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HOW TO PREVENT ACL INJURIES AND KEEP YOUR CLIENTS ON THE COURT THROUGH CORRECTIVE EXERCISE PROGRAMMING

Knee ACL iStock_000012214665_XXXLarge resized

(Republished with permission www.WebExercises.com)

Anterior cruciate ligament (ACL) injuries are one of the most common among young female athletes occurring at a conservative estimate of 38,000 incidences per year. (1) With the cost of a surgical repair ranging between $17,000-$25,000 (2), the economic impact is significant, not to mention the long term sequela to the athlete which includes a significantly greater risk of osteoarthritis in the future. (3) Approximately 80% of these injuries are non-contact, suggesting many of them can be prevented. (4)

The ACL is a ligament running from the posterior femur anteriorly to the tibia. It originates from deep within the notch of the distal femur and its proximal fibers fan out along the medial wall of the lateral femoral condyle. The ACL attaches in front of the intercondyloid eminence of the tibia and is blended with the anterior horn of the medial meniscus. It provides approximately 85% of the restraining forces preventing anterior tibial translation. It also limits excessive internal or external rotation of the tibia. (5)

Knee Normal ACL

Pubertal females are four to six time more likely to sustain an ACL injury compared to males, thereby representing the largest demographic of athletes at potential risk. (6) This is due to a variety of reasons including the rapid growth of the femur and tibia that generate larger joint forces making neuromuscular control of the lower extremities and trunk much harder. A lack of core stability has also been shown to influence knee injuries in female athletes as reported by Zazulak and colleagues. They demonstrated this decrease in core neuromuscular control increases uncontrolled trunk displacement leading to higher knee ligament strain and ACL injury. (7)

Knee ACL Tear

In order to identify at risk athletes, implementing a screening method such as the Landing Error Scoring System (LESS) test or Tuck Jump test is essential when working with all athletes in this age range. The LESS involves having the athlete stand on a 12-inch box and then jumping forward with both feet to a predetermined line followed by an immediate jump for maximal height.

The Tuck Jump test requires the athlete to perform repeated jumps flexing the knees toward the trunk for a duration of 10 seconds. Both tests have been validated in the literature to identify neuromuscular imbalances. (9) (10) (For more information on each test please refer to NASM Essentials of Corrective Exercise Training for a detailed review. (8))

One of the most common muscular imbalances identified in females over males is increased knee valgus and coronal plane rotation that has been shown to be a predictor of injury. This common finding has been associated with increased quadriceps firing and decreased gluteal activation in females, causing anterior shear stress on the tibia, which is then transferred to the ACL. (11)

Knees cave in

In order to establish proper gluteus maximus activation, a hip bridge with a resistance band above the knees is recommended. Choi and colleagues found that gluteus maximus EMG activity was significantly greater while anterior pelvic tilt angle was significantly lower in the hip bridge with isometric hip abduction compared to the hip bridge without the band. Therefore, they concluded that performing hip bridges with isometric hip abduction against isometric elastic resistance can be used to increase gluteus maximus EMG activity and reduce anterior pelvic tilt during the exercise. (16)

Exercise 1a

Hip Bridge with Resistance Band – Begin by lying on the floor with knees bent and feet flat on the floor. Place a resistance band around the thighs just above the knees. Slightly abduct the legs while simultaneously performing a hip bridge. Slowly lower to start position without bringing knees together. Perform 3 sets of 10 repetitions.

Valgus collapse of the knee can also be associated with weakness of the hip external rotators and gluteus maximus. Paterno and colleagues identified this finding as an eight times greater risk of sustaining a second ACL injury. (12) Performing the clam shell exercise will mitigate hip rotator weakness, helping to minimize this potential risk.

Exercise 2a Exercise 2b

Clam Shell with Resistance Band – Begin by lying on the side with knees together and bent to 90 degrees with resistance band around knees. Lift top knee upward while keeping feet touching. Continue lifting knee to the point just before pelvis begins to move. Perform 3 sets of 10 repetitions.

The hamstrings are also synergistic to the knee helping to stabilize the tibia against the anterior forces created by the quadriceps. A stability ball leg curl is a great open kinetic chain exercise and has been showed to elicit high EMG activity of the hamstring muscles while co-contracting the core musculature. (13)

Exercise 3a Exercise 3b

Stability Ball Leg Curl – Begin lying face up with arms extended at sides and ankles on top of the stability ball. Activate core and form a bridge position. Then flex knees, bending legs as you draw the ball inward. Reverse the movement, extending knees, and return to start position. Perform 3 sets of 10 repetitions.

In order to establish lateral stability, the side step “monster walk” with knees bent is a functional and effective exercise. Increased hip abduction strength has been shown to improve the ability of female athletes to control lower extremity alignment. (14) When performing this exercise, the stepping motion should be performed in a squat position rather than an upright straight leg position in order to generate greater gluteus maximus and medius muscle activity. (15)

Exercise 4a Exercise 4b

1/4 Squat with Lateral Steps Using Resistance Band – Begin standing with a resistance band around the thighs just above the knees. Keep your feet and knees apart enough to put resistance on the band. Perform a ¼ squat with both feet supporting body weight. Hold squat position, shift weight fully onto one leg. Take a lateral step with the other un-weighted leg. Repeat, taking several lateral steps in one direction and then doing the same in the other direction.

Another potential risk of injury occurs when landing with a knee flexion angle of less than 45 degrees. Therefore, performing long jumps can be used to train proper landing patterns. This exercise is similar to the Tuck Jump test with the addition of forward motion and is also a great way to introduce plyometric exercises. If the athlete is unable to “stick” the landing with toes straight ahead and no inward knee motion, then regress them to submaximal jumps of a shorter distance until perfect technique can be attainted. (6)

Exercise 5a Exercise 5b

Long Jump to Backward Hop – Begin in quarter squat position. Jump forward in an explosive long jump trying to “stick” the landing for 3-5 seconds. Make sure the knees are flexed to approximately 90 degrees on landing. Hop backwards two or three times returning to the start position. Perform 3 sets of 10 repetitions.

One of the most significant findings, which has been shown to reduce the incidence of ACL injuries in a number of studies, is the incorporation of high-intensity plyometric exercises as part of the training program. The split jump offers these plyometric benefits.

Exercise 6a Exercise 6b

Split Jumps – Begin in a split stance lunge position with arms raised at shoulder level. Jump upward and quickly reposition legs and land with feet in opposite positions. Raise arms while you are jumping. Continue jumps by alternating leg positions. Perform 3 sets of 10 repetitions.

If an athlete fatigues to the point that she can no longer perform the exercise perfectly, then she should be instructed to stop. The duration of each completed exercise should be noted with the goal of the next training session to continue to improve technique and to increase volume or intensity.

In addition to the NASM corrective exercise continuum of inhibit, lengthen, activate and integrate, three additional components should also be considered as part of a comprehensive training protocol. These are biomechanically correct movement patterns as noted above; neuromuscular patterning based on the identification of underlying neuromuscular imbalances as found in the assessment test; and constant biomechanical assessment through the LESS, Tuck Jump or similar test with feedback and verbal cueing to athlete both during and after training. (10)

An incorporation of a core stabilization program is not only integral but also essential in order to provide dynamic stability for the lower extremities. A weak core results in energy leakage as described by McGill requiring the weaker joints to make up for this difference. An example of this is when jumping or changing running direction, the lower extremity musculature must compensate for the lack of core stability, negatively effecting performance. (17)

All of the above displayed exercises are easy to execute and include minimal risks if performed as described. To achieve satisfying results, it is important do them on a regular basis and for a minimum of 4 weeks. The general guideline for progressing student athletes is the “10% rule”, where total training (intensity, frequency, duration, or any combination) is not increased more than 10% per week. Although there are many approaches to knee strengthening, hopefully this has provided insight into some basic strengthening strategies. Should your client’s condition worsen at any time, an evaluation with a medical professional would be warranted.

To download a copy of the above exercises, click here.

References

1) Toth AP, Cordasco FA. Anterior cruciate ligament injuries in the female athlete. J Gend Specif Med. 2001; 4:25–34.

2) de Loes, M, et al. A 7-year study on risks and costs of knee injuries in male and female youth participants in 12 sports. Scand J Med Sci Sports. 2000;10(2):90-97.

3) Ruiz AL, Kelly M, Nutton RW. Arthroscopic ACL reconstruction: a 5-9 year follow up. Knee. 2002;9(3):197-200.

4) Sadoghi, P, et al. 2012. Effectiveness of Anterior Cruciate Ligament Injury Prevention Training Programs. J Bone Joint Surg Am. 2012; 94:1-8.

5) Lowe, R. Anterior Cruciate Ligament (ACL). Retrieved from: http://www.physio-pedia.com/Anterior_Cruciate_Ligament_(ACL)

6) Myer, G. 2004. Rationale and Clinical Techniques for Anterior Cruciate Ligament Injury Prevention Among Female Athletes. Journal of Athletic Training 2004;39(4):352–364.

7) Zazulak BT, Hewett TE, Reeves NP, et al. The effects of core proprioception on knee injury: a prospective biomechanical–epidemiological study. Am J Sports Med 2007;35(3):368–73.

8) Clark, MA, Lucett, SC. (2014). NASM Essentials of Corrective Exercise Training. Burlington, MA. Jones & Bartlett Learning.

9) Padua, D. et al. 2011. Journal of Sport Rehabilitation. 20, 145-156.

10) Myer, et al. 2008. Tuck Jump Assessment for Reducing Anterior Cruciate Ligament Injury Risk. Athl Ther Today. 2008 September 1; 13(5): 39–44.

11) Zazulak, B, et al. Gender Comparison of Hip Muscle Activity During Single-Leg Landing. Journal of Orthopaedic & Sports Physical Therapy.

12) Paterno, M, et al. Biomechanical Measures During Landing and Postural Stability Predict Second Anterior Cruciate Ligament Injury After Anterior Cruciate Ligament Reconstruction and Return to Sport. Am J Sports Med October 2010 vol. 38 no. 10 1968-1978.

13) Panagiotis, T., et al. 2015.  Muscle and intensity based hamstring exercise classification in elite female track and field athletes: implications for exercise selection during rehabilitation. Open Access Journal of Sports Medicine. 6:209-217.

14) Myer , G, et al. 2008. Trunk and Hip Control Neuromuscular Training for the Prevention of Knee Joint Injury. Clin Sports Med 27:425–448.

15) Berry, et al. 2015. Resisted side-stepping: the effect of posture on hip abductor muscle activation. Journal of Orthopaedic & Sports Physical Therapy.

(16) Choi, C, et al. 2014. Isometric hip abduction using a Thera-band alters gluteus maximus muscle activity and the anterior pelvic tilt angle during bridging exercise. Journal of Electromyography and Kinesiology.

(17) McGill, S. Core Training: Evidence Translating to Better Performance and Injury Prevention. Strength and Conditioning Journal. Vol 32(3):33-46.

(18) Myer, G. 2006. The effects of plyometric vs dynamic stabilization and balance training on power, balance, and landing force in female athletes. Journal of Strength and Conditioning Research. 20(2), 345-353.

THE AUTHOR

DAVID CRUZ, DC, CSCS, FMS, SFMA

Dr. David Cruz practiced as a sports chiropractor for 18 years treating athletic injuries, from weekend warriors to professional athletes. He received his bachelor’s of science degree in athletic training and has completed graduate course work in kinesiology. He is a Certified Strength and Conditioning Specialist (CSCS) as well as having both FMS and SFMA certifications. The combination of his background in sports medicine and interest in technology made him passionate about bringing these two worlds closer together, resulting in the foundation of his company WebExercises in 2005.
WebExercises is an end-to-end solution for exercise rehabilitation professionals and is currently integrated with several EHR companies. In addition to WebExercises.com, Dr. Cruz is co-founder and partner of two other software businesses within the health care and technology industry.

HOW TO PREVENT ROTATOR CUFF INJURIES THROUGH CORRECTIVE EXERCISE PROGRAMMING (PART 1)

Shoulder pain and shoulder injuries are among the most common conditions within the general population and among athletes. Approximately 75 to 80% of these are caused by conditions related to the rotator cuff (1). The rotator cuff consists of four muscles, including the supraspinatus, infraspinatus, subscapularis and teres minor. These act to provide dynamic stability and control the position of the humeral head relative to the glenoid fossa during motions ranging from throwing to performing a push-up (2). There are many factors that can lead to shoulder pain and dysfunction, one being a muscular imbalance between the rotator cuff muscles and its relationship to the scapula and clavicle.

This two part series will describe the function of the rotator cuff and its synergistic relationship to the scapula and clavicle, while also providing exercises to strengthen the muscles of the shoulder complex. Correcting dysfunctional movement patterns of the shoulder complex typically requires a multifaceted approach including inhibiting, lengthening, and activating muscles whether the goal is preventative or rehabilitative. This part of the series will focus on corrective exercise strategies that inhibit and lengthen muscles by self-myofascial release in combination with static stretching. Part 2 of the series will provide you with corrective exercise protocols to stabilize and strengthen the rotator cuff muscles.

To understand how to implement corrective strategies we must first look at the anatomy and kinematics of the shoulder. The shoulder complex can be broken down into three distinct regions, the upper arm or humerus, scapula, and clavicle, which are working together providing movement in all three planes. These three regions create a mechanical linkage that is dependent upon one another for proper shoulder motion that is controlled by the upper trapezius, lower trapezius and serratus anterior.

Dysfunctional movement patterns are in part based on the concept of relative flexibility that suggests movement occurs through the pathway of least effort. For example, if hip movement is relatively stiff compared to that of the low back, then the movement is more likely to happen in the back (3). In the case of the shoulder, if the trapezius muscles are limiting proper scapula thoracic motion, the rotator cuff muscles will then compensate for this and become the “pathway of least effort” leading to compensation patterns. Therefore, inhibited or tight trapezius and serratus muscles will alter proper scapula motion. This results in improper clavicle movement due to these muscular imbalances ultimately affecting the rotator cuff.

In order to have properly working rotator cuff muscles, proper scapula thoracic motion must be established in order to maintain the correct length-tension ratio of the rotator cuff muscles. The motion of the scapula and upper arm is defined as a 2:1 movement ratio, meaning for every 2 degrees of upward humeral motion there is 1 degree of upward scapular motion. Muscles involved in creating this movement are the upper and lower trapezius and the serratus anterior. A change in scapula position or motion may cause an internal rotation of the humerus resulting in a shortened internal rotator muscle (subscapularis) and a stretched or weakened external rotator muscle (teres minor). Any dysfunction of these muscles will require opposing muscles acting on the shoulder complex to be affected due to their relationship with one another.

Proper shoulder motion and rotator cuff function are also dependent on clavicle movements that include protraction, retraction, elevation, depression and posterior rotation. As the scapula rotates upward the clavicle elevates up to 30 degrees at the acromioclavicular (AC) joint (4). Then as the arm elevates further the clavicle begins to rotate posteriorly along its axis allowing the scapula to further elevate upward.

This posterior clavicle rotation has been described in numerous studies including one by Ludewig and colleagues who performed a three dimensional analysis (5). Their findings indicate that as the arm elevates, 8 degrees of posterior rotation occurs when the arm is elevated to 110 degrees. Any loss of normal scapula motion will alter the clavicle motion and ultimately restrict the range of motion of the upper extremity. Therefore, prior to initiating any specific rotator cuff exercises it is imperative to restore the muscular function of the scapulothoracic, AC, and sternoclavicular (SC) joint regions.

In order to inhibit and lengthen these muscles a self-myofascial release (SMR) approach with either a foam roll or a tennis ball can be utilized. SMR using a foam roll has been shown to be effective for increasing flexibility when combined with static stretching. Mohr and colleagues demonstrated this when they compared foam rolling and static stretching of the hamstring muscles (6). Their study findings indicate using the foam roll for SMR in addition to static stretching is superior to either SMR or static stretching alone. Therefore, in order to maximize range of motion it is recommended to foam roll prior to static stretching.

The following protocol is based on the above-described findings and can be performed daily or at least 3 times per week. The SMR exercises are performed on the floor applying as much body weight pressure as can be comfortably tolerated for up to 1 minute at time.

Trapezius and Rhomboid SMR

Begin seated on floor. Lie back placing foam roll across upper back. Cross arms in front, placing hands on shoulders. Lift hips off floor. Slowly massage upper back, rolling up and down as tolerated, for duration of 1 to 2 minutes. Maintain consistent pressure with foam roll. If a painful area is found, stop rolling and REST on the area for 30 seconds as tolerated, then continue.

Posterior Shoulder Tennis Ball SMR

Begin lying on floor facing up. Place a tennis ball behind shoulder. Raise arm so elbow is at shoulder level and bent to 90°. Lift opposite shoulder slightly so that pressure is felt against tennis ball. Grasp wrist with opposite hand and move arm upward and downward massaging shoulder muscles. Perform massage for 1 to 2 minutes. Maintain consistent pressure with tennis ball. If a painful area is found, stop rolling and REST on the area for 30 seconds as tolerated, then continue.

Pectoralis Major and Minor SMR with Tennis Ball

Begin lying face down with a yoga or tennis ball situated between the floor and below the clavicle with forearm flat on the ground. Applying constant pressure on the ball, slowly move forearm upwards, pause momentarily, and then slowly return to starting position.

Static stretching to compliment the SMR exercises can be performed daily or at least 3 times per week. It is recommended that each stretch is held for 30-60 seconds and repeated three times resting 30 seconds in between stretches. When stretching the posterior shoulder a cross body stretch is recommended as this was found to be more effective than the side lying sleeper stretch by McClure and colleagues (7).

Cross Body Stretch

Begin seated or standing (ideally this is best done with the back against a wall to help stabilize the scapula and emphasize the stretch on the posterior shoulder). Extend one arm in front, and across body, at shoulder level. With opposite arm grasp arm above elbow and gently pull towards chest until a stretch is felt in the back of the shoulder. Hold for 20-30 seconds and repeat on opposite side.

Static Foam Roll Chest Stretch

Begin by positioning yourself lying on foam roll with feet flat on floor. Foam roll should support the head and run along the spine down to pelvis. Place arms to sides. Bend both elbows to 90º at shoulder level with palm facing up. Relax as chest and shoulders stretch for 30-60 seconds. Do not try to force arms to floor.

All of the above displayed exercises are easy to execute and include minimal risks if performed as described. To achieve satisfying results it is important do them on a regular basis and for a minimum of 4 weeks.

References

(1) Clark, M.A., Lucett, S.C. (2014). NASM Essentials of Corrective Exercise Training. Burlington, MA. Jones & Bartlett Learning.

(2) Arnheim, D.D., Prentice, W.E. (2000). Principles of Athletic Training. Boston, MA. McGraw Hill.

(3) Lehtola et al. BMC Musculoskeletal Disorders 2012.

(4) Kisner, C., Colby, L.A. (2002). Therapeutic Exercise Foundations and Techniques. Philadelphia, PA. F.A. David Company.

(5) Ludewig, P., et al. (2004). Three-Dimensional Clavicular Motion Durning Arm Elevation: Reliability and Descriptive Data. Journal of Orthopaedic & Sports Physical Therapy, 34(3), 141-150.

(6) Mohr, A., et al. (2014) Effect of foam rolling and static stretching on passive hip-flexion range of motion. Journal of Sport Rehabilitation.

(7) McClure P, et al. (2007). A randomized controlled comparison of stretching procedures for  posterior shoulder tightness. Journal of Orthopaedic & Sports Physical Therapy 37:108-14.

DAVID CRUZ, DC, CSCS, FMS, SFMA

Dr. David Cruz practiced as a sports chiropractor for 18 years treating athletic injuries, from weekend warriors to professional athletes. He received his bachelor’s of science degree in athletic training and has completed graduate course work in kinesiology. He is a Certified Strength and Conditioning Specialist (CSCS) as well as having both FMS and SFMA certifications. The combination of his background in sports medicine and interest in technology made him passionate about bringing these two worlds closer together, resulting in the foundation of his company WebExercises in 2005.
WebExercises is an end-to-end solution for exercise rehabilitation professionals and is currently integrated with several EHR companies. In addition to WebExercises, Dr. Cruz is co-founder and partner of two other software businesses within the health care and technology industry.