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Danielle Toney The effectiveness of ACL prevention programs Glen Allen High School

Background of the ACL: The anterior cruciate ligament is one of the four ligaments that stabilize the knee. It runs through the center of the knee joint and is a rubber like band that is no bigger than your pinkie (Berra, 2009). It prevents the tibia from sliding out in front of the femur as well as provides rotational stability to the knee (Anterior Cruciate Ligament Injuries, 2014). The purpose of the ACL is to control movement of the knee joint. The ACL limits excessive side to side motion and also helps prevents the knee from straightening past the normal range of motion (Inverarity, 2008). The ACL is not involved in activities such as jogging, but when someone goes to cut or change direction the ACL come into play (Souryai, 2009). Tim Spalding described the importance of the ACL as: The importance of the ACL is that it is the main stabilizer of the knee and without it fast pivoting and twisting actions become difficult and result in giving way of the knee. It is hard to get back to pivoting type sports without a good ACL. In addition repeated buckling or giving way of the knee leads to secondary damage of the other important structures of the knee namely the smooth bearing surface (articular cartilage) and the protective shim between the surfaces (meniscus or footballers cartilage). Once these become damaged then there is much higher risk of later problems with the knee such as pain from wear and tear arthritis. Repeated giving way of the knee is therefore not good for the knee.

How the ACL is injured: About 1 in 20 female athletes tear their ACL, which has led to a gender inequality in the injury. Due to wider hips, and weaker knees females are more than double the likelihood to tear than ACL than males (Hewett, Johnson, 2010). There are several different ways that the ACL can be injured. This includes changing direction rapidly, stopping suddenly, slowing down while running, landing from jump incorrectly, direct contact or collision, such as a tackle (Anterior Cruciate Ligament Injuries, 2014). The ACL can be injured if the knee joint bends backwards,

to the side, twists, or bends in an unusual way. Injuries can be contact or noncontact, and most likely occur during sports. The injury can happen when the foot is firmly planted on the ground and a sudden force such as a person hits it while the leg is straight or just slightly bent. Or it can happen when you plant your foot to turn in another direction It is common that other knee ligaments are damaged when the ACL tears such as cartilage and menisci (Anterior Cruciate Ligament Injuries, 2005). The most common ACL injury is actually noncontact, involving no outside force to the knee (Souryal, 2009). ACL injuries in sports There are between 250,000 and 300,000 ACL injuries per a year, and they are exclusively happening to athletes (Souryai, 2009). The highest rate of ACL injuries occurs in soccer, basketball, tennis and volleyball which involve a lot of pivoting (McCarty, Paszkewicz, Van Lunen, 2012). Types of tears: The injury itself ranges from a small tear to a severe tear. A grade one sprain of the ACL is when the ligament is mildly sprained. The ACL has been slightly stretched, but it is still able to help keep the knee joint stable. A grade two sprain of the ACL is when the ligaments stretch to the point where it becomes loose. This is a partial tear of the ACL. Partial tears to the ACL are very rare; most ACL injuries are complete tears of the ligament. A grade three sprain is a complete tear of the ACL. The ACL is split into two compete pieces, and the knee joint is unstable. Symptoms and Diagnosis:

Most people either feel or hear a popping sound when the knee is giving out from underneath. This is one of the most common signs that the ACL or other ligaments have been damaged inside of the knee. Along with the pop come pain and swelling within twenty four hours due to the bleeding in the knee joint from torn blood vessels. Other symptoms include

loss of full range of motion, tenderness along the joint line, and discomfort while walking (Anterior Cruciate Ligament Injuries, 2014). A lot of the time when the ACL is completely torn normal day activities can be difficult. The Lachmans test and pivot test are usually first done on a patient to test range of motion and stability. MRI scans are the most accurate when it comes to diagnosing ACL tears. The MRI machine uses magnetic waves to show the soft tissues of the body. The Machines creates pictures of different angles of the knee and the injury is very clear. In some cases, arthroscopy may be used to make the definitive diagnosis of there is a question to what is causing your knee the problem (A patients guide to ACL injuries, 2011). Surgery: For most people especially young athletes, the only way to ensure that the knee does not go out of place is with surgery. Surgeons can take a persons hamstring, quadriceps or patella ligament, or use a cadaver ligament. Most female patients use their hamstring ligament because females already have weak knees. Using a cadaver ligament is a hit or miss. The body can often have a hard time responding to another persons ligament and can often reject the cadaver causing the patient to go through surgery yet again (Chiaia, 2009). Patients that are treated with surgical reconstruction of the ACL have a long term success rate of 82%-95%. There are risks to the surgical reconstruction including viral transmissions, bleeding, numbness, blood clots, and growth plate injury (ACL surgery, 2009).

Gretchen Reynolds with the New York times discussed why ACL injuries sideline so many athletes. In her article she addressed the problem with fixing the ACL: The more puzzling aspect of the A.C.L., though, is that it doesnt get better. Other ligaments in the knee, including the medial collateral ligament, which is often torn along with the A.C.L., reknit after an injury. But the A.C.L. does not, and so past attempts at what doctors call primary repair, or fixing the torn ligament by stitching it back together, have generally failed.

Recovery: Whether treatment involves surgery or not, rehabilitation plays a vital role in getting back into daily activities. Following the surgery is around four months of physical therapy. The goals for rehabilitation include reducing knee swelling, maintaining mobility of knee cap, regaining full range motion, and strengthening the quads and hamstring muscles (ACL surgery, 2009). During physical therapy the injured person will slowly step by step learn how to walk, land, jump, and run again ACL injuries are no longer career ending, unless given an extreme case. However, it does take anywhere from 6 months to a year to fully recover from the injury (Berra, 2006). Physical therapy first focuses on returning motion to the joint and surrounding muscles, followed by strengthening program designed to protect the new ligament. The final phase of physical therapy is aimed at a functional return to the patients sport (ACL injuries, 2014). Current ACL Prevention Programs: Due to the frequency of the injury prevention programs have been implemented nationwide to try and stop this injury. The prevention programs include a mixture of strength, balancing, and agility to help strengthen the ACL and surrounding ligaments (Hertel, 2010). ACL prevention is often thought of as just good training. A good warm up is the first step in an ACL prevention program. Warm up exercises consist of high knee walk, heel to toes, lunges, stationary spider man, and inch worm. A proper warm up develops single leg strength, dynamic flexibility. They key to the best active warm up exercises is that they activate one muscle while

elongating another. Next is developing stability and eccentric strength. The development of stability and eccentric strength is the most important step. In many of the popular ACL prevention programs this is the major failing. Most programs concentrate too much on jumping and not enough on hopping. It is important to have the ability to land on one leg. Eccentric strength is the ability to land properly. Exercises in this phase of the prevention program include, jumping two legs to two legs. This is the basis for many programs but is not the mechanism for ACL injury. Next is hopping right leg to right leg, or vice versa. Hopping should be done forward, medially, and laterally. Bounding from right leg to left leg, and skipping are also included. Third in ACL prevention programs are progressing plyometric. Jumps should be done about twice a week and consist of jumping or hopping onto a box. This decreases the effect of gravity and lowers eccentric forces. Then there is balance. Balancing exercises consist of simple exercise such as standing on one leg, to jumping up onto a box with one and being able to remain balanced. Strength is another key element in ACL prevention programs. Strength development consists of handle bodyweight, single leg progressions, development of functional strength, development of single leg strength, and performance of both knee dominant and hip dominant single leg exercise. The last step in ACL prevention programs is mastering the change of direction. The idea of teaching change of direction is foreign to most coaches. The concepts of effective movement are taught and simple drills are used to teach athletes to stop and to crossover. Many of the concepts build on the concepts and landing skills taught in the plyometric exercises (Boyle, 2012). Michael Boyle concluded his ACL prevention program with the following comments: The bottom line is that a good strength and conditioning program is also the best ACL prevention program. Just remember the recipe analogy. No ingredient is non-essential. All of them must be included. Also remember, as a strength and conditioning coach learn to understand and appreciate your athletic trainer. Develop a cooperative relationship, not an adversarial one. If you are an athletic trainer or physical therapist, cultivate your strength coach, make him or her part of

the team. A good cooperative relationship makes everyone's job easier. Strength coaches need to become a part of the rehab team and athletic trainers need to realize that a quality strength and conditioning program will decrease workloads in the training room. All of us just need to realize that ACL prevention is just good training. Strength ACL prevention programs are broken up into several different categories, one being strength. Having adequate strength in your hips and thighs is key to providing support for the knees and preventing the knee from buckling (Chiaia, 2009). Within the strength component of the program lies several different muscles to focus on. First is the core strength. Core strength is important because the core muscles provide base for all of the bodys movement. With a strong and stable core this allows one for better body control and foundation for improved mechanics of movement. Next is hamstring strength which is essential in minimizing the risk of the injury. When the hamstrings contract they prevent the quads from pulling the tibia forward and forcing the ACL forward when one lands. Developing good hamstring strength provides better hamstring-to-quad ratio. There is also gluteal strengthening and when the gluteal muscles are strong, they are able to absorb more force which decreases the knee joint (Developing an Injury Prevention Program, 2010). Balance and Agility Another aspect of ACL prevention programs is improving balance. Many injuries occur when athletes are off balance (Chiaia, 2009). Balance training teaches the body to adapt to unexpected external forces while still maintain proper leg alignment. Athletes need to be able to maintain good knee alignment when there is unexpected force from the ground, ball, or any player. Plyometric and agility training allow an athlete to develop strength, power and practice of

maintaining knee alignment. Agility training promotes quickness and forces the athlete to apply strength and balance into one (Developing an Injury Prevention Program, 2010). Effective: There is clear evidence that that these programs prevent injuries acorss a range of female athletes: high school, collegiate, and elite European handball players, stated by Jay Hertel with Orthopedics Today. The majority of published studies demonstrate that neuromuscular training has about 50% efficacy rate for decreasing ACL injuries in female athletes. ACL prevention alters activity in the knee joint which stabilizes the ligament and decreases the rate of injury (Hewett, Johnson, 2010). When it comes to ACL tears, prevention is the best cure (Dawson, 2007). In the article ACL programs: Fact or Fiction? Hewett and Johnson discussed the effectiveness of ACL prevention and what should be incorporated in the program. All successful programs incorporate the following key elements: a dynamic warm-up period that is high energy and efficient; plyometric/jump training with emphasis placed on body parts posture and control, trunk positioning, dynamic core balance, and entire body control through a specific task; strength training for the core and lower extremity; sports-specific aerobic and skill components; and preseason and in training programs that are strictly followed. Pre-season training program may be 6 to 8 weeks in duration, 3 days a week for up to 1.5 hours per day. In season maintenance programs can be done in 15 minutes during pre-game warm-up 3 times per week. Ineffective: The percent that ACL prevention programs decrease the injury sounds good until one looks at the number of injuries that need to be treated. ACL prevention programs do work, but the amount of ACL tears that are prevented does not make up for the amount of injuries that need to be fixed. A study done at UVA involving neuromuscular prevention programs showed that a

total of 84 female athletes would have to participate in a prevention program over the course of one season to prevent one injury. Dr. Souuryal commented on the popular question of can ACL tears be prevented? He stated, That's the $64,000 question. These injuries are so rampant. There's not a good way to prevent them. We can make some recommendations: Be sure you stretch before, during and after an activity, and get those hamstrings, quadriceps and muscle-tendon units flexible so they can absorb shock. Strength and endurance training is helpful. Most physicians recommend crosstraining, because you not only develop the pure strength component but also the endurance component. That will help you in the fourth quarter of a basketball game or the second half of a soccer game. Use common sense: When you get extremely tired and your legs feel like lead pipes, that is not the time to attempt a 360 dunk. Muscles are wonderful shock absorbers. There's split-second timing that's required for a plant and a cut, and a jump and a landing, where the muscles can absorb that shock. When you're fatigued, that split-second timing is lost, and you don't necessarily have the quads strength to absorb the shock when you come down from a rebound. Really, at this point, that sort of advice is all we have. There are no braces that are preventive. There are proprioceptive exercises that most colleges and pro teams have their players do. At the recreational level, these exercises aren't normally taught.

Study: A study was done to test the effectivieness of a neuromuscular and proprioceptive training program in preventing Anterior Cruciate Ligament injuries in female athletes. Among female athletes it has not been established to whether or not ACL prevention programs will consistently reduce the incidence of ACL injuries. The purpose of this study was to determine whether a neuromuscular and proprioceptive performance program was effective in decreasing the incidence of anterior cruciate ligament injury within a select population of competitive female youth soccer players ( Garret, Griffin, Kirkendall, Knarr, Mandelbaum, Silvers, Thomas, Watanbe, 2014) . The above authors who carried out this study used the following method: In 2000, 1041 female subjects from 52 teams received a sports-specific training intervention in a prospective non-randomized trial. The control group consisted of the remaining 1905 female soccer players from 95 teams participating in the same league who were age and skill matched. In the 2001 season, 844 female athletes from 45 teams were enrolled in the study, with 1913 female athletes (from 112 teams) serving as the age- and skill-matched controls. All subjects were female soccer

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players between the ages of 14 and 18 and participated in either their traditional warm-up or a sports-specific training intervention before athletic activity over a 2-year period. The intervention consisted of education, stretching, strengthening, plyometrics, and sports-specific agility drills designed to replace the traditional warm-up. Results during the 2000 season had an 88% decrease in ACL injury compared to the control group and in the 2001 season there was a 74% decrease in the injury. This study concluded that ACL prevention programs may have a benefit to decreasing the number of ACL tears in female soccer players, but it is not consistent enough to say that it definitely prevents the injury (Garret, Griffin, Kirkendall, Knarr, Mandelbaum, Silvers, Thomas, Watanbe, 2014) . Time taken out from practice: It is important to emphasize the benefits in athletes participating in ACL prevention programs. Not only does neuromuscular exercise programs help in prevent knee injuries but they also enhance performance. Although ACL prevention programs have been proven to decrease the risk of injury, the amount of prevented ACL tears does not make up for the number of ACLs that have to be fixed. Therefore, coaches are sometimes unlikely to take 20 minutes out of three days a week of practice to spend on simple exercises, when they could be using it as training time (Hertel, 2010).

Hertel commented about the time that prevention programs take out of practice and if they are worth it. He wrote in the Orthopedics today: So should institutions invest in an ACL prevention program? I think its more of a time issue than a cost issue, because these programs can be done with minimal equipment, Hertel said. But coaches and sports medicine professionals need to ask themselves: Are these programs, which typically last about 20 minutes, three times a week, worthwhile vs. spending the time practicing. A key consideration should be that neuromuscular exercise programs have performance enhancement benefits as well. Plyometrics will increase power, vertical jump and speed, Hertel said. We also know that balance training has been shown to reduce the risk of ankle sprains, which are much more common than ACL tears. So the number of people needed to treat to prevent any lower extremity injury is likely to be much, much lower than the estimate to merely prevent ACL injuries. Improvements:

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ACL prevention programs should include exercises that are done 2-3 times a week over the course of the sports season, take no longer than fifteen minutes to complete, and be incorporated by coaches into regular training seasons (Preventing ACL injuries and Improving Performance). Successful ACL prevention programs may differ in specific exercises and drill but they share a common focus: improving flexibility, strength, balance, and agility. When practicing any of the drill, the quality of the movement, rather than the quantity (Chiaia, 2009). The risk of ACL injuries is six times more likely to occur in female athletes than in male athletes, with an average injury age of 14-21. Therefore, the push to start ACL prevention has been discussed within the past years, but not implemented (Dawson, 2009). Conclusion: The consequences of ACL injuries can be huge financial, physical and psychological standpoint. ACL injuries have a lasting effect on the patient. ACL injuries used to be a devastating injury, but now with new technologies and improvements to prevention programs we can decrease the injury rate. The ACL never has an opportunity to mend due to its position and roles in the knee. It used to end athletic participation both professionally and recreationally. Now with new surgery techniques and proper rehabilitation techniques the future is looking brighter for athletes that suffer the injury. National results show that there is 96%-98% return to the sport after the injury. Recovery still takes at least six months and the ACL injury is economically demanding involving surgery, several doctors appointments and physical therapy, but it is not career ending (Souryai). With improvements in the surgery field can be used to benefit the ACL prevention programs to ensure a long, lasting and healthy life for athletes. Long tern health is effected by knee injuries, so we need to use the knowledge we have to keep impending prevention programs, as well as improving them.

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References: Berra, L. (2009, May 13). Female athletes struggle with ACL injuries. Retrieved from http://espn.go.com/high-school/story/_/id/4083099/female-athletes-struggle-acl-injuries/
Chiaia, Theresa (2009, March). ACL Injury Prevention Tips and Exercises: Stay off the Sideline. Retrieved from http://www.hss.edu/conditions_acl-injury-prevention-stay-off-sidelines.asp

Dawson, H. Preventing ACL injuries in young female athletes. Retrieved, from http://www.multibriefs.com/briefs/exclusive/preventing_acl_injuries_female.html Hertel, J. (2010, July 18). How effective are ACL prevention programs?Retrieved from http://www.healio.com/orthopedics/rehabilitation/news/print/orthopedics-today/%7Bd7aee95a24f5-44d2-a561-28336be19c7d%7D/acl-injury-prevention-programs-found-to-be-effective-forfemale-athletes Hewett, T. E., & Johnson, D. L. (2010, January). ACL prevetion programs: fact or fiction? Retrieved from http://www.healio.com/orthopedics/sportsmedicine/journals/ortho/%7B0946dfe1-7f15-422b-b9df-b8e930e7f92d%7D/acl-preventionprograms-fact-or-fiction?full=1