Prevention of ACL Injuries Kambiz Behzadi, M.D Sports Medicine and Reconstructive Surgery

Prevention of ACL Injuries Anterior Cruciate Ligament Injuries: “ACL” Anterior Cruciate Ligament Injuries: “ACL” 100,000 ACL tears every year 100,000 ACL tears every year Majority in 15 to 25 year olds Majority in 15 to 25 year olds Cost to society 1.5 Billion dollars a year Cost to society 1.5 Billion dollars a year Short term, loss of participation and game time Short term, loss of participation and game time Long term, higher chance of arthritis in future Long term, higher chance of arthritis in future

Prevention of ACL injuries Common problem in young athlete Common problem in young athlete Girls more susceptible to injury Girls more susceptible to injury Incidence 2 to 8 times higher in girls Incidence 2 to 8 times higher in girls Why? Why? Is there anything we can do to prevent it? Is there anything we can do to prevent it?

Anatomy Patella, knee cap Patella, knee cap Femur, thigh bone Femur, thigh bone Tibia, lower leg bone Tibia, lower leg bone Fibula, small leg bone Fibula, small leg bone Articular Cartilage Articular Cartilage Meniscal Cartilage Meniscal Cartilage Major Ligaments ACL PCL Major Ligaments ACL PCL ACL PCL Articular Cartilage Meniscal Cartilage

Function Load Bearing.articular cartilage.meniscal cartilage Load Bearing.articular cartilage.meniscal cartilage Ligaments.tightness of the knee.primary stabilizers Ligaments.tightness of the knee.primary stabilizers Muscles.control of the knee.secondary stabilizers Muscles.control of the knee.secondary stabilizers

Mechanism of Injury When the athlete plants his/her leg on the ground the ACL is engaged and the Knee is stable When the athlete plants his/her leg on the ground the ACL is engaged and the Knee is stable Major function = restrict tibia from moving to the front Major function = restrict tibia from moving to the front

Neuromuscular control and Proprioception A Complex array of nerves, muscles, bones, ligaments, and cartilages work together to optimize what we know as sports performance A Complex array of nerves, muscles, bones, ligaments, and cartilages work together to optimize what we know as sports performance Neuromuscular Control: unconscious control of our movements and muscles by our brain stem Neuromuscular Control: unconscious control of our movements and muscles by our brain stem Proprioception: our body’s ability to know where our knees and ankles are in space Proprioception: our body’s ability to know where our knees and ankles are in space

ACL Injury What happens in that one in a million times that the athlete pivots and the ligament tears? What happens in that one in a million times that the athlete pivots and the ligament tears?

What causes ACL tears 70% occur when there is no contact whatsoever 70% occur when there is no contact whatsoever Biomechanical factors Biomechanical factors Body position associated with increased risk of injury Body position associated with increased risk of injury

Body Position “Crouched position”.hips and knees bent.center of gravity over feet.on their toes “Crouched position”.hips and knees bent.center of gravity over feet.on their toes “Upright position”.center of gravity behind knee.flat footed.hips and knees straight “Upright position”.center of gravity behind knee.flat footed.hips and knees straight

Body Position Position of body during landing, cutting, pivoting Position of body during landing, cutting, pivoting Hips and Knees are straight Hips and Knees are straight Landing on flat feet Landing on flat feet This puts ACL at risk This puts ACL at risk In contrast: when athlete has hips and knees bent, and lands on his/her toes, risk of ACL injury is minimized In contrast: when athlete has hips and knees bent, and lands on his/her toes, risk of ACL injury is minimized

Balance of Power Recruittment Pattern Recruittment Pattern Quadriceps muscles antagonist-stress ACL Quadriceps muscles antagonist-stress ACL Hamstring muscles agonist-protect ACL Hamstring muscles agonist-protect ACL Weak hamstrings and strong quadriceps puts ACL at risk Weak hamstrings and strong quadriceps puts ACL at risk Female Quad. dominant Female Quad. dominant Male Hamstring dominant Male Hamstring dominant Hamstrings 60% to 80% as strong as Quadriceps Hamstrings 60% to 80% as strong as Quadriceps Quadriceps Hamstrings

Other Risk Factors Anatomic Anatomic Environmental Environmental Hormonal Hormonal

Anatomic Factors Intercondylar Notch Intercondylar Notch Small notch Small notch Small Ligament size Small Ligament size Alignment of lower leg Alignment of lower leg Intercondylar notch ACL

Environmental Factors Fields Fields Cleat Design Cleat Design

Hormonal Factors Estrogen and Relaxin Estrogen and Relaxin Relax and soft tissues Relax and soft tissues Does this predispose female athlete to ACL injury? Does this predispose female athlete to ACL injury? Increased incidence of ACL tears during ovulatory phase? Increased incidence of ACL tears during ovulatory phase?

Moment of Injury Loud Pop Loud Pop Tibia subluxes forward and pops back in Tibia subluxes forward and pops back in Pain Pain Lie on turf, get comfortable Lie on turf, get comfortable Wait for coaches and trainers Wait for coaches and trainers

ACL Injuries Prevention--Biomechanical Factors critical Prevention--Biomechanical Factors critical Neuromuscular/Proprioceptive programs Neuromuscular/Proprioceptive programs Dramatic reduction in ACL tears Dramatic reduction in ACL tears Plyometric/jump training and Balance drills Plyometric/jump training and Balance drills Retrain mind on body position Retrain mind on body position

Major Studies Mandelbaum, PEP program, 80% reduction of ACL injuires over 2 year in girls playing soccer ages 14 to 18 Mandelbaum, PEP program, 80% reduction of ACL injuires over 2 year in girls playing soccer ages 14 to 18 Carraffa, Balance drills Carraffa, Balance drills Hewett, Jumping drills Hewett, Jumping drills Significant reduction of ACL tears in those who received Neuromuscular training Significant reduction of ACL tears in those who received Neuromuscular training

PEP program Prevent injury Enhance Performance Prevent injury Enhance Performance Simple, no major equipment, soccer ball and cone Simple, no major equipment, soccer ball and cone 2 to 3 times a week 2 to 3 times a week Incorporate into practice sessions Incorporate into practice sessions Retrain your body positioning in space Retrain your body positioning in space It is all about prevention, more time playing and less time on the bench It is all about prevention, more time playing and less time on the bench

PEP PROGRAM