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ACL injury screening and prevention CATS meeting 2016

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ACL injury screening and prevention CATS meeting 2016

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ACL injury screening and prevention CATS meeting 2016

  1. 1. Aaron Gray, MD @MizzouSportsDoc University of Missouri
  2. 2. I have received a Mizzou Advantage grant for research of ACL injury risk screening with video game technology. I have no other financial disclosures relevant to this talk. Matthew Busch, Missourian
  3. 3. • Epidemiology of ACL Tears in Athletes • Factors for the Female ACL Tear “Epidemic” • Neuromuscular Deficits in Female Athletes • Screening Tests for ACL Injury Risk • ACL Injury Prevention Programs
  4. 4. • About half of ACL injuries were in competitions and the injury rate was higher for competitions compared to practices.
  5. 5. • One athlete participant in one practice or game equals one athletic exposure • Example: 25 athletes completing one practice is 25 athletic exposures
  6. 6. 0 0.5 1 1.5 2 2.5 3 Female Male 4.1x 2.8x Stanley et al. AJSM, 2016.
  7. 7. www.daytondailynews.com
  8. 8. • Female athletes have 4-6x increased risk of ACL injuries than males in similar cutting sports • Since Title IX was passed in 1972 • 10x increase in participation in girls HS athletics • 5x increase in female participation in collegiate sports Arendt, et al. J Athl Train, 1999. NCAA (2002) and NFHS (2009) published data
  9. 9. • Estimated cost of surgery and rehab for an ACL injury is $17,000-25,000 • Estimated 200,000 ACL reconstructions annually in US at estimated cost of over $2 billion • In 2001 estimated 38,000 ACL injuries in girls and women at cost of approximately 650 million annually Brukner & Khan. Clinical Sports Medicine, 4th ed. 201 Toth & Cordasco. J Gend Specif Med 2001.
  10. 10. Soccer was highest mechanism of injury (26.6%) in Kaiser Permanente ACL registry ACL tears peak at age 16 in female athletes Maletis, et al. J Bone Joint Surg Am 2011. Female athletes who play soccer or basketball year- round have an annual ACL tear rate of 5% Prodromos, et al. Arthroscopy 2007.
  11. 11. • Intrinsic variables with gender differences • Anatomic • Hormonal • Neuromuscular
  12. 12. • Proposed gender differences include • Smaller size and different shape of intercondylar notch • Smaller ACL within smaller notch • Wider pelvis and greater Q angle • Greater ligament laxity • Since little can be done to modify these anatomical findings, focus has moved to what can be changed
  13. 13. • Hormonal effects on the musculoskeletal system is a complex process • Most studies suggest increased risk of ACL injury in preovulatory phase of menstrual cycle
  14. 14. • No evidence that oral contraceptives decrease ACL injuries
  15. 15. • 4-6 inch growth spurt around 10-11 years old • Center of mass rises through puberty • After growth spurt female adolescents do not gain “neuromuscular spurt” that males achieve Huston & Wojtys. AJSM 1996.
  16. 16. Ford et al. Med Sci Sports Ex 2010.
  17. 17. • 60-80% of ACL injuries are non-contact • Two common mechanisms Landing Cutting Krosshaug et al. AJSM 2007.
  18. 18. • Dynamic knee valgus on landing • Knee is relatively straight on landing • Most or all of weight is on one leg • Trunk is tilted laterally (center of mass is outside feet)
  19. 19. Olsen et al. AJSM 2004.
  20. 20. S
  21. 21. E
  22. 22. S
  23. 23. E
  24. 24. • Ligament Dominance • Quadriceps Dominance • Leg Dominance • Trunk Dominance (Core Dysfunction) Hewett et al. NAJSPT, 2010
  25. 25. • Muscles do not sufficiently absorb ground reaction forces • Joint and ligaments must absorb high forces over a short period of time • Posterior kinetic chain (gluteals, hamstrings, gastrocnemius, soleus) must be recruited to avoid ligament dominance
  26. 26. • GRF are directed toward the center of mass in the trunk of the athlete • Lateral trunk movement forces lower leg into dynamic valgus
  27. 27. • Decreased hamstring strength and recruitment • Females activate quadriceps more than males for initial knee stabilization
  28. 28. • Females land with less knee flexion than males • 3x less posterior kinetic chain activation during landing than size matched males Hewett et al. AJSM 1996. • Attempt to stabilize joint with quadriceps which results in anterior tibial translation • Quadriceps contraction increases ACL strain between 10° and 30° of knee flexion
  29. 29. Quadriceps • Single insertion • Patellar tendon into tibial tubercle • Less flexion on landing • Anterior tibial translation increases ACL stress Posterior Chain Muscles • Multiple, varied insertions • Medial and lateral tendons give frontal plane control • More flexion on landing • Prevents anterior tibial translation which decreases ACL stress
  30. 30. • Females tend to be more one-leg dominant than males • During an ACL injury most (or all) weight is on one leg • Athletes with increased asymmetry have greater risk of injury Hewett, et al. AJSM 2005. KOMU.com
  31. 31. • Athletes who had deficits of active core proprioceptive had greater risk of ACL injury Zazulak, Hewett, et al. AJSM 2007
  32. 32. Three steps needed to validate a screening test to predict and prevent sports injuries 1. Prospective cohort study to identify risk factor(s) and define cut-off value(s) 2. Validate test and cut-off value in multiple cohorts 3. Randomized controlled trial to test effect of combined screening and intervention program Bahr R. BJSM Published Online First, April 25, 20
  33. 33. AJSM, 2005.
  34. 34. 205 female HS athletes in soccer, basketball and volleyball prospectively measured for neuromuscular control with 3D motion analysis Hewett et al. AJSM 2005
  35. 35. 8.4˚ more dynamic valgus 7.6˚ more dynamic valgus 10.5˚ less knee flexion
  36. 36. External Knee Abduction Moment Knee Abduction Angle at Initial Contact
  37. 37. Norwegian professional female handball and soccer athletes completed a DVJ in preseason
  38. 38. Take Home: Medial knee displacement during the DVJ was only statistically significant predictor of ACL injury risk in Norweigian professional female handball & soccer players with Older population than Hewitt’s 2005 study and likely already participating in injury prevention program
  39. 39. • Similar to Hewitt’s Drop Vertical Jump protocol except: • 2 video cameras are used (frontal and side view) instead of marker based motion capture • Participants jump to a distance 50% of their height and immediately perform a maximum vertical jump Padua, et al. AJSM 2009.
  40. 40. Padua, et al. AJSM 2009.
  41. 41. Padua, et al. AJSM 2009.
  42. 42. Padua, et al. AJSM 2009.
  43. 43. 2691 subjects who were incoming freshman at 3 large US military academies Simultaneously analyzed with sophisticated laboratory system and inexpensive field analysis system (LESS) Results: Valid and reliable tool for identification of subjects with landing errors in multiple planes Padua, et al. AJSM 2009.
  44. 44. • Padua et al. J Athletic Training 2015. • 829 elite-youth soccer athletes (348 boys, 481 girls) • Age= 13.9 ± 1.8 years, age range = 11 to 18 years • Followed for 1217 athlete-seasons • 7 non-contact ACL tears occurred • Uninjured participants had lower LESS scores (4.43 ± 1.71) than injured participants (6.24 ± 1.75; P = .005)
  45. 45. • James et al. Sports Health, 2015. • 34 Division 1 male and soccer athletes performed a drop- landing task and were scored with LESS and lower extremity injuries were tracked during season • No statistically differences found in LESS scores in those with & without injury history. • Those injured during year had similar LESS scores to those uninjured.
  46. 46. Anterior Reach of the mSEBT Willis, et al. Under Review
  47. 47. Posteromedial Reach of the mSEBT Willis, et al. Under Review
  48. 48. Posterolateral Reach of the mSEBT Willis, et al. Under Review
  49. 49. • 4 cm or more difference in anterior reach distance between limbs at 2.5 higher risk of suffering lower leg injuries in high school basketball players • Females who demonstrated less than 94% composite reach distance were 6.5 times more likely to sustain a lower extremity injury. Plisky, J Orthop Sports Phys Ther. 2006.
  50. 50. • 3D lower extremity angles difficult to calculate without accurate hip measurement • Knee to Ankle Separation Ratio (KASR) is a reliable surrogate for dynamic knee valgus measurements Steffen, et al. IOC World Conference on Prevention of Injury & Illness in Sport, Monaco 2014. Mizner, et al. CJSM, 2012.
  51. 51. Distance between knees/Distance between ankles
  52. 52. • Hypothesis: Screening will be safe, efficient, and will identify known gender disparities • Population: 180 healthy high school athletes • Ages 14-18 (Mean age: 16.9 ± 1.31) • 80 males, 100 females • BMI: 22.8 ± 3.7
  53. 53. • Safety • There were no injuries reported during the screening testing • Efficiency • Using two motion sensor device stations, it took 3 minutes to screen and test each subject per station
  54. 54. Average KASR at Initial Contact Males: 1.13 Females: 0.967 KASR <0.9 Females 34% Males 3%
  55. 55. Average KASR at Peak Flexion Males: 1.26 Females: 1.01 KASR <0.9 Females 28% Males 3%
  56. 56. www.ukathletics.com
  57. 57. Hewett et al. NAJSPT 2010
  58. 58. Focuses on increasing recruitment of posterior kinetic chain • Gluteus maximus • Biggest, strongest muscle in body • Only three plane controller of femoral position • Quad activation reduces contraction of gluteus maximus and hamstrings
  59. 59. Squat jumps with hips and knees at 90/90 Hewett et al. NAJSPT 2010
  60. 60. Russian (or Nordic) Hamstring Curls Hewett et al. NAJSPT 2010
  61. 61. Swiss Ball Hamstring Curl Combination posterior chain and core Hewett et al. NAJSPT 2010
  62. 62. Single leg balance and hopping help restore side to side symmetry Hewett et al. NAJSPT 201 Perturbations on upside down Bosu ball
  63. 63. Core stability training Hewett et al. NAJSPT 2010. Transversus abdominis, multifidis, pelvic/hip stabilizers
  64. 64. Stabilization of pelvis through hip abductors and rotators is key! Poor hip external rotation strength after ACL reconstruction had 8X greater chance of another ACL tear Paterno et al. AJSM 2010
  65. 65. AJSM 2006 Analyzed 6 studies looking at effectiveness of neuromuscular training interventions in reducing ACL injuries Hewett, et al. AJSM 2006
  66. 66. Hewett, et al. AJSM 2006 29 total ACL injuries in training group vs 110 in control group 3 of 6 interventions showed significant reduction in ACL injury rates, while 5/6 demonstrated positive trends and reduction of odds ratio
  67. 67. • Prospective cohort study high school aged female soccer, basketball, and volleyball players • Intervention group - 15 female teams (n=366) • Control group – 15 female teams (n=463) • Control group – 13 male teams (n=434) • Intervention – 6 week neuromuscular training 3x/wk for 60-90 min/session before season • Results – Significantly decreased noncontact ACL injuries by 72% (p<0.5)
  68. 68. • Prospective cohort study for 3 seasons in Norwegian female handball • Intervention started 2nd (n=855) and 3rd (n=850) seasons • Exercises – balance board, jump exercises, balance mat exercises • Results – • 29 ACL injuries initial season, followed by 23 (p=.62) 2nd year and 17 (p=0.15) 3rd year • Non-contact ACL injuries decreased from 18 to 7 (p=0.04) from 1st to 2nd year • ACL risk decreased 36%
  69. 69. • Plyometric training • Trains muscles, connective tissue, and nervous system to effectively carry out stretch shortening cycle and appears to reduce ACL injuries • Technique education and feedback • Encouraging soft landing and maintaining knee over toe position • Balance, core stability, postural control training • Strengthening exercises
  70. 70. • Neuromuscular training programs can be effective at improving performance measures of speed, strength, and power • The key for compliance!
  71. 71. • 61 NCAA Div 1 teams were randomized • Noncontact ACL injury rate was 3.3x less in intervention group (p=0.66, 70% decrease) • Intervention athletes with history of ACL reconstruction were significantly less likely to suffer another ACL injury (p=0.046) AJSM 2008
  72. 72. • FIFA is the international soccer governing body • F-MARC is their medical research committee whose focus is injury prevention and improving standards of care for football players worldwide • Developed the 11+ warm up program to decrease injuries
  73. 73. • Grooms, et al. J. Athl Training 2013. Male college soccer athletes showed reduction in relative risk of lower extremity injury of 72% No studies looking at FIFA 11+ specifically recorded ACL injuries
  74. 74. • ACL screening tests for injury risk are promising but nothing works really well yet. • ACL injury prevention programs work for female athletes!
  75. 75. • Measure injury rates and compare to NCAA published data • Only way to see if injury prevention programs work! • Coordinate ACL injury prevention programs with strength and conditioning colleagues
  76. 76. • @MizzouSportsDoc • grayad@missouri.edu

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