The Markland ClinicCotswold Leisure CentreTetbury Road, CirencesterGL7 1US

Tel: 01285 654059www.marklandclinic.comwww.sportsperform.co.uk

Pre

vent

ing K

nee

Inju

ry

ContentsBackground 3

What is your ACL? 3

How do ACL injuries occur? 3

What are the consequences of ACL injury? 5

Can the incidence of injury be reduced? 6

ACL injuries and the female athlete 6

How to assess for injury risk factors 8

How to score the landing 9

Example 10

The JumpPerform Programme 13

The Programme in Practice 14

Contact us 16

References 17

DisclaimerThe information contained in this document is the proprietary and exclusive property of The Markland Clinic except as otherwise indicated. No part of this document, in whole or in part, may be reproduced, stored, transmitted, or used for design purposes without the prior written permission of The Markland Clinic. The information contained in this document is subject to change without notice.

The information in this document is provided for informational purposes only. The Markland Clinic specifically disclaims all warranties, express or limited, including, but not limited, to the implied warranties of merchantability and fitness for a particular purpose, except as provided for in a separate software license agreement.

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BackgroundWe understand how personally devastating sport injuries can be and the significant effect they can have on individuals, teams and clubs. By understanding injury risk factors and implementing easy to apply prevention strategies, the pain of injury can be reduced and performance enhanced.

In order to identify the most relevant and effective programme for you, we have tested scientifically proven programmes with real sports teams*. We have used their feedback to ensure the information we are providing is useful, and represents an easy to implement programme to include as part of training.

We will start by looking at the anterior cruciate ligament (ACL) and the effect injury to this area has on the athlete’s performance and recovery. Women, in particular, are prone to problems with the ACL, and so we’ll look at some specific points for women, as well as issues important to all athletes, male or female.

Once we’ve covered the basics, we’ll then look at preventing injury and improving performance through the implementation of the JumpPerform programmes and use of movement analysis.

What is the ACL?The ACL is one of the major ligaments in the knee joint. It works with the posterior cruciate ligament to stabilise the knee during movement (Silvers et al, 2007).

HOW DO ACL INJURIES OCCUR?

ACL injury occurs when an excessive tension force is applied to the ligament, causing it to rupture.

70% of anterior cruciate ligament injuries occur via a non-contact mechanism (Parkkari et al., 2008; Hewett, 1999). This means the athletes themselves are generating great forces at the knee that apply excessive loading on the ACL (Yu and Garrett, 2007). Injury most often occurs when landing from a jump or during deceleration and change of direction with a foot fixed. The torsion that occurs from making a sudden deceleration or directional change on a planted foot has been implicated as a cause of ACL tears (Boden et al., 2000; Parkkari et al., 2008; Hewett, 1999).

It is therefore not surprising that ACL injuries are particularly prevalent among athletes in sports that involve deceleration,

!* Note: Thank you to Gloster Jets and Loughborough Cougars for your involvement in this project and permission to use the pictures.

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change of direction or landing from a jump such as netball, basketball, football, rugby, hockey, lacrosse or gymnastics (Parkkari et al., 2008; Lohmander et al., 2007, Hewett et al., 2006).

MECHANISM OF INJURYThe ‘Position of No Return’ is the movement combination that most often leads to ACL rupture. If no other player is involved,

this means the athlete is placing his or her own leg in a vulnerable position.

SUSPICIOUS OF ACL RUPTURE?

The following signs and symptoms are often associated with ACL rupture:

a bad landing from a jump or decelerating and twisting injuryimmediate pain and swelling. Usually, when the ACL is torn, it bleeds and fills the knee with blooda sensation of giving way or instability

If you are concerned you may have torn your ACL please seek medical advice.

DIAGNOSING AN ACL RUPTURE

Typically A+E staff, your GP or Physiotherapist will perform a number of tests to confirm suspicion of an ACL tear. If they are concerned that you have torn your ACL they will refer you to a Knee Specialist or Orthopaedic Surgeon specialising in knees, and an MRI scan will probably be organised to confirm diagnosis.

The Position of No Return

Trunk Flexion

Hip rotating in

Knee caving in

Foot and ankle turning out

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What are the consequences of ACL injury?

ACL injuries are serious and frequently require surgical repair followed by a 9 month rehabilitation programme to return to competitive sport. The most common misconception is that ACL injuries are isolated. The graph below shows that there are frequently other structures involved too.

The long-term consequences can be devastating and result in chronic knee problems including instability, secondary injury to the menisci and articular cartilage, and early onset of osteoarthritis: the young patient with an old knee (Silvers and Mandelbaum, 2007; Lohmander et al., 2007). It is damage to the cartilage in the knee which results in early onset osteoarthritis; ACL reconstructions are most commonly performed to restore stability to the knee and therefore protect the cartilage.

OTHER STRUCTURES INVOLVED IN AN ACL INJURY

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0 20 40 60 80 100

ACL only

Meniscal

Bone Bruising

Collateral Lig

Articluar Cartilage

Percentage of ACL Injuries

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Can the incidence of injury be reduced?Yes. There is growing scientific evidence indicating that the incidence and severity of injury can be reduced with the frequent application of appropriate neuromuscular training programs that focus on awareness of movement, strength, plyometrics and proprioception. In addition, performance factors improve too. The JumpPerform video analysis and assessment can be particularly useful in identifying potential problems before they become an injury.

ACL injuries and the female athleteThe Injury Statistics are startling: all sportspeople are susceptible to injury, but women run a much higher risk, particularly of severe knee injuries.

Women are paying a high price for participating in sport. There has been a significant increase in the number of females participating in competitive sports. The cost of this is an increase in injuries to female athletes. One of the most frequent injuries amongst female

athletes is an anterior cruciate ligament (ACL) rupture (Petersen, 2005).

The highest incidence of ACL injury occurs in 15-19 year old girls playing sports that involve deceleration, change of direction or landing from a jump such as basketball, netball, volleyball, football, rugby, hockey, lacrosse and gymnastics.

Female athletes in these sports are four to seven times more likely to injure their knees than men.

If women are injuring themselves at a high frequency, should they drop team sports? No! But they should learn how to prevent injury.

A female athlete’s risk of sustaining an ACL injury is two to eight times greater than her male counterpart (Arendtt et al., 1995).The incidence of significant knee injury among females is roughly five times higher per player per hour than for males (Frank et al. 1997).

WHY ARE WOMEN MORE AT RISK?

Factors that influence susceptibility to ACL injury affect either the mechanical load placed on the ligament or the ligament’s point of failure. There are a number of risk factors which are seemingly distinct: they are all in fact interdependent and place women at higher risk of injury.

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Hormonal influences:

Sex hormones influence anatomical, neuromuscular and other intrinsic differences between the sexesOestrogen may relax soft tissue and reduce the tensile strength of the ACL

Anatomical Factors:

A smaller femoral intercondylar notch has been associated with a greater risk of ACL injuryObservational studies also indicate females have

greater anterior pelvic tiltgreater knee valgus (knock knees)greater Q angle (wider hips)

Whilst it has not been demonstrated that these factors increase injury risk, we can see we are getting close to the position of no return.

It is also conceivable that control of the knee and the loads transmitted across it are different in athletes with poor alignment.

Biomechanical Factors:

Although anatomical and hormonal differences between males and females have been described as risk factors, modifying them does not provide a reasonable solution to reducing the incidence of injury in female athletes. We can have more influence over biomechanical risk factors. As so many injuries are non-contact it means the athlete themself is placing their leg in a vulnerable position. So if they can improve how they move, then it follows that they may avoid placing their leg in a vulnerable position. This can be taught with a programme such as JumpPerform,

“We do not want to turn girls in to boys but we need to help them be as prepared to play sport as possible. The implications may not be politically correct but they are a reality.”

- Dr Tim Hewett of the University of Cincinnati College of Medicine

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How to assess for injury risk factors When implementing the JumpPerform programme, athletes have described movement analysis to be one of the most valuable components.

1. Perform this video analysis prior to implementing the programme2. Replay the video and score your landing and observe the key

points you need to focus on to improve movement quality3. Implement the JumpPerform programme4. After 6 weeks to 3 months repeat the video analysis and

observe the changes. You will be astounded at the difference in movement quality

This works very well in conjunction with assessing jump height before and after. By implementing the programme we have seen an improvement in movement patterning and a 10% increase in jump height, which is a great motivator.

EQUIPMENT AND SETUP

- x2 video cameras, one face on and one side on- 30cm step

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DROP JUMP TASK

- Vertical jump step height = 30 cm- Mark forward jump distance = approx 50% body height- Then perform a drop jump immediately followed by a maximum

vertical jump

Assess during initial landing the number of “high risk” movements (errors) on the first landing. This will give you a score and highlight your individual risk factors which you can then focus on whilst working on the JumpPerform programme.

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Score the landing using the Landing Error Scoring system1. Knee flexion at initial contact____ Greater than 30° (0)____ Between 20-30° (+1)____ Less than 20° (+2)

2. Knee valgus at initial contact____ Knees over mid-foot (0)____ Knees over great toe (+1)____ Knees over great toe (small) (+2)____ Knees over great toe (large) (+3)

3. Knee flexion displacement____ Greater than 30° (0)____ Between 20-30° (+1)____ Less than 20° (+2)

4. Knee valgus displacement____ Knees over mid-foot (0)____ Knees over great toe (+1)____ Knees over great toe (small) (+2)____ Knees over great toe (large) (+3)

5. Trunk flexion at initial contact____ Greater than 30° (0)____ Between 20-30° (+1)____ Less than 20° (+2)

6. Lateral trunk flexion at initial contact____ Trunk centred over hips (0)____ Lateral deviation of trunk over hips (+1)

7. Ankle plantar flexion at initial contact____ Toe-to-heel: toe strike (0)____ Flat foot (+1)____ Heel-to-toe: heel strike (+2)*if asymmetrical, score 1st foot to contact

8. Foot position at initial contact____ Toes straight ahead (0)____ Toes in (+1)____ Toes out (+1)*if asymmetrical, score 1st foot to contact

9. Stance width at initial contact____ Shoulder width (0)____ Less than shoulder width (+1)____ Greater than shoulder width (+1)

10. Foot contact symmetry____ Symmetric (+0)____ Asymmetric (+1)

11. Joint displacement (overall)____ Large (“soft landing”) (0)____ Average (+1)____ Small (“stiff landing”) (+2)

12. Overall impression____ Excellent (0)____ Average (+1)____ Poor (+2)

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Example

1. Knee flexion at initial contact

X Greater than 30° (0)____ Between 20-30° (+1)____ Less than 20° (+2)

2. Knee valgus at initial contact____ Knees over mid-foot (0)____ Knees over great toe (+1)X Knees over great toe (small) (+2)____ Knees over great toe (large) (+3)

3. Knee flexion displacementX Greater than 30° (0)____ Between 20-30° (+1)____ Less than 20° (+2)

4. Knee valgus displacement____ Knees over mid-foot (0)____ Knees over great toe (+1)____ Knees over great toe (small) (+2)X Knees over great toe (large) (+3)

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5. Trunk flexion at initial contact____ Greater than 30° (0)____ Between 20-30° (+1)X Less than 20° (+2)

6. Lateral trunk flexion at initial contact____ Trunk centred over hips (0)X Lateral deviation of trunk over hips (+1)

7. Ankle plantar flexion at initial contact____ Toe-to-heel: toe strike (0)X Flat foot (+1)____ Heel-to-toe: heel strike (+2)*if asymmetrical, score 1st foot to contact

8. Foot position at initial contact____ Toes straight ahead (0)X Toes in (+1)____ Toes out (+1)*if asymmetrical, score 1st foot to contact

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9. Stance width at initial contact____ Shoulder width (0)X Less than shoulder width (+1)____ Greater than shoulder width (+1)

10. Foot contact symmetry____ Symmetric (+0)X Asymmetric (+1)

11. Joint displacement (overall)____ Large (“soft landing”) (0)____ Average (+1)____ Small (“stiff landing”) (+2)

12. Overall impression____ Excellent (0)____ Average (+1)____ Poor (+2)

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The JumpPerform programmeHaving performed the video analysis you know understand your personal injury risk factors. Now it is time to start using the JumpPerform programme as your warm up.

Think Technique

Hips, knees and toes in line. Soft landing, light on toes, bent knees.

“Well-designed injury prevention programmes reduce the risk of ACL injury for athletes, particularly women.”

- Rentrom et al., 2009

There is a great deal of research supporting the frequent application of a neuromuscular training programme such as JumpPerform that focuses on awareness of movement, strength, plyometrics and proprioception to reduce injury and improve performance. We have achieved the best result when the programme has been performed 4-5 times per week as a warm up prior to training. If we are working with a team, the responsibility of delivering the programme is given to one of the players, usually the captain. Each player is then individually responsible for monitoring their own movement quality and improving their risk factors. To help you with this we have produced a pitch side reminder of the programme which can be found at the back of this book.

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The Programme in PracticeInitially the programme will feel like hard work, due to the amount of jumping involved, and will take a little longer than 10 minutes. However, we have consistently found that if the programme is performed repeatedly, within two weeks it can comfortably be completed in 10 minutes. Keep persevering - you will be delighted with the result. Here are some results to keep you motivated

Note: We have done the research for you. This is the easiest to implement and most time-efficient injury prevention programme available, and has been demonstrated to be effective in reducing severe knee injuries and increasing performance.

RESULTS

Here are the results that have been achieved by implementing this or a very similar programme:

72% reduction in the rate of non-contact ACL injury50% reduction in knee abduction and adduction moments22% reduction in ground reaction forceReduction in ankle and upper limb injuriesIncreased knee flexion angle on landingIncreased lower limb strengthIncreased hamstring to quadriceps muscle ratioIncreased hamstring muscle power 10% increase in vertical jump height Improved single hopImproved balance

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I HAVE HAD AN ACL RECONSTRUCTION. CAN I TEAR THE LIGAMENT AGAIN?

Unfortunately, once you have torn an ACL there is an increased risk of it happening again and an increased risk of osteoarthritis. The information in this book helps you understand how to look after your knee to minimise the chance of another ACL injury and Osteoarthritis.

If your injury occurred whilst playing a team sport we ask you to discuss the information in this e-book with your team members, and encourage them to assess their own injury risk factors and implement our simple JumpPerform injury prevention programme as their warm up.

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Think Technique

Hips, knees and toes in line. Soft landing, light on toes, bent knees.

Key PointsMost at risk when decelerating/pivoting/awkward landing

ACL rupture is a serious injuryAssess individual risk factors

KEY RISK FACTORS

Reduced knee flexionIncreased knee valgus (caving in)Increased tibial rotation (toe-in / toe-out)Reduced trunk flexion (very upright posture)Trunk lateral flexion (leaning to the side)Asymmetrical foot contact (single leg)

Raise athletes’ awareness of movement quality (Think Technique)

Injury risk factors reduced and injuries preventedImproved performance is another fantastic outcome from implementing the programme.

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Contact UsPlease contact us if we can help you in any way.

We offer detailed assessments of your and/or your team’s injury risk factors.

We are also happy to present injury prevention and sports preparation advice and information to your sporting course, meeting or conference.

appt@marklandclinic.com01285 654059

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Think Technique

Hips, knees and toes in line. Soft landing, light on toes, bent knees.

Find us on Facebook facebook.com/marklandclinic

Follow us on Twitter twitter.com/marklandclinic

Connect on LinkedIn uk.linkedin.com/in/katemarkland

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ReferencesArendtt, E. & Dick, R. Knee injury patterns among men and women in collegiate basketball and soccer: NCAA data and review of literature. American Journal of Sports Medicine 1995; 23:694-701.

Borowski, L., Yard, E., Fields, S. & Comstock, D. The epidemiology of US High School basketball injuries, 2005-2007. American Journal of Sports Medicine 2008; 36: 2328.

Bressel, E., Yonker, J., Kras, J. & Heath, E. Comparison of static and dynamic balance in female collegiate soccer, basketball, and gymnastics athletes. Journal of Athletic Training 2007;42(1):42–46.

Deitch, J., Starkey, C., Walters, S., & Moseley, J. Injury risk in professional basketball players. A comparison of women’s National Basketball Association and National Basketball Association athletes. American Journal of Sports Medicine 2006; 34: 1077-1083.

Frank, C.B. & Jackson, D.W. The science of reconstruction of the anterior cruciate ligament. Journal of Bone and Joint Surgery of America 1997; 79:1556-1576.

Hewett, T.E., Ford, K.R. & Myer, G.D. Anterior cruciate ligament injuries in female athletes. American Journal of Sports Medicine 2006; 34:490-498.

Hewett, T.E., Stroupe, A.L., Nance, T.A. et al. Plyometric training in female athletes. American Journal of Sports Medicine 1996; 24:765-773.

Lohmander, L.S., Englund, P.M., Dahl, L.L. et al. The long-term consequence of anterior cruciate ligament and meniscal injuries: Osteoarthritis. American Journal of Sports Medicine 2007; 35:1156-1769.

Messina, D., Farney, W., & DeLee, J. The incidence of injury in Texas High School basketball. A prospective study among male and female athletes. American Journal of Sports Medicine 1999; 27: 294-2.

Olsen, O., Myklebust, G., Engbretsen, L,, et al. Exercises to prevent lower limb injuries in youth sports: cluster randomized controlled trial. British Medical Journal 2005; 330: 449-452.

Parkkari, J., Pasanen, K., Mattila, V., et al. The risk for a cruciate ligament injury of the knee in adolescents and young adults: a population-based cohort study of 46 500 people with a 9 year follow-up. British Journal of Sports Medicine 2008; 42:422-426.

Petersen, W., Braun, C., Bock, W., et al. A controlled prospective case control study of a prevention training program in female team handball players: the German experience. Archives of Orthopaedic Trauma Surgery 2005;125:614–621.

Renstrom, P., Ljungqvist, A., Arendt, E., et al. Non-contact ACL injuries in female athletes: an International Olympic Committee current concepts statement. British Journal of Sports Medicine 2008; 42:394-412.

Schiltz, M., Lehance, C., Maquet, D. et al. Explosive strength imbalances in professional basketball players. Journal of Athletic Training 2009; 44(1):39–47.

Silvers, H.J. & Mandelbaum, B.R. Prevention of anterior cruciate ligament injury in the female athlete. British Journal of Sports Medicine 2007; 41 (suppl1), pp.i52-i59.

Yu, B. and Garrett, W.E. Mechanisms of non-contact ACL injuries. British Journal of Sports Medicine 2007; 41 (suppl1), pp.i47-i51.

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