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

2. 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

3. 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%

4. 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

5. 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

6. 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)

7. 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

8. 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

9. 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

10. 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.

11. 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

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

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

14. 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!

15. 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

16. 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)

17. 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

18. 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)

19. 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(?)

20. 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
= medium risk
<0.6 = high risk

21. 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

22. 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

23. 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

24. 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)

25. 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

26. So what do we do with all this information?

27. 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

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

29. 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

30. 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: /s 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),
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):
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  (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),
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),
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):

31. References
Butler, Robert J., et al. "Differences in soccer players' dynamic balance across levels of competition." Journal of athletic training 47.6 (2012):
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):
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),
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
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),
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),
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),
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

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

33. THANK YOU!