Functional Screening Techniques for ACL Injury Prevention in Female Athletes

1. Functional Screening Techniques for ACL Injury Prevention in Female Athletes Michele Loftis, Daniel MacLea, Mollie Malone, Sara Melby, Kerry Wilbar

2. Questions to start the process…. • What are the most valid, reliable and practical screening tools used to identify those female student-athletes who may be at risk for significant knee injury (ACL)? • What are the best training techniques to address neuromuscular deficits in individual student-athletes? • What are the best training techniques, used in a group / team setting, to prevent significant knee injury (ACL)?

3. Methodology: • EBM literature review using search words: screening tools for ACL, ACL prevention programs, neuromuscular training for ACL, ACL prevention exercises, SL squat as a screening tool • After complete comprehensive literature review, research divided into 3 areas: • Screening tools available to identify neuromuscular deficits which may predispose female student-athletes to ACL Injury • First year • Training techniques used to correct these neuromuscular deficits in the individual • First year / Second year • Training programs used to address training for a team setting • Second year

4. Procedure Stand with toe of dominant limb behind tape Hop forward as far as possible with hands behind the back Land on the same leg Hold landing for at least 3 seconds. If unable, repeat hop Measure 3 trials from toe-to-toe (cm) Repeat with non-dominant limb Calculate mean of 3 hops for limb symmetry. Calculate symmetry index - mean of dominant leg divided by mean of non-dominant limb, result multiplied by 100. Limb symmetry at least ≥ 85% Assessment Criteria Hands behind back: yes or no Able to hold landing for at least 3 seconds: yes or no Limb symmetry of at least 85% between the dominant and non-dominant legs: mean DL/ mean NDL x 100 = _____, ≥ 85% yes or no Screening Tools:Single Leg Hop and Hold (SLH) for Distance

5. Single Leg Hop and Hold Test • Hop tests are used by clinicians as a practical means to assess lower leg muscular strength, normal limb symmetry, the integrated effect of neuromuscular control, and the ability to perform activities that involve knee stability. • Compared to isokinetic testing, hop tests are inexpensive to administer and utilize more functional athletic movements (Cates, 2009).

6. Procedure Subject stand on 31 cm box with feet 35 cm apart Drop down off box and immediately perform maximum vertical jump, raising both arms Land on both legs Perform 3 trials Assessment Criteria Do both feet hit the ground at the same time on initial contact: yes or no Pronation of the feet on initial contact:yes or no Evidence of medial knee motion during initial contact: yes or no Evidence of medial knee motion during the final landing: yes or no Screening Tools: Drop Vertical Jump (DVJ)

7. Drop Vertical Jump • During the DVJ, an athlete may display substantial medial knee motion in the coronal plane that can be visually identified (also known as ligament dominance) (Myer, 2004). • Medial knee motion may be related to an overall dynamic knee valgus, which includes femoral adduction, femoral internal rotation in relation to hip, tibial external rotation in relation to femur with or without foot pronation. (Myer, 2004)

8. Procedure Stand on 1 leg and perform single leg squat Hands out to side or on hips 10 reps 45-60°of knee flexion Assessment Criteria Pronation or supination of the foot: yes or no Knee valgus: yes or no Hip internal rotation: yes or no Extension or flexion of the trunk: yes or no Able to maintain balance (falling or touching a surface with opposite foot or hand): yes or no Able to perform the entire set of 10 reps: yes or no Screening Tools:Single Leg Squat (SLS)

9. Single Leg Squat • The SLS simulates a common athletic position, requires control for the body over a planted leg, and is used to screen for poor hip strength and trunk control. • Female subjects have a tendency to have a decreased hip control when going down and coming up in a squat which can cause knee valgus movement (Zeller, 2003). • Knee valgus is thought to be a possible factor for noncontact ACL injury (Hewett, 2004).

10. Assessment: • From the literature, these three screening tools were selected based on validity, reliability, and practicality for our collegiate setting. • These tools will be used to identify those athletes who are at risk for a significant knee injury (ACL). • Those individuals will then complete a program designed to address their specific neuromuscular deficits. • There will also be programs developed to be used in a team setting • One program used as a warm up in-season (10-15 min) • Another program used in the off-season which is more comprehensive (~ 45 min)

11. Categorized into: Range of Motion Strength Lower extremity Core Hip/pelvis/trunk Plyometric Intensity + volume Dynamic movement Agility Sport-specific Speed Resistance Balance All progressions should be from double leg to single leg Stable surface to unstable surface Unanticipated cutting movements should be the last progression Literature-Based Exercises:

12. The next step… • July-September 2009 • Implement Screening Tools and identify those student-athletes at risk (WBB, LAX, SOC). Implement the individual training programs as needed. Incorporate the team training during pre-season conditioning programs (WBB, LAX). • September 2009 – February 2010 • Evaluate data from individual pre-training and post-training screenings (WBB, LAX) • January 2010 • Implement team training programs with (SOC). • March 2010 • Re-evaluate, modify and adjust training programs as needed. • Final write up of findings.

13. Questions?