomy Smaller intercondylar notch Smaller intercondylar notch ACL may get stretched across bone and torn ACL may get stretched across bone and torn Athletes with bilateral ACL injuries have smaller ICN Athletes with bilateral ACL injuries have smaller ICN Harner 1994 AJSM, Anderson 1999 AOSSM

21 Female Gender Lower extremity alignment Lower extremity alignment Women more knock-kneed Women more knock-kneed May allow quad to exert more stress on ACL May allow quad to exert more stress on ACL Data not great Data not great Nisell 1985 ActaOrthopScandSuppl

22 Prevention Strategies Shoe wear / field surface Shoe wear / field surface Bracing Bracing Exercise Programs Exercise Programs Change muscle strength + activation Change muscle strength + activation Change landing / Pivoting patterns Change landing / Pivoting patterns Sportmetrics Sportmetrics PEP PEP

23 Prevention: shoe wear Shoes with lower ACL injury risk: Shoes with lower ACL injury risk: Cleats flat, all the same size on forefoot Cleats flat, all the same size on forefoot Screw in cleats with 0.5in ht/diameter cleats Screw in cleats with 0.5in ht/diameter cleats Pivot disk: 10-cm circular edge on sole of forefoot Pivot disk: 10-cm circular edge on sole of forefoot Flat shoes on turf Flat shoes on turf Want balance of too much / too little traction Want balance of too much / too little traction Lambson 1996 AJSM

24 Prevention Improve playing field???? Improve playing field????

25 Bracing Several studies Several studies Inconclusive results Inconclusive results No change in muscle activation patterns No change in muscle activation patterns No ACL shown in any study No ACL shown in any study Loads placed on brace during play exceeds brace Loads placed on brace during play exceeds brace BUT, many kids who have had ACL surgery FEEL more stable in brace BUT, many kids who have had ACL surgery FEEL more stable in brace

26 Training Programs Balance board training Balance board training Improves balance + joint position sense Improves balance + joint position sense Caraffa, 1996, Knee Surg Sports Traum Arthrosc Caraffa, 1996, Knee Surg Sports Traum Arthrosc 20 min training sessions 20 min training sessions 87% ACL injuries 87% ACL injuries 7x injury 7x injury

27 Training Programs Frappier Acceleration Training Program Frappier Acceleration Training Program Frappier Acceleraton, Fargo, North Dakota Frappier Acceleraton, Fargo, North Dakota Heidt, 2000, Amer Orthop Soc Sports Med Heidt, 2000, Amer Orthop Soc Sports Med 7 wk preseason training: 3d/wk 7 wk preseason training: 3d/wk 2d/wk treadmill sessions 2d/wk treadmill sessions 1d/wk plyometric (jump training) 1d/wk plyometric (jump training) d total # serious knee injuries d total # serious knee injuries ACL d but not significantly ACL d but not significantly

28 Training Programs Sportmetrics Sportmetrics Hewett, 1999, Amer J Sports Med Hewett, 1999, Amer J Sports Med Cinicinnati Sportsmedicine Research and Education Foundation Cinicinnati Sportsmedicine Research and Education Foundation PEP (Prevent injury Enhance Performance) PEP (Prevent injury Enhance Performance) Mandelbaum, 2005, Amer J Sports Med Mandelbaum, 2005, Amer J Sports Med Santa Monica Orthopedic and Sports Medicine Research Foundation Santa Monica Orthopedic and Sports Medicine Research Foundation

29 Program Goals Emphasize proper jump/land techniques Emphasize proper jump/land techniques Land on balls of feet Land on balls of feet Soft landing Soft landing Toe-to-heel rocking of the foot Toe-to-heel rocking of the foot ground reactive forces ground reactive forces Knees flexed Knees flexed Knees forward Knees forward Discourage inward buckling of knees (knock-kneed landing) Discourage inward buckling of knees (knock-kneed landing) Chest over knees Chest over knees Hewett 1999 AJSM, Mandelbaum 2005 AJSM, Boden 2000 Physportsmed

30 Training Programs Sportmetrics Sportmetrics 6 week Preseason-training program 6 week Preseason-training program 60 – 90 minute work-out 60 – 90 minute work-out PEP PEP 15 minute work-out 15 minute work-out Use in place of usual pre-practice warm-up 3 d/wk Use in place of usual pre-practice warm-up 3 d/wk

31 PEP Program Warm-up Warm-up Jog 50yd Jog 50yd Shuttle run 50yd Shuttle run 50yd Backward run 50yd Backward run 50yd Stretch Stretch Calf, quad, ham, inner thigh, hip flexor Calf, quad, ham, inner thigh, hip flexor 2 x 30s each 2 x 30s each Designed to replace usual warm-up Designed to replace usual warm-up Mandelbaum 2005 AJSM correct incorrect

32 PEP Program Strength Strength Walking lunges 20yd x 2 Walking lunges 20yd x 2 Russian hamstr 30s Russian hamstr 30s Single toe raise 30x Single toe raise 30x Mandelbaum 2005 AJSM

33 PEP Program Plyometrics Plyometrics Lateral hops 30s Lateral hops 30s Forward hops 30s Forward hops 30s Single leg hops 30s Single leg hops 30s Vertical jumps 30s Vertical jumps 30s Scissor jumps 30s Scissor jumps 30s Mandelbaum 2005 AJSM

34 PEP Program Agilities Agilities Shuttle run 40yd Shuttle run 40yd Diagonal run 40yd Diagonal run 40yd Bounding run 50yd Bounding run 50yd Knees bent Knees bent Avoid upright position Avoid upright position Mandelbaum 2005 AJSM correct incorrect

35 Sportsmetrics Warm-up: Warm-up: Stretching: 3 sets, 30s each Stretching: 3 sets, 30s each Calf, quad, hamstring, hip flexor, IT Band, low back, posterior deltoids, latissimus, pects/biceps Calf, quad, hamstring, hip flexor, IT Band, low back, posterior deltoids, latissimus, pects/biceps Skipping: 2 laps Skipping: 2 laps Side shuffle: 2 laps Side shuffle: 2 laps

36 Sportsmetrics Hewett 1999 AJSM Phase I: Technique Week 1 Week 2 Wall jumps Tuck jumps Broad jumps: hold landing Squat jumps Double-leg cone jumps 180 jumps Bounding in place 20s20s 5 reps 10s30s/30s20s20s25s25s 10 reps 15 s 30s/30 s 25s25s (Side-side/front-back)

37 Sportsmetrics Phase II Week 3 Week 4 Wall jumps Tuck jumps Jump, jump, jump, vertical jump Squat jumps Bounding for distance Double-leg cone jumps Scissors jump Hop, hop hold landing 30s30s 5 reps 20s 1 run 30s/30s30s 5 rep/leg 30s30s 8 reps 20s 2 runs 30s/30s30s 4 rep/leg Hewett 1999 AJSM

38 Sportsmetrics Phase III Week 5 Week 6 Wall jumps Step, jump up, down, vertical Mattress jumps Mattress jumps (Side-side/front-back) Single-leg jumps distance Squat jumps Jump into bounding Hop, hop, hold landing 30s 5 reps 30s/30s 5 reps/leg 25s 3 runs 5 reps/leg 30s 10 reps 30s/30s 5 reps/leg 25s 4 runs 5 reps/leg

39 Jump Definitions 180 jumps: 2-footed, rotate 180 in the air 180 jumps: 2-footed, rotate 180 in the air Bound for distance: start bounding in place, increase distance with each step, knees high Bound for distance: start bounding in place, increase distance with each step, knees high Broad jumps-hold landing: 2-footed jump, as far as possible hold landing 5s Broad jumps-hold landing: 2-footed jump, as far as possible hold landing 5s Cone jumps: double leg, side-side, front-back Cone jumps: double leg, side-side, front-back Hop, hop, stick: single leg hop, stick landing 5s Hop, hop, stick: single leg hop, stick landing 5s Jump into bounding: 2-footed jump, land on 1 leg, progress into bounding for distance Jump into bounding: 2-footed jump, land on 1 leg, progress into bounding for distance Jump, jump, jump, vertical: 3 broad jumps with vertical jump after last broad jump Jump, jump, jump, vertical: 3 broad jumps with vertical jump after last broad jump Mattress jumps: 2-footed jump on mattress/tramp, side-side + front-back Mattress jumps: 2-footed jump on mattress/tramp, side-side + front-back Hewett 1999 AJSM

40 Jump Definitions Scissors jump: start in stride position, one foot in front of other, jump up alternating foot position in air Scissors jump: start in stride position, one foot in front of other, jump up alternating foot position in air Single-leg jumps, distance: single-leg hop for distance, hold landing 5s Single-leg jumps, distance: single-leg hop for distance, hold landing 5s Squat jumps: standing jump, raise arms overhead, land in squat position hands on floor Squat jumps: standing jump, raise arms overhead, land in squat position hands on floor Step, jump up, down, vertical: 2-footed jump onto step, jump off with 2 feet, then vertical jump Step, jump up, down, vertical: 2-footed jump onto step, jump off with 2 feet, then vertical jump Tuck jump: standing, bring both knees up to chest, repeat Tuck jump: standing, bring both knees up to chest, repeat Wall jumps: ankle bounces, arms overhead bounce up/down off of toes Wall jumps: ankle bounces, arms overhead bounce up/down off of toes Hewett 1999 AJSM

41 Sportsmetrics Weight-training: 12 reps upper body, 15 lower Weight-training: 12 reps upper body, 15 lower Abdominal curl Abdominal curl Back hyperextension Back hyperextension Leg press Leg press Calf raises Calf raises Pullover Pullover Bench press Bench press Lat pull downs Lat pull downs Forearm curl Forearm curl Warm-down, stretch Warm-down, stretch Hewett 1999 AJSM

42 Training Programs Both PEP and Sportmetrics well studied Both PEP and Sportmetrics well studied Aim: Aim: Change landing / pivoting patterns Change landing / pivoting patterns Flex knees more Flex knees more Stop over several steps instead of sudden stop Stop over several steps instead of sudden stop Improve hamstring strength + activation Improve hamstring strength + activation BOTH prevent ACL + other serious knee injury by achieving these aims BOTH prevent ACL + other serious knee injury by achieving these aims

43 Goals Emphasize proper landing technique Emphasize proper landing technique WRONGRIGHT

44 Proper landing Before Training Before Training After training Barber-Westin, 2006, AJSM; Noyes 2005 AJSM

45 Decreased Injury d non-contact injuries in trained groups d non-contact injuries in trained groups Sportsmetrics Hewett 1999 AJSM PEP Mandelbaum 2005 AJSM UT: Untrained T: Trained MC: Male Control

46 Performance Enhancement vertical jump vertical jump 10% jump height 10% jump height strength strength 44% hamstring strength 44% hamstring strength sprint speed sprint speed Improved power endurance Improved power endurance Improved running economy Improved running economy Diallo JSMPF 2001, Turner JSCR 2003, Siegler JSCR 2003, Spurs EJAP 2003, Newton MSSE Witzke MSSE 2000, Hewett 1999 AJSM

47 Improved Bone Density Female athletes participating in jump training build more bone Female athletes participating in jump training build more bone risk for stress fracture risk for stress fracture Prevent time lost from injury Prevent time lost from injury risk for osteoporosis later in life risk for osteoporosis later in life

48 References Barber-Westin SD et al. Jump-Land Characteristics and muscle strength development in young athletes. Amer J Sports Med. 2006: 34(3)1-10 Barber-Westin SD et al. Jump-Land Characteristics and muscle strength development in young athletes. Amer J Sports Med. 2006: 34(3)1-10 Boden BP et al. Etiology and prevention of noncontact ACL injury. PhysSportsMed. 2000: 29(4) Boden BP et al. Etiology and prevention of noncontact ACL injury. PhysSportsMed. 2000: 29(4) Caraffa A et al. Prevention of anterior cruciate ligament injuries in soccer: a prospective controlled study of proprioceptive training. KneeSurgSportsTraumatolArthrosc. 1996:4:19-36 Caraffa A et al. Prevention of anterior cruciate ligament injuries in soccer: a prospective controlled study of proprioceptive training. KneeSurgSportsTraumatolArthrosc. 1996:4:19-36 Heidt RS et al. Avoidance of soccer injuries with preseason conditioning. AmJSportsMed. 2000: 28(5) Heidt RS et al. Avoidance of soccer injuries with preseason conditioning. AmJSportsMed. 2000: 28(5) Hewett TE et al. The effect of neuromuscular training on the incidence of knee injury in female athletes: a prospective study. Amer J Sports Med (6) Hewett TE et al. The effect of neuromuscular training on the incidence of knee injury in female athletes: a prospective study. Amer J Sports Med (6) Lambson RB et al. Football cleat design and its effect on anterior cruciate ligament injuries: a 3-yr prospective study. AmJSportsMed.1996:24(2)155-9 Lambson RB et al. Football cleat design and its effect on anterior cruciate ligament injuries: a 3-yr prospective study. AmJSportsMed.1996:24(2)155-9

49 References Mandelbaum BR, Silvers HJ, Watanabe DS. Effectiveness of a neuromusclular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: a 2-year follow-up. Amer J Sports Med. 2005: 33(7) Mandelbaum BR, Silvers HJ, Watanabe DS. Effectiveness of a neuromusclular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: a 2-year follow-up. Amer J Sports Med. 2005: 33(7) Noyes et al. The Drop-Jump Screening Test. Amer J Sports Med. 2005: 33(2) Noyes et al. The Drop-Jump Screening Test. Amer J Sports Med. 2005: 33(2)


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