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 n 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 n 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 n RISK FACTORS n 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 n Noncontact-70% n Running or jumping with sudden deceleration while pivoting n Knee in valgus and tibia internally rotated n Contact-30% n Direct blow causing hyperextension or valgus deformation of knee HISTORY AND EXAM n 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 n Immediate n PRICE and crutches n ? NSAIDS n 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 n GRAFT SELECTION ???? n PATELLAR n Initially stronger but more anterior knee pain; OA more likely n Bone to bone healing; not used with open growth plates n 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 n PEDIATRIC PATIENTS n 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 n PREVENTION n 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 n n n 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 n WIPP (Sportsmetrics Warm-up for Injury Prevention & Performance) PEP (Prevent Injury & Enhance Performance) FIFA 11+ (Soccer Injury prevention) n - Con: PEP doesn’t incorporate dynamic flexibility n - Pro: All involve flexibility, strengthening, agility, plyometrics, proprioception n 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 n * WIPP Program: “Twenty exercises in 20 minutes” Dynamic Warm Up/Stretching n Prepares the body for training with functional based activities that use sport specific motions n Designed to help prevent injury during training n 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 n 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. n 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. n Squat jumps – 30 seconds Common mistakes: 1. 2. Knees over toes Knee going inward *** VERY IMPORTANT to correct! Plyo’s cont. n 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. n 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 n 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. n 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. n 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. n 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) n 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!
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