The Athletic Knee, Part II

PREVENTION
Unfortunately, ACL injuries have become a major part of athletics. In particular, female soccer players have a reported 4-6 times greater risk of ACL injury than the male athlete and over 30,000 ACL injuries are reported every year with an estimated healthcare cost of over 720 million dollars. In response, over the past several years, many programs have been developed, designed and promoted to reduce the risk of ACL Injury. Results from this focus on proper athletic development have returned a reduced rate of injury in as much as 75% for athletes in a specifically designed program. (Boone 2007)

A properly designed training program should consist of nine basic components: evaluation, movement preparation, plyometrics, core strengthening, weak point training, integrated strength training, multi-directional speed training, footwork, and proper recovery drills.

1. Evaluation/Testing

Just as a coach evaluates the tactical and technical skill of the player, it is vital to asses the overall functional movement skills of the athlete. Can the player move correctly? Do they react quickly? Do they have the ability to stop or change direction?
Again, there are many programs that have been marketed to do this, including Cook’s Functional Movement Screen, Sportsmetrics, Jumpmetrics, and the ACL Hop & Stop Test. No matter the program, it is important to asses 6 areas of basic athletic movement.
• Posture
• Single Leg Stance & Movement
• Jumping
• Landing
• Posterior Chain (hamstring and glute development)
• Deceleration & Directional Change

2. Performance Preparation

Prior to performing any athletic activity, the body must be prepared to move in all directions, speeds, and methods that will be required during that activity. The days of taking two laps and playing are over. If the body is not properly prepared and the neuromuscular system is not fully engaged, there will be a greater risk of injury to the athlete. In particular, both the mobility and flexibility of the athlete must be addressed. The purpose is NOT to just “warm-up”, this is PART of the workout!

– Increase core temp, mobility, flexibility, stability and strength; “activate muscles”; use muscles in stretched position; establish and maintain ability to reproduce movements
– Mobility: range of motion with stability & control – correct motion at correct joint at correct plane at correct time (Gray, 2000)
– Flexibility: range of motion (ROM) around a joint (Gambetta, 2007)
• Static Flexibility – static flexibility is a limiting factor to athletic mobility
• Dynamic Flexibility – just like balance and posture flexibility is dynamic, not just static in nature

3. Plyometrics

Plyometrics are not a new training program and have been employed as far back as the late 1950’s. Plyometrics are simply a method of training that develops explosive power and have often been referred to as “jump training”. There are several forms of plyometric training that need to be employed in any athletic training program in order to maximize the power of the athlete.
• Rapid Fire Plyo – quick, short burst of jumps and landings with minimal time spent on the ground
• Max effort Plyo – focus on exploding off the ground with as much force as possible and allowing a full, complete landing
• Lateral v. Linear – Jumping both front-back and side to side
• SL v. DL – Jumping and landing on both a single leg and a double leg
• Landing/Tech – The correct biomechanics of landing in order to properly control the body and reduce stress on ankle, knee and hip. The most common problem with female athletes is the inability to bend the knees to assist in force dispersal as well as a “knock-knee” when landing creating an increased stress in the medial knee and ACL.

4. Torso Training

The term “CORE Training” is so over used and misused that we have gone away from that term and have begun to utilize the term “torso training”. This training is the focus on any body part with the exception of the arms and legs. It is more than just abs! It includes low back, hips, glutes, mid back & scapula stabilizing muscles. A proper program will focus on the ability to prevent rotation as well as the ability to produce rotation from the torso. Without the ability to stabilize the body, you can not mobilize its segments, namely the arms and legs. In order to produce and reduce force properly, it is vital to have a strong and efficient torso.

5. Weak Point Training

Another overused and misapplied word is prehabilitation or injury prevention exercises. It is impossible to prevent all injury. At best our goal is to reduce the likelihood of injury while promoting an increase in sport performance. In order to do so, each athlete must work on particular areas of the body that were addressed in the evaluation & testing component that have been viewed as a limiting factor. These areas that affect the lower extremity and the ACL often include:

• Foot
• Ankle
• Knee
• Hip
• Low Back

6. Integrated Strength Training

Strength is the basic building block of any athletic development program. Without strength it is impossible to produce and, more importantly, reduce force. Therefore, a properly designed program will address both the knee dominant exercises (lower body pushing exercises such as squat, lunge and step-ups) as well as hip dominant exercises (both closed chain – foot on the ground exercise such as deadlifts, glute hams & open chain – foot moving exercises such as stability ball curls, band kickbacks, etc)

• Knee Dom – squat, lunge, step-up
• Hip Dom – posterior chain development (both open chain and closed chain)

7. MDST

MDST is multi-directional speed training. Soccer athletes must develop foot speed in all directions not just straight ahead; too many athlete focus on getting quicker for the 30m or 40 yard dash. Athletes need to develop translatable speed in all directions. Most importantly, athletes need to focus on proper mechanics of decelerating. The ability to stop is one of the least trained yet most often causes of injury.
• Form/Tech – proper mechanics of running to increase efficiency or form
• Resisted – training designed to resist the athlete from running at highest speed and tax the muscular system developing an increase in stride length
• Assisted – training designed to assist the athlete to run at highest speed and develop a greater stride rate.

8. Footwork & Quickness

Lateral Speed, agility and foot quickness are just as important as linear speed to the soccer athlete. The athlete must not only posses great directional speed but also the ability to react and change direction with the appropriate body control in order to avoid injury.
• Directional
• Reactional

9. Recovery & Regeneration

Finally, the athlete must reduce stress on the muscular system and avoid adhesions and flexibility-limiting problems through a planned regeneration and recovery program utilizing massage, stretching and rest periods.

TREATMENT
The treatment for ACL injuries can be either non-operative or operative. Non-operative treatment consists of supervised physical therapy, activity (sport) modification and bracing. However, many initial non-operative treatments end up requiring surgery due to continued instability and/or further injury. The operative treatment of ACL injuries has progressed significantly over the past 20 years. Due to new arthroscopic techniques, better graft selection and improved postoperative rehabilitation, an increased number of athletes have been able to return to their chosen sport more quickly and safely than ever before. If surgery is chosen it is usually performed in an outpatient setting. Recovery times to return to sport depend on many factors and can vary from 3 – 8 months with aggressive rehabilitation.

SUMMARY
ACL injuries are increasing due to increased sport participation and continued year round training. Prevention programs are available and have proven to reduce risks of injury by up to 75%. If necessary, surgery has a high rate of success if performed by an experienced Orthopedic Surgeon and followed with an aggressive rehabilitation plan supervised by an experienced physical therapist and/or certified athletic trainer.

Gary A. Levengood, M.D., is the Founder and President of Sports Medicine South, LLC. Board certified in Orthopaedic Surgery and Sports Medicine by the American Board of Orthopedic Surgeons, Dr. Levengood completed a Sports Medicine fellowship at The Hughston Clinic in Columbus, Georgia, where he specialized in Arthroscopic Surgery and Sports Medicine. He also holds membership in the American Academy of Orthopedic Surgeons. He was the former Team Physician of the Georgia Force Arena Football Team and the Atlanta Silverbacks Soccer team; serves as the Medical Director for the Georgia State Soccer Association’s Olympic Development program and served recently as the Chief of Orthopedics at Gwinnett Medical Center.