ACL PreventionACL Prevention

Amanda KW Kelly, MDAmanda KW Kelly, MD

Case Western Reserve UniversityCase Western Reserve University

Rainbow Babies and Children’s Rainbow Babies and Children’s HospitalHospital

OutlineOutline

BackgroundBackground Injury risk factorsInjury risk factors ACL prevention programsACL prevention programs

BackgroundBackground

250,000 ACL injuries/yr in USA250,000 ACL injuries/yr in USA $1.5 billion annual cost$1.5 billion annual cost

80 - 90% return to previous level of 80 - 90% return to previous level of playplay Typical recovery 6-9 moTypical recovery 6-9 mo

> 70% ACL injuries are NON-contact > 70% ACL injuries are NON-contact

Boden 2000 Physspportsmed

Importance of ACL InjuryImportance of ACL Injury Season ending injurySeason ending injury

6-9 mo recovery time6-9 mo recovery time Children often must wait several yrs for Children often must wait several yrs for

repairrepair CostlyCostly

ACL AnatomyACL Anatomy

ACL

MCL

LCL

PCL

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

femurfemur

Injury MechanismsInjury Mechanisms

PivotPivot Landing from Landing from

jumpjump Contact Contact

http://sportzfun.com/v-web/gallery/slideshow.php?set_albumName=soccer

Injury Mechanism: PivotInjury Mechanism: Pivot Deceleration + change of direction, foot Deceleration + change of direction, foot

plantedplanted Causes twisting injury of kneeCauses twisting injury of knee Traction at shoe/playing surface interfaceTraction at shoe/playing surface interface Often close to another playerOften close to another player

ACL

Mechanism: PivotMechanism: Pivot

Importance of Importance of ground-shoe ground-shoe surface interface surface interface in pivot in pivot mechanismmechanism

Shoe surface interface

Mechanism: landing Mechanism: landing Knee slightly flexed on landingKnee slightly flexed on landing Quad pulls tibia forwardQuad pulls tibia forward

Mechanism: ContactMechanism: Contact Hit on outside of legHit on outside of leg Foot plantedFoot planted Twisting of kneeTwisting of knee

Mechanism Mechanism

Pivoting with knee slightly bent, Pivoting with knee slightly bent, twisting kneetwisting knee

Landing from jump: knees slightly Landing from jump: knees slightly bent, quads pull tibia forward bent, quads pull tibia forward

Too much shoe tractionToo much shoe traction Poor balancePoor balance Uneven ground throwing off balanceUneven ground throwing off balance

Risk FactorsRisk Factors

Poor landing + pivot stylePoor landing + pivot style Stronger quads than hamstringsStronger quads than hamstrings Shoe / playing surface interfaceShoe / playing surface interface Playing surface qualityPlaying surface quality Female genderFemale gender

Risk FactorsRisk Factors Landing / Pivoting with knee slightly Landing / Pivoting with knee slightly

bentbent Places ACL in vulnerable positionPlaces ACL in vulnerable position Additional torsion/twisting can Additional torsion/twisting can injury injury

Boden 2000 Physsportsmed

Risk FactorsRisk Factors Hamstring/Quadriceps Hamstring/Quadriceps

imbalanceimbalance Poor hamstring strengthPoor hamstring strength

Hamstrings protect ACLHamstrings protect ACL Quads stretch/stress ACLQuads stretch/stress ACL

Slow activation of hamstring Slow activation of hamstring muscles with pivot / landingmuscles with pivot / landing

http://www.preventaclinjury.com/knee_biomechanics.htm

Hewett AJSM 1999, Crosier AJSM 2002, Huston 1996 AJSM, Orchard AJSM 1997, Baratta AJSM 1988

Risk FactorsRisk Factors FootwearFootwear

Longer cleats at edge of sole with fewer, Longer cleats at edge of sole with fewer, smaller cleats in the middle of the solesmaller cleats in the middle of the sole ’’s torsional resistances torsional resistance

Lambson 1996 AJSM

Risk FactorRisk Factor Uneven playing surfaceUneven playing surface

Unexpected foot position may Unexpected foot position may change muscle activation patternschange muscle activation patterns

Balance thrown offBalance thrown off

Boden, Orthopedics

Risk FactorsRisk Factors Female GenderFemale Gender

2-8x more common in girls2-8x more common in girls Poor ham:quad strengthPoor ham:quad strength Activate hams more slowly Activate hams more slowly Land with knees sl bentLand with knees sl bent

Boys land with knees more bentBoys land with knees more bent

Female GenderFemale Gender

Hormonal InfluencesHormonal Influences ACL has estrogen receptorsACL has estrogen receptors Estrogen can Estrogen can ligament looseness ligament looseness Estrogen levels Estrogen levels in girls compared to boys in girls compared to boys Estrogen Estrogen ’d at specific times in menstrual ’d at specific times in menstrual

cyclecycle Studies VERY inconsistent Studies VERY inconsistent Every phase of cycle has been implicated Every phase of cycle has been implicated

in at least 1 studyin at least 1 study

Female GenderFemale Gender

Knee anatomyKnee anatomy Smaller intercondylar Smaller intercondylar

notchnotch ACL may get stretched ACL may get stretched

across bone and tornacross bone and torn Athletes with bilateral Athletes with bilateral

ACL injuries have ACL injuries have smaller ICN smaller ICN

Harner 1994 AJSM, Anderson 1999 AOSSM www.hughston.com

Female GenderFemale Gender

Lower extremity Lower extremity alignmentalignment Women more knock-kneedWomen more knock-kneed May allow quad to exert May allow quad to exert

more stress on ACLmore stress on ACL Data not greatData not great

www.hughston.comNisell 1985 ActaOrthopScandSuppl

Prevention StrategiesPrevention Strategies

Shoe wear / field surfaceShoe wear / field surface BracingBracing Exercise ProgramsExercise Programs

Change muscle strength + activationChange muscle strength + activation Change landing / Pivoting patternsChange landing / Pivoting patterns

SportmetricsSportmetrics PEPPEP

Prevention: shoe wearPrevention: shoe wear Shoes with lower ACL injury risk:Shoes with lower ACL injury risk:

Cleats flat, all the same size on forefootCleats flat, all the same size on forefoot Screw in cleats with 0.5in ht/diameter cleatsScrew in cleats with 0.5in ht/diameter cleats Pivot disk: 10-cm circular edge on sole of forefootPivot disk: 10-cm circular edge on sole of forefoot Flat shoes on turfFlat shoes on turf

Want balance of too much / too little tractionWant balance of too much / too little traction

Lambson 1996 AJSM

PreventionPrevention

Improve playing field????Improve playing field????

BracingBracing Several studies Several studies

Inconclusive resultsInconclusive results No change in muscle No change in muscle

activation patternsactivation patterns No No ACL shown in any study ACL shown in any study

Loads placed on brace during Loads placed on brace during play exceeds braceplay exceeds brace

BUT, many kids who have BUT, many kids who have had ACL surgery had ACL surgery FEELFEEL more more stable in bracestable in brace

Training ProgramsTraining Programs Balance board trainingBalance board training

Improves balance + joint position senseImproves balance + joint position sense Caraffa, 1996, Knee Surg Sports Traum Caraffa, 1996, Knee Surg Sports Traum

ArthroscArthrosc 20 min training sessions20 min training sessions 87% 87% ACL injuries ACL injuries

7x 7x injury injury

Training ProgramsTraining Programs

Frappier Acceleration Training ProgramFrappier Acceleration Training Program Frappier Acceleraton, Fargo, North DakotaFrappier Acceleraton, Fargo, North Dakota Heidt, 2000, Amer Orthop Soc Sports MedHeidt, 2000, Amer Orthop Soc Sports Med 7 wk preseason training: 3d/wk7 wk preseason training: 3d/wk

2d/wk treadmill sessions2d/wk treadmill sessions 1d/wk plyometric (jump training)1d/wk plyometric (jump training)

’’d total # serious knee injuriesd total # serious knee injuries ACL ACL ’d but not significantly’d but not significantly

Training ProgramsTraining Programs SportmetricsSportmetrics

Hewett, 1999, Amer J Sports MedHewett, 1999, Amer J Sports Med Cinicinnati Sportsmedicine Research and Cinicinnati Sportsmedicine Research and

Education FoundationEducation Foundation

PEPPEP (Prevent injury Enhance Performance) (Prevent injury Enhance Performance) Mandelbaum, 2005, Amer J Sports MedMandelbaum, 2005, Amer J Sports Med Santa Monica Orthopedic and Sports Medicine Santa Monica Orthopedic and Sports Medicine

Research FoundationResearch Foundation

Program GoalsProgram Goals Emphasize proper jump/land Emphasize proper jump/land

techniquestechniques Land on balls of feetLand on balls of feet

Soft landing Soft landing Toe-to-heel rocking of the footToe-to-heel rocking of the foot

ground reactive forcesground reactive forces Knees flexedKnees flexed Knees forwardKnees forward

Discourage inward buckling of knees Discourage inward buckling of knees (knock-kneed landing)(knock-kneed landing)

Chest over kneesChest over knees

www.physsportsmed.comHewett 1999 AJSM, Mandelbaum 2005 AJSM, Boden 2000 Physportsmed

Training ProgramsTraining Programs

SportmetricsSportmetrics 6 week Preseason-training program6 week Preseason-training program 60 – 90 minute work-out60 – 90 minute work-out

PEPPEP 15 minute work-out15 minute work-out Use in place of usual pre-practice warm-up 3 Use in place of usual pre-practice warm-up 3

d/wkd/wk

PEP ProgramPEP Program

Warm-upWarm-up Jog 50ydJog 50yd Shuttle run 50ydShuttle run 50yd Backward run 50ydBackward run 50yd

StretchStretch Calf, quad, ham, Calf, quad, ham,

inner thigh, hip inner thigh, hip flexor flexor

2 x 30s each2 x 30s each

Designed to replace usual warm-upDesigned to replace usual warm-up

Mandelbaum 2005 AJSM

correct incorrect

PEP ProgramPEP Program StrengthStrength

Walking lunges 20yd x Walking lunges 20yd x 22

Russian hamstr 30sRussian hamstr 30s Single toe raise 30xSingle toe raise 30x

Mandelbaum 2005 AJSM

PEP ProgramPEP Program

PlyometricsPlyometrics Lateral hops 30sLateral hops 30s Forward hops 30sForward hops 30s Single leg hops 30sSingle leg hops 30s Vertical jumps 30sVertical jumps 30s Scissor jumps 30sScissor jumps 30s

Mandelbaum 2005 AJSM

PEP ProgramPEP Program AgilitiesAgilities

Shuttle run 40ydShuttle run 40yd Diagonal run Diagonal run

40yd40yd Bounding run Bounding run

50yd50yd Knees bentKnees bent

Avoid upright Avoid upright positionposition

Mandelbaum 2005 AJSM

correct incorrect

SportsmetricsSportsmetrics

Warm-up:Warm-up: Stretching: 3 sets, 30s eachStretching: 3 sets, 30s each

Calf, quad, hamstring, hip flexor, IT Calf, quad, hamstring, hip flexor, IT Band, low back, posterior deltoids, Band, low back, posterior deltoids, latissimus, pects/bicepslatissimus, pects/biceps

Skipping: 2 lapsSkipping: 2 laps Side shuffle: 2 lapsSide shuffle: 2 laps

SportsmetricsSportsmetrics

Hewett 1999 AJSM

Phase I: TechniquePhase I: Technique Week Week 11

Week Week 22

Wall jumpsWall jumps

Tuck jumpsTuck jumps

Broad jumps: hold landingBroad jumps: hold landing

Squat jumpsSquat jumps

Double-leg cone jumpsDouble-leg cone jumps

180180 jumps jumps

Bounding in placeBounding in place

20s20s

20s20s

5 reps5 reps

10s10s

30s/30s/30s30s

20s20s

20s20s

25s25s

25s25s

10 10 repsreps

15 s15 s

30s/30s/3030ss

25s25s

25s25s

(Side-side/front-back)

SportsmetricsSportsmetricsPhase IIPhase II Week 3Week 3 Week 4Week 4

Wall jumpsWall jumps

Tuck jumpsTuck jumps

Jump, jump, jump, vertical Jump, jump, jump, vertical jumpjump

Squat jumpsSquat jumps

Bounding for distanceBounding for distance

Double-leg cone jumps Double-leg cone jumps

Scissors jumpScissors jump

Hop, hop hold landingHop, hop hold landing

30s30s

30s30s

5 reps5 reps

20s20s

1 run1 run

30s/30s30s/30s

30s30s

5 5 rep/legrep/leg

30s30s

30s30s

8 reps8 reps

20s20s

2 runs2 runs

30s/30s30s/30s

30s30s

4 4 rep/legrep/leg

Hewett 1999 AJSM

SportsmetricsSportsmetrics

Hewett 1999 AJSM

Phase IIIPhase III Week 5Week 5 Week 6Week 6

Wall jumpsWall jumpsStep, jump up, down, Step, jump up, down, verticalverticalMattress jumps Mattress jumps (Side-side/front-back)

Single-leg jumps distanceSingle-leg jumps distance

Squat jumpsSquat jumps

Jump into boundingJump into bounding

Hop, hop, hold landingHop, hop, hold landing

30s30s

5 reps5 reps

30s/30s30s/30s

5 5 reps/legreps/leg

25s25s

3 runs 3 runs

5 5 reps/legreps/leg

30s30s

10 reps10 reps

30s/30s30s/30s

5 5 reps/legreps/leg

25s25s

4 runs4 runs

5 5 reps/legreps/leg

Jump DefinitionsJump Definitions 180180 jumps: 2-footed, rotate 180 jumps: 2-footed, rotate 180 in the air in the air Bound for distance: start bounding in place, increase Bound for distance: start bounding in place, increase

distance with each step, knees highdistance with each step, knees high Broad jumps-hold landing: 2-footed jump, as far as Broad jumps-hold landing: 2-footed jump, as far as

possible hold landing 5spossible hold landing 5s Cone jumps: double leg, side-side, front-backCone jumps: double leg, side-side, front-back Hop, hop, stick: single leg hop, stick landing 5sHop, hop, stick: single leg hop, stick landing 5s Jump into bounding: 2-footed jump, land on 1 leg, Jump into bounding: 2-footed jump, land on 1 leg,

progress into bounding for distanceprogress into bounding for distance Jump, jump, jump, vertical: 3 broad jumps with vertical Jump, jump, jump, vertical: 3 broad jumps with vertical

jump after last broad jumpjump after last broad jump Mattress jumps: 2-footed jump on mattress/tramp, Mattress jumps: 2-footed jump on mattress/tramp,

side-side + front-backside-side + front-back

Hewett 1999 AJSM

Jump DefinitionsJump Definitions Scissors jump: start in stride position, one foot in front Scissors jump: start in stride position, one foot in front

of other, jump up alternating foot position in airof other, jump up alternating foot position in air Single-leg jumps, distance: single-leg hop for distance, Single-leg jumps, distance: single-leg hop for distance,

hold landing 5shold landing 5s Squat jumps: standing jump, raise arms overhead, Squat jumps: standing jump, raise arms overhead,

land in squat position hands on floorland in squat position hands on floor Step, jump up, down, vertical: 2-footed jump onto step, Step, jump up, down, vertical: 2-footed jump onto step,

jump off with 2 feet, then vertical jumpjump off with 2 feet, then vertical jump Tuck jump: standing, bring both knees up to chest, Tuck jump: standing, bring both knees up to chest,

repeatrepeat Wall jumps: ankle bounces, arms overhead bounce Wall jumps: ankle bounces, arms overhead bounce

up/down off of toesup/down off of toes

Hewett 1999 AJSM

SportsmetricsSportsmetrics Weight-training: Weight-training: 12 reps upper body, 15 lower12 reps upper body, 15 lower

Abdominal curlAbdominal curl Back hyperextensionBack hyperextension Leg pressLeg press Calf raisesCalf raises PulloverPullover Bench pressBench press Lat pull downsLat pull downs Forearm curlForearm curl Warm-down, stretchWarm-down, stretch

Hewett 1999 AJSMhttp://www.sportsmetrics.net/

Training ProgramsTraining Programs

Both PEP and Sportmetrics well studiedBoth PEP and Sportmetrics well studied Aim:Aim:

Change landing / pivoting patternsChange landing / pivoting patterns Flex knees moreFlex knees more Stop over several steps instead of sudden Stop over several steps instead of sudden

stopstop Improve hamstring strength + activationImprove hamstring strength + activation

BOTH prevent ACL + other serious BOTH prevent ACL + other serious knee injury by achieving these aimsknee injury by achieving these aims

GoalsGoals

Emphasize proper landing techniqueEmphasize proper landing technique

WRONGRIGHT

Proper landingProper landing

Before TrainingBefore Training After trainingAfter training

Barber-Westin, 2006, AJSM; Noyes 2005 AJSM

Decreased InjuryDecreased Injury ’’d non-contact injuries in trained d non-contact injuries in trained

groupsgroups

SportsmetricsHewett 1999 AJSM

0.05

0

0.35

PEPMandelbaum 2005 AJSM

UT: UntrainedT: TrainedMC: Male Control

0.09

0.47

Performance Performance EnhancementEnhancement

vertical jumpvertical jump 10% 10% jump height jump height

strengthstrength 44% 44% hamstring strength hamstring strength

sprint speedsprint speed Improved power enduranceImproved power endurance Improved running economyImproved running economy

Diallo JSMPF 2001, Turner JSCR 2003, Siegler JSCR 2003, Spurs EJAP 2003, Newton MSSE 1999. Witzke MSSE 2000, Hewett 1999 AJSM

Improved Bone DensityImproved Bone Density

Female athletes participating in jump Female athletes participating in jump training build more bonetraining build more bone risk for stress fracturerisk for stress fracture

Prevent time lost from injuryPrevent time lost from injury risk for osteoporosis later in liferisk for osteoporosis later in life

ReferencesReferences Barber-Westin SD et al. Jump-Land Characteristics and muscle Barber-Westin SD et al. Jump-Land Characteristics and muscle

strength development in young athletes. Amer J Sports Med. 2006: strength development in young athletes. Amer J Sports Med. 2006: 34(3)1-1034(3)1-10

Boden BP et al. Etiology and prevention of noncontact ACL injury. Boden BP et al. Etiology and prevention of noncontact ACL injury. PhysSportsMed. 2000: 29(4)PhysSportsMed. 2000: 29(4)

Caraffa A et al. Prevention of anterior cruciate ligament injuries in Caraffa A et al. Prevention of anterior cruciate ligament injuries in soccer: a prospective controlled study of proprioceptive training. soccer: a prospective controlled study of proprioceptive training. KneeSurgSportsTraumatolArthrosc. 1996:4:19-36KneeSurgSportsTraumatolArthrosc. 1996:4:19-36

Heidt RS et al. Avoidance of soccer injuries with preseason Heidt RS et al. Avoidance of soccer injuries with preseason conditioning. AmJSportsMed. 2000: 28(5)659-62conditioning. AmJSportsMed. 2000: 28(5)659-62

Hewett TE et al. The effect of neuromuscular training on the Hewett TE et al. The effect of neuromuscular training on the incidence of knee injury in female athletes: a prospective study. incidence of knee injury in female athletes: a prospective study. Amer J Sports Med 1999. 27(6) 699-706Amer J Sports Med 1999. 27(6) 699-706

Lambson RB et al. Football cleat design and its effect on anterior Lambson RB et al. Football cleat design and its effect on anterior cruciate ligament injuries: a 3-yr prospective study. cruciate ligament injuries: a 3-yr prospective study. AmJSportsMed.1996:24(2)155-9AmJSportsMed.1996:24(2)155-9

ReferencesReferences Mandelbaum BR, Silvers HJ, Watanabe DS. Mandelbaum BR, Silvers HJ, Watanabe DS.

Effectiveness of a neuromusclular and proprioceptive Effectiveness of a neuromusclular and proprioceptive training program in preventing anterior cruciate training program in preventing anterior cruciate ligament injuries in female athletes: a 2-year follow-ligament injuries in female athletes: a 2-year follow-up. Amer J Sports Med. 2005: 33(7) 1003-9up. Amer J Sports Med. 2005: 33(7) 1003-9

Noyes et al. The Drop-Jump Screening Test. Amer J Noyes et al. The Drop-Jump Screening Test. Amer J Sports Med. 2005: 33(2)197-207Sports Med. 2005: 33(2)197-207