Upload
others
View
10
Download
0
Embed Size (px)
Citation preview
15-‐01-‐16
1
IDENTIFYING RISK FACTORS AND PROGRAMMING FOR INJURY
PREVENTION
ACL INJURY / RE-INJURY PREVENTION
2014-12-16
PhD Candidate, Faculty of Medical Science, University of Calgary
Director of Strength and Conditioning, Canadian Sport Institute-Calgary
Director of Sport Science | Sport Medicine, Canadian Alpine Ski Team
MATT JORDAN, M.Sc., CSCS
PRESENTATION OVERVIEW
§ Identify modifiable (trainable) risk factors for ACL injury
§ Consequences of ACL injury
§ Programming for ACL injury / re-injury prevention
© Matt Jordan 2014
§ A database of ski racers with French Alpine Ski Team was analyzed
§ Of 379 athletes registered, 28% suffered at least one ACL injury § 50% of top ranked skiers suffered ACL injury
(Pujol et al., 2007) © Matt Jordan 2014
§ More than 30% of top ranked skiers suffered ACL re-injury
(Pujol et al., 2007) © Matt Jordan 2014
ACL
ACL
TIBIAL FRACTURE
TIBIAL FRACTURE
TIBIAL FRACTURE
ACL
RE-INJURY
NON-CONTACT ACL INJURY
Anterior Cruciate Ligament
§ Female athletes at greater risk (4-6x male counterpart) (Arendt et al., 1995; Myer et al., 2009; Prodromos et al., 2008)
§ Non-contact injury occurs in transitional zones (i.e. deceleration of the BCM) (Beynnon et al., 1998)
§ Increased risk for non-contact ACL injury attributable to risky biomechanics and altered intermuscular coordination (Hewett et al., 2005; Zebis et al., 2009)
© Matt Jordan 2014
15-‐01-‐16
2
FORCES THAT LOAD THE ACL
Prodromos, (2008). The Anterior Cruciate Ligament: Reconstruction and Basic Science © Matt Jordan 2014
Anterior shear load on the tibia ***
Valgus loading
Tibial internal rotation
FORCES THAT LOAD THE ACL
0-30° and 90° + knee flexion
Prodromos, (2008). The Anterior Cruciate Ligament: Reconstruction and Basic Science
Aggressive quadriceps contraction / hamstring inactivation
© Matt Jordan 2014
§ Rapid eccentric deceleration (landing jumps / changing direction) high risk sport movement
§ Hard landing (Hewett et al., 2005)
§ Greater posterior vGRF
§ Small angles of knee flexion / quad strength dominant (Demorat et al., 2004 ; Colby et al., 2000; Myer et al., 2006)
§ Time frame of injury < 50 ms (Krosshaug et al., 2007)
§ Highlights importance of pre-activation strategies and rapid muscular force development
© Matt Jordan, 2013
ACL RISK FACTORS: LANDING MECHANICS
Prodromos, (2008). The Anterior Cruciate Ligament: Reconstruction and Basic Science
0
1000
2000
3000
51.0 51.5 52.0TIME (s)
FOR
CE
(N)
vGRF RIGHT vs LEFT
0
30
60
90
120
51.0 51.5 52.0TIME (s)
EMG
RM
S
VASTUS LATERALIS
0
30
60
90
51.0 51.5 52.0TIME (s)
EMG
RM
S
VASTUS MEDIALIS
0
30
60
90
51.0 51.5 52.0TIME (s)
EMG
RM
S
SEMITENDINOSUS
0
30
60
90
51.0 51.5 52.0TIME (s)
EMG
RM
S
BICEPS FEMORIS
§ Female athletes may have
altered H/Q activation and reduced hamstrings strength (Huston & Wojstys, 1996; Prodromos et al., 2008; Zebis et al., 2009; Zebis et al., 2011)
§ ACL injured females increased VL-ST activity difference (Zebis et al., 2009)
§ ACL injured females had lower hamstrings strength but no difference in quadriceps strength compared to matched male controls (Myer et al., 2009)
§ Quadriceps dominant landings linked to increased ACL loading (Bessier et al., 2003; Demorat et al., 2004; Markolf et al., 2004)
ACL RISK FACTORS: HAMS / QUADS
Semitendinosus
Biceps femoris
§ Hamstrings important ACL agonist (decreases ACL loading) (Mac Williams et al., 1999; Markolf et al., 2004)
§ Assists by preventing anterior translation of tibia b/w 30-90° flexion but not in extension (Mac Williams et al., 1999; Markolf et al., 2004)
§ Medial hamstrings / medial quadriceps (VM) important for ACL unloading and medial joint compression (anti-valgus) (Zebis et al., 2009)
§ H/Q co-contraction increases valgus/varus stiffness (Mac Williams et al., 1999)
HAMSTRINGS – AN ACL AGONIST
© Matt Jordan 2014
(Gio Auletta, Pentaphoto)
© Matt Jordan 2014
MECHANISMS OF INJURY
15-‐01-‐16
3
SLIP AND CATCH
(Bere et al., 2011)
-10
0
10
20
30
40
50
60
70
0 80 160
KN
EE J
OIN
T A
NG
LE
TIME (ms)
Knee Flexion
Valgus
Internal Rotation
INJURY PERIOD (60 ms)
SLIP AND CATCH MECHANISM
Bere et al. The American journal of sports medicine 41.5 (2013): 1067-1073.
§ Rapid increase in knee flexion 26° to 63°
Barone et al. Skiing Trauma and Safety, 12th Edition (1999): 63-81.
© Matt Jordan 2014
§ Skier out of balance and backward in flight
§ Lands on ski tails
§ Boot and knee extensor torque cause anterior translation of tibia
LANDING BACK WEIGHTED
© Matt Jordan, 2013 (Bere et al., 2011)
FHAMSTRINGS
FANTERIOR SHEAR
(Barrata et al., 1988; Herzog & Read, 1993; Mac Williams et al., 1999; Markolf et al., 2004; Prodromos et al., 2008)
FACL
IMPORTANCE OF THE HAMSTRINGS
FHAMSTRINGS
FPT
FANTERIOR SHEAR
(Barrata et al., 1988; Herzog & Read, 1993; Mac Williams et al., 1999; Markolf et al., 2004; Prodromos et al., 2008)
FQUADRICEPS
FACL
IMPORTANCE OF THE HAMSTRINGS IMPORTANCE OF THE HAMSTRINGS
© Matt Jordan 2014
15-‐01-‐16
4
SUMMARY OF MECHANISMS
§ Range of knee flexion
§ Skier out of balance
§ Lateral to medial knee joint loading (valgus loading)
§ Twisting load (internal rotation of tibia)
§ Back to front load on tibia (anterior displacement of tibia)
§ Time frame of injury (< 60 ms)
© Matt Jordan 2014
RISKS FACTORS FOR ACL INJURY
§ Equipment § Speed
§ Changing snow conditions
§ Course setting
§ Physical factors (e.g. fitness, strength)
(Spörri et al., 2012) © Matt Jordan 2014
(Bere et al., 2011; Bere et al., 2011; Ferguson, 2009; McConkey, 1996; Natri et al., 1999; Pujol et al., 2007)
THE INJURY / RE-INJURY CYCLE
Pre-Injury Factors!
Extrinsic!Intrinsic!
Modifiable!
Fatigue!Strength / Fitness
Factors!Technical Ability!
INJURY!!
RETURN TO SPORT
ASSESSMENT!
Graft Strength /
Knee stability!
EARLY RETURN TO SPORT??!
Athlete Confidence!
Medical Team
Subjective Opinion / Consensus!
Accepted Timelines!
Fitness!
Functional Neuromuscular Assessment / Envelope of Function!!
EARLY PHASE REHAB!
LATE PHASE REHAB!
RETURN TO
PODIUM!
SURGERY!
Time from Injury!
Secondary Injury!
Meniscus!
Articular Cartilage!
Multi-ligament!
Bone Bruise!
Capsule!
Complications?!
Active/Passive ROM!
Muscle Recruitment!
SLeg Weight Bearing!
MID PHASE REHAB!
Closed Kinetic Chain (SLeg, DLeg)!
Balance!
Thigh Muscle Mass!
Return to Sport Training!
Reactive Strength!
Explosive Strength!
Sleg and !DLeg Muscle
Power!
Bilateral Symmetry!
Thigh Muscle Maximal Strength!
Procedure!
ABC’s / Pivoting!
0-2 Mnths! 2-5 Mnths! 5-8 Mnths! 8-12 Mnths! 12-36 Mnths!
RETURN TO SPORT PHASE!
Quantify Training Load!
Neuromuscular Monitoring!
Stabilization of Fitness Factors!
On Snow Technical !
Re-Acquisition!Advance Through
Milestones!!
Graft Vulnerability!!
Re-injury?!
Perceived vs. ACTUAL!
readiness??!
Increasing Cognitive and Physical
Demands!Concentric/Eccentric Symmetry!
Maximal and Repetitive Load
Tolerance!
Mvmnt!Strategy!
Subjective Knee Form / Giving Way?!
RETURN TO SPORT
MONITORING!Training Load!
Adaptive!Potential! FNS! Technical
Ability!
Snow Performance!
Psych!
Performance Stabilization!
Performance On Demand! Risk Taking!
Recovery and Regeneration Strategies!!
Ecc Decel / Landing Mechanics!
Mechanism!
Fear of Re-Injury! Psych!
Factors!
Psycho-Emotional!
0
100
200
300
400
500
600
700
800
900
1000
15.2 15.7 16.2
FOR
CE
(N)
TIME (s)
ACL-R Limb Unaffected Limb
(Jordan et al., 2014) © Matt Jordan 2014
FUNCTIONAL ASYMMETRY
15-‐01-‐16
5
0
200
400
600
800
1000
15.2 15.7 16.2
FOR
CE
(N)
TIME (s)
0
200
400
600
800
1000
12.5 13 13.5 14
FOR
CE
(N)
TIME (s)
ACL-RECONSTRUCTED SKIER UNINJURED SKIER ACL-R Limb Unaffected Limb
Left Right
(Jordan et al., 2014)
FUNCTIONAL ASYMMETRY
Noraxon MyoVideo Report
Project Project 1First Name HannahLast Name LomasSex Female
PatientName CMJ_HANNAH_21OCTOBER2013Date Measured 10/21/2013 4:56 PMNumber of periods 1
Record
2
Record Comments
Patient Comments
Report at 11.9 secLogitech HD Pro Webcam C920
Parameters
Report at 12.1 secLogitech HD Pro Webcam C920
Parameters
LT Knee, Logitech HD Pro WebcamC920, deg 0.33
RT Knee, Logitech HD Pro WebcamC920, deg 7.29
Report at 12.4 secLogitech HD Pro Webcam C920
Parameters
Report at 12.7 secLogitech HD Pro Webcam C920
Parameters
LT Knee, Logitech HD Pro WebcamC920, deg 9.41
RT Knee, Logitech HD Pro WebcamC920, deg -9.70
Noraxon MyoVideo Report
Project Project 1First Name HannahLast Name LomasSex Female
PatientName CMJ_HANNAH_21OCTOBER2013Date Measured 10/21/2013 4:56 PMNumber of periods 1
Record
2
Record Comments
Patient Comments
Report at 11.9 secLogitech HD Pro Webcam C920
Parameters
Report at 12.1 secLogitech HD Pro Webcam C920
Parameters
LT Knee, Logitech HD Pro WebcamC920, deg 0.33
RT Knee, Logitech HD Pro WebcamC920, deg 7.29
Report at 12.4 secLogitech HD Pro Webcam C920
Parameters
Report at 12.7 secLogitech HD Pro Webcam C920
Parameters
LT Knee, Logitech HD Pro WebcamC920, deg 9.41
RT Knee, Logitech HD Pro WebcamC920, deg -9.70
Noraxon MyoVideo Report
Project Project 1First Name HannahLast Name LomasSex Female
PatientName CMJ_HANNAH_21OCTOBER2013Date Measured 10/21/2013 4:56 PMNumber of periods 1
Record
2
Record Comments
Patient Comments
Report at 11.9 secLogitech HD Pro Webcam C920
Parameters
Report at 12.1 secLogitech HD Pro Webcam C920
Parameters
LT Knee, Logitech HD Pro WebcamC920, deg 0.33
RT Knee, Logitech HD Pro WebcamC920, deg 7.29
Report at 12.4 secLogitech HD Pro Webcam C920
Parameters
Report at 12.7 secLogitech HD Pro Webcam C920
Parameters
LT Knee, Logitech HD Pro WebcamC920, deg 9.41
RT Knee, Logitech HD Pro WebcamC920, deg -9.70
Noraxon MyoVideo Report
Project Project 1First Name HannahLast Name LomasSex Female
PatientName CMJ_HANNAH_21OCTOBER2013Date Measured 10/21/2013 4:56 PMNumber of periods 1
Record
2
Record Comments
Patient Comments
Report at 11.9 secLogitech HD Pro Webcam C920
Parameters
Report at 12.1 secLogitech HD Pro Webcam C920
Parameters
LT Knee, Logitech HD Pro WebcamC920, deg 0.33
RT Knee, Logitech HD Pro WebcamC920, deg 7.29
Report at 12.4 secLogitech HD Pro Webcam C920
Parameters
Report at 12.7 secLogitech HD Pro Webcam C920
Parameters
LT Knee, Logitech HD Pro WebcamC920, deg 9.41
RT Knee, Logitech HD Pro WebcamC920, deg -9.70
AI = 22.5% AI = 17.5%
Fz R Fz L Fz R Fz L INCREASE KNEE
ABDUCTION MOMENT (Kristianslund et al., 2014)
© Matt Jordan 2014
Countermovement Jump (CMJ) Squat Jump (SJ)
© Matt Jordan 2014
© Matt Jordan 2014
ASYMMETRY LEG MUSCLE MASS (%)
SJ M
ID T
O L
ATE
PHA
SE K
INET
IC IM
PULS
E A
SYM
MET
RY IN
DEX
(%)
−10
0
10
20
−4 −2 0 2 4 6 8 10
STATUSACL−RCONTROL
ASYMMETRY LEG MUSCLE MASS (%)
CM
J C
ON
CEN
TRIC
PH
ASE
KIN
ETIC
IMPU
LSE
ASY
MM
ETRY
IND
EX (%
)
−5
0
5
10
15
−4 −2 0 2 4 6 8 10
STATUSACL−RCONTROL
RELATIONSHIP B/W FUNCTIONAL ASYMMETRY AND MUSCLE ASYMMETRY
RE-INJURY CMJ CONCENTRIC PHASE SJ PHASE 2
STATUSCM
J EC
CEN
TRIC
DEC
EL P
HA
SE K
INET
IC IM
PULS
E A
SYM
MET
RY IN
DEX
(%)
0
5
10
ACL−R CONTROL
STATUSACL−RCONTROL
(Jordan et al., 2013)
15-‐01-‐16
6
SJ LATE PHASE KI ASYMMETRY INDEX (%)
CM
J C
ON
CEN
TRIC
PH
ASE
KI A
SYM
MET
RY IN
DEX
(%)
0
5
10
15
−5 0 5 10 15 20 25
BADEXA02468
10
STATUSCOPERNON COPER
MUSCLE MASS AI
IDENTIFYING AT RISK SKIERS:KINETIC IMPULSE ASYMMETRY INDEX IDENTIFYING AT RISK ATHLETES
§ N = 71 athletes § Females: n=51, Age=20.6±2.3 years, Body Mass =
67.8±11.5 kg
§ Males: n=20, Age=20.1±1.7 years, Body Mass = 78.7±16.5 kg)
§ Alpine skiing, luge, soccer, rugby, wrestling
§ Assessed at the start of the off-season preparatory period and throughout training (1x/week)
ASY
MM
ETRY
IND
EX C
MJ
ECC
DEC
EL P
HA
SE (%
)
5
10
15
20
STATUSUNINJUREDINJURED
ASY
MM
ETRY
IND
EX C
MJ
ECC
DEC
EL P
HA
SE (%
)
5
10
15
20
STATUSUNINJUREDINJURED
IDENTIFYING PREVIOUSLY UNINJURED AT RISK ATHLETES
Odds of injury 1.2x (95% CI = 1.1-1.4x) (P<0.01)
ACL INJURIES 2010 – 2014 = NONE
ACL RE-INJURIES = NONE
LOWER BODY RE-INJURIES = 2
STRATEGIES FOR ACL INJURY/RE-INJURY PREVENTION
TRAINING CONSIDERATIONS
Can the system find the right solution?
Can the motor system generate the right solution?
WHERE IS THE BREAKDOWN?
(Aagaard, 2003; Sale, 2003)
282 mechanism for adaptation
For example, it has been estimated that in tricepsbrachii, only about 5% of the motor units areType IIb (IIx), but this small number of units contains about 20% of the total number of musclefibres in the muscle (Enoka & Fuglevand 2001).The second way increased activation could occuris through increased motor unit firing rates (Fig.15.3, middle panel). By increasing or decreasingfiring rate (also referred to as discharge rate orrate coding), a motor unit can vary its force out-put over an approximately 10-fold range, knownas the force–frequency relationship. The motorunit firing rates observed in maximal voluntarycontractions appear to be lower than needed formaximum force output (Enoka & Fuglevand2001; cf. Bellemare et al. 1983). Training mayallow for firing rates consistently high enough tobe on the plateau of the force–frequency relation-ship, where force is maximal. The third wayincreased activation could occur is also throughincreased motor unit firing rates (Fig. 15.3, bot-tom panel). When the intent is to contract themuscle as fast as possible with maximum rate offorce development (so-called ‘ballistic’ contrac-tions), motor units begin firing at a very high fre-quency, followed by a rapid decline in frequency(Zehr & Sale 1994). The peak firing rates attained
Fig. 15.1 Control of muscle by the nervous system.Voluntary strength performance is determined notonly by the quantity and quality of the involvedmuscle mass, the ‘engine’, but also by the ability of thenervous system, the engine controller, to effectivelyactivate the muscles. Nervous system adaptations tostrength training may improve the control of musclesto increase maximum force (strength). These ‘neural’adaptations may occur in higher brain centres orwithin the spinal cord.
Strength training
Neural adaptation
Appropriatesynergist activation
HAntagonistactivation
Agonistactivation
HForce and/or rate of force development
HStrength performance
Fig. 15.2 Neural adaptations to strength training may take the form of increased activation of agonistmuscles, more appropriate activation of synergistmuscles (‘coordination’), and decreased (relative)activation of antagonist muscles. These adaptationswould act to increase maximum force (strength)and/or rate of force development.
© Matt Jordan 2014
15-‐01-‐16
7
TRAINING FOR INJURY PREVENTION MOTOR CONTROL NEUROMUSCULAR FACTORS
Unilateral Deceleration Motor Control
Core Control
Rested and Fatigued
Positional Strength
Bilateral Force Symmetry
Rate of Force Development (Explosive Strength)
Inter-Muscular Synergy and Muscle Balance
Thigh Muscle Strength Curve
Deceleration Strength
Bilateral Deceleration Motor Control
Muscle Pre-Activation / Anticipation
Expected / Unexpected Events
© Matt Jordan 2014
WARM UP
ACTIVATION
MOTOR CONTROL
PRIMARY LIFTS
SECONDARY LIFTS
ASSISTANT CIRCUIT
MOTOR CONTROL → Use a variety of loads and velocities but ensure
some specificity → Identify compensation strategies - ‘we are designed
to compensate’ → Groove motor patterns under expected conditions
→ Challenge system with fatigue conditions or unexpected conditions
→ Performed daily as a part of warm up and in combination with activation exercises
© Matt Jordan 2014
WARM UP Quotidian movement assessment
Dynamic warm up
Mobility
1. Omni Prone Plank
ACTIVATION
2. Omni Side Plank
3. Mini Band Mummy Walks
4. Mini Band Full Squats
© Matt Jordan 2014
MOTOR CONTROL
1. Jump Rudiment
2. Double Leg Freeze Drops
3. Single Leg Drops
4. Single Leg Drops Eyes Closed
© Matt Jordan 2014
LOWER BODY STRENGTH
15-‐01-‐16
8
STRENGTH DEVELOPMENT
→ Don’t train on top of poor technique
→ Develop range of motion appropriately
→ Use a combination of uni-lateral and bilateral lifts
→ Develop positional strength AND positional rapid force production
© Matt Jordan, 2013
NEUROMUSCULAR FACTORS
→ Lower body symmetry → Train to be ambidextrous
→ Strengthen ACL agonists → Identify periods of strength development and
strength maintenance
→ Performed 1-2x / week as a part of microcycle
© Matt Jordan 2014
ESSENTIAL MOVEMENTS
→ Full range of motion unilateral / bilateral exercises
→ Hamstring (closed chain / open chain)
→ Hip abductor strength
→ Quadriceps strength balance (VM vs. VL)
© Matt Jordan 2014
ZONE TYPE REPETITION RANGE
RELATIVE INTENSITY 1RM=100%
TRAINING EFFECT
1
SSC 6-10 BW – 20% REACTIVE STRENGTH
2
DYNAMIC EFFORT 3-8 30% - 80%
EXPLOSIVE STRENGTH /
MECHANICAL POWER
3
REPEATED EFFORT 6-15 60% - 85% MUSCLE
HYPERTROPHY / WORK CAPACITY
4
MAXIMAL EFFORT 1-6 85% - 100% MAXIMAL MUSCLE STRENGTH
© Matt Jordan 2014
PRIMARY LIFTS
1. Full Power Clean
2. Full Back Squat
STRONG AND EXPLOSIVE BELOW 90 DEGREES
© Matt Jordan 2014
SECONDARY LIFTS
3. Full Depth Single Leg Squat Off Box
4. Band Resisted Romanian Dead Lift
BILATERAL STRENGTH SYMMETRY / CORE STRENGTH
© Matt Jordan 2014
15-‐01-‐16
9
ASSISTANT CIRCUIT
5A. Heel Elevated Step Down
5B. Eccentric Leg Curl
HAMSTRING / QUADRICEPS STRENGTH BALANCE
5B. Band Hip Abduction
© Matt Jordan 2014
FATIGUE → Ski related injuries occur in a fatigued state (Bere et al., 2013)
→ Fatigue leads to risky biomechanics in landing (Kernozek et
al., 2008)
→ Alterations in hamstrings/quadriceps co-contraction observed in an acutely fatigued state (Zebis et al., 2011)
→ Evaluating neuromuscular function in the ACLR athlete under fatigue (Myer et al., 2006)
© Matt Jordan 2014
© Matt Jordan 2014
BALANCE AND LOWER BODY MOTOR CONTROL
→ Does an exercise require balance or train balance
→ New and unpredictable movements train balance
→ The best movement = the new movement
© Matt Jordan 2014
© Matt Jordan 2014
SUMMARY → ACL injury affects many athletes (ski racers,
recreational skiers, female athletes in field sports)
→ We can identify modifiable (trainable) risk factors
→ Programming for injury prevention is multi-faceted
→ Daily motor control component
→ Strengthening component
→ Strategies can be very effective for injury prevention
© Matt Jordan 2014
15-‐01-‐16
10
ACKNOWLEDGEMENTS Canadian Sport Institute-Calgary
Own the Podium
Dr. Walter Herzog
Dr. Per Aagaard
Dr. Steve Norris
The Herzog Group (Azim Jinha)
Scott Maw, Stu McMillan, Jer Barnert, Dan Pfaff
The CSI-Calgary S & C Team
CANADIAN SPORT INSTITUTE
INSTITUT DU SPORTCANADIEN
THANK YOU
www.jordanstrength.com
@JordanStrength
Generating athlete performance solutions for strength coaches, teams, sports organizations and sports medicine professionals