ACL Injury Prevention Program

Jenny Giampalmo
Independent Research
25 May 2017
Advisor: Nick Campanaro
Instructor: E. Leila Chawkat
 Abstract

This research focused on the issue of ACL tears in female athletes. This

injury is very common and there is not much consensus about the best injury

prevention method. After gathering background information about the anatomy of

the knee and ACL injuries a review of literature was conducted that focused on

injury risk factors associated with different demographics and current injury

assessment methods. Then, meta analysis was used to analyze several aspects of

injury prevention programs including fatigue, time and frequency of the program,

and the effects of specific exercises. It was found that the most effective exercises,

which should make up a majority of the program are the ones that cause co-

activation of the quadriceps and hamstrings. Static stretching should be avoided or

at least very limited. Overall, a trained professional to give the participants real-

time feedback to correct as many errors as possible.

Introduction

Every year in the United States there are 150,000 Anterior Cruciate

Ligament (ACL) tears in the United States every year. Over eighty percent of

these tears occur in noncontact situations such as pivoting or change of direction

movements (Dharamsi et. all, 2013). For those who do tear their ACLs,

reconstructive surgery followed by a minimum of nine months of physical therapy

is required to regain knee function (Mayo Clinic Staff, 2017b). The short term,

immediate consequences of this injury are loss of knee stabilization and decreased

knee function. The long term consequences that exist even after ACL
 reconstructive surgery include limited return to athletics and early onset

osteoarthritis (Dharamsi et. all, 2013). This problem of common ACL tears with

lifelong effects and severe limitation in future sports participation (Mayo Clinic,

2017a) lead to the research question, How might the most effective

neuromuscular training program be designed to decrease the risk of ACL tears in

female athletes? Currently there are several prevention methods and protocols.

Despite this there is no conclusive decision about what the best method of ACL

injury prevention is for high school aged female athletes. Through background

research and meta analysis the following thesis was developed. If female lacrosse

players participate in a strength-training program focused on coactivation of the

quadricep and hamstring muscles then they will decrease their risk of ACL injury.

Review of Literature

In order to understand the function of the ACL and what causes injury to

this ligament, one must know the general anatomy of the knee. Four major bones

join at the knee: the femur, commonly known as the thigh bone, the tibia, the

collateral shin bone, the fibula, the shin bone on the lateral side, and the patella

which is the kneecap. The patella rests in the intercondylar groove, which is

located at the base of the femur. This groove is also an important part of ACL

injury because the ACL runs through this groove. Another key part of knee

function are the four ligaments used for stabilization: the Medial Collateral, the

Lateral Collateral, The Posterior Cruciate and the Anterior Cruciate. The Medial

Collateral ligament runs on the inside of the knee and the Lateral Collateral

Ligament runs on the outside of the knee. Both are used for stabilization in
sideways motions. The Posterior Cruciate Ligament runs from the posterior of the

tibia to the anterior of the femur. This ligament prevents dislocation of the femur.

The final ligament in the knee is the Anterior Cruciate Ligament. This ligament

runs from the anterior side of the tibia to the posterior side of the femur and is

primarily responsible for stabilizing the shin and preventing it from moving

forward (AAOS 2014). For more details about the anatomy of the knee view the

diagram below. The overall structure of the knee as well as the functions of the
individual components of the knee is essential to the study of ACL injury.

The next important research area related to ACL tears is the risk factors

that make this injury more likely to occur. Over eighty percent of ACL tears occur

in non-contact situations and are heavily influenced by several factors. The first

factor is fatigue. In a study conducted by the Journal of Athletic Training a group

of female and male athletes had their Landing Error Scoring System (LESS)

numbers taken, then completed a functional training program to the point of

fatigue which was characterized by participants demonstrated a decrease in

vertical-jump height of at least 5 cm (2 in) on 2 consecutive course repetitions,

and then had their LESS scores recorded again. The LESS score is an indicator of

the number of errors made by an athlete in a depth jump that is followed

immediately by a vertical jump. I. The results were that, Overall, postexercise

scores were significantly higher than pre exercise scores (mean difference = 1.3,

95% CI = 0.8, 1.8). The increase in LESS scores indicates that as athletes

become fatigued they commit more errors in their landing and jumping

movements; this can contribute to ACL injury (Wesley et. all, 2014). Another risk

factor is footstrike. Forefoot contact is better than rearfoot contact because it gives

a more even distribution of force. Rear-foot contact causes a large spike in force

on the knee. The graphs below show the difference in force distribution in a

rearfoot strike versus a forefoot strike and indicates that a rearfoot strike is much

more damaging to the knee because of the pressure shock it causes.

 Another movement that has a high association with ACL injury is change

of direction movements. Often the reason that these movements are risky is

because they are usually accompanied by valgus knee movement (inward twist of

the knee) and low knee flexion. One study found that, jumping to the left had the

smallest maximum flexion angle and was significantly less than jumping

vertically (P= .003) or to the right (P < .001). The maximum knee flexion angle at

PPGRF was also significantly less when jumping to the left compared with

vertical jumps (P = .008) (Timothy et. all). The decreased knee flexion in change

of direction movements was prevalent in both right and left cuts; however this

study found left movements to be the most dangerous (Sell et. all 2006). Having a

low knee flexion is dangerous because it relies mainly on the hamstrings to

control the knee, which in turn leads to muscle imbalances and a high risk of

injury.

In addition to these risk factors females are also at risk of ACL injury for

even more reasons. Why females are different than males at movements (Yu et.

all, 2014) The first is joint laxity. Females joints are more flexible and looser

overall. This can increase the likelihood of hyperextension and causes general

joint weakness. Other neuromuscular factors also affect females. For one they

tend to rely more on their quadriceps and as a result have underdeveloped

hamstring muscles. In addition females frequently have one leg that is stronger

than the other. A very dangerous risk that females face is that most rely on their

bones and ligaments to bring their body to a halt. This puts extreme stress on

ligaments instead of putting the force more safely on the quadricep, hamstring,

and gluteal muscles (Smith, 2012). Females also have physical factors that

increase their chances of ACL injury. This is because they tend to have a smaller

intercondylar groove. The ACL runs through the intercondylar groove, so the

smaller this groove is the smaller and weaker ACL. Overall there are many risk

factors for all people that make them likely to injure their ACLs; in addition, there

are also many more factors that pertain specifically to women and cause them to

have a much higher risk of injury than men.

Another portion of background research consisted of identifying current

assessment methods that are meant to determine a persons risk of ACL tear. One

method that is used to determine the movement of the tibia bone is the Navicular

Drop Test. The movement of the tibia directly translate to the risk of ACL injury
because the tibia is on stabilized by the ACL. For this test the distance between

the subtalar bone and the ground is measured. Then the test subject rocks side to

side while keeping their feet planted. During this rocking the maximum distance

between the subtalar bone from the ground is recorded. The difference between

these two scores is recorded as the navicular drop score and the higher the score

the more the tibia has shifted. High scores indicates a weak ACL.

Another test is the Landing Error Scoring System (LESS) score. In this

predictor test the test subject performs a depth jump from half of their height and

immediately after landing they complete a vertical jump as high as possible. A

reviewer has a checklist and if something is done incorrectly the test subject gets a

point. A higher score is bad and indicates that more errors were committed during

the test. These errors such as low knee flexion and lack of hip flexion put

increased stress on the knee and specifically on the ACL which can cause injury.

A final test used to determine risk of ACL injury is the single leg squat.

The single leg squat is used to evaluate knee and hip flexion during movement. In

a clinical study done by (Weeks et. all, 2012) a sample of twenty two participants

performed single leg squats and were evaluated for hip flexion, hip adduction and

abduction, and the degree of knee flexion and rotation. Internal and external

rotation of the knee and the hip is best as a minimum. This test worked best for

evaluating peak knee flexion, the degree to which the knee bends. This test only

somewhat reliable for the other test areas, but overall it can be used to evaluate

the general movement patterns and errors committed. It is not the most useful

assessment method.
 A final part of the background research was to analyze a few current

training techniques to help people recovering from ACL reconstruction (ACLr)

regain knee strength. Many sources mentioned this type of training as essential to

strengthening the entire knee region. Eccentric training is described as movements

in which a muscle is contracted while bearing a load. It causes a prolonged

contraction that in turn leads to a boost in muscle development and strength of the

targeted region. Nick Campanaro, a gym owner, explained in an interview that,

eccentric strength is basically just your ability to resist weight and control it...

The eccentric strength is the most important aspect of rehabilitating someone

from the ACL (2017). This statement was supported with data from a clinical

trial that analyzed the effects of eccentric exercises after two to three weeks. The

results, improvements in quadriceps femoris and gluteus maximus muscle

volume were 23.3% (SD=14.1%) and 20.6% (SD=12.9%), respectively, in the

eccentric exercise group and 13.4% (SD= 10.3%) and 11.6% (SD=10.4%),

respectively (Herman 2009) indicated that the usage of eccentric training was

particularly beneficial in generating muscle development. In all areas of measure

the participants who had used eccentric training were always more than one

standard deviation above the mean in each category of muscle development

(ACSM, 2013). This is a strong indicator that eccentric training can be used as an

effective part of an ACL prevention and and an ACLr recovery program.

Research Methods and Data Collection/ Results and Data Analysis

Optimization of the anterior
cruciate ligament injury
prevention paradigm: Novel
feedback techniques to enhance
motor learning and reduce injury
risk
Exercises that facilitate
optimal hamstring and quadriceps
coactivation to help decrease ACL
injury risk in healthy females: A
systematic literature review
Neuromuscular training to target
deficits associated with second
anterior cruciate ligament injury
Preventive neuromuscular training
for young female athletes:
Comparison of coach and athlete
compliance rates
Feedback is an essential part of a strength- training
program because athletes need the opportunity to correct
their mistakes. Dyad training gives a visual example and
then expects participants to replicate it. Visual simulation
overlay uses a computer to assess knee bend, flexion and
other errors. Real-time feedback involves a trainer
watching and correcting the participant's movements. The
negatives of this is that the feedback is not as exact and
not all errors are noted.
This source examined lower extremity exercises to
determine the ones that created the highest rate of co-
activation in the hamstring and quadriceps muscles. It was
found that the optimal range of motion for these exercises
was 42 to 72 degrees, and that single leg exercises in that
range of motion were optimal. The limitation of this
source is that only a small range of exercises were studied.
This source was used the least. It examined risk factors for
ACL injury and examined how effective different methods
were to lessen these factors. The group that this study
mainly focused on was young, active females and so it
may not be very applicable to other demographics.
Overall it was found that the prevention programs were
useful in almost all areas of controllable risks, just to
varying degrees.
This source found that the compliance rate of athletes
participating in exercise programs was not affected by the
time and frequency of the program. Athletes consistently
had a very high rate of completion. Also, the in season
attendance rates were higher; however, the number of
sessions was limited with conflicts.
Evaluation of the effectiveness of
anterior cruciate ligament injury
prevention programme training
components: A systematic review
and meta-analysis.
This systematic review of current ACL injury prevention
programs analyzed different components of the programs
including balance, dynamic/static stretching, and
feedback. It was found that static stretching done was
harmful and increased injury risk. The three areas that
made up a majority of the successful programs were
strengthening, explosiveness, and agility

This research utilized meta analysis to gather data for developing the most

effective anterior cruciate ligament (ACL) prevention program for female lacrosse

players. The meta analysis mainly focused on systematic reviews of particular

parts of current ACL prevention programs and other studies related to ACL

prevention protocols. This method of data collection was used because this topic

is an area of science research that relies on raw data but the researcher does not

have the access resources for conducting a firsthand experiment. By using meta

analysis the researched is able to use statistics from professional systematic

reviews about areas of ACL prevention programs including balancing the length

of time with user compliance, instructional feedback and effectiveness of

exercises used.

The time length and frequency of training programs was shown to have

little to no effect the overall effectiveness of the protocol or on the compliance

rates of participants. A wide range of single session duration and overall duration

of program were examined and found to have no statistical significance on the

rate of ACL injury during or after participation in the program (Taylor et. All,

2013). Overall it was determined that the compliance of athletes and coaches

participating in injury prevention programs was not affected by duration and

frequency. However, it was found that the frequency of athletes attending

programs was very high and very consistent. Surprisingly, it was the coaches who

had lower compliance to follow through with instructing and overseeing the

programs. As the level of coaching increased so did compliance with training. In

season compliance tended to be higher however, the frequency of the programs

decreased due to a lack of time and game of meet conflicts. This indicates that for

an ACL training program to be successful it must be relatively short and should

possibly be integrated with practices (4).

Another factor that has a strong influence on the effectiveness of an ACL

training prevention program is the level of feedback. There are multiple ways to

give feedback. The first is dyad training. In dyad training the athlete is given a

visual example of the correct way to execute a particular movement or exercise.

Another type of feedback given is visual stimulation video overlay. In this the

movements of two comparable exercises are overlaid via a computer to evaluate

how similar the movement was in each. The goal of this is to reach one hundred

percent of the same movement. A final type of feedback that is reviewed is real-

time visual feedback. In this there is a qualified trainer to oversee the movement

and make on the spot adjustments to form. The dyad training and the real-time

feedback are the most feasible of the feedback options. They do require an expert

with enough training to allow them to identify and correct mistakes in form. Both

of those two feedback mechanisms are less precise than the visual overlay

because they are done without the assistance of a computer and rely solely on the

training of a professional; however dyad and real-time feedback allow a training

program to be more widespread (Benjaminse et. All, 2015).

 The main causes of noncontact ACL tears are the forward movement of

the tibia as well as a lack of stability in the overall knee region. Exercises that

target the quadriceps and the hamstrings as they work together are found to be the

most effective for developing strength and stability. Particular exercises that target

the co-activation of the hamstring and the quadriceps include lunging, single leg

squat, depth jumps and tuck jumps. The co-activation of muscle has been found to

be the most effective due to the more even and gradual distribution of force (Stasi

et. All, 2015) (Dedinsky et. all, 2013). A large percent of the exercises in current

successful training programs most of the exercises consist of strengthening,

explosiveness, and agility; these three areas of exercises should be the main focus

in ACL injury prevention protocols. One surprising thing was that static stretching

was associated with an increased risk of ACL tear (Sugimoto et. All, 2013). The

reasoning for this was not very clear and should be researched further. However,

until more conclusive data is published with the true effectiveness of static

stretching on ACL injury it should be a very minimal part of an effective training

program.

All sources found training protocols to be effective but to varying degrees

depending on a few factors. When all the strengths and weaknesses of the

systematic reviews are compared it is found that the time of the protocol is not

very important in terms of effectiveness; however, in order to have a higher in

season compliance rate training programs need to have a time limit. Also, it is

going to be important to have a trained professional running the program so that

errors in movement can be corrected early on. The most effective exercises that
 should make up a majority of the program should strengthen the quadriceps and

hamstrings and their co-activation. Static stretching should be avoided or at least

very limited. Overall a main weakness in the data that should be researched

further is the effectiveness of individual exercises on general knee strength and

ACL tear prevention.

Discussion and Conclusion

Throughout this research several conclusions about what makes an ACL exercise

protocol aimed at preventing injury have been reached. The first is that the duration and

frequency this product does not affect the effectiveness of the program. This does not

affect the compliancy of the participants. However, it is still important to consider that as

participants become fatigued they commit more errors in movements that increase their

risk of injury. In game situations a majority of the ACL injuries occurred in the final

minutes, indicating that fatigue is a major component of injury. Another important

component is feedback. There is a variety of feedback methods; however the most

feasible is to have real time feedback from a professional. This ensures that athletes can

immediately be alerted to the mistakes that they are making and have the opportunity to

correct them.

The product of this research is a sample exercise program with the focus of

decreasing ACL tear risks in female athletes. The program will consist of a short list of

exercises with specific instruction about duration and technique. Exercises that target the

quadriceps and the hamstrings as they work together are found to be the most effective

for developing strength and stability. These exercises include lunges, single leg squat,

depth jumps and tuck jumps. The co-activation of the hamstrings, glutes, and quadriceps
muscle have been found to be the most effective due to the more even and gradual

distribution of force. Another component of the prevention program will be eccentric

exercises, as they have been found to be an effective part of leg muscle development in

ACL injury prevention and ACLr recovery programs. The main group that will be

targeting by the product is players and coaches.The goal is for the coaches to add the

small workout program created to their practices as a way to help strengthen their players

and prevent their risk of injuring their Anterior Cruciate Ligaments.

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