Prevention of Prevention of ACL InjuriesACL InjuriesKambiz Behzadi, M.DKambiz Behzadi, M.D

Sports Medicine Sports Medicine

andand

Reconstructive SurgeryReconstructive Surgery

Prevention of Prevention of ACL InjuriesACL Injuries

Anterior Cruciate Ligament Injuries: “ACL”Anterior Cruciate Ligament Injuries: “ACL” 100,000 ACL tears every year100,000 ACL tears every year Majority in 15 to 25 year oldsMajority in 15 to 25 year olds Cost to society 1.5 Billion dollars a yearCost to society 1.5 Billion dollars a year Short term, loss of participation and game Short term, loss of participation and game

timetime Long term, higher chance of arthritis in Long term, higher chance of arthritis in

futurefuture

Prevention of ACL Prevention of ACL injuriesinjuries

Common problem in young athleteCommon problem in young athlete Girls more susceptible to injuryGirls more susceptible to injury Incidence 2 to 8 times higher in girlsIncidence 2 to 8 times higher in girls Why?Why? Is there anything we can do to Is there anything we can do to

prevent it?prevent it?

AnatomyAnatomy

Patella, knee capPatella, knee cap Femur, thigh boneFemur, thigh bone Tibia, lower leg boneTibia, lower leg bone Fibula, small leg Fibula, small leg

bonebone Articular CartilageArticular Cartilage Meniscal CartilageMeniscal Cartilage Major LigamentsMajor Ligaments

ACL ACL PCLPCL

ACLPCL

Articular Cartilage

MeniscalCartilage

FunctionFunction

Load BearingLoad Bearing.articular cartilage.articular cartilage.meniscal cartilage.meniscal cartilage

LigamentsLigaments.tightness of the .tightness of the kneeknee.primary stabilizers.primary stabilizers

Muscles Muscles .control of the .control of the knee .secondary knee .secondary stabilizersstabilizers

Mechanism of InjuryMechanism of Injury

When the athlete When the athlete plants his/her leg plants his/her leg on the ground the on the ground the ACL is engaged ACL is engaged and the Knee is and the Knee is stablestable

Major function = Major function = restrict tibia from restrict tibia from moving to the frontmoving to the front

Neuromuscular control Neuromuscular control and Proprioceptionand Proprioception

A Complex array of nerves, muscles, A Complex array of nerves, muscles, bones, ligaments, and cartilages work bones, ligaments, and cartilages work together to optimize what we know as together to optimize what we know as sports performancesports performance

Neuromuscular ControlNeuromuscular Control: unconscious : unconscious control of our movements and control of our movements and muscles by our brain stemmuscles by our brain stem

ProprioceptionProprioception: our body’s ability to : our body’s ability to know where our knees and ankles are know where our knees and ankles are in spacein space

ACL InjuryACL Injury

What happens in What happens in that one in a that one in a million times that million times that the athlete pivots the athlete pivots and the ligament and the ligament tears?tears?

What causes ACL tearsWhat causes ACL tears 70% occur when 70% occur when

there is no contact there is no contact whatsoeverwhatsoever

Biomechanical Biomechanical factorsfactors

Body positionBody position associated with associated with increased risk of increased risk of injuryinjury

Body PositionBody Position ““Crouched Crouched

position”position”.hips and knees bent.hips and knees bent.center of gravity .center of gravity over feetover feet.on their toes.on their toes

““Upright position”Upright position”.center of gravity .center of gravity behind kneebehind knee.flat footed.flat footed.hips and knees .hips and knees straightstraight

Body PositionBody Position

Position of body Position of body during landing, during landing, cutting, pivotingcutting, pivoting

Hips and Knees are Hips and Knees are straightstraight

Landing on flat feetLanding on flat feet This puts ACL at This puts ACL at

riskrisk In contrast: when athlete has In contrast: when athlete has

hips and knees bent, and lands hips and knees bent, and lands on his/her toes, risk of ACL on his/her toes, risk of ACL injury is minimized injury is minimized

Balance of PowerBalance of Power Recruittment PatternRecruittment Pattern Quadriceps muscles Quadriceps muscles

antagonist-antagonist-stress stress ACLACL

Hamstring muscles Hamstring muscles agonist-agonist-protect ACLprotect ACL

Weak hamstringsWeak hamstrings and and strong quadriceps strong quadriceps puts ACL at riskputs ACL at risk

Female Female Quad. dominantQuad. dominant Male Male Hamstring dominantHamstring dominant Hamstrings 60% to Hamstrings 60% to

80% as strong as 80% as strong as Quadriceps Quadriceps

Quadricep

sHam

stri

ngs

Other Risk FactorsOther Risk Factors

AnatomicAnatomic EnvironmentalEnvironmental HormonalHormonal

Anatomic FactorsAnatomic Factors Intercondylar Intercondylar

NotchNotch Small notchSmall notch Small Ligament Small Ligament

sizesize Alignment of lower Alignment of lower

legleg

Intercondylar notchACL

ACL

Environmental FactorsEnvironmental Factors

FieldsFields Cleat DesignCleat Design

Hormonal FactorsHormonal Factors

Estrogen and Estrogen and RelaxinRelaxin

Relax and soft Relax and soft tissuestissues

Does this Does this predispose female predispose female athlete to ACL athlete to ACL injury?injury?

Increased incidence of ACL tears Increased incidence of ACL tears during ovulatory phase?during ovulatory phase?

Moment of InjuryMoment of Injury

Loud PopLoud Pop Tibia subluxes Tibia subluxes

forward and pops forward and pops back inback in

PainPain Lie on turf, get Lie on turf, get

comfortablecomfortable Wait for coaches Wait for coaches

and trainersand trainers

ACL InjuriesACL Injuries Prevention--Biomechanical Factors Prevention--Biomechanical Factors

criticalcritical NeuromuscularNeuromuscular//ProprioceptiveProprioceptive

programsprograms Dramatic reduction in ACL tearsDramatic reduction in ACL tears Plyometric/jump training and Plyometric/jump training and

Balance drillsBalance drills Retrain mind on Retrain mind on body positionbody position

Major StudiesMajor Studies Mandelbaum, PEP Mandelbaum, PEP

program, 80% program, 80% reduction of ACL reduction of ACL injuires over 2 year in injuires over 2 year in girls playing soccer girls playing soccer ages 14 to 18ages 14 to 18

Carraffa, Balance drillsCarraffa, Balance drills Hewett, Jumping drillsHewett, Jumping drills Significant reduction Significant reduction

of ACL tearsof ACL tears in those in those who received who received Neuromuscular Neuromuscular trainingtraining

PEP programPEP program

PPrevent injury revent injury EEnhance nhance PPerformanceerformance Simple, no major equipment, soccer Simple, no major equipment, soccer

ball and coneball and cone 2 to 3 times a week2 to 3 times a week Incorporate into practice sessionsIncorporate into practice sessions Retrain your body positioning in spaceRetrain your body positioning in space It is all about prevention, more time It is all about prevention, more time

playing and less time on the benchplaying and less time on the bench

PEP PROGRAMPEP PROGRAM