Can non-contact, poor form injuries be prevented and can my clinic expand to take a significant role in this effort? Yes! We examine injury screening and prevention through the lens of ACL injury. A significant number of non-contact ACL injuries to athletes and weekend warriors are preventable. Injuries carry significant quality of life and financial costs. Poor movement patterns linked with injury risk can be detected through systematic screening using objective movement analysis using expert supervised protocol and movement analysis software.

Background

Physical therapy today is predominantly instituted to ameliorate injury or symptoms secondary to activities involving poor form. In some cases, physical therapy is used to improve the chances of success for certain surgical operations. There is room for growth in positioning physical therapy in the context of prevention of injuries. This post centers in on ACL injuries and yet the approach taken here is equally applicable to other poor form non-contact injuries.

What if

What if poor form could be detected and quantified before knee or ACL injuries occurred? In that case, physical therapists and trainers could readily detect poor form and intervene by mitigating through corrective exercises. This would focus therapy on performance optimization, as opposed to injury recovery and add potentially add a valuable stream of business and revenue to a clinic’s existing customer pipeline.

Anterior cruciate ligament (ACL) injuries

ACL injuries occur in less than 1% of all soccer injuries but carry a significant impact for patients’ careers and lifestyle [8]. Physical therapy experts estimate that up to 80% of all ACL injuries are preventable with the appropriate exercise program [12].

Knee injuries can be painful. But can they be prevented? [16]
Knee injuries can be painful. But can they be prevented? [16]

Clinical studies have shown that specific types of knee loading have been linked with increased risk of knee injuries, such as ACL injury [1]. Experts have suggested that with targeted musculoskeletal training, it is possible to reduce the risk of ACL injury.

Paterno et. al. reported a 15-fold increase of ACL injury incidence after primary ACL reconstruction procedure [2]. Kucera et. al. found that a history of lower extremity injury risk is associated with increased incidence of low extremity injury during cadet basic military training [3]. Kucera recommended consideration of prevention programs to help mitigate this risk.

Now that we have established ACL injury as a significant impact of quality of life, are there poor movement patterns linked with ACL injury that we can screen for? Absolutely! Take for example hip strength and range of motion.

The notion of having adequate hip strength as a requirement to preventing ACL injuries (Anterior Cruciate Ligament) tells only half the story. In particular to non contact ACL tears, the knee experiences a high valgus force that causes the ligament to tear. This is where hip range of motion comes into play. Research has shown subjects with ACL tears also had limited hip internal and external range of motion. Lacking adequate hip internal range of motion means more stress on the knee. Having sufficient internal range of motion allows the hip to control the position of the knee which leads to less shearing forces placed on it in moments of extreme knee valgus [13][14][15].

Why do ACL injuries matter?

For professional athletes, ACL injuries result in substantial earning reductions (on the order of millions of dollars for NFL players) [10]. For any professional, collegiate or even high school athlete, quality of life is negatively impacted. Injuries can end a career, increase risk of arthritis and knee pain in the future. Some individuals may even required a total knee replacement.

There is potential for other compensatory injuries to occur post ACL injury such as hip degeneration which can lead to hip surgery. People naturally pick up aberrant movement patterns to compensate for the repaired knee, which highlights the importance of an objective movement form screening tool such as EuMotus to help detect red flags.

The role of physical therapy

Physical therapy is routinely prescribed by surgeons and sports doctors as a postoperative modality. Physical therapy has been shown to improve recovery and ‘return to sport’ odds [11]. However, physical therapy is not solely a post-operative procedure, and should be considered in the broader view of healthcare, and namely in preventative check-ups. Physical therapists expert knowledge and expertise in the movement of the human body put them in the powerful position of being able to catch serious consequences of poor form such as pain and injury before they occur. Physical therapists can then prescribe treatment plans to tackle the issues observed and assessed.

Fifa warm-up

An example of an effective injury prevention program within the context of non-contact injuries and soccer is the Fifa 11+. World soccer body FIFA’s F-Marc (medical assessment and research center) has designed a prevention program to reduce the incidence of football injuries [4]. Exercises are focused on core strength, dynamic stability and plyometrics designed to teach proper form (i.e. avoid extreme Valgus loading and collapse). The exercise instruction manual provides key visuals and important pointers on proper form.

Randomized control trials tested on collegiate male soccer players have shown that the Fifa 11+ program reduces injury risk by 46.1% and decreases time loss injury by 28.6% compared to control groups not adhering to the Fifa 11 intervention [5][7]. Another randomized control study of Canadian youth football female players found that the 11+ program significantly improved functional balance and reduced injury risk [6].

Systematic movement analysis and assessment (#trusttheprocess)

The English Institute of Sport is currently evaluating EuMotus BodyWatch movement analysis software and systematically screening their athletes for signs of problematic movement patterns that could result in injury. Poor form or fatigue could potentially be detected through the use of movement analysis software. By performing movement assessments systematically, without the use of markers and in the order of minutes, the English Institute of Sport can now afford to perform movement assessment on a more frequent basis than previously.

Considering integrating movement analysis assessment into your practice? Click below.

Leading the way through systematic movement screening [17]
Leading the way through systematic movement screening [17]

Killington Mountain School, one of America’s top ski academies also uses EuMotus BodyWatch movement analysis software to screen for fatigue and injury. Their program focuses on lower extremities, as 30% of all skiing injuries include knee sprains and tears [9]. The exercise set includes single leg hops, squats and side lunge. These exercises are tailored towards athletes and measure test range of motion, stability and symmetry.

Discussion

Of course not all injuries can be avoided (for example, contact injuries). However, we believe that a significant portion of all injuries can be prevented. Namely, non-contact injuries. Several injuries generally originate from poor form. If poor form is detected early and remediated, the risk of initial injury occurrence can be mitigated. Preventing an initial injury from occurring also improves the odds of athletes and patients by averting recurring injuries.

Summary: How can we reduce the risk of preventable non-contact ACL injuries?

  • Institute systematic movement analysis screening for your customers and athletes.
  • Use objective movement analysis software to help screen athletes for and quantify faults and movements associated with poor movement patterns - for example knee valgus, femur internal rotation and pelvic rotation etc.
  • If poor form is detected, the clinician, physical therapist or trainer applies their expert judgment and sets up remedial training and strengthening exercises, designed to improve current body biomechanics, thereby reducing the risk of ACL injury.
  • Through professionally prescribed and supervised training and remedial exercises, the risk of non-contact knee injury is reduced.

Questions & comments? Please let us know by contacting us!

References

[1] McLean et. al., Association between lower extremity posture at contact and peak knee valgus moment during sidestepping: Implications for ACL injury. Clinical Biomechanics. Oct 2005. Vol 20 Issue 8. http://www.sciencedirect.com/science/article/pii/S0268003305001117/. Accessed July 2017.

[2] Paterno et. al., Incidence of Contralateral and Ipsilateral Anterior Cruciate Ligament (ACL) Injury After Primary ACL Reconstruction and Return to Sport. Clin J Sport Med. March 2012. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4168893/. Accessed July 2017.

[3] Kucera et. al., Association of Injury History and Incident Injury in Cadet Basic Military Training. Med Sci Sports Exerc. June 2016. https://www.ncbi.nlm.nih.gov/pubmed/26765627. Accessed July 2017.

[4] Fifa 11 Booklet. FIFA/F-Marc. https://www.kort.com/uploadedFiles/KORT/Content/Services/Sports_Medicine/Concussion_Management/FIFA-the-11-Booklet.pdf. Accessed July 2016.

[5] Granelli et. al. Efficacy of the FIFA 11+ Injury Prevention Program in the Collegiate Male Soccer Player. The American Journal of Sports Medicine. September 2015. http://journals.sagepub.com/doi/abs/10.1177/0363546515602009. Accessed July 2017.

[6] Steffen et. al. High adherence to a neuromuscular injury prevention programme (FIFA 11+) improves functional balance and reduces injury risk in Canadian youth female football players: a cluster randomised trial. http://bjsm.bmj.com/content/47/12/794. Accessed July 2017.

[7]Owoeye et. al. Efficacy of the FIFA 11+ Warm-Up Programme in Male Youth Football: A Cluster Randomised Controlled Trial. J Sports Sci Med. 2014 May; 13(2): 321–328. Published online 2014 May 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3990886/. Accessed July 2017.

[8] FIFA Medicine Diploma ACL Course. http://fifamedicinediploma.com/courses/anterior-cruciate-ligament/. Accessed July 2017.

[9] Move Forward PT. http://www.moveforwardpt.com/Resources/Detail/preventing-skiingrelated-knee-injuries. Accessed July 2017.

[10] Secrist et. al. The Financial and Professional Impact of Anterior Cruciate Ligament Injuries in National Football League Athletes. Orthopaedic Journal of Sports Medicine. August 2016. http://journals.sagepub.com/doi/abs/10.1177/2325967116663921. Accessed July 2017.

[11] Han et. al. Increased Compliance With Supervised Rehabilitation Improves Functional Outcome and Return to Sport After Anterior Cruciate Ligament Reconstruction in Recreational Athletes. Orthopaedic Journal of Sports Medicine. December 2015. http://journals.sagepub.com/doi/full/10.1177/2325967115620770. Accessed July 2017.

[12] Haggerty. Lohud.com. March 2014. http://www.lohud.com/story/sports/high-school/2014/03/15/health-pros-say-girls-acl-injuries-preventable/6466969/. Accessed July 2017.

[13] Gomes et. al. Decreased hip range of motion and noncontact injuries of the anterior cruciate ligament. Arthroscopy. 2008 Sep;24(9):1034-7. doi: 10.1016/j.arthro.2008.05.012. https://www.ncbi.nlm.nih.gov/pubmed/18760211. Accessed July 2017.

[14] Yasuda et. al. Hip rotation as a risk factor of anterior cruciate ligament injury in female athletes. J Phys Fitness Sports Med, 5 (1): 105-113 (2016). https://www.jstage.jst.go.jp/article/jpfsm/5/1/5_105/_pdf. Accessed July 2017.

[15] Bagherifard et. al. Hip Restricted Range of Motion in Physical Examination: A Possible Risk Factor For Non-Contact ACL Injury. Shafa Ortho J. 2015 August;2(3):e2338. http://cdn.neoscriber.org/cdn/dl/56481bc6-e70a-11e6-9e28-c370dd798e59. Accessed July 2017.

[16] Swindon Town Football Pain Injury Soccer Boo http://maxpixel.freegreatpicture.com/Swindon-Town-Football-Pain-Injury-Soccer-Boo-2399974. Accessed July 2017.

[17] Mo Farah 5000m Olympic Final https://commons.wikimedia.org/wiki/File:Mo_Farah_(5000m_Olympic_Final).jpg. Accessed July 2017.