1. health and fitness
2. exercise

ACL Injury & Prevention:
An Epidemic…Who’s at Risk & Why?
Dr. Robert Nielson, MD
Saratoga Family Physicians
Lisa Muscatello, PTA, ATC, CSCS
Regional Therapy Center @ Wilton
Saratoga Hospital
CURRENT
DISCLOSURES
n 
n 
n 
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Fellow AAFP/CAQ SM
School health director
Schuylerville
Argyle
South Glens Falls
Ballston Spa
Galway
CIC
Saratoga Regional Medical
Group Concussion Clinic
§  Saratoga Regional Sports
Medicine
§  USABOXING
n  NYSAC
§  ABRM President
§  ACSM subject matter expert
for ringside certification
ANATOMY AND FUNCTION
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Stabilizing ligament
n  Primary-control
anterior translation
n  Secondary-tibial rotation and varus/valgus stress
n 
2 bundles
n  Anteromedial
tight in flexion
n  Posterolateral tight in flexion
n 
Anatomy
n  Anterior
tibia to lateral meniscus
n  Middle geniculate artery
n  Tibial nerve-posterior articular branch
EPIDEMIOLOGY
100,000-200,000 ruptures per year in US
n  1/3500 people in US ??
n  Majority are non contact
n  53% of the total-NCAA football
n  Highest rate in female gymnasts-1/3000 practices
n  Respective sports incidence-female 3.5: male 2.7
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RISK FACTORS
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Women engaged in pivoting sports
n  Quadriceps
vs hamstring deceleration-weaker/slower
n  Knee anatomy-valgus angle, decreased intercondylar notch, bone length
n  Estrogen effect
Shoe-surface interface-less than 5 % occur on wet surfaces
n  Possibly less in females on birth control pills
n 
MECHANISM AND PRESENTATION
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Noncontact-70%
n  Running
or jumping with sudden deceleration while pivoting
n  Knee in valgus and tibia internally rotated
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Contact-30%
n  Direct
blow causing hyperextension or valgus deformation of knee
HISTORY AND EXAM
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Feel a pop and acute swelling then feeling of giving out
n  Almost
100% have hemarthroisis
n  2/3 of knee trauma patients with hemarthroisis have ACL injury
n 
Examine as soon as possible and compare to opposite leg
n  Lachman-30
degree flexed and shift tibia forward: 85% sn/94% sp
n  Pivot shift-relaxed knee, valgus stress with tibia int. rotated and move
from extension to flexion feeling for subluxing clunk: 24% sn/98% sp
n  Anterior drawer-90 degree flexion while pulling tibia forward: 92%sn/
91% sp
TREATMENT
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Immediate
n  PRICE
and crutches
n  ? NSAIDS
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Operative reconstruction
n  Young,
active and high level athletes
n  Multiple knee structures injured
n  High degree instability
n 
Non operative
n  Older
patients that do not rely on squat or pivot activities
SURGERY RESULTS
90% return to normal knee funtion
n  81% return to some athletic activity
n  65% return to preinjury level (55% in elite athletes)
n  Over age 40 can have good results, but most over age 55 do not
get repaired
n 
NONOPERATIVE RESULTS
0-13% osteoarthritis
n  21-48% osteoarthritis in patients with associated meniscal tears
n  More likely to undergo subsequent knee surgery
n  Greater decrease in activity
n  In athletes that initially passed dynamic functional testing with an
isolated ACL -40% returned to previous level and 60% ultimately
underwent ACL reconstruction
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GRAFT SELECTION ????
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PATELLAR
n  Initially
stronger but more anterior knee pain; OA more likely
n  Bone to bone healing; not used with open growth plates
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HAMSTRING-quadruple strand
n  Stronger
when healed and less anterior knee pain
n  All tendon-osseous tunnel and 1 year to regain hamstring strength
n 
ALLOGRAFT
n  Less
surgical time, no harvest site morbidity and range of sizes
n  Disease transmission, immune reactions, slower integration, cost
n 
QUADRICEP-avoids nerve/tibial tuberosity
TIMING ????
Prehabilitation 2-4 weeks to normal ROM, decrease swelling and
maintain strength
n  Early repair better motion outcome in patient with swelling
n  Additional injury possible in delayed surgery
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PEDIATRIC PATIENTS
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Repair unless within 6-9 months of growth plate closure in an
adolescent then wait until closed
n  Reduces
development of instability from 75% to 13%
n  Reduces meniscal tear from 35% to 4%
n  Increases return to previous level of activity from 0% to 85%
REHABILITATION
Establish ROM first
n  Closed chain kinetic (both feet on floor –squats) to regain
hamstring and quadriceps strength
n  Open chain exercises after 6 weeks??
n  Balance, proprioception, core and sport specific exercises
n  Bracing ?? Surgeon dependent
n  Return to activity when equal to unaffected knee 6-12 mos
n  Motivation; observed proper technique; HEP
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PREVENTION
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AAOS/ACSM recommend a proper neuromuscular training
program for all female athletes (reduced ACL injuries by 2/3)
n  Plyometric
jumping program
n  Biomechanical analysis with direct feedback
n  At least 2 x per week x 6 consecutive weeks
n  Strength training alone did not decrease injury
n  Start before bad habits develop
RESEARCH
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The evidence shows that neuromuscular training
including plyometrics, balance, and technique
training reduces the risk of serious knee injuries in
female athletes
All current preventative programs are different but
center on alteration of neuromuscular risk factors
Training may facilitate NM adaptations to increase
joint stabilization and muscular preactivation and
reactivation patterns which help protect the ACL
Lisa Muscatello, ATC, PTA, CSCS
Regional Therapy Center
3040 Route 50
Saratoga Springs, NY 12866
[email protected]
518-583-8383
Big differences in regards to training:
n 
Females are more ligament dominant in stabilization of the knee
joint whereas, males are more MUSCLE dominant…
ü  Males
use more hip-dominant strategy (land with butt back,
knees flexed)
ü  Females more quad strategy (land with stiff, knock-kneed
position with hip internal rotation)
* Critical to change these abnormalities in females!
Formalized warm-up/injury prevention
programs
ü  Evidence
of reducing ACL injuries
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WIPP (Sportsmetrics Warm-up for Injury Prevention & Performance)
PEP (Prevent Injury & Enhance Performance)
FIFA 11+ (Soccer Injury prevention)
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- Con: PEP doesn’t incorporate dynamic flexibility
n 
- Pro: All involve flexibility, strengthening, agility, plyometrics,
proprioception
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n 
Components of Program
Dynamic Warm up/Stretching – preferred over static pre-activity
n  Plyometrics/Jump training
n  Agility & Conditioning
n  Strength training
n  Cool Down – static stretches
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* WIPP Program: “Twenty exercises in 20 minutes”
Dynamic Warm Up/Stretching
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Prepares the body for training with functional based activities that use sport specific motions
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Designed to help prevent injury during training
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Set up two markers about 10-20 yards away from each other and have the players perform
the following: forward run, backward run, side shuttle run
n 
Dynamic stretching: Toy Soldiers, Inch Worm, Cradle Walk, Hip Rotator “Close and Open
the Gate”
Plyometrics
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Tuck jumps – 20 seconds
Common mistakes:
1. Bringing chest to knees with head down
2. Double bouncing b/w jumps
3. Landing loudly
4. Landing with straight knees
Plyo’s cont.
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180 degree jumps – 30 seconds
Common mistakes:
1. 
2. 
3. 
4. 
Over-rotating
Body not turning as a unit
Landing with straight knees
Jumping the same direction
Plyo’s cont.
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Squat jumps – 30 seconds
Common mistakes:
1. 
2. 
Knees over toes
Knee going inward *** VERY IMPORTANT to correct!
Plyo’s cont.
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Scissor jumps – 30 seconds
Common mistakes:
1. Wobbly knees upon landing
2. Knee past toe
3. Forward knee going inward
4. Landing with straight leg – lead leg
Plyo’s cont.
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Hurdle hops – side to side
Common mistakes:
1. Stiff knee landing
2. Landing with straight knee
3. Landing knee going inward
* 6-8 inch hurdle
* Perform double leg jump is too difficult
Strengthening
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Hip Extensions
1. 30 seconds per leg
2. Body control is important to avoid torso bending or
extending
3. Keep the knee of stationary leg slightly bent
Strengthening cont.
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Lateral stepping
1. 
2. 
3. 
4. 
30 seconds per direction
Band around the ankles
Start with feet shoulder width apart, step out 10-12 inches, slowly
return trail leg to start position
Avoid trail leg coming back to close to cause slack in the band
Strengthening cont.
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Supine hamstring bridge
1. 
2. 
3. 
4. 
5. 
30 seconds per leg
Place heel close to the buttocks
Press with the heel of the bent knee
Keep other leg straight
Avoid over extension of the low back
Strengthening cont.
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Plank – 60 seconds
Elbows under shoulders
2.  Place feet hip distance apart
3.  Important to maintain NEUTRAL spine
* Can add variety by performing Side Planks, T Planks
1. 
n 
Abdominal Crunch
60 seconds
2.  Keep knees bent, feet off floor
3.  Raise until shoulders are off floor
4.  Keep neutral head/neck in neutral position
5.  Arms can be crossed in front
* Add Variety: Oblique Crunch
1. 
Agility
n 
The ability to explosively initiate a movement, decelerate to
change direction of motion in the most efficient means
Pick 2-3 agility patterns that is most specific to your sport!
n  Lots of great agility patterns
n  Examples:
n 
1. 
2. 
3. 
Quick Feet
T Drill
Nebraska Drill
Static Stretching – Cool down
1.
1. 
Hamstrings
2. 
Hip Flexor
3. 
Calf
4. 
Quadriceps
* Hold all stretches for 20
seconds, each leg, then move to
the next stretch
3.
2.
4.
S.P.O.R.T. Services @ Regional Therapy
Center
Outpatient center @ Wilton, Route 50
n  Initial Consultations –60-90 minute session
n  Conditioning sessions are 45-60 minute sessions
n  Program is designed according to person’s deficiencies; sports or
functional-specific needs
n  Exercises changed on weekly basis for variation & increased
intensity
n  Once program is complete, client transitions to home, or facility
of choice
n 
Return-to-Sport (RTS) Program
For injured athletes who need additional sport-specific training/
conditioning with the AT after discharge from PT/OT
n  Sport-specific program
n  Self pay program
n  5 and 8 visit pre-pay specials; cost effective!
n 
Athletic Competitive Enhancement (ACE)
Program
For non-injured athletes who want sport-specific strength &
conditioning
n  Addresses strength, agility, power, & flexibility
n  Clients are generally not patients, but injured athletes may take
advantage of program in the future
n  Self pay program
n  5 and 12 visit pre-pay specials
n  8 pre-pay special for group of 2 (from same sport)
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Discussion
n 
Would the coaching staff at Schuylerville Central School be
interested in:
1. 
2. 
3. 
More presentations? If so, what?
Weekend sport injury clinics?
Other?
- 
Communicate with AD, School MD, Athletic Trainer
Thank you!