Originally posted in 2009
Is ACL injury prevention just good training? I think so.
The program we use for ACL injury prevention is actually the same program we use with everyone! The truth is ACL injury prevention programs often consist more of packaging than new concepts. Calling a program an ACL prevention program may be nothing more than a way into the head of the athletic trainer, physical therapist or coach. But, if that's what it takes, I'm all for it. However, as coaches we have to realize that we should be practicing great injury prevention concepts with all our athletes and our weekend warriors.
Because female athletes are much more likely to be injured, those who coach female athletes tend to be more interested in the concept of ACL injury prevention. However, obviously both genders can be injured. In fact, estimates run to over 100,000 ACL tears per year, with 30,000 of them high school age females. In any case, coaches should still practice these injury reduction concepts with both male and female athletes. Then again, ACL injury prevention may be the thought that gets your women's basketball coach to buy into the program.
Reduction vs. Prevention
Although some might argue that I am getting caught up in semantics, I think we should use the term reduction instead of prevention when talking about any injury. No matter what we do as athletic trainers, sport coaches or as strength and conditioning coaches, we can't prevent injury, we can only reduce the incidence. Using the word prevention is giving ourselves too much credit.
The Female Athlete
My feeling is that when training the female athlete we need to stop lamenting the plight of the female athlete and start doing something about it. Complaining about the number of injuries that occur to females will do nothing to change the situation. Neither will studying things like menstrual cycles. We cannot change gender however we can change lower body strength and stability. We realize that certain contributing factors (Q angle, intercondylar notch, menstrual status etc. etc.) but they are all in the "things I cannot change" category.
The Slippery Slope
One area of study is the effect of menstrual cycle on probability of ACL tears? My question is what do we do when we know? Will we see parents holding their "blue chipper" out of the big game because it is a risky time period?
ACL Reduction Strategies
ACL reduction is simple but systematic. We need to work on all of the items listed below. This is not a menu to pick from. It's more like a recipe. Try to bake a cake and leave out a key ingredient. What happens? Usually a disaster.
- Active Warm-up
- Power and Stability / Eccentric Strength=landing skills
- Strength Development- (emphasis on 1 Leg)
- Change of Direction Concepts- learning how to stop
- Change of Direction Conditioning- developing conditioning
Functional training may be the big key to ACL injury prevention. Although the words function and functional training have been over used the concept is still valid. In order to fully appreciate functional training simply look at it as the application of functional anatomy to training. The key to understanding functional anatomy is to realize that everything changes when you stand on one leg. From an anatomical standpoint this is undeniable.
ACL Reduction Strategy 1 -- Active Warm-up
A good warm-up is the first step in the ACL prevention program. Guess what, a good warm-up is the first step in any program. A proper warm-up develops single leg strength, dynamic flexibility, and increases proprioception. The key to the best active warm-up exercises is that they activate one muscle while elongating another.
Reduction Strategy 2 - Develop Stability/ Eccentric Strength
If active warm-up is the first step, the development of stability and eccentric strength is the most important step. In many of the popular ACL prevention programs this is the major failing. Most programs concentrate too much on jumping and not enough on hopping. Some might again argue semantics but it is critical to understand that a jump and a hop are not the same. As we said above everything changes when you stand on one leg and, everything changes when you LAND on one leg. The key to injury prevention is developing the ability to land on one leg. Eccentric strength is the ability to land properly. Make sure you understand the terminology below.
• Jump- two legs to two legs. This is the basis for many programs but is not the mechanism for ACL Injury.
• Hop- right leg to right leg or vice versa. Hops are neglected in most programs but are actually the key to ACL prevention. Hopping must be done forward, medially and laterally.
• Bound- right leg to left leg.
• Skip- two foot contacts per foot.
The key to progressing plyometrics is simple. Phases should last a minimum of three weeks and jumps can be done twice per week. In our system we will do our plyometric exercises every training day but, we will not repeat the same exercise twice in one week.
Phase 1 - Jump or hop up to a box. This decreases the effect of gravity and lowers eccentric forces. Jumps are done forward. Hops should be done forward,medially and laterally as shown above, we have eliminated box hops. We have found low amplitude hops to be safer even though they violate our "up first". Rule
Phase 2 - Jump or hop over an object. In phase 1 we were attempting to decrease the effect of gravity and the subsequent eccentric force. In phase 2 the concept is to reintroduce the acceleration due to gravity by jumping or hopping over an object. The same concept applies as above but instead of jumping or hopping onto a box the jumps and hops are done over a hurdle. Hurdles of varying sizes from 6" to 30" can be used. For lateral hops we could increase from 6" to 12"
Quality Vs. Quantity - If the quality decreases with the addition of gravity then strength is an issue. Do not proceed to the next phase. In fact return to the previous phase. Strength and conditioning legend Al Vermeil makes the simple statement,"the bigger (or weaker) the athlete, the smaller the obstacle
Phase 3 - Introduction of elasticity. In phase 3 the same exercises are used as in phase 2. The difference is that in phase 3 a "bounce" is added. This is best understood by watching the video clips below.
Phase 4- True plyos. This is the reactive stuff we commonly recognize as plyometrics.
Jim Radcliffe "jump and land from the same position."
Reduction Strategy 3 -- Strength Development
Strength is development is the second big key. In ACL prevention the strength program must be geared toward a functional single leg approach.
- Handle Bodyweight- single leg progressions
- Develop Functional Strength- no machines
- Develop Single Leg Strength- difference in hip mechanics
- Perform both knee dominant and hip dominant single leg exercise
These two exercises are key!
Ideally all athletes should progress to a true single leg squat and a loaded one leg straight leg deadlift.
Reduction Strategy 4- Change of Direction Concepts
The idea of teaching change of direction is generally a foreign concept to most coaches. We like to distinguish between teaching movement versus timing movement. In many agility programs athletes simply run from cone to cone. In our change of direction program the concepts of effective movement is actually taught. Simple drills are used to teach athletes to stop and to crossover. Many of the concepts build on the concepts and landing skills taught in the plyometric exercises. The agility ladder is an excellent tool to teach direction change concepts.
Reduction Strategy 5 - Change of Direction Conditioning
The concept of change of direction conditioning is not new. Basketball players have run suicides for years. Hockey players have incorporated stop and start sprints for decades. Football players ran "gassers" a cross -field stop and start. However the heavy influence of track coaches and technology have had a negative effect. Many conditioning programs shifted to a track style interval program based around linear distances like 110, 220 and 440 yard runs. Even worse, many athletes began to condition on cardiovascular pieces like the stationary bike, elliptical trainer or stairclimber. What is often missing in conditioning programs is the planned incorporation of stops and starts. Injuries occur in acceleration and deceleration. We need to incorporate stopping and starting into the conditioning program to minimize injuries. On the days we don't do change of direction running we actually incorporate the slideboard for lateral conditioning.
The bottom line is that a good strength and conditioning program is also the best ACL prevention program. Just remember the recipe analogy. No ingredient is non-essential. All of them must be included. Also remember, as a strength and conditioning coach learn to understand and appreciate your athletic trainer. Develop a cooperative relationship, not an adversarial one. If you are an athletic trainer or physical therapist, cultivate your strength coach, make him or her part of the team. A good cooperative relationship makes everyone's job easier. Strength coaches need to become a part of the rehab team and athletic trainers need to realize that a quality strength and conditioning program will decrease workloads in the training room.
All of us just need to realize that ACL prevention is just good training.