Posts tagged ACL injury
Reducing ACL Injury Risk With Physical Therapy Exercise Programs

ACL injuries are one of the most common sports medicine injuries encountered in a Physical Therapy practice. These injuries can be treated successfully with either conservative or surgical interventions depending on the athlete’s presentation and athletic goals. In addition to the post injury management of these athletes, researchers and clinicians have also focused on reducing an athlete’s risk for future ACL injury. Successful prevention programs for knee injury, including ACL tears, have been developed by numerous researchers and clinicians. Strong evidence supports their utilization in both pre season and in season athletes, especially among female athletes who are 6-8 times more likely to injure their ACL compared to a male in the same sport.

A recent clinical practice guideline, combining the available evidence and expert opinion, was released in the Journal of Orthopedic and Sports Physical Therapy documenting the impact of these risk reduction programs (Arundale et al. 2018). The practice guidelines highlighted the modifiable risk factors for future knee injury including abnormal muscle function and poor movement patterns in athletes. While bracing has continued to fall out of favor in preventing knee injury, Physical Therapy exercises have consistently been shown to effectively reduce injury risk.

Injury risk reduction programs are cost and clinically effective and can be easily implemented by Physical Therapists, coaches, parents, and athletes. Training should incorporate strength and agility training, plyometrics, and sport specific movements required during play. Ideally each program should be completed for 20 minutes, 3-4 times per week. These programs are appropriate for all youth athletes, athletes 12 to 25 years of age, and especially female athletes. Consistent with all exercise interventions, these programs require high degrees of compliance by coaches, clinicians, and athletes in order to reach optimal effectiveness.

Reducing Non Contact ACL Injuries

Non contact ACL injuries remain one of the most common traumatic injuries encountered in sports medicine.  The most common mechanism of injury involves a sudden twisting motion at the knee with the foot planted.  Many factors are at play in this scenario including shoewear, field and court conditions, and the athletes ability to resist the forces at the knee joint.  Intervening at the level of the athlete remains one of the most successful interventions to reduce ACL injury risk.  Within these programs, Physical Therapists work to identify and improve impairments in the athlete including agility, balance, strength, and power.  Athletes who complete these programs have been shown to be 50% less likely to injury their ACL compared to their untrained peers.  

A recent review of the literature reveals these programs may offer our best chance to reduce ACL injury risk.  Authors reviewed all the available research on both modifiable and non modifiable risk factors for ACL injury (Pfeifer et al. International J of Sports Physical Therapy. 2018).  The results of this review indicate the main modifiable risk factor for ACL tears is core and hip weakness.  Athletes entering their season with weakness in these muscles are significantly more at risk than their stronger peers.  Thankfully, Physical Therapy prevention programs have been shown to successfully resolve these risk factors reducing the risk for future ACL injury.  

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No Differences Found Between Operative and Non Operative Treatment of ACL Tears

ACL injuries continue to rise among our high school and collegiate athletes.  In particular, among female athletes who are 6-8 times more likely to injure their ACL compared to a male in the same sport.  The vast majority of these athletes will elect to undergo surgical repair of their injured ligaments, but current research suggests many athletes can cope and adapt to a ACL deficient knee after a comprehensive Physical Therapy program.  This research indicates individuals treated both surgically or conservatively with Physical Therapy reach equivocal functional outcomes at long term follow up.

A recent research article in the American Journal of Sports Medicine compared functional outcomes among 105 athletes status post ACL rupture (Wellsandt et al. 2018).  Each athlete was tested for strength, agility, jumping ability, and propriopception, as well as, subjectively evaluated for current symptoms and activity level.  At 5 year follow up, no differences were found between the surgical and Physical Therapy groups on pain, strength, functional performance, activity level, quality of life, or presence of knee arthritis.  Authors reported athletes treated surgically subjectively reported greater global ratings of knee function and less fear compared to their conservatively treated peers. 

This study adds to our existing research indicating successful outcomes can be achieved with non operative treatment of ACL ruptures.  Further research is needed to better identify patients who require surgical vs. physical therapy interventions.  

Injury Prevention Program Reduces ACL Risk by 38% in Female Basketball Players

In our previous posts on ACL injury we have highlighted girls are 6-8 more likely to sustain an ACL injury compared to boys in the same sport.  Multiple research studies have attempted to reduce this risk by implementing sport specific strength, agility, and balance programs.  On average, these programs have a significant impact on injury rates with ACL injury by 1/3 to 1/2.  A recent long term study was conducted over a 12 year period studying the impact of a hip focused prevention program on girls basketball players.   

Omi and colleagues conducted a prospective intervention study on 309 college female basketball players (Am J Sp Med. 2018) over a 12 year period.  The girls were tracked and observed over the first 4 years of the study and sustained 16 ACL injuries (13 non contact).  Next the authors implemented an 8 year intervention program consisting of strengthening, balance, and agility exercises.  The authors reported ACL injuries were 1/3 as frequent during the intervention program compared to the observation period.  Dropping the risk of ACL injury by 38%.  Amazingly, the exercise compliance rate was 89% during the trial demonstrating the impact of focused, consistently performed exercises in this population.

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Leg strength not found to be associated with mechanics during cutting

Cutting movements utilized in soccer, football, basketball, and lacrosse are one of the most common mechanisms of non contact knee injuries.  Athletes who cut with poor mechanics demonstrate larger hip and knee angles placing the ligaments of the knee, such as the ACL, at greater risk of injury.  These movements at the knee are driven by two main factors: leg weakness and poor mechanics.  A recent study analyzed the mechanics of athletes performing cutting movements to determine the extent strength plays a role in poor mechanics.

Husted and colleagues analyzed 85 athletes for hip strength and muscle activation during a cutting task (International Journal of Sports Physical Therapy, 2018).  The authors found no association between lower body strength testing measurements and muscle contraction during the cutting task.  This study highlights the importance of first improving an athlete's lower body strength to give them the capacity to move properly.  Once the strength foundation is established we are able to work on the athlete's mechanics to ensure they utilize the most optimal movement strategy for their sport specific task.  This study highlights the importance of not assuming mechanics will improve with a strength training program alone.

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Risk Factors for Second ACL Injury with Return to Sport

We have written previously about the high rates of subsequent knee injuries after an athlete returns to sport and activity after ACL surgery.  Interestingly, the most common site of injury is on the opposite knee indicating athlete's are using a compensatory balance and coordination strategy during play.  Current research is working on developing physical therapy rehabilitation programs to reduce the risk of injury upon return to sport.  Some research has shown delaying a return to sport longer than 9 months can reduce re injury rates by as much as 84%.  A current study has identified other risk factors which may place an athlete at risk for future knee injury after returning to sport following ACL reconstruction surgery.

An article in the Orthopedic Journal of Sports Medicine followed 163 patients who underwent ACL reconstruction to determine risk factors for a second ACL injury (Paterno et al. 2017).  The authors reported 1 in 5 of the returning athletes sustained a second ACL injury.  These athletes were then examined to determine which factors correlated with their injury.  The authors placed these athletes in either a high or low risk pool based on established factors for ACL injury.  High risk athletes for a second tear included one of two groups

1.  < 19 years old, limited and asymmetrical triple hop distance

2. <19 years old, female sex, high knee confidence, limited and asymmetrical triple hop distance

Athletes in either high risk group were 5 times more likely to injure their ACL again compared to a lower risk athlete.

Athletes are encouraged to complete all of their prescribed physical therapy visits up to 9 months as well as successfully pass return to sport testing before considering a return to sport.