ACL Injury Prevention Program

4th Annual Marino Lecture and Symposium

ACL/ Injury Prevention ProgramPhases

Sports and Physical Therapy Associates

Cincinnati Sports Medicine

1999 Using a combination of Jump Training/ PlyometricsStrength Training and Flexibility6 week preseason program Reduced ACL injuries in the Trained Women vs. Untrained women

Hewett 1999 AJSM

PEP Program

USC, Santa Monica California, from 2000 to 2002 completed 3 studies Highly specific Training session Used to replace the conventional warm upDramatic reduction in ACL injuries from 72% to 88% compared to the control groups

Mandelbaum AMJS 2005

Training To Reduce ACL Injuries

Cincinnati Children’ HospitalTimothy Hewett, Ph.D.Jump Training www.cincinnatichildrens.org/sportsmedPep ProgramDr. Bert Mandelbaum, MD www.aclprevent.com

ACL/General Injury Prevention Program Phases

Dynamic Warm-up/Cool downPlyometrics/ Neuro Muscular Re-edProprioception/ BalanceStrengthening Lower Extremities/CoreFlexibilityAgility PEP/Cincinnati Sports Medicine

Dynamic Warm up

Prepares the Body for the demands of the work out or practiceIncreases heart and respiratory rate and blood flow to musclesIncreases core body TemperatureEnhances Muscles elasticityAthlete Should break a sweat w/o excessive fatigue

Usually 10-20 minutesNSCA

Dynamic Warm Up

Progress from low to high intensityInclude all planes of motion, Multi directional and Diagonal PatternsWarm up should include exercises for both upper and lower extremitiesWarning: May induce fatigue in deconditioned athlete

NSCA

Dynamic Warm Up

Many Of the Components of The Injury Prevention Program can be worked on during this phase

DukeHealth.org: Mike Huff and VerneGambetta have taken Low intensity agilities, Plyos and dynamic stretchesto act as warm up

Cool Down

Following Sport or Activity Cool down consists of moving in same movement patterns as warm up withdecreasing IntensityStatic Stretching Optimal TimeRehydrate/ Refuel CarbsRelax

Ian Jeffreys MS CSCSNSCA

Plyometrics/StrengthProgressive Leaping and bounding exercisesThis gives Muscle pre stretch which enhances muscle contraction Allerheigen 1994

Jump Training/ Neuro Muscular ControlDevelop stability during the movement patterns that seems to put knee in most vulnerable landing or cutting positionsValgus landing with rotationCo contraction of Muscles to Stabilize Joint

Mandelbaum 2000

ACL Injury

Prior to starting Plyos

Instruct Athlete on the stability/power position Knees bent 25-30 degreesHip and Knee in Neutral alignmentControl valgusGreatest level of Ham to quad co contraction

NSCA

Reps and SetsFoot Contacts per workout:

Level Low intensity Med Intensity High Intensity Beginner 40 60 80

Intermediate 60 80 100Advanced 100 120 140

McNeely NSCA 2008

Criteria for Advancing

Once Athlete has mastered each jump for at least 2 consecutive practice sessions , this means good form and DOMS has subsided you may progress to greater level of difficulty.If athlete is in middle of high volume jumping season, basketball, volley ball etc. watch for signs of overtraining NSCA

Plyometrics/Jump Training

Higgins/Duke

Proprioception

The ability to maintain stability and orientation during static and dynamic activities. Mechano Receptors are neuro sensory cells that are responsible for monitoring joint position and movement.6 exteroceptive senses 1 interoceptive sense

Kinetics

Proprioception

A proprioception program should stimulate these mechano receptors. The ability to know where you are in space

NSCA

Strengthening

StrengtheningTo increase a muscles

tolerance to physical stress. This in turn will increase its cross sectional area.

Progressive Resistive means move up!!!

NSCA

Isolation Exercises Isolates Muscle groups to address Imbalancepost injury or surgery

+Less chance of injury during training- Costly- Doesn’t strengthen stabilizing muscles

NATA

Multi Muscle Group Training

Sports Specific Training– Training muscle

groups to work together in concert. Training the body to work per the required needs to the specific demands of a sport.

NATA

Multi Muscle Group Examples

Field exercises

Squats

Diagonal PatternsNATA

Open Chain Exercises

Open Chain : Foot is free to move– SLR, SAQ, LAQ– Leg Extension machines– Leg Curl machines

Hamstring /Quad Ratio+great for isolating muscle

groups

Closed Chain Exercises

Closed chain: Foot is Fixed– Wall slides, squats, lunges– Leg Press Machine– Hack Squat Machine+ co-contraction of leg and hip muscles- don’t isolate muscles as well

Which is Better??

Open Chain vs. Closed ChainStudies show long term no greater results in strengthening and no greater result in injury. PFS or ACL– Use them appropriately

Erik Witrvrouw, AJSM 2004Hooper & Morrisey AJSM 2001

Repetitions How Many?

Science of Repetitions– Physiologically higher

repetitions give the joints and tendons better blood flow

– Used better for post-season or rehabilitating an injury 15-20 reps

– Lower reps better for strength/power, used better during power cycles and pre-season

Grimsby

Frequency of Training?How often to train the same movements/muscles?– It depends on similar

variablesIn-season, pre-season, off-season, age and sport of the athlete

– Typically the same muscle group no more than 2 x/week

NSCA

Periodization

The science of cycling reps and intensities during different parts of the training cycle.

NSCA

Flexibility:Improving a Joints Range of Motion

Types of Stretching– Active- Hold 2-3 sec

repeat 20 times

– Static – hold 30 seconds repeat 2 times

– Dynamic -Active Movements through exaggerated ranges NSCA

ACL Injuries/ Patellofemoral Pain

The age group that ACL injuries occur 13-17:Also age group marked decrease in flexibility which can lead to Patellar Tendinitis and or PFS

Witvrouw AJSM 2001

Stretches to decrease Patella Tendinitis Witvrouw AJSM 2001

Stretches– Rectus/Quadriceps

- Hamstring

Time to stretch?

Optimal time to stretch– After warm-up – At end of Cool

Down

Ian Jeffreys, MS CSCSNSCA

AgilitiesMost Sports are in themselves agility movements However practicing cutting movements that tend to cause stress to the athlete’s knee can create improved coordination and strength through sports specific movements NSCA

Pick Agilities to Fit Sport

Agility Patterns that mimic sports movements– Grapevines

Side to side– Run ,plant and cut

NSCA

ACL Prevention Today

Although the Pep program and Cincinnati prevention programs reduced ACL injuries significantly.

Both groups readily admit it is unclear which aspect of their programs were responsible for the reduction in injuries

USC/Cincinnati Sports Medicine

ACL Project Prevent

USC ACL Project Prevent

A 3 year Study Funded By the NIH

Identify Gender Specific Movement Patterns

That may predispose Female Athletes to ACL Injuries

As Athletic Trainers and Physical TherapistsUtilize evidence based Medicine as the backbone of your rehab!Develop a program that works for your coaches, teams and patients !Achieve participation with resources and time available !One Size doesn’t Fit All

FIELD DRILL FOR Injury PREVENTION

Run Back Peddle Run Back Peddle

Cut and Run

Plyometrics, Squats, Side to Side, etc.

Raise level of difficulty as season

progresses

Side to Side, Carioca, etc

30 yards x 30 yards

If Budget is really Bad

1 piece of Chalk1 pebble4 single Leg Jumps2 Double leg Jumps1 180 Degree Jump1 Single Leg SquatMake the Squares BiggerStart Again