How to Prevent ACL Injuries

How to Prevent ACL Injuries  

- Talk by Dr. Peter Gorman

There is a new technology called optojump.

ACL (knee ligament) injuries can be career ending.

Will discuss susceptibility and injury prevention.

An international conference in Barcelona each year marries science and sports.

Today the emphasis is on bigger, faster, stronger – but an athlete must be tuned to adjust to increased speed.

There are 200,000 ACL tears/year, 4,000 tears/week, 600 tears/day, 100,000 surgical interventions per year. The majority of ACL injuries happen to females. Most ACL injuries are non-contact injuries caused by jumping, cutting, turning, and landing. The athlete hears classic “pop” behind the knee, where ACL is located. A person must know reaction recovery time, speed and acceleration of each leg and flight time in order to understand proper firing of our muscles and symmetrical development over time. Otherwise an athlete becomes like a car out of alignment. The ACL injury is already harboring inside a child day in and day out as a result of speed imbalance – need symmetry of motion.

Instability in lower extremity leads to ACL injury. An athlete needs to be taught about this. a Landing Error Scoring System is the Gold Standard for evaluating ACL injury susceptibility developed by UNC at Chapel Hill. Evaluation is from both the front and side view for biomechanical correctness regarding posture. Deviations are given a point value of susceptibility. The popular baseball song line “Put me in coach.  I’m ready to play” really should be “I’m ready to finish” because an athlete has had proper conditioning.

Increased female susceptibility is related to:

• Size and shape of the femoral notch
• Increased pelvis width changes angle to knee.
• Quadriceps dominance
• Hamstring weakness
• Increased flexibility
• Heavy calves
• Hormonal
• Shoe wear for field conditions
• Stiffness – female doesn’t absorb shock

Modifiable risk factors can be adjusted in athlete’s favor – postural alignment can reduce ACL injury risk by 40%:

• Knee/valgus should be straight
• Good stance width
• Foot position
• Lateral trunk flexion should be straight

Sports should help with development early on to eliminate problems. Coaches need to look at the athletes stance – Are feet outside shoulders?  If so, re-teach jump and landing.

Are feet turned in or out?  If so, give up power for correctness and redevelop!

Females tend to have less knee flexion than males. Females should do a trunk extension. And when they jump their toes must initiate contact when landing. The more upright they are on their landing, the more susceptibility. Bad form can happen when athlete gets fatigued later in a game.

Leg bone and thigh bone are shearing so they don’t absorb shock. An athlete training for strength, speed, and agility while disregarding proper mechanics is a prescription for failure. One can reduce ACL injury susceptibility with proper form combined with athletic ability. There is a fine line between training and abusing - athletes should be able and agile in all directions.

How to Reduce Susceptibility to Injury

Every child athlete has the right to symmetrical development over time so they are agile in all directions.

Reduce anterior forces on the knee:

• Soft landings are imperative in absorbing shock and preventing force on knee.
• Gastronemeus (calf) must be able to stretch properly.
• Good hamstring control will prevent anterior shear valgus stress and tibial rotation - Need properly functioning soleus muscle.
• Can’t be quadriceps dominant –
• A good exercise to do is squat, keep knees stratigh, butt down, and don’t let heels come off the ground.
• Pelvic tilt exercise and butt squeeze – lie flat on back, knees up, feet on ground – practice pressing curve of lower back to ground by rolling pelvis (also increases core strength).

Must control varlgus-varus movement of knee:

• Pick proper shoe to control pronation and supination.
• Gluteal tone to control unnecessary rotation of knee.
• Prevent inner thigh tightness by stretching – good stretch is to make leg into #4 shape.

We must prevent knee extension:

• Having knees extended minimizes the effect – evenness of the hamstrings.
• Don’t lock knees so train for forward position of knee.

Athlete is usually evaluated when not fatigued. Evaluate influence of stress and fatigue on jumping ability and postural alignment using OPTOGAIT developed by Dr. Gorman.

OPTOGAIT – determines how symmetrical a child athlete is in movement. But the test won’t tell you the reason for asymmetry. Asymmetry can be from hits to the head possibly. Conditions can occur such as chronic traumatic encephalopathy that is like carpal tunnel of the brain.  Second impact syndrome is usually fatal so determine if asymmetry exists before a tragedy happens.

Dr. Gorman developed a system to put heart rate monitor on all athletes on the field.  If a child goes above a certain rate, he or she must come off the field.  The heart rate is monitored on the side line. OPTOGAIT is based on principles of physics and gravity (i.e., how long athlete is off the ground). This system takes pictures from various angles and can evaluate form on most powerful jumps. Then you can see when fatigue sets in. The goal is for biomechanical correctness to get better over time as a result of the evaluation. Also, this system shows the speed of acceleration as an athlete runs through a test area.  Acceleration should increase gradually.  An example of a power differential is when one leg doesn’t push as hard as the other leg. You can analyze the jumps to show the left and right leg power – shows load/explode concept.

It shows power vs. instability – does the leg shift to the side or front/back while the athlete is jumping?

AIM = STABILITY

After the OPTIGAIT analysis, a coach can work on improving the athlete’s stability before increasing power.

I FUN FACT: Tiger Tail Myofacial Compression Tool – is an effective neuromuscular warm up tool.

CONCLUSION

Good balance control is necessary to obtain optimal performance and reduce risk of injury.

Without Balance è No Stability è No Abiltiy

Simple test – pouring cold water in the ear affects balance/equilibrium.

Try balancing on one leg with your eyes open – then challenge yourself to the next level by balancing on one lag with your eyes closed – Is there a different result on the left vs. the right side?  Repeat exercise daily, gradually increasing amount of time you balance.

Journal Entries from the Past

11/14/11  Time - 2:10-3:45   Duration - 1.5 hours

Today there were two soccer players Dr. Mullen evaluated. The first injured girl had already gotten four other opinions from doctors and an MRI of her knee. Once Dr. Mullen evaluated the injury, he concluded that because there was no pulling of the right knee inward, there was nothing wrong with her MCL. But the pain was from her kneecap being stretched too much, which is why her knee only hurt when she bent it (i.e. walking up and down stairs because it made her quadriceps contract and stretch the kneecap). The other injury was an ankle/calf injury where the girl only had a problem because it hurt due to the fact that it was bruised and only bruised. She was fine.

11/23/11  Time -4-7:30   Duration – 3.5 hours

Today I shadowed Dr. Mullen during a basketball scrimmage. I was watching the JV while he was watching the Varsity. He told me that if anyone got hurt, then I should get him. While I was up watching JV, Dr. Mullen told me to get a bag of ice and bring it to his office. When I got there with the ice, I saw Dr. Mullen saran wrapping an athlete’s arm against his stomach so that it would not move. Dr. Mullen then showed me the player’s collarbone and it was bruised and jutting out a little bit. Dr. Mullen then explained that he wrapped the player’s arm against his body in order to prevent him from moving his arm, which would move his collar bone and make it worse. He then explained that because the player’s collarbone was only slightly bruised, he could have only sprained a ligament. But the bad news for the player was that he might still be out 4-8 weeks either way.

12/7/11  Time -2:30-4:15   Duration – 1.75 hours

Today I first showed two girls who play varsity soccer how to strengthen their hamstring by doing one-legged kettle bell/dumbbell lifts. After that I watched Dr. Mullen diagnose an athlete who thought that his tooth went through his lip. The player just got elbowed and had a small cut on which Dr. Mullen

put a special type of band-aid to tighten it up so it will not scar. Then Dr. Mullen taught me how to tape an ankle, so I taped his ankle. He instructed me on how to tape it correctly and told me that if there are bumps in the tape, it can lead to cuts or blisters on the skin.

12/13/11  Time -2:10-3:30   Duration - 1.25 hours

Today I watched Dr. Mullen try to figure out what was wrong with a men’s track athlete who had leg pain by his calf-shin region. I then practiced taping a player’s ankle so I can try to improve my taping skills. It was a slow day in the office of Dr. Mullen.

12/14/11  Time -2:10-3:10   Duration – 1 hour

Today I watched Dr. Mullen do an arch taping where he basically makes and arch in the foot of a basketball player who doesn’t have an arch. After that I watched Dr. Mullen diagnose a basketball player, who came in the day before with leg pain from flat feet - meaning the athlete just needed inserts to create an arch in his foot.  Dr. Mullen then taped a wrestler’s ankle and then he left to go and see Peter Pan with his family.

12/15/11  Time - 4:00-7:00   Duration – 3 hours

Today I watched Dr. Mullen during a basketball tournament at the high school. I then got some water and ice for the teams and then gave a player a bag of ice for his face because he was elbowed. I then helped Dr. Mullen tape a player’s ankle. I only did the pre-wrap though.

12/19/11   Time -2:10-4:00   Duration – 1.75 hours

Today I taped Dr. Mullen’s ankle again. Then I saw him tape an athlete’s head that had dead ringworm on it. He then told basketball coach Dom that he had ringworm on his elbows. Then I got ice and water for the basketball game later for Dr. Mullen to have on hand. Dr. Mullen then diagnosed a player’s elbow pain as possible tendonitis and told him to massage the back to break up scar tissue to make the tendonitis go away.

12/20/11    Time -2:10-3:30   Duration – 1.25 hours

Today I watched Dr. Mullen tape a wrestler who was having problems with his shoulder. I suggested it might be his posterior labrum and Dr. Mullen said I might be right. He taped his shoulder in a way that restricted it from coming up all the way. I then taped a basketball player’s ankle and he said it felt great during practice. Finally I taped Tom Barcia’s ankle and according to Dr. Mullen I did a “great” job.

12/22/11  Time - 2:10-7:30   Duration – 5.25 hours

Today I watched Dr. Mullen tape a basketball player who was having problems with his ankle. Dr. Mullen then showed me how to saran wrap an ice bag to a shoulder. I then set up the ice, water, desks, towels, and garbage cans for the girl’s basketball game. Afterwards I watched both the JV and Varsity girl’s basketball games and no injuries occurred.

1/4/12      Time - 2:10-7:30     Duration - 5.25 hours

Today I watched Dr. Mullen tape a basketball player who was having problems with his ankle. The girl’s basketball coach then came in to get a bad blister treated so Dr. Mullen put skin lubricant on it and then a band-aid, which fixed it right up.  I then watched the varsity boy’s basketball game. No injuries occurred during the game, but I helped set up again by getting ice and putting out the garbage cans, desks, water, and towels.

1/5/12      Time - 2:30-6:30     Duration - 4 hours

Today I watched Dr. Mullen tape a basketball player who was having problems with his ankle. I then watched him diagnose a basketball player with a sore Achilles tendon, but I found out how to test for a torn Achilles injury by pressing/squeezing spots and seeing if the foot moves. Next a wrestler came in who had a heavy object freakishly fall on his head, resulting in head trauma. Dr. Mullen called his parents and told them to come and pick him up because his pupils were dilated and he had a headache and was nauseous. Finally I watched a wrestling match with Dr. Mullen and a wrestler dislocated his shoulder, so Dr. Mullen saran wrapped it and I went outside to tell the ambulance where to go and held the door open for the stretcher to come in and out. Dr. Mullen then explained to me how the injured wrestler’s bone and muscle were sticking out, even though Dr. Mullen was able to pop it back in slightly.

1/6/12      Time - 2:30-7:30     Duration - 5 hours

Today I watched Dr. Mullen do a fascial massage on an athlete’s back to get the knots out. Then I watched the JV and Varsity girl’s basketball games. The game was uneventful.  Of course, I set up the water, desks, towels, and garbage cans before the game though.

1/10/12    Time - 2:30-7:45     Duration - 5.25 hours

Today, Dr. Mullen taught me how to fix a clavicle structure problem where the clavicle isn’t straight. He then taught me again how to stretch out the shoulder in more detail. I tried it on my brother at home and he said it felt great. Then I watched the JV and Varsity boy’s basketball games in addition to a wrestling match. No injuries occurred, but, as always, I set up the water, desks, towels, and garbage cans before the games again.

1/11/12    Time - 2:10-6:30     Duration - 4.25 hours

I taped an ankle for practice and Dr. Mullen said I did an amazing job and that I am getting a lot better at taping ankles. I then told a basketball player to ice his ankle on 20 minutes and off for 30 minutes because it was swollen. I then shadowed Dr. Mullen during a varsity wrestling match and a player possibly tore his ACL.  He tweaked his knee when getting flipped.  I got ice to put on the wrestler’s knee.

1/12/12    Time - 2:10-7:30     Duration - 5.25 hours

I set up water and all the other materials such as water, towels, desk, and cups for the boys’ varsity basketball games. The games were rather uneventful in terms of injuries, but before the varsity game Dr. Mullen was taping an ankle and realized the player would be out 4-6 weeks with either a high ankle sprain or a stress fracture in the ankle.

1/18/12    Time - 2:10-7:30     Duration - 5.25 hours

I set up water and all the other materials for the girls’ JV and varsity basketball games.  There were no injuries at all during these games, so I just sat with Dr. Mullen and watched our girls lose two basketball games.

1/20/12    Time - 2:10-7:30     Duration - 5.25 hours

I set up water and all the other materials for the girls’ JV and varsity basketball games.  Nothing happened; I just sat with Mullen and watched two basketball games and 2 losses. It’s a shame the girls could not win as they just didn’t play close to their potential.

2/6/12      Time - 2:10-7:30     Duration - 5.25 hours

Today was the first day Dr. Mullen had me read my anatomy book. While I was reading the book a female athlete on the track team came in complaining about her calves and feet and Dr. Mullen basically said that she needed new running shoes. I set up water and all the other materials for a freshman basketball game. There were no injuries, but I sat with Dr. Mullen and watched a nice basketball game in which Somers won.

2/9/12      Time - 2:15-8:00     Duration - 5.75 hours

Today I taped an ankle almost perfectly. Dr. Mullen said I was getting really good at taping ankles. We also reviewed anatomy for probably the final time. While shadowing Dr. Mullen during a JV basketball game, a player hurt his ankle and I wrapped ice around it. I then watched the Varsity game with Dr. Mullen and a player twisted his ankle but did not need ice. Dr. Mullen just taped his ankle so he could keep playing. After the game when I was done putting the desks and other materials away, Dr. Mullen gave me a present to thank me for being such a great intern for him. The present was a fanny pack because trainers use fanny packs a lot.