Prehabilitation & Improved

Performance for Athletes (P.I.P.A.)

Tina NguyenMay 2, 2011

KSN 501

Table of Contents Introduction

Prehabilitation

Other ACL Prevention Programs

P.I.P.A. Program

Program Overview

Program Component Details

Recommendations

Introduction~200,000 ACL injuries occur each year in the

U.S.

70% non-contact: cutting, jumping

ACL Injury Mechanism 1. Anterior Tibial Shear 2. “Knee Valgus Collapse”

Bien, D.P., (2011). Rational and implementation of anterior cruciate ligament injury prevention warm-up programs in female athletes. Journal of Strength & Conditioning Research, 25(1), 271-285.Thomas, A.C., McLean, S.G., Palmieri-Smith, R.M. (2010). Quadriceps and hamstrings fatigue alters hip and knee mechanics. Journal of Applied Biomechanics, 2, 159-170.

Prehabilitation Why?

Secondary injury Financial (surgery/rehab) Psychosocial Costs

Benefits Drawbacks

Less time Lack of high-intense loads

Cost effective Increase time demands

Improve compliance Unable to change warm-up for variability

Increase fatigue Monotony

Bien, D.P., (2011). Rational and implementation of anterior cruciate ligament injury prevention warm-up programs in female athletes . Journal of Strength & Conditioning Research, 25(1), 271-285.

Program Comparison

Program Components

Time/Duration

Feedback

Research

KLIPCenter for Orthopaedic and Biomechanics Research, Boise State University

PlyometricsAgility

20 minutes3x/week7 weeks

InstructionsVideotapeHandouts

Irmischer et al, 2004Pfeiffer et al, 2006

PEPSanta Monica Orthopaedic and Sports Medicine Research Foundation

Warm-UpStretchStrengthPlyometricsAgility

15-20 mins3x/week

InstructionsVideotape

Pollard et al, 2006Mandelbaum et al, 2005

WIPPSportsMetrics, Cincinnati Sports Medicine and Orthopaedic Center

Warm-UpPlyometricsStrengthFlexibilityAgility

20 mins3x/week6 weeks

InstructionsVideotape

Barber-Westin et al, 2010Barendrecht et al, 2011

P.I.P.A. ProgramActive Warm-Up

Jog

Walking Calf Raise

High Knee Walk

High Knee Cradle

Heel to Glute Stretch

Jog

Strength/EccentricSingle-Leg Split Squat

Single-Leg Dead Lift

Squat Jumps

Single Leg Hops

Plyometrics

Single-Leg Lateral Bound

Forward Bound

Squat Jumps over cone

Single-Leg Jumps over coneSingle-Leg Lateral Jumps over cone

Agility

Diagonal Quick Steps

Diagonal RunShuffle (*add unanticipation)

T Drill

~20 minutes 3 X/ week7-weeks Pre-SeasonBrophy et al. , 2010

Holcomb et al., 2007

Brophy, R.H., Silvers, H.J., Mandelbaum, B.R. Anterior cruciate ligament injuries: Etiology and prevention. Sports Med Arthrosc 18: 2-11, 2010.Holcom, W.R., Rubley, M.D., Lee, H.J., Guadagnoli, M.A. Effect of hamstring-emphasized resistance training on hamstring:quadriceps strength ratios. Journal of Strength & Conditioning Research 21: 41-47, 2007.

P.I.P.A. Overview Purpose: To reduce the incidence of ACL injuries through

neuromuscular training, which reduces the risk factors associated with the injury

Population: Female athletes that require jump landing, change of direction, and decceleration

Females are 2-8 times more likely to suffer an ACL injury than males

Females: Greater hip adduction & internal rotation (knee valgus) knee flexion time activation in hip musculature in response to sudden

loading Quad dominant Smaller intercondylar notch

Thomas, A.C., McLean, S.G., Palmieri-Smith, R.M. Quadriceps and hamstrings fatigue alters hip and knee mechanics. Journal of Applied Biomechanics 2: 159-170, 2010.

Active Warm-Up

blood flow to working muscles

core temperature

muscle stiffness

Active = progression

Activation of one muscle while contracting another

Active Warm-UpJog

Walking Calf Raise

High Knee Walk

High Knee Cradle

Heel to Glute Stretch

Jog

Strength/Eccentric Single-Leg (SL) exercises - glute/hamstring activation

Hamstrings – tibia internal and external rotation Hams-to-Quad Ratio

Decrease hip adduction (P= .015) Decrease knee abduction (P= .038) Decrease ankle eversion (P= .020) Increase knee flexion (P= .005)

Myer, et al., 2006

Leg Dominance (Myer et al., 2006) Glute Activation

Medius – hip abduction; Maximus – hip external rotation “Eccentric load of hamstrings was more effective in increasing

hamstring-to-quadriceps strength ratios than traditional concentric exercises in multiple studies.” (Kaminski et al., 1998)

Strength/Eccentric

Single-Leg Split Squat

Single-Leg Dead Lift

Squat Jumps

Single Leg Hops

Bien, D.P., (2011). Rational and implementation of anterior cruciate ligament injury prevention warm-up programs in female athletes . Journal of Strength & Conditioning Research, 25(1), 271-285.Herman, D.C., Onate, J.A., Weinhold, P.S., Guskiewicz, K.M., Garrett, W.E., Yu, B., Padua, D.A. The effects of feedback with and without strength training on lower extremity biomechanics. The American Journal of Sports Medicine 37(7): 1301-1308, 2009.Kaminski, TW, Wabbersen, CV, and Murphy, RM. Concentric versus enhanced eccentric hamstring strength training: Clinical implications . J Athl Train 33: 216–221, 1998.Myer, G.D., Ford, K.R., Brent Jensen, L., Hewett, T.E. The effects of a plyometric versus dynamic stabilization and balance training on power balance, and landing force in female athletes. Journal of Strength & Conditioning Research 20(2): :345-353, 2006.

Strength/Eccentric cont.

Blackburn & Padua, 2009: Trunk flexion = GRF (F1.38 = 41.607, P< .001)

Shimokochi et al, 2009 (At peak knee extensor, mean ± SD): Sagittal-plane ankle internal moment, Nm/kg 0.2 ± 2.1 Peak knee-extensor moment, Nm/kg -3.8 ± 2.1 Sagittal-plane hip internal moment, Nm/kg 0.8 ± 2.7 Anterior-posterior center of pressure, m -0.026 ±

0.046

Strength/Eccentric

Single-Leg Split Squat

Single-Leg Dead Lift

Squat Jumps

Single Leg Hops

Blackburn, T.J., Padua, D.A. Sagittal-plane trunk position, landing forces, and quadriceps electromyographic activity. Journal of Athletic Training 44(2): 174-179, 2009.Shimokochi, Y., Lee, S.Y., Shultz, S.J., Schmitz, R.J. The relationships among sagittal-plane lower extremity moments: Implications for landing strategy in anterior cruciate ligament injury prevention. Journal of Athletic Training 44:91): 33-38, 2009.

• Squat Jumps• Technique

Emphasis• Posterior Kinetic

Chain• Core Stability

Training

Plyometrics

Purpose: Introduction to acceleration/speed Power development in flexor musculature Static to progressive (forward/lateral) movement

Effects: GRF deep knee flexion

SL Forward/Lateral Jumps Over Cone – Coronal plane knee control Side to side imbalances (multiplane knee load)

Shimokochi & Shultz, 2008: multiplane loadings are primary mechanism

Plyometrics

Single-Leg Lateral Bound

Forward Bound

Squat Jumps over cone

Single-Leg Jumps over cone

Single-Leg Lateral Jumps over cone

Myer, G.D., Ford, K.R., Brent Jensen, L., Hewett, T.E. The effects of a plyometric versus dynamic stabilization and balance training on power balance, and landing force in female athletes. Journal of Strength & Conditioning Research 20(2): :345-353, 2006.Lephart, S.M., Abt, J.P., Ferris, C.M., Sell, T.C., Nagai, T., Myers, J.B., Irrgang, J.J. Neuromuscular and biomechanical characteristic changes in high school athletes: A plyometric versus basic resistance program. Biomechanical Journal of Sports Medicine 39: 932-938, 2005.Shimokochi, Y. & Shultz, S.J. Mechanicms of noncontact anterior cruciate ligament injury. Journal of Athletic Training 43(4): 396-408, 2008.

Improved shock absorption (~20%)(Lephart et al, 2005)

Agility Addresses change of direction and deceleration

Focus: driving off back foot, lower extremity mechanics

Agility

Diagonal Quick Steps

Diagonal RunShuffle (*add unanticipation)T Drill

Shuffle (*add unanticipated directional change) Simulates sport

movement Sell et al, 2006:

Unanticipation vs. Planned

Sell, T.C., Ferris, C.M., Abt, J.P., Yung-Shen, T., Myers, J.B., Fu, H.F., Lephart, S.M. The effect of direction and reaction on the neuromuscular and biomechanical characeristics of the knee during tasks that simulate the noncontact anterior cruciate ligament injury mechanism. The American Journal of Sports Medicine 34(1): 43-54, 2006.

Agility cont.

Imwalle et al, 2009: Hip and knee internal rotation (p = 0.008) increased during 90° cut

vs the 45° cut Mean hip flexion (p < 0.001) was also greater in 90° cut

T Drill: incorporates multiplane movements and most concepts from previous components

Imwalle, L.E., Myer, G.D., Ford, K.R., Hewett, T.E. Relationship between hip and knee kinematics in athletic women during cutting maneuvers: A possible link to noncontact anterior cruciate ligament injury and prevention. Journal of Strength & Conditioning Research 23(8): 2223-2230, 2009.

P.I.P.A. Summary Emphasize Technique

Induce Fatigue Affects muscle spindles & Golgi tendon organs decreased

proprioceptive feedback to CNS & decreased neuromuscular control (Fischer, 2006)

Chappell et al 2005: 21% peak proximal tibial anterior shear force Females had greater knee extensor moments (P = .001) 96% knee valgus moment/ 43% knee varus moments for females 14% knee flexion angle

Provide Feedback Herman et al, 2009:

Feedback showed significant improvements in kinetic and kinematic variables

Chappell, J.D., Herman, D.C., Knight, B.S>, Kirkendall, D.T., Garrett, W.E>, Yu, B. Effect of fatigue on knee kinetics and kinematics in stop-jump tasks. The American Journal of Sports Medicine 33(7): 1022-1029, 2005.Fischer, D.V. Neuromuscular training to prevent anterior cruciate ligament injury in the female athlete. Strength & Conditioning Journal 28(5): 44-54, 2006.Herman, D.C., Onate, J.A., Weinhold, P.S., Guskiewicz, K.M., Garrett, W.E., Yu, B., Padua, D.A. The effects of feedback with and without strength trainfing on lower extremity biomechanics. The American Journal of Sports Medicine 37(7): 1301-1308, 2009

Future Recommendations

Optimal Duration

Unanticipated changes of direction

Young age population

Implicit learning (Benjaminse & Otten, 2010)

References Barber-Westin, S.D., Smith, S.T., Campbell, T., Noyes, F.R. The drop-jump video screening test: retention of

improvement in neuromuscular control in female volleyball players. Journal of Strength and Conditioning Research 24(11): 3055-3062, 2010.

Barendrecht, M., Lezeman, H.C.A., Duysens, J., Smits-Engelsman, B.C.M. Neuromuscular training improves knee kinematics, in particular in valgus aligned adolescent team handball players of both sexes. Journal of Strength and Conditioning Research 25(3): 575-584, 2011.

Benjaminse, A., Otten, E. ACL injury prevention, more effective with a different way of motor learning? Knee Surg Sports Trauatol Arthrosc 19(4): 622-627, 2010.

Dienst, M., Schneider, G., Altmeyer, K., Voelkering, K., Georg, T., Kramann, B., Kohn, D. Correlation of intercondylar notch cross sections of the ACL size: A high resolution MR tomographic in vivo analysis. Arch Orthop Trauma Surg 127: 253-260, 2007.

Irmischer, B.S., Harris, C., Pfeiffer, R.P., DeBeliso, M.A., Adams, K.J., Shea, K.G. Effects of a knee ligament injury prevention exercise program on impact forces in women. Journal of Strength & Conditioning Research 18(4): 703-707, 2004.

Mandelbaum, B.R., Silvers, H.J., Watanabe, D.S., Knarr, J.F., Thomas, S.D., Griffin, L.Y., Kirkendall, D.T., Garrett, W. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. The American Journal of Sports Medicine 33(7): 1003-1010, 2005.

Pfieffer, R.P., Shea, K.G., Roberts, D., Grandstrand, S., Bond, L. Lack of effect of a knee ligament injury prevention program on the incidence of noncontact anterior cruciate ligament injury. The Journal of Bone and Joint Surgery 88-A8: 1769-1774, 2006.

Pollard, C.D., Sigward, S.M., Ota, S., Langford, K., Powers, C.M. The influence of in-season injury prevention training on lower-extremity kinematics during landing in female soccer players. The clinical Journal of Sport Medicine 16(3): 223-227, 2006.