2. “Is It Possible?” Baker Campbell DPT “Is It Possible?” Baker Campbell DPT

3.  Approximately 100,000 per year in the US  3-5times higher in females vs. males

4.  Pain  Knee Instability  Chrondal lesions/OCD  Early onset osteoarthritis of the LE  Difficulty performing/participating in recreation/sport/dynamic movement activities  Loss of function/decrease quality of life  Financial Loss ($625million-1billion)

5. Patient Education (Provide Knowledge) What is it What does it do What are the consequences (anatomy/physiology)

6. Patient Education (Provide Knowledge)  Why does it happen Predisposing factor Mechanism of injury(MOI)  What’s the prognosis Surgical intervention vs. nonsurgical intervention Rehabilitation post injury/surgery Return to Prior Level of Function(PLOF)

7. Patient Education (Provide Knowledge) Prevention

8. Patient Education (Provide Knowledge) What is it What does it do What are the consequences (anatomy/physiology)

10.  Provide Stability  Aid in screw home mechanism  Provides Neuromuscular Input/Proprioception  Prevents excessive anterior tibial translation  Prevents Hyperextension  Aids in limiting excessive tibial rotation (IR > ER)

11. Patient Education (Provide Knowledge)  Why does it happen Predisposing factor Mechanism of injury(MOI)

12.  Age  Sex  Decrease proprioception  Decrease hip/LE/trunk strength/stability/stamina  LE malalignment (Q angle, excessive foot pronation, genu recurvatum)  Shoe/ surface interface

16. Jumping/Landing Injuries  Shallow/slight knee flexion  Valgus stress  Excessive internal tibial rotation

17. Acceleration/Deceleration Injuries  High speed  Foot firmly planted and lateral to the knee  Slight/shallow knee flexion

18. Patient Education (Provide Knowledge) Prevention

19.  Caraffa et al (1996)  Mandelbaum et al (2007)  Gilchrist et al (2008)  Petersen et al (2005)  Hewett et al (1999)

20.  600 soccer players, 40 semiprofessional teams, over 3 seasons  5 phase balance training consisting of balance activities with no apparatuses and progressively increasing difficulty with application of a variety of balance boards. Experimental Group(Proprioceptio n training with balance boards x20min/day) Control Group (Trained Normally) ACL injuries10 injuries (.15 per season/team) 70 injuries (1.15 per season/team)

21.  20 minute warm-up prior to athletic participation consisting of education, stretching, strengthening, plyometrics, and sport specific agility drills. Experimental Group Control Group 2000Number of Participants =1041 Number of Participants =1905 ACL injuries=2ACL injuries=32 88% decrease in ACL injuries 2001Number of Participants =844 Number of Participants=1913 ACL injuries=4ACL injuries=35 74% decrease in ACL injuries

22.  Program performed 3days per week  Overall incidence in rate in the intervention group was 1.7x less  Noncontact incidence rate in the intervention group was 3.3.less  Rate of incidence in individuals with history of an ACL injury was 5x less 1435 NCAA females soccer players Control Group=852 Experiment Group=583 ACL injuries18 (12 in games)(6 in practice) 7 (all game related)

23.  Intervention group received mechanism of injury education, balance board activities and jump training. Control group= 134 Experimental group=142 ACL injuries51

24.  Untrained female athlete 3.6x higher than trained female athlete  Untrained female athlete 4.8x higher than male athletes  Incidence of ACL injuries for trained females and males was not significantly different 1263 High School soccer, basketball, and volleyball athletes Control Group=463 female athletes Experimental Group=366 female athletes Untrained Male athletes=434 ACL injuries10 (8 noncontact)2 (0 noncontact)2 (1 noncontact) no significant difference

25. Proprioception/ Neuromuscular control training Strengthening Stability Stamina Agility Proper Length-Tension Relationship/Flexibility Jump training Plyometrics Postural Awareness/Education

26.  Hip (23 muscles) (6)flexors (4)extensors (2)abductors (5)adductors (6)external rotators (internal rotation control by glut med/minimus and TFL) (controls femur)(longest bone in the body) (extremely long lever arm)  Knee (11 muscles) (4) extensors (5) flexors (2) hip adductors  Ankle (4) dorsiflexors (2) everters (3) inverters (3) plantar Flexors

27.  Functional activities/Combination Movements  Slow control motions  Maintain/Hold positions  Repetition

28.  Static Balance  Dynamic Balance  Trunk Control  LE Control  Perturbation training

29.  High intensity  Short Duration  Explosive Activities  Bounding  Box jumps  One legged hops  Jump Squats  Jump Lunges

30.  Short intervals  Change in directions  Foot-speed

31. Lunge Technique  Tall spine/Head up  Knee 90deg  Knee inline with between 1 st and 2 nd toe  Knee does not migrate over toes

32. Squat Mechanics  Straight back/Core engaged,  Hips/Bottom back,  Feet shoulder width apart,  Weight on heels,  Knees stay inline with great toe  Knees do not migrate over toes.

33. Double Leg Landing  Hips and knees flexed  Straight back  Avoiding Knee Valgus

34. Single Leg Landing  Hip and knee flexed  Tall spine  Center of mass over the knee

35.  Postural/Positional Faults  Decrease joint mobility  Decrease Mechanical Advantage  Weakness/Stability issues  Decrease proprioception

36.  Warm-up (Jogging, skipping, high knees)  Movement Prep/Dynamic Stretching (Lunge/half- kneel stretch)  Strengthening/Stability (squats/lunges/planks/ bridges)  Balance Activities (perturbation training, compliant surfaces, barefoot, and SLS activities  Plyometrics (Bounding, jump squats, lunge jumps)  Agility (cone drills, shadow drills, sprints)

37. Carrafa et al, “Prevention of anterior cruciate ligament injuries in soccer.”Knee surg. Sports traumatol, arthoscopy(1996) 4 : Gilchrist et al, “A Randomized Controlled Trial to Prevent Noncontact Anterior Cruciate Ligament Injury in Female Collegiate Soccer Players.” Am. J. Sports Med. 2008; 36; 1476 Olsen et al, “Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial” BMJ, doi:10.1136/bmj.38330.632801.8F (published 7 February 2005) Mandelbaum et al, “Effectiveness of a Neuromuscular and Proprioceptive Training Program in Preventing Anterior Cruciate Ligament Injuries in Female Athletes 2-Year Follow-up” Am. J. Sports Med. 2005; 33; 1003 originally published online May 11, 2005; DOI: 10.1177/0363546504272261 Sadoghi et al, “ Effectiveness of Anterior Cruciate Ligament Injury Prevention Training Programs.” J Bone Joint Surg Am, 2012 May 02; 94 (9): 769 -776 Petersen et al, “A control prospective case control study of a prevention training program in female handball player: the German experience. Arch Orthop Trauma Surg. 2005;125:614-21

38. Liu-Ambrose, T. “The anterior cruciate ligament and functional stability of the knee joint.”BCMJ, Vol.45, No 10, December 2003, p495-499 Bahr, R; Krosshaoug, T; “Understanding injury mechanisms: a key component of preventing injuries in sport.” Br J Sports Med 2005; 39: 324-329 Zazulak et al, “Deficits in Neuromuscular Control of the Trunk Predict Knee Injury Risk: A Prospective Biomechanical-Epidemiologic Study” Am. J. Sports Med. 2007; 35; 1123 originally published online Apr 27, 2007 Craig, Bruce, “ What is the Scientific Basis of Speed and Agility?” Strength and Conditioning Journal; June 2004 13-14. Hep2go.com athleticperformancetc.wordpress.com upliftfitness.com.au www.nhs.uk blogs.longwood.edu physiotalk.co.uk excalcarate4.rssing.com

39. snyderphysicaltherapy.com Alfredo Dutilh D. (@alfredotmc) | Twittertwitter.com fitnesspainfree.com www.kilcockphysiotherapy.ie acl-lords.weebly.com www.webmd.com http://www.nata.org/sites/default/files/prevent_acl.pdf http://smsmf.org/smsf-programs/pep-program www.prehabexercises.com