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5 Ways to Decrease the Risk for an ACL Injury

Injuries to the Anterior Cruciate Ligament (ACL) are some of the most common injuries in the active population. As incidence of other injuries have decreased, injuries involving the ACL have rose astronomically over the years.  There have been numerous studies done looking at what causes the ACL to tear. More specifically, female athletes are 4-5x more likely to tear their ACL as compared to their male counterparts.

Like with any injury, it cannot be blamed on one thing. Injuries are multi-factorial as well as non-preventable.  Injuries will always happen.  The only thing that we can do is to decrease the frequency or incidence of them. Luckily, as we continue to learn more about the mechanism of injury, we have developed some strategies to reduce your chance of ACL injuries.

 

5 Ways to Decrease the Risk for an ACL Injury

Here are 5 things to focus on when designing programs to reduce ACL injuries.

 

Optimize Mobility

If you look at the human body, there are many joints. Some of those joints require mobility and some of those joints require stability. Depending on which plane of motion you are in, mobility or stability is usually more imperative than the other.

When it comes to mobility, there are certain joints in the body that we need to have optimal mobility in order to decrease the risk for an injury to the ACL. The two joints that come to mind are the talocrural joint of the ankle, and the femoroacetabular joint of the hip.

For the ankle, specifically dorsiflexion range of motion is imperative to decrease strain at the knee. If the ankle doesn’t have the ability to dorsiflex and absorb force during a land from a jump or cutting maneuver, the mid foot or knee are the two joints that will have to have increased mobility to accommodate the athletic endeavor.

 

Ankle Mobility

To assess for adequate ankle mobility, use the Knee to Wall Ankle Mobility Test.

Key Points:

  • Place your foot 4 inches away.
  • Keeping your foot flat on the floor, attempt to touch your knee to the wall.
  • Don’t allow for valgus or varus collapse.

If you can reach the wall from 4 inches, then you have sufficient ankle mobility to run, squat, and perform without playing increased stress through the knee due to poor ankle mobility.

The other joint in the body that needs to have optimal mobility is the hip.  The motions at the hip that need adequate mobility are hip flexion, hip extension, hip abduction, hip internal and external rotation.

Now, you may be saying, “Wow, that’s a lot of areas that need mobility.”  Well, let’s break it down!

 

Hip Flexion

5 ways to reduce ACL injuriesAnecdotally, I like to see clients present with full hip flexion. If there is decreased mobility into hip flexion, this can send a signal to the brain to alter movement and muscle firing patterns and in turn, can affect how someone lands or moves.

A quick and easy test is to test passive hip flexion range of motion.  

This involves bringing your knee towards your chest. Ideally, your thigh should reach the inferior aspect of your rib cage. Now, everyone is made differently and depending upon what sport you play, hip structure can vary from person to person.

If you cannot reach your thigh to your rib cage, slightly abduct your thigh and see if you can go further. If you can, then your hips are structured a little differently.

 

Hip Extension

Key Points:

  • Thigh should be able to reach parallel to ground.
  • Knee should be at 90 degrees to thigh.
  • Thigh should drop straight down and not flare out towards side of body.

Hip extension mobility is necessary to be able to activate the gluteus maximus and hamstrings in order to decrease incidence of a valgus collapse. If adequate hip extension mobility is not present, then muscular compensation will occur and in turn, possible injury.

 

Hip Internal Rotation (IR)

Even though hip internal rotation is part of the combination of movements that contribute to an ACL injury, not having the requisite mobility is a risk factor. If the body doesn’t have certain available ranges of motion, then the brain and central nervous system are not able to prevent going into those said ranges of motion. Therefore, if someone doesn’t have adequate hip internal rotation, then the body has no way to prevent that motion from occurring.

VandenBerg et al. in Arthroscopy: The Journal of Arthroscopic & Related Surgery that “risk of ACL injury is associated with restricted hip IR, and as hip IR increases, the odds of having an ACL tear decreases.”

 

Hip External Rotation

Hip external rotation is important because avoidance of a knee valgus position is necessary to avoid injury to the ACL. Having adequate hip external range of motion will allow the athlete to be able to get into an athletic position to avoid that valgus position.

 

Learn How to Land

You watch any NFL or NBA game and guys are jumping to catch a ball to to tap in a rebound for 2 points. Most injuries to the ACL don’t occur on the jumping portion as it does on the landing portion.

When athletes have to land from a jump, the body has to absorb 7-10x their body-weight in forces from the ground.  If joints aren’t in an ideal position to absorb and adapt to stress, injuries can happen.

landing mechanics ACL injury

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Therefore, we need to assess athletes in their landing patterns and mechanics to make sure their body is resilient and capable to land properly.

 

Step Down Test

 

The Step Down Test is a simple way to determine an athlete’s predisposition to absorbing eccentric stress. Ideally, we like to see the pelvis, hip, knee, and ankle remain in a line during descent.

 

If someone steps down and the femur internally rotates and the knee goes into valgus collapse,  this is something that needs to be rectified.

If you want to use a more quantitative analysis of landing mechanics and skill as compared to the contralateral limb, then here are 3 tests that can help with that.

 

Single Leg Hop for Distance

Key Points:

  • Instruct the athlete to jump as far as then can and land on 1 leg.
  • They must stick the landing without hopping around or using their leg/arm for balance.
  • Perform 2 trials.  Measure each jump, take the average of the 2 trials, then repeat on the opposite leg.

 

Triple Hop for Distance

Key Points:

  • Instruct the athlete to jump as far as they can, land on 1 leg, and continue for 2 more hops, sticking the 3rd landing
  • They must stick the landing without hopping around or using their leg/arm for balance.
  • Perform 2 trials.  Measure each jump, take the average, then repeat on the opposite leg.

 

Crossover Hop for Distance

Key Points:

  • Instruct the athlete to jump as far as they can, land on 1 leg, and continue for 2 more hops, sticking the 3rd landing while crossing over a tape line on the floor with each jump.
  • They must stick the landing without hopping around or using their leg/arm for balance.
  • Perform 2 trials.  Measure each jump, find the average, then repeat on the opposite leg.

Now that you have the average for all 3 jumps, we need to determine if the difference between the two limbs is significant. According to Adams in the Journal of Orthopaedic and Sports Physical Therapy, limb symmetry indexes of 90% have previously been suggested as the milestone for determining normal limb symmetry in quadriceps strength and functional testing.

According to Phil Plisky, one of the developers of the Y-Balance Test, he advocates that the athlete’s reconstructed lower extremity be within 95% on the non-involved leg.

To determine if distances hopped are significant, the involved limb must be within 90-95% of the non-involved side. If it is less than 90%, then that athlete is at risk for future knee injury.

Using a regimen consisting of single leg plyometrics in the sagittal, frontal, and transverse planes as well as single leg exercises that focus on power development can help to improve any major deficits.

 

Achieve Symmetry

If an athlete presents with a gross asymmetry, their risk for injury can increase 3-17x. Besides using the Hop Tests, one way to assess gross asymmetry is also using the Y-Balance Test.

The Y-Balance Test consists of 3 lower and upper body movements. For the sake of this post, we will be focusing on the lower body. The movements consist of:

y balance test ACL injuries

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If there is greater than a 4 cm difference right vs left on the anterior reach (1st picture), this is considered a risk factor for a lower extremity injury.

Smith, Chimera, and Warren found in Medicine and Science in Sports & Exercise that “ANT (anterior)  asymmetry >4 cm was associated with increased risk of noncontact injury.”

If there is greater than a 6 cm difference right vs left on the posteromedial or posterolateral reaches, pictures 2 and 3, then this is considered a risk factor for a lower extremity injury.

Asymmetry is a normal thing.  Everyone from elite level athletes to the average joe has natural asymmetries right vs left. Some asymmetries may not change and some asymmetries may make someone the elite level athlete that they are. Having a relative asymmetry right vs left is ok, but having a gross asymmetry is not.

 

Enhance Core Stability

The core musculature is responsible for providing a stable base for the pelvis, hips, knees, ankles, etc. to function off of in life and in sport. If a stable base is not provided, then it can create instability and injury further down or up the kinetic chain.

Decreased core stability can cause:

  • Pelvic Drop
  • Femoral Internal Rotation
  • Knee Valgus
  • Tibial External Rotation
  • Subtalar Excessive Pronation

All these movements are associated with injuries of the ACL. By stabilizing proximally and providing a stable base for all of the aforementioned areas to work off of, this can decrease the risk for injury.

In order to test for core stability, the Trunk Stability Push-Up (TSPU) by Functional Movement is a good test.

This is a great test to determine if someone can maintain a neutral spine while performing a push-up, but also to determine if they have a base level of core stability to maintain a certain trunk position during life/sport.

If someone cannot maintain a specific trunk position, this doesn’t mean that they have a “weak core.” or weak upper extremities. It means that the athlete doesn’t have the capability to stabilize their core proximally in order to exude force distally.

 

Learn How to Decelerate

Most athletes are fast or at least quick on their feet. The great athletes can speed up and slow down better than anyone. One common risk factor we see with ACL injuries is the inability or subpar ability to be able to decelerate.

What this means is that if someone is going to stop or change direction, they need to have the necessary skills to control their body in space when going from accelerating, to decelerating, and then back to accelerating again.

All fast cars are fast! All really fast cars have great brakes!

In order to assess an athlete’s ability to decelerate, observe how the do with change of direction drills.  For example, movements such as:

 

Sprint/Backpedal w/ Redirection

Lateral Shuffles w/ Redirection

Sprint with 45 Degree Cut

Sprint with 90 Degree Cut

Backpedal, Stop, to 90 Degree Sprint

Backpedal, Stop, to 45 Degree Sprint

All of these various movements test an athlete’s ability to accelerate, decelerate and change directions in all planes of movement. A coach, personal trainer, or physical therapist should be present to provide the athlete with the redirection component. This makes it more random and unpredictable to make sure the athlete can react and move appropriately.

While observing these various change of direction movements, observe the mechanics of the pelvis and lower extremity.

Does the pelvis and hip/knee stay in a relative stable and neutral position when decelerating and stopping?

Does the pelvis and hip/knee go into a valgus collapse during decelerating, stopping, and accelerating phases of movement? Compare these right versus left lower extremities.

If you are having trouble observing these things with the naked eye, film it!  There are apps such as DartFish or Hudl that you can download to film athletes and then you can watch it in slow motion to observe any differences side to side.

If differences are seen in right and left comparison, then work on change of direction drills. When first starting off, start the athlete at ½ or ¼ speed so that they can work on their deceleration, stopping, and accelerating mechanics.

We don’t necessarily want to bombard the athlete with too much information about biomechanics of the lower extremity, but having a basic discussion with them and showing them how they currently move and how you would want them to move safely and more efficiently is ideal.

Then once, then can master ¼ or ½ speed, then increase the speed of the drills until you are working at full speed on both sides. There are a multitude of drills out there to work on acceleration, deceleration, stopping, and change of direction. Make sure start with the sagittal plane, and then progress into the frontal and transverse planes.  

If you can’t master the sagittal plane, then the frontal and transverse planes will be much more challenging.

Assessing mobility, landing mechanics, relative lower extremity symmetry, core stability, and acceleration/deceleration can all help to improve an athlete’s performance as well as decrease their risk for an ACL injury.

 

About the Author

Andrew Millett is a Boston-based physical therapist in the field of orthopedic and sports medicine physical therapy.  He helps to bridge the gap between physical therapy and strength and conditioning.  Visit his website at AndrewMillettPT.com.

 

 

 

6 Keys to ACL Rehabilitation

The latest Inner Circle webinar recording on 6 Keys to ACL Rehabilitation is now available.

 

6 Keys to ACL Rehabilitation

6 keys to acl rehabilitationThis month’s Inner Circle webinar is on 6 Keys to ACL Rehabilitation.  In this presentation, I’ll go over the 6 key foundational principles that you need to understand to maximize your results with ACL rehab.  There are many surgical and patient variables that may speed up or slow down the standard rehab progression, however, you can build an optimal program by following these 6 principles.

This webinar will cover:

  • The #1 complication after ACL rehab, prolonged weakness, and how to minimize this
  • The two most important things to focus on during the first week of rehabilitation
  • How to develop advanced strength programs and alter periodization schemes in the rehab setting
  • My simple, yet effective, criteria to return to activities

 

To access this webinar:

 

The Use of Non Motorized Treadmills to Facilitate Gait and The Posterior Chain

We’ve recently started playing more with non motorized treadmills at Champion and have been very happy with the results.

Non motorized treadmills have gained popularity in the fitness realm as alternatives to self-powered conditioning machines like bikes and rowers. The Assault Air bikes and Concept 2 rowers have long been popular for their ability to produce amazing workouts.

I am a big fan of conditioning machines that increase their intensity based on the amount of effort exerted. Essentially, the harder you go, the harder they push back!

These have done wonders for high intensity interval training and sprint conditioning work.

Woodway has recently developed the Woodway Curve self-powered manual treadmill. Past non motorized treadmills seemed really cheap to me, but Woodway, who makes some of the best treadmills, has really made an exceptional machine with the Curve. I started using them for sprint work with the Red Sox, but have recently been using it more and more with my rehabilitation clients at Champion.

Because it is nonmotorized, your posterior chain is nicely engaged while walking and running on the Curve. A simple period of ambulation on the Curve does a great job engaging the hamstrings and glutes. I’ve been using these in everyone with diagnoses like patellofemoral pain, low back pain, and even postoperative. We start with a slow walk and slowly build up the speed and eventually get to running.

In the video below I explain more. I’m a big fan of nonmotorized treadmills to facilitate a proper gait form and engage the posterior chain.


The Best and Easiest Way to Restore Knee Extension

One of the most common complications following a knee injury or surgery is not restoring full knee extension.  Losing knee extension causes a lot of issues, ranging from anterior knee pain, to altered movement patterns, to even difficulty when walking.

It’s super important to assure you restore full knee extension.

In this video below, Lenny Macrina, my co-owner of Champion and co-author of OnlineKneeSeminar.com, shares what he considers the best way to restore full knee extension.  Luckily, it’s not only the best in our minds but also the easiest to perform!  More importantly, he discusses why he doesn’t like one of the most common exercises that people tend to use.

 

 

Learn Exactly How I Evaluate and Treat the Knee

Want to learn even more about how I evaluate and treat the knee?  My online program on the Recent Advances in the Evidence-Based Evaluation and Treatment of the Knee is now available.  I’ll show you everything you need to master the knee.  Click the button below for more information and to sign up now!

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The One Thing You Must Do When Evaluating for an ACL Injury

Anterior cruciate ligament (ACL) injuries are common. When evaluating the ACL, special tests like a Lachman Test or Anterior Drawer have been shown to have great reliability and validity.

However, there is one main reason why you may get a false positive for an ACL injury of the knee that is often overlooked – you actually injured your posterior cruciate ligament (PCL)!

I know, it seems backwards, but watch this quick video for my explanation!

 

Learn Exactly How I Evaluate and Treat the Knee

Want to learn even more about how I evaluate and treat the knee? My online program on the Recent Advances in the Evidence-Based Evaluation and Treatment of the Knee is now available. I’ll show you everything you need to master the knee.  Click the button below for more information and to sign up now!

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Learn Exactly How I Evaluate and Treat the Knee

After many years in the making, I am super excited to announce that my online program teaching you exactly how I evaluate and treat the knee is now available!

Many of my readers have taken my online shoulder program and LOVED it. The testimonials speak wonders. I am humbled yet proud of how well received that program has been over the years. When I first started the program, I had no idea what to expect, but I think many people agreed with me at the time that online education was the future.

Not a month has gone by since I started ShoulderSeminar.com that people haven’t asked me “when is the knee version coming out?”

Well, today is the day!

 

Recent Advances in the Evidence-Based Evaluation and Treatment of the Knee

reinold macrina online knee seminar

I have teamed up with my co-owner and Director of PT at Champion, Lenny Macrina, to build an online program that teaches you exactly how we evaluate and treat the knee. Together, we’ve put together what we think is an amazing resource for rehabilitation specialists.

The program includes 7 modules of detailed information on anatomy, basic science, healing responses, evaluation, treatment progressions, nonoperative rehabilitation, surgical techniques, and postoperative rehabilitation.

You’ll learn exactly how we approach:

  • Clinical Evaluation of the Knee
  • Treatment Progressions for the Knee
  • Anterior Cruciate Ligament
  • Patellofemoral
  • Meniscus
  • Articular Cartilage
  • Osteoarthritis

evaluation and treatment of the knee

Best of all, you can learn at your own pace in the comfort of your own home. No more nodding off in the back of a room and losing an entire weekend. I am a firm believer that you will learn more and be able to apply the information much better when learning in small chunks at your own pace. Finish the program in a few days or several weeks, it’s up to you!

Each module contains a video introducing the material, a detailed presentation on the topic, several journal articles that we hand selected to learn the material, and discussion questions. This is an in depth course that will take your understanding of the knee to the next level.

CEU applications have been submitted to the Federation of State Boards of Physical Therapy for approval with several states. The course is approved for 22.5 hours of CEU credit through the NATA for Athletic Trainers. We provide all the information needed if you need to apply to another board for approval.

 

reinold macrina eval treat knee

 

Start Mastering the Knee Today!

The course is value at $349.99.  That’s less than a typical CEU course and I promise you’ll get way more out of this one!

Visit OnlineKneeSeminar.com or click below to learn more and start the program today!

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Expert Advice on Youth ACL Injuries

youth acl injuriesFor this week’s post, I wanted to share what I thought was a great video from the American Orthopedic Society for Sports Medicine (AOSSM) on youth ACL injuries.

In this video, noted orthopedic surgeons Chris Harner, Lyle Micheli, James Andrews, and Peter Indelicato share their advice on several topics regarding youth ACL injuries, return to play, female ACL injuries, and preventative programs.

Videos like this are important to education the parents and coaches on the realities of issues like youth ACL injuries.

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Do ACL Hamstring Grafts Fail More than Patellar Tendon Grafts?

This month’s issue of the American Journal of Sports Medicine included two studies comparing the revision rates of ACL reconstruction between hamstring grafts and patellar tendon grafts of over 25,000 people.  The overall number of people studied between the two groups was really compelling to me as a sample size this big is certainly worth discussing.

In recent years the graft choice for ACL reconstruction has been slowly shifting towards favoring hamstring grafts rather than patellar tendon grafts.  Recent reports have noted 84% of ACL reconstructions in Denmark and Sweden use hamstring grafts, 60% in Norway, and now are even becoming more popular in the US with 44% of ACL reconstructions using a hamstring graft compared to 42% using a patellar tendon graft.

Many research papers have been published showing that both grafts result in very good stability of the knee with excellent subjective outcome scores.  The major complaint of patellar tendon grafts is the increased risk of issues after surgery, such as patellofemoral pain and loss of motion.  Despite the reports of good stability and subjective outcomes, revision surgery is probably a more important factor to consider.

 

Do ACL Hamstring Grafts Fail More than Patellar Tendon Grafts?

The first study reviewed the nationwide Danish Knee Ligament Reconstruction Registry, which included 13,647 people undergoing ACL reconstruction between 2005 and 2011.

The revision rates for hamstring tendon grafts were 0.65% at 1 year after surgery, and 4.45% at 5 years after surgery.  The revision rates for patellar tendon grafts were 0.16% at 1 year after surgery, and 3.03% at 5 years after surgery.

Essentially, hamstring grafts had a 4x greater risk of revision in year one and 1.5x at 5 years following ACL reconstruction.

ACL reconstruction revision rates

The second study reviewed the nationwide Norwegian Cruciate Ligament Registry, which included 12,643 people undergoing ACL reconstruction between 2004 and 2012.

The revision rates for hamstring tendon grafts were 5.1% at 5 years after surgery, and 2.1% for patellar tendon grafts.  This study also looked at different age groups and found this increased rate to be consistent across all age group.s  However, the younger group (age 15-19) had a 9.5 revision rate at 5 years using the hamstring graft in comparison to 3.5% using a patellar tendon graft.

Together, there was a 2x greater risk of revision overall when using the hamstring graft, but closer to 3x greater risk for younger people.

ACL hamstring patellar tendon graft

 

Both Grafts are Great Options for ACL Reconstruction

When we really assess the numbers, it is clear that both graft options are great choices with low revision rates.  Even though we are comparing the two, realistically the revision rates after ACL reconstruction are low for both hamstring grafts and patellar tendon grafts.  There are many factors that go into deciding which graft to use.  Also realize this does not apply to skeletally immature patients.  This revision information is just a piece of the puzzle.

The patellar tendon graft has less failure rate and has been reported to heal faster in animal models due to the bone-to-tendon interface.  While this is true there are also reports of increased anterior knee pain and loss of motion.  I have discussed this in the past, but I really do believe that many of the issues with patellar tendon grafts after surgery are minimized or eliminated with proper physical therapy (in addition to excellent patient compliance).  This is especially true if these factors are the primary emphasis of the early phases of ACL rehabilitation.

SEE ALSO: 6 Keys to the Early Phases of Rehabilitation Following ACL Reconstruction Surgery

That all being said, hamstring grafts have also been shown to result in less strength of the hamstrings after surgery.  Considering the role of the hamstring to assist the ACL in control anterior tibial translation, this has to be considered when reviewing the higher ACL reconstruction revision rate when using hamstring grafts.  Perhaps it really has nothing to do with the graft itself and more to do with the hamstring strength.

Regardless, the revision rate following ACL reconstruction is higher when using a hamstring graft than when using a patellar tendon graft.

 

 

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