ACL Prevention in the PPE: What more can we do? Matt Gauthier, PT, DPT, SCS

My background Work for Athletico’s Niles/Northwest Chicago clinic Undergraduate degree from Purdue University Doctorate in Physical Therapy from Indiana University Sports Physical Therapy Certification from Evidence in Motion Board Certified in Sports Physical Therapy Head of Athletico’s Overhead Athlete Program Member of the USOC Physical Therapy Volunteer Program

Start with the end in mind After ACL reconstruction, only 23% of patients passed Return-to-Sport criteria Passing RTS criteria reduces risk of a re-tear by 60%. Passing RTS criteria increases risk of a contralateral ACL tear by 235%

The anatomy of an ACL injury Most common mechanism of injury is dynamic valgus with landing, cutting, or pivoting 70% of ACL injuries are non-contact due to poor neuromuscular control Female athletes experience ACL injury 4- 6x more likely than male athletes

Biomechanical deficits with landing/cutting/pivoting Why does this happen? Biomechanical deficits with landing/cutting/pivoting Increased knee abduction moment Greater ground reaction force Shorter stance time Decreased knee flexion Increased quadriceps (VL) activity Decreased hamstring (ST) activation Decreased dynamic balance Numerous studies have identified neuromuscular control as a possible modifiable risk factor

How do we effectively and efficiently identify these deficits? Functional Movement Screen (FMS) Y-Balance Test (YBT) Drop Vertical Jump Assessment (DVJ) Landing Error Scoring System (LESS) Tuck Jump Assessment (TJA)

Functional Movement Screen (FMS) The Functional Movement Screen is among the most widely used functional tests as it uses objective scoring and is backed by considerable supporting evidence. Uses 7 movements to identify asymmetries and functional limitations Provides a simple, common language that can be used between health professionals to describe a patient’s strengths and weaknesses Establishes a standardized, objective baseline of performance that can easily be reproduced

Functional Movement Screen (FMS) It is important to remember that the FMS is a screen, and that it does not provide specific diagnoses. The screen looks at the patient’s ability to perform specific movement patterns. If the patient is unable to perform the given movement, this is a red flag that further evaluation is needed. Can the patient perform the movement? Yes – move on No – further assessment needed to determine why

Functional Movement Screen (FMS) The FMS consists of 7 movements which are scored on a 0-3 scale for a total possible score of 21 Deep Squat Hurdle Step In-Line Lunge Shoulder Mobility Impingement clearing test Active Straight Leg Raise Trunk Stability Pushup Lumbar extension clearing test Rotary Stability Lumbar flexion clearing test

Functional Movement Screen (FMS) Scoring: 3 trials of each movement are performed Each movement receives a 0-3 scale 3 – Completion of movement without compensation. Perfect performance. 2 – Completion of movement with compensation or aberrant movement. Imperfect performance. 1 – Cannot complete movement, but no pain present. 0 – Presence of pain, regardless of ability to complete movement. “Clearing tests” are paired with 3 movements. If clearing test is positive, the patient scores a 0 on that movement regardless of performance.

Functional Movement Screen (FMS) Interpretation of results In general, consistently low scores indicate a mobility issue, while inconsistent scores indicate a motor control issue Hierarchy of concern 0 – pain Therapy needed R-L asymmetry involving a 1 – poor mechanics cause microtrauma R-L asymmetry not involving a 1 – poor mechanics cause microtrauma, but less severe as above Therapy needed, possibly via HEP Bilateral 2s – microtrauma can occur at high intensity Can likely get by with comprehensive HEP

Functional Movement Screen (FMS) Sophomore 16 year old Male Right-handed pitcher

Functional Movement Screen (FMS) Senior 18 year old Female Soccer player

Functional Movement Screen (FMS) Treat mobility deficits first, stability deficits second This is according to FMS, but think about it… When emphasizing stability, work bilaterally Different core control motor programs in different positions Avoid loading painful, pathologic movement patterns i.e., Don’t perform weighted squat if deep squat hurts. Address mobility and stability deficits first!

FMS Case Example 18 year old female soccer player entering senior year R-L asymmetries with split stance activities L ACL tear 2 seasons ago Alterations during strength training Split stance exercises Lunges, step ups with hip flexion, split squats Offset weight to increase difficulty UE strengthening in single leg stance Leg lowering progression Screen again in 6 weeks

Functional Movement Screen (FMS) Lower scores on the FMS (<15/21) have been shown to be predictive of lower extremity injuries in multiple demographics (Chorba 2010, Kiesel 2007, Butler 2013, O’Conner 2011, Lisman 2013) Some researchers cast doubt on whether the FMS is as predictive of injury as previously reported (Bardenett 2015, Dorrel 2015)

Functional Movement Screen Pros Cons Reliable Repeatable Valid and predictive of injury in several patient demographics Identifies those in need to NM training Implementation can be time-consuming Lack of plyometric component Lacks predictive validity in high school population

Y-Balance Test (YBT) Tests an athlete’s combined strength, balance, and flexibility in multiple planes Research suggests significant increase in lower extremity injury risk if right-left asymmetry is present, or if the composite score is less than 89% (Plisky 2006, Smith 2014, Plisky 2012, Gribble 2012, Butler 2012) Some research points to different normative values for different demographics (Butler 2012)

Y-Balance Test Pros Cons Reliable Equipment necessary for test Repeatable Valid and predictive of injury in several patient demographics Quick application (<5 minutes) Identifies those in need to NM training Equipment necessary for test Lack of plyometric component Different normative values for different demographics(?)

Drop Vertical Jump Assessment (DVJ) This field-based exam uses video to identify athletes at increased injury risk secondary to NM control deficits in performing a depth jump (Redler 2016) Video stopped a lowest point of jump, and ratio of knee-hip separation distance was measured >0.8 = low risk 0.6-0.8 = medium risk <0.6 = high risk

Drop Vertical Jump Assessment (DVJ) Pros Cons Good inter- and intra-rater reliability High sensitivity Does not require significant training Quick application Includes plyometric component Identifies those in need to NM training Equipment necessary for test No reported values for validity or injury prediction

Landing Error Scoring System (LESS) The LESS is a 17-point assessment of an individual’s jump-landing technique, examining trunk, hip, knee, and foot/ankle position (Padua 2009) The LESS has been shown to be predictive of injury in youth athletes, but not in high school or college athletes (Smith 2012, Fox 2015) >5/17 = increased injury risk

Landing Error Scoring System (LESS) Pros Cons Good-Excellent inter- and intra-rater reliability Quick application Includes plyometric component Identifies those in need to NM training Requires some training for proper administration Use of 2 camera views recommended in original iteration Not predictive of injury in high school or college athletes

Tuck Jump Assessment (TJA) The TJA is a 10-point assessment of repeated tuck jumps over the course of 10 seconds, examining the knee and thigh, foot position, and plyometric technique (Myer 2008) Athletes exhibiting >5 flaws are to be targeted for NM training (Myer 2008, Fox 2015, Read 2016)

Tuck Jump Assessment Pros Cons Good-Excellent inter- and intra-rater reliability Very fast application Includes plyometric component Identifies those in need to NM training Use of 2 camera views recommended in original iteration No reported validity or injury prediction values

So what do we do with all this information?

So what do we do with all this information? Implement testing batteries Single leg control Plyometric control Functional movement Cast a wide net Highly sensitive tests Be efficient, but deliberate Include at least one non-plyometric and one plyometric test

So what do we do with all this information? DO SOMETHING ABOUT IT FIFA 11+ KIPP Santa Monica PEP

Athletico’s ACL 3P Program Athletico offers team-wide ACL prevention screening Screening events use a battery of tests, specific to the athlete’s current sport At-risk athletes are identified and provided information. Coach/athletic trainer are provided with team-wide information with general recommendations based on results

References Webster, K. E., & Hewett, T. E. (2019). What is the evidence for and validity of return-to-sport testing after anterior cruciate ligament reconstruction surgery? A systematic review and meta-analysis. Sports Medicine (Auckland, N.Z.), doi:10.1007/s40279-019-01093-x Schilaty, N. D., Bates, N. A., Krych, A. J., & Hewett, T. E. (2017). How Anterior Cruciate Ligament Injury was averted during Knee Collapse in a NBA Point Guard. Annals of musculoskeletal medicine, 1(1), 008. Lisman, P., O’CONNOR, F. G., Deuster, P. A., & Knapik, J. J. (2013). Functional movement screen and aerobic fitness predict injuries in military training. Medicine & Science in Sports & Exercise, 45(4), 636-643. Kiesel, K., Plisky, P. J., & Voight, M. L. (2007). Can serious injury in professional football be predicted by a preseason functional movement screen?. North American journal of sports physical therapy: NAJSPT, 2(3), 147. O’Connor, Francis G., et al. "Functional movement screening: predicting injuries in officer candidates." Med Sci Sports Exerc 43.12 (2011): 2224-30. Chorba, R. S., et al. "Use of a functional 343 movement screening tool to determine injury risk in female collegiate athletes." N Am J Sports 344 Phys Ther 2.47-54 (2010): 345. Butler, R. J., Contreras, M., Burton, L. C., Plisky, P. J., Goode, A., & Kiesel, K. (2013). Modifiable risk factors predict injuries in firefighters during training academies. Work, 46(1), 11-17. Bardenett, S. M., Micca, J. J., DeNoyelles, J. T., Miller, S. D., Jenk, D. T., & Brooks, G. S. (2015). Functional Movement Screen normative values and validity in high school athletes: can the FMS™ be used as a predictor of injury?. International journal of sports physical therapy, 10(3), 303. Dorrel, B. S., Long, T., Shaffer, S., & Myer, G. D. (2015). Evaluation of the functional movement screen as an injury prediction tool among active adult populations: a systematic review and meta-analysis. Sports health, 7(6), 532-537. Gribble, Phillip A., Jay Hertel, and Phil Plisky. "Using the Star Excursion Balance Test to assess dynamic postural- control deficits and outcomes in lower extremity injury: a literature and systematic review." Journal of athletic training 47.3 (2012): 339-357.

References Butler, Robert J., et al. "Differences in soccer players' dynamic balance across levels of competition." Journal of athletic training 47.6 (2012): 616-620. Plisky, Phillip J., et al. "Star Excursion Balance Test as a predictor of lower extremity injury in high school basketball players." Journal of Orthopaedic & Sports Physical Therapy 36.12 (2006): 911-919. Plisky, Phillip J., et al. "The reliability of an instrumented device for measuring components of the star excursion balance test." North American journal of sports physical therapy: NAJSPT 4.2 (2009): 92. Smith, C. A., Chimera, N. J., & Warren, M. (2015). Association of y balance test reach asymmetry and injury in division I athletes. Medicine and science in sports and exercise, 47(1), 136-141. Redler, Lauren H., et al. "Reliability of a Field-Based Drop Vertical Jump Screening Test for ACL Injury Risk Assessment." The Physician and Sportsmedicine, vol. 44, no. 1, 2016, pp. 46-52. Padua, D. A., Marshall, S. W., Boling, M. C., Thigpen, C. A., Garrett Jr, W. E., & Beutler, A. I. (2009). The Landing Error Scoring System (LESS) is a valid and reliable clinical assessment tool of jump-landing biomechanics: the JUMP-ACL study. The American journal of sports medicine, 37(10), 1996-2002. Smith, H. C., Johnson, R. J., Shultz, S. J., Tourville, T., Holterman, L. A., Slauterbeck, J., ... & Beynnon, B. D. (2012). A prospective evaluation of the Landing Error Scoring System (LESS) as a screening tool for anterior cruciate ligament injury risk. The American journal of sports medicine, 40(3), 521-526. Fox, A. S., Bonacci, J., McLean, S. G., Spittle, M., & Saunders, N. (2016). A systematic evaluation of field-based screening methods for the assessment of anterior cruciate ligament (ACL) injury risk. Sports medicine, 46(5), 715- 735. Read, P., Oliver, J. L., CROIX, M. B. D. S., Myer, G. D., & Lloyd, R. S. (2016). Reliability of the tuck jump injury risk screening assessment in elite male youth soccer players. Journal of strength and conditioning research/National Strength & Conditioning Association, 30(6), 1510. Myer, Gregory D., Kevin R. Ford, and Timothy E. Hewett. "Tuck Jump Assessment for Reducing Anterior Cruciate Ligament Injury Risk." Athletic Therapy Today : The Journal for Sports Health Care Professionals, vol. 13, no. 5, 2008, pp. 39-44.

Matt Gauthier, PT, DPT, SCS Physical Therapist, Board-Certified in Sports Physical Therapy O:773.774.4291 C: 219.805.1231 773.774.4527 Matthew.Gauthier @athletico.com athletico.com

THANK YOU!