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Can We Prevent ACL Can We Prevent ACL Injuries?Injuries?

Texas Girls Coaches Association Texas Girls Coaches Association 2011 Summer Clinic 2011 Summer Clinic

Randy Brewer MS, PES, CESrbrewer413@hotmail.com817-368-3578

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One Mother’s PerspectiveOne Mother’s Perspective

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Our Situation?Our Situation?

Female athletes are injuring knees at an alarming rate.

We have been aware of the ACL issue for close to 20 years but have yet to make a big dent in the injury rate.

Lack of “coach friendly” assessment tools in the field that could be used to potentially identify “at risk” athletes.

Haven’t implemented a wide scale program for training female athletes to reduce ACL injury rate.

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Female AthletesFemale Athletes

As they mature: Up to 8 more times likely to tear their ACL’s Changes during pubertal process negatively effect

neuromuscular control (Hewett et al, JBJS 2004) Land differently from a jump than boys (Hewlett, et al,

JBJS 2004) Increase quadriceps strength greater than hamstring

strength (Ahmad et al, AJSM 2005) Exhibit less muscular protection of knee ligaments

during external loading (Wojtys et al, JBJS 2003) Aggressive quadriceps loading with the knee in slight

flexion can produce significant anterior tibial translation ie. ACL injury! (De Morat et al, AJSM 2004)

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BackgroundBackground

Musculoskeletal growth during puberty, in the absence of corresponding neuromuscular adaptation, may facilitate the development of certain intrinsic ACL injury risk factors.

Lack of core proprioception and decrease lumbo-pelvic strength has been implicated as a major risk factor for the female athlete.

Core stabilization appears to be just as much about neuromuscular control as it is about strength.

Up to 80% of ACL injuries are “non-contact” in nature and many may be preventable.

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Why the Concern?Why the Concern?

How does the ACL get stressed

Lack of proprioception and kinesthesia lead to increased stress on the ACL during functional loading activities

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Non Contact MechanismNon Contact Mechanism

Mechanism of injury NonContact (80%) vs Contact (20%)

Non contact forceful valgus collapse in near full extension with rotation of the tibia (internal or external)

Deceleration plant and twist with foot fixed

Higher risk with turf High risk sports:

Soccer Basketball Football

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Etiological TheoriesEtiological Theories

Anatomical Q-angle Narrow Intercondylar notch Thigh length

Hormonal Collagen strength Joint laxity

Neuromuscular Ligament Dominance Quadriceps Dominance Leg Dominance Trunk Dominance “Core” Dysfunction

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Neuromuscular IssuesNeuromuscular Issues Ligament Dominance

Imbalance between neuromuscular and ligamentous control of dynamic knee stability (lack of shock absorption)

Quadriceps Dominance Imbalance between quad and hamstring

strength, recruitment and coordination Leg Dominance

Imbalance between the two legs with respect to strength, coordination and control (many times from previous injury)

Trunk Dominance “Core” Dysfunction Imbalance between the inertial demands of the

trunk and control and coordination to resist it. Knee is “dumb joint” stuck in the middle of

the hip and ankle (“It’s not my fault!)

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What does the research What does the research say?say? Decrease in Neuromuscular Control with

Pubertal Growth Spurt (Hewett et al, JBJS 2004)

Core Stability Measures as Risk Factors for Lower Extremity Injury in Athletes (Leetun et al, MSSE 2004)

Deficits in Neuromuscular Control of the Trunk Predict Knee Injury Risk (Zazulak et al, AJSM 2007)

The Drop-Jump Video Screening Test: Retention of Improvement in Neuromuscular Control in Female Volleyball Players (Barber-Westin et al, JSCR 2010)

A Training Program to Improve Neuromuscular Indices in Female High School Volleyball Players (Noyes et al, JSCR 2011)

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What does the research What does the research say about screening?say about screening?

Biomechanical Measures Predict ACL Risk in Female Athletes (Hewett et al, AJSM 2005)

Two Dimensional Analysis Screening and Evaluation Tool (McLean et al, BJSM 2005)

Correlation Between two-dimensional Video Analysis and Subjective Assessment in Evaluating Knee Control Among Elite Female Team Handball Players (Stensrud et al, BJSM 2010)

Real-Time Assessment and Neuromuscular Training Feedback Techniques to Prevent Anterior Cruciate Ligament Injury in Female Athletes (Myer et al, Strength and Conditioning Journal 2011)

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Three Pronged Approach Three Pronged Approach to Preventing ACL Injuries to Preventing ACL Injuries

Injury Risk Screening Intervention Dynamic Neuromuscular

Training

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RecommendationsRecommendations Implement Wide Spread Injury Prevention

Programs for Female Athletes Focus on ages 12 and up

Injury Risk Increases at onset of Puberty Individual Orthopedic and Functional Injury

Risk Assessments Identify “at risk” athletes Injury History Review

Implement injury prevention warm-up Implement “functional” strength

program (in-season and off-season) designed to

Correct biomechanical dysfunction Strengthen and improve core function Improve overall performance and athleticism Improve neuromuscular control

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RecommendationsRecommendations Injury History Review (previous injury is a

big predictor of future injury) – Smoke Alarm!! Low Back Pain Ankle Sprains Knee Pain Unilateral hip pain/discomfort or muscle pulls

Perform Orthopedic and Functional Injury Risk Assessments Performance Enhancement Specialists Athletic Trainers Physical Therapists

“Every Nerve and Fiber” When your determination changes, everything

will begin to move in the direction you desire. The moment you resolve to be victorious, every nerve and fiber in your being will immediately orient itself toward your success.

Daisaku Ikeda

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Functional ScreenFunctional Screen

Bi-Lateral Squat technique Single leg squat technique Balance reach tests

Lower quarter Upper quarter

Vertical Drop Jump Repeat Tuck Jumps

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Bi-Lateral Squat Bi-Lateral Squat

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Single Leg SquatSingle Leg Squat

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Vertical Drop JumpVertical Drop Jump

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Tuck Jump ScreenTuck Jump Screen

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Orthopedic Screen - Orthopedic Screen - InterventionIntervention

Previous Injuries Screen for biomechanical

deficiencies SI dysfunction Ankle mobility Hip mobility

Knee Pain Back Pain Muscular Injuries

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Training ProgramTraining Program

Corrective Soft Tissue Work Core Activation Core Strength Dynamic Warm-Up Injury Prevention – Neuromuscular

Control Performance Training – Vertical

Jump, Agility, Speed, Explosion Strength – Multi-Planar Strength Flexibility

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Core Activation - StrengthCore Activation - Strength

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Core Activation - StrengthCore Activation - Strength

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Core Activation - StrengthCore Activation - Strength

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Warm-UpWarm-Up

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Neuromuscular ControlNeuromuscular Control

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Neuromuscular ControlNeuromuscular Control

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WorkoutWorkout

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The FutureThe FutureThe ACL Prevention Program Must The ACL Prevention Program Must

Correct Poor Functional Correct Poor Functional Movement Movement

Neuromuscular Control Dynamic Joint Stabilization Rate of Force Production Eccentric Strength Dynamic Flexibility Postural Control Previous Injuries

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The FutureThe FutureThe ACL Prevention Program The ACL Prevention Program

“Must-Haves”“Must-Haves”

Prevention efforts should be included in overall performance enhancement training program

Prevention efforts should be “user/coach friendly” and easily implemented in the field

All athletes should complete functional injury risk assessments

“At Risk” athletes may need medical intervention followed by corrective exercise program

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The FutureThe FutureBiggest Areas “in the field” That Biggest Areas “in the field” That

Can Impact ACL Injury RatesCan Impact ACL Injury Rates

Education and Awareness efforts for parents, athletes, and coaches

Appreciate the significance of previous ankle sprains, knee and back pain, and muscle injuries

Can’t “power-through” dysfunction Piling training on a dysfunctional

athlete creates bigger injury risk Creating dysfunction with poor training

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The FutureThe FutureImplementation Implementation

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