This article http://nyti.ms/hUy9pi and some of the information (misinformation) in article in Sunday New York Times sports page is disturbing. The topic of the female athlete and ACL injuries is complex and sometimes controversial. It is a real problem and a crisis given the economic and human cost.
Let’s look at a couple of the points of emphasis in the article and then I will look a bit more globally and offer some solutions.
The following is often offered up as a solution to prevent ACL injuries: “bend at the hips and knees to softly absorb the load, keeping their knees behind the toes, striking the ground toe to heel.” Watch a game or practice you will see it is impossible to keep the knees behind the toes and still play the game. You may do it a completely controlled artificial environment, but in the real world at game speed the knee will go where it has to go. It will go into extreme valgus and varus positions. The knee will go way out beyond the toe. The key is that the knee goes where it needs to go with control. As far as foot strike, it is completely dictated by the movement requirement, landing from a rebound could be a different foot strike than on planting and cutting. This strategy will robotize the player by taking instinctual and reflexive movements and making them cognitive, conscious and mechanical. In my opinions (I emphasize it is my opinion) we may actually be predisposing the athlete to injury with these types of prevention programs. It is certainly not time well spent.
Here is another solution from the article: “The knee should be in a neutral position; ideally, … said, the center of the kneecap should be aligned with the second toe.” Neutral is a position the knee passes through in a millisecond. In an artificial controlled environment you may be able to align the kneecap with the second toe, but it won’t happen at the speed you must play in order to be able to execute jumps, stops, starts and turns. It is a dynamic, ballistic environment that is not sterile and controlled. Once again the result will be robotic movement.
The information in both quotes represents what is thought to be cutting edge research, but it does not represent what must be done in the real world in the competitive arena. These types of so-called prevention programs and strategies are fundamentally unsound. If in doubt my rule of thumb is to go back to common sense. If these strategies worked then why aren’t they preventing ACL tears? Everyone is doing some variation of these programs; in some cases devoting up to thirty minutes a day to them, still the rate of ACL tears has not dropped, if anything it has increased.
It begs a simple question: Do these players have the physical competencies and fundamental movement skills necessary to compete? We know they have the basketball, soccer, or specific sport skill, but do they have the underlining physical competencies and movement skills to give them a fair change to avoid injury? Part of the solution is quite simple – identify and assess the physical competencies. Then train those competencies in parallel to the sport skill. The dark hole is what is being done in the off-season, preseason and in- season in regard to strength training. In many situations strength training is only done in the off-season, reduced in pre-season and almost nonexistent in-season.
For the female athlete a commitment to year around strength training is a requirement, not an option. It must continue in-season through the championship season. Unlike her male counterpoint that has a great percentage of muscle mass and higher testosterone levels, the female cannot afford to take off from strength training. Obviously the greatest investment should be on leg strength. The great majority of ACL tears are noncontact and in most of those cases they are a deceleration injuries (As are ankle sprains). It stands to reason then that we should focus on training the decelerators. Stop focusing on the knee and think kinetic chain, emphasize the linkage of ankle, knee, hip and the trunk. The knee is stuck in the middle; it is at the mercy of the joints above and below.
The sports that put the knee at greatest risk are sports that require quick starts, stops and changes of direction off one leg onto the other leg. This dictates that the training emphasize work on one-leg and reciprocal movements. The single leg squat is the cornerstone (True single leg squat, not some of the permutations labeled as such), lunges in all planes and step-ups at various heights. Double leg squats are important, starting with bodyweight and progressing to appropriate loads based on developmental level and sport demands.
Dynamic balance should be part of daily warm-up, as should a mini band routine to work the intrinsic muscles of the hip. Once a foundation of leg strength is established then progressively add agility work that starts with known programmed movements and progresses to random chaotic movements. Incorporate jump rope as a means to teach good coordination and foot strike. Progress to multi dimensional jumps and hops.
The clincher here is that this must be systematically addressed in the female athlete starting just before puberty. Think of it as preparation to play the game that runs parallel to skill development. In most cases it should slightly precede skill development. The two must go hand in glove, not either or. The functionally strong young female athlete will be more receptive to skill learning and be better able to apply the skills to the game. TRAIN TO PLAY, DON”T PLAY TO TRAIN!
Select movements that link and connect the ankle/knee and hip as a functional unit to reduce and produce force. Include exercises that have a high proprioceptive demand. Above all train on your feet! A simple rule of thumb, if you lying prone or supine or seated you are not preparing to attenuate the ground reaction forces that are demanded in the game. You must train with you feet on the ground to effectively learn to shock absorb and use the ground.
Don’t say it can’t be done, it can. It takes organization, focus and commitment. You don’t need a lot of equipment or huge time blocks. You need to be consistent and relentless. Training can be done anywhere; it can be on the field or on the court if necessary. Apply the “weight room without walls” concept. Make it challenging mentally and physically to prepare for the stress of competition. The bottom line is that to prevent ACL tears you must train the body for the rigors of competition. The prevention program should be a transparent component of training.