Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

KNEE INJURY PREVENTION IN SPORT

Fco. Javier Linde Cot
Degree in Physiotherapy Degree in Ciences of Physical Activty and Sport Mster in High Performance

INJURY PREVENTION IN THE OVERHEAD ATHLETE

CENTRE DALT RENDIMENT OLYMPIC TRAINING CENTRE

SANT CUGAT DEL VALLS, BACERLONA.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

FOCUSED ON
!! Epidemiology !! Biomechanics !! Isokinetic and strength testing !! Functional tests !! Muscle activation assessment and reventive work !! Physiotherapy

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

EPIDEMIOLOGY
!! We are going to focus on knee injuries in sport. !! Most of that injuries are sustained over ligaments and tendons. !! Also muscle strains. !! Whats the incidence of knee injuries in single/team sports?

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

EPIDEMIOLOGY
!! ACL 20,3% !! PCL 0,65% !! Medial Meniscus 10,8& !! Lateral Meniscus 3,7% !! LCL 1,1% !! MCL 7,9&

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

EPIDEMIOLOGY
!! 87% injuries in lower limbs. !! 37% strains & 19% sprains. !! 58% of all them non-contact injuries !! 7% of re-injuries
The association football medical research programme: an audit of injuries in professional football. RD Hawkins, MA Huise et al. BJ Sports Med 2001;35:43-47

!! Multiligament injury
!! Knee dislocations were historically considered exceptionally rare injuries !! In that case ACL and PCL can be brokened and become a neural and vascular risk

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

EPIDEMIOLOGY
!! Single/Team sports
!! More common soft tissue injuries, normally due to an overload or an explosive

action.
!! Non contact injuries affect more nonsoft tissues. Can be held in a landing or in a

flexion.
!! It is very important to determinate risk factors that can be controlled. In example, in

team sports, some risks are derivated in opposition or handicap tasks, that will increase injury risk.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

THEORETICAL MARK
!! High Performance sports practice as we know it, implies itself high

training loads.
!! That high training loads are one of the most clear differential factors

between amateur/nonprofessional athletes and professional athletes training.

!! It is very common in professional sport that the needed time to recover

the body of that loads is not respected, and by the way, to accumulate organique fatigue that will lead to an overtraining or maybe cause an overuse injury,

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

THEORETICAL MARK
!! Traditionally, isokinetic measurements testings have been used (Croisier et

al, etc ...) to prospective studies (Schache et al) and assessments of strength in flexo-extensor groups of the knee, both to determine the risk of ACL rupture and more recently to determinate the risk of rupture of hamstring muscles. !! On the other hand in U.S. analyzing has grown in 3D regarding to Drop Jump (DJ) (Hewett et al, etc) to determine the risk of ACL rupture due to excessive valgus or by alterations in the pattern of loading damping, usually attached to the measurement on a force platform. !! These traditional methods have been joining simpler ones (not so modern), as Tensiomiophy (TMG), which is a simple tool used for fast and reliable information about muscle state by applying an electrical stimulus on a muscle group that causes a response that is measured by a transducer.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

THEORETICAL MARK
!! There is a clear difference between sports and location of the most

common incidence, mostly depending on the kind of sport practised: i.e. Sports that imply contact like taekwondo, or team sports like football or handball.
!! For example, in football the incidence of rupture of the Medial Lateral

Ligament is greater than general epidemiology statistics.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

THEORETICAL MARK
!! According to Van Beijsterveldt et al, in the Netherlands is produced

annually about 3.6 million sports injuries, of which about 19% (679,000) of sports injuries occur in football. 38% of all sports injuries require medical treatment of some type, all of which generates direct and indirect costs estimated of 1.3 Billion ! / year.
!! Time off work. !! Costs for the club. !! Loss of 20% of the competition on average. !! Small investment in prevention saves money.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

!! The first point into any re-training or process of return to play, is to

avoid the injury incidence, it is to PREVENT!

!! Use as many kinds of evaluation as can be used to assess the risk.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

EXAMINATION
!! STATIC
!! Palpation of surfaces. Are them painfull? !! Patella positioning. !! Joint stability
!! LML stability test !! LCL stability test !! Lachman test !! Other tests for ACL or PCL !! Meniscus evaluation.

!! Chondrotic test. !! Functional testings !! Perimetre of the thigh. !! Etc

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

EXAMINATION
!! DYNAMIC
!! Biomechanical assessment
!! DJ !! CMJ !! Squat

!! COMBINATION WITH EMG !! WALK/RUN ANALYSIS

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

BIOMECHANICS LEVEL:
!! Ground reaction forces !! Knee flexion (moment of extension). !! Moment of valgus. !! Tibial external rotation. !! !! Control of dorsal flexion. !! Control of hip flexion. !! Control of trunc inclination.

Where is the centre of masses going?

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

CORRECTIONS IN THE KNEE WHEN LANDING AND FLEXING

!! The distribution of the loading line over the body when performing

knee flexion, landings ... must pass at the level of the joints to prevent overloads in unwanted areas.
!! This correction must be taken into account when doing closed kinetic

chain strengthening work.

!! Avoid VALGUS!! When flexing the knee.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

THE HAMSTRING MUSCLE IS RESPONSIBLE FOR MAINTAINING OR PREVENTING THE TIBIA ANTERIOR TRANSLATION PERFORMED IN KNEE EXTENSION AND FLEXION, THEREFORE ARE PROTECTIVE OF THE ACL.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

!! THEREFORE, WE MUST BE CAREFUL TO AVOID WORKING

EXCESSIVELY QUADRICEPS.
!! T H I S WO R K

M U S T B E C O M P E N S AT E D WO R K I N G SPECIFICALLY THE POSTERIOR KINETIC CHAIN MUSCLES. EXTENSORS (GLUTEUS SYNERGISTS).

!! MUST TAKE THE HAMSTRINGS AS KNEE FLEXORS AND HIP

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

HOW TO WORK THE CORRECTION

!! Should be used according to the technique of the exercise. !! Start with no-load, focusing on implementation. !! Gradually increase the load. !! Technique can be difficulted by implementing disturbing elements of

proprioception.

!! If it is possible, work in front of a mirror to integrate new body image.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

HOW TO WORK THE CORRECTION

!! THERE IS A GREATER RISK OF INJURY IN LCA IN GIRLS THAN

BOYS, INCREASING AS THE GIRLS ARE YOUNGER.

!! Eg sports like handball, women's football, TKD ...

MURPHY DF ET AL. RISK FACTORS FOR LOWER EXTREMITY INJURY: A REVIEW OF THE LITERATURE. BJSM 03 HEWETT TE ET AL. BIOMECHANICAL MEASURES OF NEUROMUSCULAR CONTROL AND VALGUS LOADING OF THE KNEE PREDICT ANTERIOR CRUCIATE LIGAMENT INJURY RISK IN FEMALE ATHLETES. A PROSPECTIVE STUDY. AJSM 2005 HEWETT TE ET AL. VALGUS KNEE MOTION DURING LANDING IN HIGH SCHOOL FEMALE AND MALE BASKETBALL PLAYERS. MSSE 2003

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

RISK FACTORS
!! Extrinsic risk factors
!! Opposition. !! Weather conditions. !! Interaction foot-surface. !! Footwear.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

RISK FACTORS
!! Intrinsic risk factors
!! ANATOMICAL: relative mass, joint laxitude, hip and trunk position, Q angle,

intercondyle notch space, tibia posterior inclination, pronation, age, somatotipe, gender, fitness, previous injury history.
!! HORMONAL: sexual hormones, laxitude, efect of force in ACL tension, effects over

neuromuscular function.
!! NEUROMUSCULAR: relative strength and recruitment, stability and relative stiffness

of the joint, muscle fatigue.

!! BIOMECHANICS: sagital plane, coronal plane, transversal plane.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

RISK FACTORS
!! Modifiables:
!! Loss of flexibility !! Hamstrings force deficit !! Imbalance in ratio between hamstrings and quadriceps !! Bad CORE stability !! Muscle fatigue !! Poor warm up !! Decrease in ankle dorsal flexion angle !! Poor return to play

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

RISK FACTORS
!! Non modifiables
!! Age !! Previous injury history !! Degeneration of spinal discus

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

KNEE FLEXION AND VALGUS MOMENT

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

GROUND REACTION FORCES

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

POWER CURVE

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

POWER LEG VERSUS LEG

34% de dficit de media

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

" SQUAT AND AND MULTIJUMP

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

PREVENTION - CORE
!! CORE INSTABILITY !! On a sporting level, is a recurrent cause of pain that can and should be

treated.
!! Lumbopelvic instability is a significant factor in that it will cause pain in

the lumbar region. BUT NOT ONLY IN THE LUMBAR REGION!

!! The stability of a joint implies that the body is able to control the entire

range of movement of that joint.

!! If we refer to as a physical law, to move a lever in a stable and secure

way, we need a fulcrum to support it. In this case, a strong CORE should be the fulcrum of the entire lever.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

CORE!!

CORE stability Literature findings Related to Athletic performance and injuries

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

!! Core instability is increasing related with lower limbs injuries. In that

case we are interested in knee injuries related with core instability.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

THERE ARE THREE INTERRELATED SYSTEMS THAT ARE RESPONSIBLE FOR GENERATING STABILITY:
Control (Neural)

Passive (Lumbar spine)

Active (GSS & LSS) (Lumbar muscles)

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

Control System (Neural)

- The control system plays an important role in stabilizing the spine, anticipating the application of loads. Anticipation facilitates rapid activation of the stabilizing musculature. - The afferent neural system receives information from t h e a c t i ve a n d p a s s i ve systems (GSS / LSS, spinal discs ...) to determine the specific requirements necessary to maintain stability in the spine.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

Currently people is working more and better the correction and avoidance of patterns of instability in the lumbar region, especially through exercises of control of the transverse pelvic contraction.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

PREVENTION - ISOKINETIC
!!The isokinetic assessment is an objective method that allows us

to have a fast and reliable comparison between agonistic and antagonistic muscles of the knee during dynamic exercise, as well as it allows us to compare between sides. By its use it is possible to determine muscle performance of that muscle groups.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

PREVENTION - ISOKINETIC
!! Peak Torque !! Maximal Repetition Work !! Angle of Peak Torque !! Fatigue !! Ratio !! Asymmetries !! Differences between curves !! Comparison subject/control group !! New testing modalities

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

PREVENTION - TMG
!! Tensiomyography (TMG) is a measuring method for detecting skeletal

muscles contractile properties. It enables selective measurements of radial muscle belly enlargements in single muscle or whole muscle group. Muscle is stimulated with single electrical stimulus or train of electrical stimuli (tetanic stimulation). Measurements are carried out under isometric conditions.
Tc
12 TMG [mm]

Tr

Ts

Td
0 0 50 100 150 200 250 300 350 400 450 Time [ms] 500

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

PREVENTION - TMG
!! It gives us information about
!! Tc, Dm, Ts, Tr and Td !! Histochemichal characteristics of muscle dominant fibers. !! Neural or structural fatigue. !! Muscle activation. !! Muscle stiffness. !! Muscle contractile properties. !! Muscle imbalances. Also ratios?

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

PREVENTION TRAINING CONTROL

!! TRAINING CONTROL !! Control of hours of training !! Control of resting time !! Control of nutrition/hydration !! Control of number of jumps!!!! Depending on age?? !! Strengthening !! Control of intensity !!

Prevention programmes must be performed!

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

NEW MODEL OF TENDON PATHOLOGY:

!! Reactive tendinopathy (short-term adaptation to overload that thickens the tendon,

reduces stress and increases stiffness).

!! Tendon disrepair (attempt to tendon healing but with greater matrix breakdown.

Separation).
!! Degenerative tendinopathy (little capacity for reversibility of pathological changes.

Disorganized matrix with vessels, biochemichal products).

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

!! Placing EXERCISE in this model tendinopathy:

!! Eccentric exercise !! High resistance Training !! Preventive plans including core, strength, coordination, plyometrics

When a tendon increases in size and strength, is subjected to greater stress unless it also amplifies its CSA. Theoretically, an increased tendon CSA may protect against overload injuries since it will reduce the tendon stress, which will reduce the magnitude of the tendon strain for a given external applied force.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

PREVENTION - PROPRIOCEPTION
!! Objectives of proprioception !! To give joint and ligament stability. !! To improve efficacy and eficiency of neuromuscular response in front to

a new situation.
!! Improve control of position and movement. !! Acquire new abilities to response to new movements. !! Achieve a funtional state.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

PREVENTION - PHYSIOTHERAPY
!! Manual Therapy mantain ROM of the joints free, recover ROM deficits

after an injury competition

!! Massage Different kind of massage after, before, intense, pre!! Stretching During how long? What kind? Pre or post? Active or passive? !! Recovery measures Cooling, slow activity after competition !! Hydrotherapy sauna, jacuzzi, hot and cool baths !! Electrotherapy

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

PREVENTION - PHYSIOTHERAPY
A) Synchronic restitution (during) B) Primary restitution (until 2h) C) Secondary restitution (from 2h to 3 days) D) Restitution in the overtraining.

Oradea, 25 26 of May 2012 Faculty of Geography,Tourism and Sports

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