How to

reduce the risk

of acl tears in athletes.

Maria Mountain,
MSc,CSCS,CEP

www.revolutionconditioning.com

Section One - Introduction 1. Introduction 2. What is the ACL? 3. How does it get injured? 4. What happens when it does get injured? section Two Risk evaluation 1. Evaluating risks. 2. Understanding proper mechanics. Section three building smart strong muscles 1. Building 3D glute strength 2. Developing the hamstrings. 3. Jumping with better mechanics. developing functional movement patterns 1. Hitting the brakes Learning to Stop 2. Movement with Transitions. 3. Movement Complexes

Section four

Section five The workout 1. Level One Program weeks 1-3 2. Level Two Program weeks 4-6 3. Level Three Program weeks 7-9

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Section one introduction Welcome to the Revolution Sport Conditioning special report on reducing the risk of ACL tears in athletes. As they say, numbers do not lie and the numbers surrounding the incidence of ACL (Anterior Cruciate Ligament) tears in recent years is staggering!

NCAA

2,200 ACL Injuries every year in the Female Athletes have a 4-8 times higher Predicted that 1:100 female high school Predicted that 1:10 female college

incidence of ACL injury

athletes will injure her ACL.

athletes will injure her ACL.

If the statistics above have an upside it is the fact that most of these injuries are non-contact mechanisms, meaning, it is not force or impact from another player which causes the injury, rather its a structural breakdown that comes when the force produced by the muscles which cross the knee joint are not attenuated by appropriate reflex motor patterns. What does this mean for athletes? Well, since the mechanism which causes the injury comes purely from within the body, then there may be an opportunity to train the athlete to use their muscles in a way that reduces the risk. Before we get into the nuts and bolts of injury prevention lets take a look at what the ACL is and what it does in the body. What is the ACL? The ACL is one of the four major ligaments in the knee. Ligaments on their own provide structural stability but no dynamic stability as they are non-contractile.
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The role of the ACL is to prevent anterior translation of the tibia with respect to the femur, in laymans terms this means that it prevents the shin bone from sliding forward underneath the thigh bone. The ACL and its partner in the PCL (posterior cruciate ligament) are found deep in the center of the knee joint. On the outside of the knee are the medial and lateral collateral ligaments which provide side to side stability for the knee.

Grays Anatomy Illustration of the knee as seen from the front. ACL indicated with red arrow.

How does it get injured? There are two mechanisms of ACL injury, the first is a passive mechanism which would occur when another player or an object, collides with the athletes knee forcing it into a position where the ACL is ruptured. This is often the mechanism when you see athletes collide knee on knee. The key point is the presence of an external force. The second mechanism in the one that we are concerned with, it is the active mechanism which occurs when a co-contraction of the muscles crossing the knee fail to provide dynamic stability. What happens when it does get injured? When you hear an athlete say that they were just running or changing direction or jumping when their knee gave way this is an active mechanism of injury. The giving way or shifting episode is accompanied by pain and often a popping sound. Often the athlete will hear it and sometimes even bystanders will hear the sound. So if
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you experience a shifting episode accompanied by pain and acute swelling, the knee will often puff up like a balloon, these are signs that you need to go visit your sport medicine specialist to get it evaluated. If an athlete has torn their ACL and they are involved in a sport that requires dynamic movement as most team sports and individual sports do, they will probably want to have the ACL reconstructed to regain the anatomical structural stability. A reconstruction it is a routine operation for the orthopaedic surgeon who will use different tissues to create a new ACL and position it in the knee. In London, Ontario where Revolution Sport Conditioning is located surgeons typically harvested the graft using a portion of the hamstrings tendon. This procedure is performed as a day surgery usually requiring no overnight stay in the hospital. Following surgery the athlete is on crutches and will be sent to follow up with a sport physiotherapist. The athlete should expect to participate in physiotherapy for approximately six months before considering a return to Sport. In the five years I worked at the Fowler Kennedy Sport Medicine Clinic as the exercise specialist one thing became clear; the athletes that put the most into their rehabilitation had the most successful return to sport..

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section Two

Risk evaluation

There is evidence to suggest that faulty muscle recruitment patterns may contribute to these non-contact injuries. Mainly an over utilization of the quadriceps and an under utilization of the glutes and hamstrings may help set up the right environment for ACL tears. Alignment at the hip, knee and ankle may also play a key role. Evaluating Risks How do you know if you have poor alignment or a faulty recruitment pattern? You can always get a thorough assessment from your sport physiotherapist, but here are two tests you can try at home: Stand facing a full length mirror and jump straight up in the air. Absorb the landing with your legs such that you finish in a half squat position. Are your knees pointing inward? If yes, you need to work on your dynamic alignment. Now, stand sideways to that full length mirror. Jump up in the air and absorb the landing with your legs such that you finish in a half squat position. Are your heels off the floor or is your weight shifted toward the balls of your feet after you have landed? If yes, you may be exhibiting some quadriceps dominance. Understanding Proper Mechanics. Now that you have used the evaluations outlined above to evaluate your movement patterns, I want to make sure that you have a clear picture of proper alignment and mechanics. What were looking for in athletes is that their hips, knees and ankles stay in alignment during both jumping and landing. We are also looking to see if the athlete lands on the forefoot (ball of the foot) and then quickly transitions to full foot contact. Landing without the transition to full foot contact, increases the force on the quadriceps and suggests that the athlete is not effectively recruiting his/her glute muscles.

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Section three
Building 3D Glutes

building smart, strong muscles

Squat with Tubing above the knees. This exercise will help teach proper squatting technique and correct movement patterns for landing jumps, while activating the Gluteus medius muscle which helps one maintain proper knee alignment. To perform this exercise stand approximately 20cm away from the front edge of a chair or bench. Position a resistance band (tie the ends of a 50cm piece of rubber tubing together to create a loop approximately 30cm in diameter) above the knees and maintain a slight outward pull. To begin the movement reach back with your buttocks you should feel pressure toward the heels of your feet not the balls. Remember to keep your chest up and squat down until you just lightly make contact with the bench or chair. Do not sit down, simply tap and return to the standing position. Count to four as you lower yourself to the chair.

Sumo squat Take a double hip width stance and point your toes outward slightly. You may use a weight to overload this exercise, but make sure your technique is perfect. To begin the movement, reach back with your buttocks, again the pressure will be on your heels. As you lower into the squat remember to keep your knees in alignment with your feet, you will feel that you are pulling your knees outward slightly. Remember
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to keep your chest up throughout the exercise. You should feel this exercise working the fronts of your thighs (quadriceps) and your outer glutes.

Supine Glute Bridge and Hold Lie face up with your knees bent and feet flat on the floor. You will brace lightly with your abdominals (as if you are going to receive a light punch in the stomach) and lift your hips and back off the floor all at once. Push your heels straight down into the floor and squeeze your glutes (buttocks).

Developing the Hamstrings The hamstrings are a critical dynamic stabilizer of the knee. Efficient timing of the co-contraction between the quadriceps and the hamstrings can reduce the risk of noncontact ACL tears. The hamstrings must fire at the proper time and with adequate
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force to stabilize the tibia under the femur, thus preventing the shear mechanism that results in an ACL tear. Testing of athletes often shows an imbalance between the strength of the quadriceps and hamstrings; with the hamstrings appearing much weaker relative to the quadriceps. A 2006 article published in the American Journal of Sports Medicine also found that female athletes after menarche increase their quadriceps strength greater than their hamstring strength, putting them at risk for anterior cruciate ligament injury.

female athletes after menarche increase their quadriceps strength greater than their hamstring strength, putting them at risk for anterior cruciate ligament injury.
Ahmad et al. AJSM 34:370-374

The following exercises are intended to improve the functional strength of the hamstrings. Hamstring Curl Progression using the Stability Ball Lie face up on the floor with your heels on a stability ball. Lift your hips off the floor into a bridge position. Maintain this perfect position with your body as you bring your knees in toward your chest. During this exercise there is little to no overall change in the length of your hamstrings, but you will learn to maintain a nice contraction over the full range of motion.

Basic Isometric Hamstring Curl

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Advanced Hamstring Curl

Lie face up on the floor with your heels on the stability ball (exactly the same as the previous exercise). Brace lightly with your abdominals and lift your hips up off the floor to make a straight line from your shoulders, through your hips, to your ankles. Maintain the straight line position from your shoulders to your knees as you curl your heels toward your butt. You should not bend at your hips as you did in the previous exercise. Slowly straighten your knees back to the starting position. Do not set your hips down until you have finished the entire set.

Butt Kickers This exercise can be completed with or without resistance. To add resistance, fix the middle portion of a 6resistance tube and loop the other ends around your ankles. Use a light resistance (similar to a red band in the Theratube brand).

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Stand with a tall torso position and perform a running buttkicker motion as you quickly bring your heels to your buttocks. Remember to keep your toes pulled up throughout the drill; do not allow your toes to point. A useful cue is to think about smashing your calf into your hamstring. Once the technique is perfect the tempo of the exercise should be at a sprinting pace.

Crab Walks You will need 10-15 metres of space to perform this next exercise. Get into your crab walk position. Remember to keep your hips up and level throughout the entire movement. Perform the crab walk feet first so you have to pull yourself forward using your hamstrings. Focus on pulling with your hamstrings through a full range of motion. Also, make sure you are maintaining good knee alignment; do not let your feet flare out.

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Jumping with Better Mechanics Now that we have taught your glutes to fire and built some functional strength in your hamstrings, it is time to use these muscle groups to perform a complex functional pattern. Jumping is a great pattern to start with because it allows the athlete to fine tune both acceleration (take-off) and deceleration (landing) mechanics. The acceleration movement is also referred to as Triple Extension as this describes the extension at the hip, knee and ankle. It makes sense then that the deceleration movement is often referred to as Triple Flexion as the hips, knees and ankles flex (or bend) to absorb the landing. If possible, a grassy surface is ideal for this type of exercise. Drop Squat & Hold The emphasis here is on triple extension. Stand with your feet hip width apart and quickly drop down into a squat position. Make sure your hips, knees and ankles are in proper alignment with your heels on the floor. Hold this position for 3 seconds try to imprint the feel of this position. Return to the standing position. Make sure you can do this exercise with perfect alignment before moving on to the next exercise.

Squat Jump & Hold Do this exercise in front of a mirror so you can observe and correct your form. Do not go by what feels right; go by what looks right. Keep your hips knees and ankles in a line on both take off and landing. Strive for a quick but quiet landing where you absorb the impact by using your legs as shock absorbers. Developing this skill will lay the foundation for efficient deceleration. Upon landing, you will contact with the
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balls of your feet first, followed quickly by a lowering of the heels. As you absorb the impact you will reach back with your buttocks into a squatting position, rather than driving your knees forward. Perform 3 squat jumps then stick the landing on the third repetition using your triple flexion as you decelerate. Hold the landing for 3 seconds before beginning your next three jumps. Lateral Hop Over Barrier For this exercise you will perform a lateral hop over a barrier (such as a shoe or micro hurdle). You will use triple flexion/extension to absorb and explode. Make sure the barrier you chose is not an immovable object such as a bench. Choosing an immovable object exposes the athlete to a risk of injury if they miss a jump. Focus on linking your jumps and maintaining quick and quiet landings.

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Section four

developing functional movement patterns

Hitting the brakes Learning to Stop Many sport coaches and trainers are consumed by acceleration and first step quickness, but the foundation should really begin with deceleration training. If you think about it, injuries often occur during the lengthening contractions of deceleration and from a sport perspective, any change in direction must be preceded by a quick and efficient deceleration. Using the Legs to Absorb Energy If I am running straight down a field and wish to make a cut right; I must first stop running straight ahead. This will happen quickly and seamlessly in a trained athlete, but the fact remains that the energy from running forward must be harnessed and dissipated to facilitate the change of direction. I can use my connective tissue, an external object like a brick wall or my muscles to absorb this energy. The brick wall is clearly not a great choice, after all who is going to scrape you off the brick wall every time you want to change direction? Using your connective tissue can be a definite problem as we already discussed in the mechanism for ACL tears, so the best option is to learn how to absorb these forces using the proper muscles. How do you use your legs to absorb energy? Well first you need to have strong legs. If you cannot produce enough force with your legs to decelerate, then you will end up jamming on the brakes and sending the stress to your connective tissue and bony structures rather than using your muscles like shock absorbers. To practice deceleration try this exercise: Run at approximately 75% of your top speed to begin with, then you can increase your speed. Run forward over approximately 5-10 metres. Without hesitation decelerate over 1-2 metres by using your legs. To use your legs, make contact with your heel first and then let your full foot contact the floor. As your feet make contact bend your knees and drop your butt. You should be balanced over your feet rather than forcing the pressure to the ball of your foot. Walk back to your starting point and repeat.

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Gradually increase the speed until you can complete this skill at game speed.

Squat Jump to Run to Decelerate This exercise will help you learn to accelerate and decelerate from transitions. Begin with three squat jumps using perfect technique. Upon landing the third jump, you will immediately accelerate over 10 metres and then come to a quick stop using the technique described above. Walk back to the starting point and repeat.

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Movement with Transitions Now that you can use the strength of your legs to decelerate your body, you need to learn the skill of changing direction. Efficient change of direction is what makes an athlete agile. Learning to move with powerful execution and without wasting steps will improve your noticeable speed on the field of play. Your coaches will notice and so will your opponents. Run Forward to Backpedal Accelerate over 10 metres use your legs to brake and without hesitation begin your backpedal. When you backpedal, make sure you do not lean backwards with your torso. This is what I call shifting into reverse. If you are playing a multi-directional sport where there is an offense and defense you are automatically putting yourself a step behind your opponent by doing this. Remember to stay balanced over your feet with your knees bent in a great athletic/reactive position. Shuffle with Change of Direction The key to efficient lateral movement is to stay low and reactive in the legs. Use your hip, knee and ankle to move laterally rather than rotating at the hip alone. If you are getting most of your movement from hip rotation you will see your knees angling inward with each step. The other technique I want you to learn when moving laterally is keeping your toes pointing straight ahead resist the temptation to point your lead toe outward as this telegraphs your movement to your opponent and it requires an additional step when the direction of play changes. To complete this exercise, place two small markers on the floor/field approximately 10 metres apart. Stay low and practice shuffling side to side over the 10 metre distance. At each end, practice decelerating with the legs and quickly exploding back in the opposite direction. Your head should stay level, there should not be much up and down movement at all. Keep your arms under control do not let them swing around.

10 metres

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Angle Runs This drill allows the athlete to practice transition from a lateral movement to a sprint. Also try repeating the drill in reverse with a backpedal to a shuffle. Try to maintain your speed throughout the drill by using your legs to decelerate the forward movement and initiate a quick and explosive shuffle.

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Movement Complexes Jump to Run STOP Jump to Backpedal Begin with three squat jumps and upon landing the third jump, immediately accelerate over 10 metres. Use your legs to decelerate and without hesitation perform three squat jumps. Immediately upon landing the third jump push off into a quick tempo backpedal. Repeat. Box Drills Set out a box pattern measuring 5-10 metres square. Place a marker in each corner. The marker can be a small pylon or just something you find around the house like a rolled up pair of socks. Just make sure that it is not something that you could trip over. Box drills are a great way to improve your reactivity which will play a role in both injury prevention and improved performance by training you to be more agile. You can make the patterns as easy or difficult as you wish, but always keep in mind the purpose of the drill is to teach you to use optimal movement mechanics while executing complex movement patterns. Here are a few of my favourite patterns: Box 1: Run-Shuffle-Backpedal

Run Shuffle Backpedal Start

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Box 2: Run-Shuffle-Backpedal with Jump

J S J

Run Shuffle Backpedal Start Jump

J
Box 3: Run Shuffle-Backpedal with Zig Zag

J S

Run Shuffle Backpedal Start

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Box 4 Hour Glass Run

Run Shuffle Backpedal Start

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Section five

The workout

Level One Weeks 1-3 Complete these exercises three times per week on non-consecutive days. If you do not have perfect jumping mechanics by the end of this three week phase despite your best efforts, then there may be some more complex issues affecting your movement. To be safe you should get a thorough musculoskeletal evaluation from your preferred sport medicine practitioner. In my opinion physiotherapists have great hands on evaluation skills and they are fantastic at figuring out movement mysteries, such as why cant I squat without pinching my knees in? Exercise Squat w Tubing Above Knees Glute Bridge & Hold Drop Squat & Hold Squat Jump & Hold Week 1 3x10 5x15s hold 3x10- hold 3s Week 2 3x15 5x20s hold 3x10- hold 5s 5x5 hold 5s 5x10 hold 5s Week 3 3x20 5x30s hold

Level Two Weeks 4-6 Complete these exercises three times per week on non-consecutive days. You must have perfect squatting mechanics and perfect drop & stick mechanics before you move on to this phase. Exercise Sumo Squat Isometric Hamstring Curl with Ball Lateral Hop Over Barrier Butt Kickers Decelerations Shuffle with Change of Direction Squat Jump to Run & Decelerate Week 4 3x10 3x5-10 3x10 3x15s 3x3 3x15s Week 5 3x15 3x10 3x10 4x15s 3x4 6x15s 3x3 Week 6 3x20 4x10 3x10 5x15s 10x15s 3x5

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Level Three Weeks 7-9 Complete these exercises three times per week on non-consecutive days. You will incorporate some single leg training in this phase make sure you maintain your perfect alignment during the single leg exercises. Gradually increase the speed of the multi-directional exercises, such as Angle Runs, Box Drills and Shuffles with change of direction until you are up to game speed and maintaining perfect mechanics. Exercise Advanced Hamstring Curl Single Leg Squat Jump & Hold (small jump) Crab Walk Angle Runs Box Drills Shuffle with Change of Direction Single Leg Squat w Band Above Knees Week 7 2x8 Week 8 3x10 4x5ea 3x10m 3x10s each 3x2 each 3x15s 3x5 4x10m 4x10s each 3x3 each 3x8 Week 9 3x15 5x5ea 5x10m 5x10s each 3x4each 3x10

The preceding exercises are intended for healthy, uninjured athletes. They are not intended to treat injury. If you experience discomfort during any of the exercises, stop immediately and consult your preferred sport medicine professional. Following the exercise program outlined in this special report will not guarantee an injury free season, but it may help reduce the risks.

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About the author

Strength coach Maria Mountain is the owner of Revolution Sport Conditioning. She helps athletes of all ages by providing the quality training that not only improves performance, but reduces the risk of injury. The art and science of the Revolution methodology is backed by Marias academic preparation having earned both an honors and Masters degree in Kinesiology. In addition to her specialization in sport conditioning, Maria applies her 5-years of experience from the Fowler Kennedy Sport Medicine Clinic to get injured athletes back to the top of the podium. The goal of Marias post-rehabilitation conditioning is to return athletes to competition not only as adept as they were before the injury, but surpassing their pre-injury performance level, with more strength, more speed and more stability. Learn more and download FREE workouts by visiting: www.revolutionconditioning.com

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