Posts tagged prevention
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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Physical Therapy Shown To Be Deterrent of Future LBP Flare Ups
low back pain-prevention-treatment

Death, taxes, and low back pain are three of the certainties of life with over 90% of individuals reporting low back pain at some point in their lives.  Our previous posts have described the ability of Physical Therapy to both accelerate a patient's recovery from low back pain and reduce its' risk of recurrence.  A recent study examined the factors that are correlated with a "flare up" or exacerbation of symptoms in patients with acute LBP.  

Authors studied 48 patients with low back pain (<3 months duration) and assessed for periods of either baseline symptoms or flare ups described as a period of increased pain lasting at least 2 hours (Suri, P et al. Spine. 2018).  Prolonged sitting, > 6 hours, was the only activity significantly associated with a flare up.  Patients who sat greater than 6 hours were 4 times more likely to have a flare up.  Mental health, including stress or depression, was also associated with a low back pain flare up.  The authors showed patients undergoing Physical Therapy treatments reported significantly less flare ups.

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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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Reducing Hamstring Strains in Sprinters

Hamstring strains or pulls are a common injury among acceleration sports including rugby, soccer, and sprinting.  Our previous blogs have written about the causes and treatments of these muscle injuries.  One of the common causes of injury involves a lengthening contraction (eccentric) of the muscle during these explosive sports movements.  If the muscle is unable to handle the forces placed upon it an injury occurs.  To reduce this injury risk, researchers and clinicians have focused on improved the strength and tissue capacity of the hamstring through training.  

A long term study was reported in the Orthopedic Journal of Sports Medicine describing 3 different interventions utilized to reduce the risk of hamstring injury (Sugiura et al. 2017).  Authors assessed 3 different prevention methods in a group of top ranked collegiate and national level sprinters over a 24 year period.  The first training program utilized over a 4 year period consisted of strengthening on a leg curl machine.  During this period 16 strain injuries occurred in a group of 116 sprinters.  The staff then included hip strengthening, agility and hurdle work in addition to the leg curl.  The authors reported a 56% reduction in hamstring strains over this 9 year period.  Finally, the authors included exercises from the first two interventions as well as dynamic stretches and nordic curl training for the hamstring.  This group of close to 300 sprinters sustained only 2 strain injuries over a 12 year period, almost a 90% reduction in strain rates.  



This study adds to our existing evidence on the importance of of hamstring strengthening for both performance and injury prevention among sprinting athletes 

Evidence Supports Not Using FMS To Predict Future Injury

The functional movement screen was designed to screen athletes and individuals on both upper and lower body movement tasks in order to identify those at risk for future injury.  As participants move through the 7 movement tasks, Physical Therapists are able to identify areas of weakness, tightness, or decreased coordination.  Based on these results exercises or manual therapy interventions are provided to help improve an individual's performance on a test.  The FMS was initially shown to be a predictor of injury in both NFL draft prospects and firefighters, but has not held up as well in future research.

Previous review articles have called into question the validity of these tests for athletic performance and testing, as well as, their ability to predict injury.  A recent review article of the available evidence was conducted to determine if an individual's composite scores are predictive of future injury (Moran et al. Br J Sp Med. 2017).  The authors 24 studies on the FMS and found the relationship between a cut off score of 14 out of 21 and future injury was small.  Further their was moderate evidence to recommend not using the FMS as a prediction test in soccer and conflicting evidence for other sports.  This study adds to the existing literature moving away from using the FMS for injury prediction, but single tests may hold value for certain sports and patient populations.