How to reduce the risk of Anterior
Cruciate Ligament Injuries of the Knee
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MONICA ACL INJURY PREVENTION PROGRAM
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Tens of thousands of serious knee injuries occur in female collegiate
and high school athletics each year. The majority of these injuries (80%) are non-contact
injuries. These injuries often occur while landing from a jump or pivoting when running.
A number of studies have unequivocally
demonstrated that female athletes who participate in jumping and cutting sports are about
five times more likely to sustain serious knee injuries than males. The anterior
cruciate ligament, posterior cruciate ligament, and medial collateral ligament all connect
the femur and tibia together and keep the knee stable. The lateral collateral ligament
connects the femur and fibula. The anterior cruciate ligament (ACL) controls pivoting and
“sliding” motion of the knee and, along with the quadriceps and hamstrings
muscles, helps stabilize the joint. Patients who tear this ligament often have an unstable
knee that can collapse, causing falls and further damage to the knee. ACL tears usually
require surgical reconstruction in order to resume the ability to play at a high level.
The cost of serious knee injuries in female athletes may reach $100 million at both high
school and collegiate levels in the United States, where over two million females
participate in high school sports. Therefore, even though high school female knee injury
rates are only about one-tenth as high as for collegiate females (approximately one knee
injury per 100 participants), athletic participation at the high school level is expected
to account for twice as many injury occurrences yearly (over 20,000 knee injuries) as are
found at the collegiate level.
WHY THE HIGHER INJURY RATES?
Three theories: anatomy,
hormones, training.
Some reports attribute injury rate differences
to physiological differences, such as increased joint laxity among women, while others
refute this claim. Several reports suggest that the hormone estrogen is directly involved
in increased female injury rates. It has also been argued that anatomical differences in
pelvic structure and lower extremity alignment (i.e. Q-angle) may account for differences
in male and female injury rates. These have not been shown to be statistically significant
factors.
The training theory: here is where we can make
a difference!
A consensus group of members from the American Orthopaedic Society
for Sports Medicine, Orthopaedic Research and Education Foundation, National Athletic
Trainers Association Research and Education Foundation and the National Collegiate
Athletic Association, concurred that while there is not presently a "clear
understanding of the cause of noncontact ACL injuries…prevention programs designed to
increase neuromuscular control, improve balance and teach avoidance strategies for at-risk
situations appear to be effective in decreasing injury rates." Jump training programs
incorporating stretching, plyometric exercises and weight lifting have been advocated to
increase performance and decrease injury risk in competitive athletes in jumping
sports.
Biomechanical studies have shown that decreased neuromuscular strength and
coordination in the musculature that stabilizes the knee joint may be responsible for this
increase in injuries. A biomechanical study showed that males activate their knee flexors
at three times the level of females during landing from a jump. It also showed that the
female hamstrings were significantly weaker than males prior to training. With a
“jump training” program, females showed increased hamstrings strength and
improved ability to control dangerous forces at the knee.
The hamstrings and calf muscles are the key to decreasing dangerous torques and impact
forces. Another biomechanical study demonstrated a marked imbalance between hamstrings and
quadriceps strength in female athletes prior to training. A plyometric, stretching and
strength training program was demonstrated to decrease peak landing forces by decreasing
varus (tendency to bow outward) and valgus (tendency to bow inward) forces at the knee.
The program also significantly increased hamstrings power and strength, increased
hamstrings to quadriceps peak torque ratios, and decreased hamstrings side-to-side
strength imbalances. Such training, if effectively used on a widespread basis, might help
to significantly decrease the number of athletes injured each year.
CHESAPEAKE
ORTHOPAEDIC & SPORTS MEDICINE CENTER
Comprehensive Orthopedic Care for Your
Family
Dear Coach:
I am pleased to introduce the
Santa Monica Prevent Injury / Enhance Performance (PEP) program. I am working with the
Santa Monica Orthopedic Group to bring this important Anterior Cruciate Ligament (ACL)
Knee injury prevention program to Maryland. Over the last two years, this has been used at
nine Division One college soccer programs. The Southern California Soccer Olympic
Development Program has begun to use it as well. This Warm-up / Training program has been
shown to help reduce the risk of ACL injuries and has the added benefit of improving
athletic performance.
Maryland State Youth
Soccer Association Olympic Development Program coaches were given this tape to use for
their practices this past spring.
As a coach of girls, and
father of two soccer players, I am personally as well as professionally aware of the need
to reduce injury risk as much as possible.
Over the last several
years, it has become increasingly known that in soccer, basketball and other competitive
sports, the incidence of ACL injuries in girls / women is two to eight times greater than
that seen in men. Extensive research as been done to evaluate the reasons for this and to
look for solutions.
Neuromuscular training
programs that incorporate agility, plyometrics, avoidance of riskier knee / leg positions
combined with overall strengthening have been shown to reduce the incidence of ACL
injuries in women. This Santa Monica program is particularly well suited to youth and high
school athletics. It is specific, well documented and easy to set up as a warm-up /
strengthening program for practices.
For further details about
ACL injury prevention and other sports medicine topics, please see the public information
web site for our practice: www.orthopedicdoc.net.
Please let me know if I
can be of any other assistance to you.
Best wishes for a safe
and successful season.
Sincerely yours,
Jim York
The Santa Monica PEP
Program: Prevent injury and Enhance Performance
This prevention program consists of a warm-up, stretching, strengthening,
plyometrics, and sport specific agilities to address potential deficits in the strength
and coordination of the stabilizing muscles around the knee joint. It is important to use
proper technique during all of the exercises. The coaches and trainers need to emphasize
correct posture, straight up and down jumps without excessive side-to-side movement, and
reinforce soft landings. This program should be completed 2 to 3 times a week at a
minimum.
The field should be set up 10 minutes prior to the warm-up. This will allow for a
smooth and quick transition between all of the activities. A sample field set-up has been
included in your packet.
This program should take approximately 15 minutes to complete. Along side each
exercise you will notice a box with the approximate amount of time that should be spent on
each activity. This will serve as a guideline to you in order to conduct your warm-up in a
time efficient manner.
1. Warm-up: Warming up and cooling down
are a crucial part of a training program. The purpose of the warm-up section is to allow
the athlete to prepare for activity. By warming up your muscles first, you greatly reduce the risk of injury.
A.
Jog line to line (cone to
cone):
Elapsed Time: 0 - 0.5 min.
Purpose: Allows the
athletes to slowly prepare themselves for the training session while minimizing the risk
for injury. Educate athletes on good running technique; keep the hip/knee/ankle in
straight alignment without the knee caving in or the feet whipping out to the side.
Instruction:
Complete a slow jog from near to far sideline
B. Shuttle Run (side to side)
Elapsed Time: 0.5 to 1 min.
Purpose:
engage hip muscles (inner and outer thigh). This exercise will promote increased speed.
Discourage inward caving of the knee joint.Instruction: Start is an athletic stance with a
slight bend at the knee.
Leading
with the right foot, sidestep pushing off with the left foot (back leg). When you drive
off with the back leg, be sure the hip/knee/ankle are in a straight line. Switch sides at
half field.
C. Backward Running
Elapsed
Time: 1 -1.5 min.
Purpose: continued warm-up;
engage hip extensors/hamstrings. Make sure the athlete lands on her toes. Be sure to watch
for locking of the knee joint. As the athlete brings her foot back, make sure she
maintains a slight bend to the knee.
Instruction:
Run backwards from sideline to sideline. Land on your toes without snapping the knee
back. Stay on your toes and keep the knees slightly bent at all times.
2. Stretching: It is important to incorporate a
short warm-up prior to stretching. Never stretch a "cold muscle". By doing the
exercises outlined here, you can improve and maintain your range of motion, reduce
stiffness in your joints, reduce post exercise soreness, reduce the risk of injury and
improve your overall mobility and performance.
A. Calf stretch (30 seconds x 2 reps)
Elapsed Time: 1.5 to 2.5
min.
Purpose: stretch the calf
muscle of the lower leg
Instruction: Stand leading with your right leg. Bend forward
at the and place your hands on the ground (V formation). Keep your right knee slightly
bent and your left leg straight. Make sure your left foot is flat on the ground. Do not
bounce during the stretch. Hold for 30 seconds.
Switch sides and repeat.
B. Quadricep stretch (30 seconds x 2 reps)
Elapsed Time: 2.5 to 3.5 min.
Purpose: stretch the quadricep muscle of the front of the thigh
Instruction: Place your left hand on your partner's
left shoulder. Reach back with your right hand and grab the front of your right ankle.
Bring your heel to buttock. Make sure your knee is pointed down toward the ground. Keep
your right leg close to your left. Don't allow knee to wing out to the side and do not
bend at the waist. Hold for 30 seconds and switch sides.
C. Figure Four Hamstring stretch (30 sec x 2
reps) Elapsed Time: 3.5 - 4.5 min
Purpose: To stretch the
hamstring muscles of the back of the thigh.
Instruction: Sit on the ground with your right leg
extended out in front of you. Bend your left knee and rest the bottom of your foot on your
right inner thigh. With a straight back, try to bring your chest toward your knee. Do not
round your back. If you can, reach down toward your toes and pull them up toward your
head. Do not bounce. Hold for 30 seconds and repeat with the other leg.
D. Inner Thigh Stretch (20 sec x 3 reps)
Elapsed Time: 4.5 - 5.5 min
Purpose:
Elongate the muscles of the inner thigh (adductor group)
Instruction:
Remain seated on the ground. Spread you legs evenly apart. Slowly lower yourself to
the center with a straight back. You want to feel a stretch in the inner thigh. Now reach
toward the right with the right arm. Bring your left arm overhead the stretch over to the
right. Hold the stretch and repeat on the opposite side.
E. Hip Flexor Stretch - (30 sec x 2 reps)
Elapsed Time: 5.5- 6.5 Min
Purpose:
Elongate the hip flexors of the front of the thigh.
Instruction:
Lunge forward leading with your right leg. Drop your left knee down to the ground.
Placing your hands on top of your right thigh, lean forward with your hips. The hips
should be square with your shoulders. If possible, maintain your balance and lift back for
the left ankle and pull your heel to your buttocks. Hold for 30 seconds and repeat on the
other side.
3. Strengthening: This portion of the program
focuses on increasing leg strength. This will lead to increased leg strength and a more
stable knee joint. Technique is everything; close
attention must be paid to the performance of these exercises in order to avoid injury.
A. Walking Lunges
(3 sets x 10 reps) Elapsed Time: 6.5 -- 7.5 min
Purpose:
Strengthen the thigh (quadriceps) muscle.
Instruction.
Lunge forward leading with your right leg. Push off with your right leg and lunge
forward with your left leg. Drop the back knee straight down. Make sure that your keep
your front knee over your ankle. Control the motion and try to avoid you front knee from
caving inward. If you can't see your toes on your
leading leg, you are doing the exercise incorrectly.
B. Russian Hamstring (3 sets x 10 reps)
Elapsed Time: 7.5--8.5 min
Purpose:
Strengthen hamstrings muscles
Instruction:
Kneel on the ground with hands at your side. Have a partner hold firmly at your
ankles. With a straight back, lead forward leading with your hips. Your knee, hip and
shoulder should be in a straight line as you lean toward the ground. Do not bend at the
waist. You should feel the hamstrings in the back of your thigh working. Repeat the
exercise for 3 sets of 10, or a total of 30 reps.
C. Single Toe Raises (30 reps x 2 reps)
Elapsed Time: 8.5 - 95 min
Purpose: This exercise
strengthens the calf muscle and increases balance.
Instruction: Stand up with your arms at your side.
Bend the left knee up and maintain your balance. Slowly rise up on your
right toes with good balance. You may hold your arms out ahead of you in order to help.
Slowly repeat 30 times and switch to
the other side. As you get stronger, you may need to add additional repetitions to this
exercise to continue the strengthening effect of the exercise.
4. Plyometrics - These exercises are explosive and help
to build, power, strength and speed. The most important element when considering
performance technique is the landing. It must be
soft! When you land from a jump, you want to softly
accept your weight on the balls of your feet slowly rolling back to the heel with a
bent knee and a straight hip. These exercises are basic, however, it is critical to
perform them correctly. Please take the time to ensure safe and correct completion of
these exercises.
A. Lateral Hops over Cone (20 reps)
Elapsed Time: 9.5 - 10min.
Purpose:
Increase power/strength emphasizing neuromuscular control
Instruction: Stand with a
6" cone to your left. Hop to the left over the cone softly landing on the balls of your feet land
bending at the knee. Repeat this exercise hopping to the right.
B. Forward/Backward Hops over cone (20 reps)
Elapsed Time: 10 - 10.5 min
Purpose: Increase power/strength emphasizing
neuromuscular control
Instruction:
Hop over the cone/ball softly landing on the balls of your feet and bending at the knee.
Now, hop backwards over the ball using the same landing technique. Be careful not to snap
your knee back to
straighten
it You want to maintain a slight bend to the knee. Repeat for 20 reps.
C. Single Leg hops over cone (20 reps)
Elapsed Time: 10.5 -11 min.
Purpose:
Increase power/strength emphasizing neuromuscular control.
Instruction:
Hop over the cone/ball landing on the ball of your foot bending at the knee. Now, hop
backwards over the ball using the same landing technique. Be careful not to snap your knee
back to straighten it. You
want to maintain a slight bend to the
knee. Repeat for 20 reps. Now, stand on the left leg and repeat the exercise. Increase the
number of repetitions as needed.
D. Vertical Jumps with headers (20 reps)
Elapsed Time: 11 -11.5 min.
Purpose: Increase height of vertical jump.
Instruction:
Stand forward with hands at your side. Slightly bend the knees and push off jumping
straight up. Remember the proper landing technique; accept the weight on the ball of your
foot with a slight bend to the knee. Repeat 20 times and switch sides.
E. Scissors Jump (20 reps)
Elapsed Time: 11.5 –12
min.
Purpose:
Increase power and strength of vertical jump.
Instruction:
Lunge forward leading with your right leg. Keep your knee over your ankle. Now, push
off with your right foot and propel your left leg forward into a lunge position. Be sure
your knee does not cave in or out. It should be stable and directly over the ankle.
Remember the proper landing technique; accept the weight on the ball of your foot with a
slight bend to the knee. Repeat 20 times.
5. Agilities
A. Shuttle run with
forward/backward running
Elapsed
Time 12-13 min.
Purpose: Increase dynamic
stability of the ankle/knee/hip complex
Instruction: Starting at the
first cone, sprint forward to the second cone, run backward to the third cone, sprint
forward to the fourth cone (etc...).
B.
Diagonal runs (3 passes)
Elapsed Time 13-14 min.
Purpose:
To encourage proper technique/stabilization of the planted foot to deter the position from
occurring.
Instruction:
Face forward and run to the first cone on the left. Pivot off left foot and run to the
second cone. Now pivot off the right leg and continue onto the third cone. Make sure that
the outside leg does cave in. Keep a slight bend to the knee and make sure the knee over
the ankle joint.
C. Bounding run (44 yds.)
Elapsed Time 14 -15 min.
Purpose: To increase hip flexion strength/increase power/speed
Instruction:
Starting on the near sideline, run to the far side with knees up
toward chest. Bring your knees up high. Land on the ball of your foot with a slight
bend at the knee and a straight hip. Increase the distance as this exercise gets easier.
6. Alternative Exercises- Warm
Down and Cool Down
We all know how imperative a cool down
is. Please don't skip it. It allows the muscles that have been working hard
throughout the training session to
elongate and deters the onset of muscle soreness. Please emphasize the importance of
adequate fluid intake (optimally water). Athletes should have a water bottle by their side
during the cool down. The
cool down should take approximately 10
minutes. It should begin with a slow jog to allow the heart rate to come down before
stretching. This should be followed by some light strength training exercises. We are
recommending two strengthening exercises (see below). Finally, stretch the hamstrings,
calves, inner thigh, quadriceps, and low back (all of these are explained in the
protocol). In addition to those basic stretches, we are offering some additional stretches
to target 3 muscle groups that are often forgotten.
A. Bridging with Alternating Hip
Flexion (30 reps)
Purpose: Strengthen outer hip
muscles (Hip abductors, flexors) and buttocks
Instruction:
Lie on the ground with your knees bent with feet on the ground. Raise your buttocks up
off the ground and squeeze. Now, lift your right foot off the ground and make sure that
your right hip does not
dip down. Lower your right foot and now
lift your left foot making sure your left hip does not dip down. Repeat 30 times on each
side. As you get stronger, you will place your feet on top of a ball and repeat the
exercise.
B. Abdominal Crunches (30 reps x 2 reps)
Purpose: Strengthen the
abdominals (rectus abdominus, obliques)
Instruction:
Lie on the ground with you knees bent. Place your hands behind your head with your
elbows out wide. Support your neck lightly with your fingers. Take a deep breath in and
slowly contract your abdominal muscles as you exhale. Repeat 30 times. Drop your legs off to the right side.
Slowly crunch up with your elbows out wide. You should feel your oblique muscles working
on the side of your waist. Repeat 30 times and switch to the other side.
C. Single and Double Knee to Chest
(supine) (30 sec x 2
reps)
Purpose:
Elongate the low back muscles
Instruction:
Lie on your back. Bring your right knee toward your chest and hug firmly. Keep
your left leg out straight in front of you. You should feel a stretch along your low back
and into your buttocks. Hold the stretch for 30 seconds and switch sides. Now bring both
knees to chest. If you feel any pain in the low back, discontinue the stretch and inform
your coach/trainer.
D. Figure Four Piriformis stretch- supine (30
sec x 2 reps)
Purpose: Elongate the rotators
of the hip.
Instruction:
Lie on your back and bend both of your knees. Fold your left ankle over your right
knee. Place your hands behind your right thigh and pull your right knee to chest. You
should feel a good stretch in the left gluteals region and the side of the thigh. Hold for
30 seconds and repeat on the other side. If you experience and low back pain with this
stretch, slowly lower your legs down and let your coach/trainer know.
E. Seated Butterfly stretch -
seated (30 sec x 2
reps)
Purpose: Elongate the inner
thigh muscles (adductors).
Instruction:
Sit up bringing your feet in so that the soles of your feet are touching. Gently place
your elbows on your knees and slowly push down. You should feel a good stretch of the
inner thigh. Hold this for 30 seconds and repeat 2 to 3 times.
If you have
any questions or concerns regarding this program, please contact James J. York, M.D. at
jjyork@ix.netcom.com
or 410-768-5555.
Copyright: Santa Monica Orthopedic
Group
