This document discusses using real-time 3D motion capture technology to assess movement quality and risk of ACL reinjury in football players returning to sport. 25 elite male football players performed drop jumps, single leg squats, and other tests which were analyzed for biomechanics using the technology. Results showed asymmetry, excessive knee valgus, and other high risk movements. The system can establish baselines, guide rehab to correct mechanics, and help clear players for return to play by ensuring safe, symmetrical movement quality. This pilot study aims to develop normative data to establish evidence-based return to sport guidelines for football players post-ACL injury.

1. Movement Performance 3D
Real-Time Dynamic Assessment
For the Return to Sport in ACL Injury
DR KERITH AGINSKY
PhD (Exercise Science)
Dr Maya Cale-Benzoor
FOOTBALL MEDICINE STRATEGIES RTP
April | 2016

2. The numbers behind the goals
Source: stack.com
Biomechanics
modifiable risk factor

3. INTRODUCTION
• ACL injury compromises:
• Neuromuscular control
• Mobility
• Strength
• Stability
• Current RTP guidelines = No quality of movement assessment during
dynamic tasks
• Faulty lower extremity biomechanics place athlete at risk of ACL injury &
thus re-injury if not addressed prior to RTP
Myer et al (2006), Waters (2012), Bizzini (2012), Paterno et al (2010)

4. FOOTBALL SPECIFIC MOVEMENT ERRORS FOR
RISK OF ACL INJURY & RE-INJURY
• ↑ dynamic knee valgus at initial contact
• ↑ maximal knee valgus which ↑ anterior tibial
translation.
• ↓ maximal knee flexion angle at initial contact
• ↓ knee flexion displacement ↑ ACL loading
• Asymmetrical loading
Myer et al (2006), Waters (2012) Hewett et al (2005), Padua et al (2012), Hirth and Padua (2007), Dufek and Bates (1991), Fukuda et al (2003),
Lloyd and Buchanan (2001), Markolf et al (1995)

5. IMPORTANT TO IDENTIFY: SPECIFIC CAUSE FOR FAULTY PATTERN
• Knee valgus may be due to:
• ↓ ankle dorsiflexion ROM
• Assess also dorsiflexion lunge test
• ↓ gluteal muscle activation
• ↓ joint displacement on LESS/single leg squat
• ↑ hip-adductor activation
• Adductor squeeze test

6. LIMITATIONS FOR ASSESSMENT
• Lab-based 3D assessment
• Specialised equipment, expensive and not available to the clinician
• 2D video analysis
• Human error, time-consuming, trained clinician
• Inability to frequently retest
• Cannot asses rotational patterns of movement

7. 7
Introducing
A Real-Time cloud based technology that reliably scores athletes' risk
of injury And functional performance. Leveraging evidence-based
functional movement Tests, for training programs to address athletes'
personal condition.

8. AIMS
• Pilot study:
• Use of real-time marker-less 3D software to assess quality of
movement assessment in football players.
• In progress:
• Database development of normative kinematics in football players
per age group, level of participation and gender.
• Use normative data to establish guidelines for RTP following ACL
injury in football players.

9. METHODS
• 25 Elite, male football players
• 25,2 ± 4,8 years
• No current ACL injuries
• Drop Jump test assessed with LESS criteria (22 and 17 criteria)
• Eg: Landing kinematics, symmetry, joint displacement,
neuromuscular control, mobility, dynamic stability
• Single leg squat
• Dorsiflexion lunge, Unilateral vertical jump, Dynamic knee stability

11. Validated Technology
11
Prof. Darin Padua
UNC Sports Sciences
AND COLLEAGUES
VALIDATION STUDY (PH 1 — AUG 2014)1
LARGE-SCALE (PH 2 — AUG 2015)2
MICROSOFT KINECT vs VICON3
Padua et al (2015), Lee et al (2015), Gray et al (2014), Eltoukhy et al (2016), Yang et al (2015), Chen (2014)

12. RESULTS FOR LESS
CRITERIA DOMINANT NON-DOMINANT
Overall Score LESS 22 6.6 ± 2.2
Medial knee position at IC (o) -1.0 ± 4.4 -1.8 ± 4.4
Medial knee displacement (o) 5.1 ± 12.2 3.6 ± 9.8
Knee flexion at IC (o) 17.5 ± 13.8 18.5 ± 13.9
Knee flexion displacement (o) 62.0 ± 26.1 61.4 ± 25.7
Hip flexion at IC (o) 22.9 ± 15.7 24.4 ± 15.3
Hip flexion displacement (o) 42.3 ± 27.7 41.9 ± 28.0
Joint displacement 1 ± 1 1 ± 1

13. RESULTS FOR SINGLE LEG SQUAT
CRITERIA DOMINANT NON-DOMINANT
Overall Score 4.9 ± 1.3 4.4 ± 1.0
Maximal knee valgus (o) 13.6 ± 14.9 14.8 ± 12.2
Maximal knee flexion (o) 81.5 ± 18.1 78.5 ± 16.3
Maximal hip Flexion (o) 75.7 ± 18.2 73.9 ± 18.1
Pelvic hike (o) 4.2 ± 4.6 1.5 ± 5.4
Lateral trunk flexion (o) -1.1 ± 4.3 1.8 ± 5.0
Dynamic knee stability (%) 17.4 ± 14.4 10.5 ± 14.7

14. PREVENTION + REHAB + RETURN TO SPORT
RIGHT
Reduced knee
flexion @ IC
Low knee
flexion
displacement
Asymmetrical
weight shift to the
RIGHT
RIGHT
Increased knee
valgus at IC
and increases
with
displacement
• Establish a quantitative orthopedic baseline for
in-season monitoring or return-to-sport
• Enhanced rehabilitation, working their incorrect
biomechanics
• Compare athletes to norms, pre-injury level and
bilateral comparison
• Range of bilateral & unilateral dynamic tests
LESS, Single leg squat, Dorsiflexion lunge, Single
leg hop, Countermovement jump, SEBT

15. CONCLUSIONS
• Quality of movement criteria for RTP to
avoid re-injury should include:
• ↓ excessive knee valgus
• ↓ medio-lateral displacement
• Adequate, symmetrical knee flexion
• Adequate dynamic knee instability
• Full dorsiflexion ROM
• No bilateral deficits in movement quality
• Adequate joint displacement
• Important need for objective, quality of
movement assessment in RTP decision-
making following non-contact ACL in
football players

16. Juan Torrijo Navarro
“PhysiMax data takes our training to next level, Using
latest scientific methods to objectively analyze &
monitor players. Saving us time in our prevention
workouts.”
Head Fitness Coach
Maccabi Tel Aviv F.C
Fitness Coach
Valencia CF
1996-2012

17. REFERENCES
• Hewett TE, Myer GD, Ford KR, Heidt RS, Jr., Colosimo AJ, McLean SG, et al. Biomechanical measures of neuromuscular control and valgus loading of
the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. The American journal of sports medicine.
2005;33(4):492-501.
• Padua DA, Marshall SW, Boling MC, Thigpen CA, Garrett WE, Jr., Beutler AI. The Landing Error Scoring System (LESS) Is a valid and reliable clinical
assessment tool of jump-landing biomechanics: The JUMP-ACL study. The American journal of sports medicine. 2009;37(10):1996-2002.
• Padua DA, Bell DR, Clark MA. Neuromuscular characteristics of individuals displaying excessive medial knee displacement. Journal of athletic training.
2012;47(5):525-36.
• Hirth CJ, Padua DA. Clinical movement analysis to identify muscle imbalances and guide exercise. Athl Ther Today. 2007;12(4):10–14.
• Dufek JS, Bates BT. Biomechanical factors associated with injury during landing in jumping sports. Sports Med. 1991;12:326-337.
• Fukuda Y, Woo SL, Loh JC, et al. A quantitative analysis of valgus torque on the ACL: a human cadaveric study. J Orthop Res. 2003;21:1107-1112.
• Lloyd DG, Buchanan TS. Strategies of muscular support of varus and valgus isometric loads at the human knee. J Biomech. 2001;34:12571267.
28.Markolf KL, Burchfield DM, Shapiro MM, Shepard MF, Finerman GA, Slauterbeck JL. Combined knee loading states that generate high anterior
cruciate ligament forces. J Orthop Res. 1995;13:930-935
• Gustavsson A, Neeter C, Thomee P, et al. A test battery for evaluating hop performance 585 in patients with an ACL injury and patients who have
undergone ACL reconstruction. 586 Knee Surg Sports Traumatol Arthrosc. 2006;14:778-788.
• Myklebust G, Holm I, Maehlum S, Engebretsen L, Bahr R. Clinical, functional, and 641 radiologic outcome in team handball players 6 to 11 years after
anterior cruciate 642 ligament injury: a follow-up study. The American journal of sports medicine. 643 2003;31:981-989.
• Paterno MV, Schmitt LC, Ford KR, et al. Biomechanical measures during landing and 657 postural stability predict second anterior cruciate ligament
injury after anterior cruciate 658 ligament reconstruction and return to sport. The American journal of sports medicine. 659 2010;38:1968-1978.
• Gray AD, Marks JM, Stone EE, Butler MC, Skubic M, Sherman SL. Validation of the Microsoft Kinect as a portable and inexpensive screening tool for
identifying ACL injury risk. . The Orthopaedic Journal of Sports Medicine. 2014;2(7 (supp 2)).
• Eltoukhy M, Kelly A, Kim CY, Jun HP, Campbell R, Kuenze C. Validation of the Microsoft Kinect(R) camera system for measurement of lower extremity
jump landing and squatting kinematics. Sports biomechanics / International Society of Biomechanics in Sports. 2016:1-14.
• Yang L, Zhang L, Haiwei D, Alelaiwi A, Saddik A. Evaluating and Improving the Depth Accuracy of Kinect for Windows v2. IEEE SENSOR JOURNAL.
2015:1-12.
• Chen C. Verification of specifications and aptitude for short-range applications of the Kinect v2 depth sensor. In: University C, editor. Lewis’
Educational and Research Collaborative Internship Project (LERCIP): NASA Glenn Research Center, Graphics & Visualization/Dr. Herb Schilling; 2014.
• Bizzini M, Hancock D, Impellizzeri F. Suggestions from the field for return to sports participation following anterior cruciate ligament reconstruction:
soccer. The Journal of orthopaedic and sports physical therapy. 2012;42(4):304-12.
• Myer GD, Ford KR, McLean SG, Hewett TE. The effects of plyometric versus dynamic stabilization and balance training on lower extremity
biomechanics. The American journal of sports medicine. 2006;34(3):445-55.
• Waters E. Suggestions from the field for return to sports participation following anterior cruciate ligament reconstruction: basketball. The Journal of
orthopaedic and sports physical therapy. 2012;42(4):326-36.

18. Thank you!kerith@pmax.co www.pmax.co