I rehab far too many athletes under the age of 18 with ACL tears. In many cases, I am rehabbing some who have suffered multiple ACL ruptures before they graduate from high school. The burning question is why do so many clients suffer a graft failure or contralateral injury so so often?
Is it related to genetics? Is sports specialization to blame? Perhaps fatigue and limited recovery is a problem. I think the answer is multifactorial, but to be perfectly honest we as a profession have yet to truly arrive at a consensus as to when the “right time” to return to play is. Opinions vary widely based on the athlete, sport, native movement patterns, graft choice, additional injuries (ligament, cartilage or soft tissue) and the provider.
As a clinician dedicated to both prevention and the best rehab, I am always re-evlauating my own algorithm and rehab techniques, while looking for scientific rationale to direct my exercise selection and decision making processes. A recent paper by Webster and Feller in the November 2016 edition of AJSM looked at subsequent ACL injuries in subjects who underwent their primary ACLR under the age of 20 utilizing a hamstring autograft reconstruction procedure.
As a sports medicine professional and physical therapist working with lots of athletes after ACL surgery, I am always looking for ways to improve post-op rehab and prevent a subsequent ACL injury. While we have lots of research looking at neuromuscular, genetic, sex and morphologic risk factors, we have not been able to make significant progress in injury reduction. So many athletes suffer the dreaded “pop” making a simple athletic maneuver they have done a thousand times before.
Based on nearly 19 years of experience training and rehabbing athletes from youth to professionals, I see strong links to a genetic predisposition (family history and prior injury) as well as concerns over neural fatigue. We already know the age of injury is a significant as research indicates those tearing at a younger age (around 20-21 y/o) are more likely to suffer a second injury. But what we know less about is the impact of ankle biomechanics (namely limited dorsiflexion) and how proximal weakness in the hip affects injury risk.
The latter topic was the focus of a study just published in the current edition of the American Journal of Sports Medicine. In this prospective study, researchers sought to determine if baseline hip strength can predict future non-contact ACL tears in athletes.
Every month there are new papers on ACL surgery and rehab appearing in the literature. I do my best to stay up on them as this is one area of my practice I am extremely passionate about. I am driven to understand as much as I can about both prevention and rehab, but find myself increasingly focused on preventing secondary ACL tears in my patients.
I feel poor movement patterns, muscle imbalances and inefficient neuromuscular control are major risk factors for athletes suffering a primary ACL tear. We also know being female markedly increases injury risk. Research also tells us that males are more likely to suffer a re-tear of the same side, whereas females are more likely to suffer a contralateral injury.
A study just published in the July issue of the American Journal of Sports Medicine looked at the incidence of second ACL injuries 2 years after a primary ACL reconstruction and return to sport. In a nutshell, the findings were:
This information is not surprising as I have seen it firsthand in 17 years as a physical therapist. What we do not have much information about is how do the younger patients (e.g 15 and under) really recover from this injury. When should they be cleared? I worked with a young female soccer athlete who tore her ACL and medial meniscus at age 13. She worked diligently with me in rehab 3x/week for about 6 months and then continued training with me at least 2x/week until she was about 1 year out from surgery.
Well, Thanksgiving is upon us in 2011. I want to wish you and your family a wonderful holiday. In today’s post I will review a November 2011 article in the American Journal of Sports Medicine that looked at the effect of the Nordic hamstring exercise on hamstring injuries in male soccer players.
For those not familiar with Nordic hamstring exercises, see the photo below:
In this randomized trial, the researchers had 54 teams from the top 5 Danish soccer divisions participate. They ended up with 461 players in the intervention group (Nordic ex) and 481 players in the control group. The 10 week intervention program was implemented in the mid-season break between December and and March because this was “the only time of the year in which unaccustomed exercise does not conflict with the competitive season.
The trial was conducted between January 7, 2008 and December 12, 2008 with follow-up of the last injury until January 14, 2009. In the intervention group, all teams followed their normal training routine but also performed 27 sessions of the Nordic hamstring exercises in a 10 week program (as follows)
The athletes were asked to use their arms to buffer the fall, let the chest touch the ground and immediately get back to the starting position by pushing with their hands to minimize the concentric phase. The exercise was conducted during training sessions and supervised by the coach. The teams were allowed to choose when in training it was done, but they were advised not to do it prior to a proper warm-up program.
And the results…..
In my last post, I shared some practical plyometric drills with you to help teach proper landing mechanics in an effort to reduce ACL injuries. Yesterday, I presented my comprehensive approach to knee training at our ACL Symposium in Cary, NC.
One of the fundamental errors I see coaches and athletes make is abandoning their pre-season training efforts during the in-season. While athletes need to spend the majority of the in-season focusing on sports skills, they must also maintain the neuromuscular training adaptations acquired in the off-season and pre-season.
In my mind, the phrase “use it or lose it” is applicable for the neuromuscular training effects we see with balance, strength, agility and plyometric training. This is especially true for our high risk female athletes like soccer and basketball players who suffer knee sprains, ACL tears and patellofemoral pain at disproportionate rates.
I often hear coaches say, ” I don’t have time to get workouts done and still accomplish what needs to be done at practice.” While, time management may be difficult, I think coaches could probably squeeze in a single training session lasting 15-20 minutes if they simply knew how important it was to the overall health and performance capacity of their team.
With that said, I like to offer simple, yet effective exercises that can be done on a court or field with the whole team simultaneously without the need for expensive equipment. Exercises should focus on activating the glutes (including the medius and minimus) as well as training the hamstrings more since most female athletes tend to be quad dominant.
These exercises are just as effective for males too. So, in the video below I will reveal some exercises I prefer to do to increase strength and reduce injury risk. Perform 2-3 sets of 8-15 reps focusing on strict form throughout.