With her team down by one point and time running out, a basketball player jumps for the offensive rebound. She grabs the ball from the rim and is about to put the ball back up to win the game. The crowd erupts in cheers, but she lands awkwardly and injures her knee. This athlete just suffered a non-contact anterior cruciate ligament (ACL) injury due to faulty landing and improper deceleration.

Another example is an athlete who suffered a non-traumatic knee injury. His injury was initially mild, perhaps from overtraining, but has gradually become chronic and is affecting his performance.

Could these two injuries have been prevented? Maybe, maybe not. But in most scenarios, non-traumatic injuries at the knee can be prevented through proper training.

Elite Sports Medicine, Connecticut Children's Medical Center's sports medical division, in Farmington, CT, has created a program that includes proper training and neuromuscular re-education to prevent knee injuries. Carl Nissen, MD, orthopedic surgeon and director of Elite Sports Medicine, believes that athletes may be able to prevent common knee injuries with proper prevention programs designed to increase strength and change mechanics during play.

"Young athletes suffer serious knee injuries more commonly than any other population," according to Dr. Nissen. "While many of these injuries are unavoidable, non-contact twisting injuries can be significantly reduced with planned, progressive pre-season training programs directed at neuromuscular control of ground reaction forces and external moments encountered regularly in lower-extremity-dominant sports."

Sports Injuries on the Rise

Sports participation has grown dramatically in recent years. As a result, there has been an increase in sports-related injuries, estimated at 2 million each year. Knee injuries account for nearly 30 percent of that 2 million, followed by ankle injuries which represent about 12 percent and shoulder injuries ranking at nearly 11 percent.¹Knee ligament injuries are the most common injury to athletes requiring surgery. ACL injuries are one of the most talked about injuries that occur at the knee, and an estimated 70 percent of ACL injuries are non-contact.²Usually these injuries occur due to improper landing during the deceleration phase of movement. Education and proper training can reduce the likelihood of ACL injuries.

Dr. Nissen agrees that while knee ligament tears are not completely avoidable, they can be significantly reduced by getting involved in a planned neuromuscular training program.

"Neuromuscular injury prevention programs offer the opportunity to significantly reduce injuries in athletes-regardless of age or gender-when done on a planned pre-season fashion," he said.

Injuries can lead to loss of playing time, decreased function, and feelings of frustration and depression for the athlete. Minimizing the risk of injury from occurring in the first place is crucial and can be accomplished with a knee injury prevention program.

Overtraining With Little Education

Not only has participation in sports grown but athletes now focus on one sport, and play on multiple teams a season, as opposed to playing different sports. When an athlete focuses on one sport, he will perform the same sport-related movement patterns repeatedly, versus involvement in different sports that require different movement patterns.

Combine this repetitive action with playing year-round on multiple teams, and an athlete faces an increased risk for injury. Once an injury occurs, it is more likely to occur again.

Athletes recently began focusing on off-season strengthening and learning proper squatting, jumping and landing mechanics. Coaches often do not know what proper and improper mechanics look like, nor do they want to set aside time to work on their athletes' strength and mechanics because that reduces practice time. Fortunately, the trend has been for athletes to participate in injury prevention programs during the off-season and pre-season to prepare them for play.

Elite Sports Medicine's knee injury prevention program addresses the strength deficits and incorrect mechanics commonly seen in athletes. "The knee injury prevention program not only assists athletes with techniques to prevent injuries, but also enhances performance while instilling confidence," said Laura Miele, PhD, sports psychologist and program manager of the sports injury prevention program.

Breaking Down the Program

The program, sponsored by Elite, consists of education, pre- and post-testing, a dynamic warm-up and exercises.

Poor mechanics include decreased hip flexion, medial collapse of the knee, knees falling anterior relative to the feet and hard landings. These improper mechanics are often the result of the athlete having weak hip muscles, a weak core and decreased proprioception.

On the first day of the program, athletes undergo pre-testing that includes assessing upper body, lower body and core strength, along with a series of timed speed and agility tests. The PTs also conduct an analysis of a two-dimensional image of the athletes' form while jumping and landing. After athletes are educated on proper and improper mechanics, the PTs instruct them on the proper way to squat, jump, land and move while preventing the most common faulty mechanics.

Athletes begin the training sessions with a dynamic warm-up to "loosen up" muscles and prepare for the rest of the workout. The session includes a timed circuit where the athletes rotate from station to station and participate in speed and agility exercises, such as lateral slides and mountain climbers.

After circuit training, athletes are directed through exercises to increase strength and retrain the neuromuscular system to improve their form. Some of these exercises include broad jumps, depth jumps, bent knee touches and step-downs. Athletes are monitored closely to ensure they are performing the exercises correctly and to their best ability.

Throughout the entire program, the instructor reminds the athletes to maintain proper form while performing strengthening exercises and plyometrics. Athletes focus on facilitating hip and knee flexion while keeping knees posterior relative to their feet.

After the Program

After the six- to 12-week program is completed, athletes are post-tested to determine progress and improvement. Last summer, 88 percent of program participants showed more than a two-thirds increase in hip and oblique strength and a one-third increase in core strength. All athletes improved their form and mechanics involved in jumping and landing.

Although every injury cannot be prevented, the risk of non-contact and non-traumatic injury can be minimized by enrolling athletes in a knee injury prevention program. These well-supervised programs will help address athletes' weaknesses and retrain their bodies to perform sports-related movements. This program may not only mean the difference between winning and losing the game, but can also potentially preserve playing time and participation in sports.

References

1. The American Orthopedic Society for Sports Medicine. (2009). New injury rate statistics for high school athletes highlights need for increased prevention efforts. http://www.sportsmed.org/tabs/newsroom/AOSSMPressReleaseDetails.aspx?DID=636. Updated August 26, 2009.

2. Zeiger, T. (2009). Understanding ACL injuries in females: Non-contact ACL injuries are gender-specific. http://knee-jointinjuries.suite101.com/article.cfm/understanding_acl_injuries_in_females.

Danielle Barone is a PT at Elite Sports Medicine, part of The Connecticut Children's Medical Center. Dr. Barone specializes in the rehab of pediatric and young adult sports medicine-related conditions and runs the clinic's knee injury prevention program.

Exercises That Can Prevent Knee Injuries

Danielle Barone, PT, DPT, CSCS, recommends a series of exercises to prevent knee injuries

but cautions patients to consult with a physician, trainer or PT before attempting

these exercises. Listed below are four exercises Dr. Barone includes in her knee injury prevention program.

Improper mechanics include decreased hip flexion, decreased knee flexion, medial collapse of knees, knees anterior relative to toes and hard landing. Proper mechanics include appropriate hip flexion, appropriate knee flexion, absence of medial collapse of knees, knees posterior relative to toes and soft landing.

Broad Jump: Begin in proper squat position. Quickly bend at hips and knees while maintaining an upright trunk and then jump forward while swinging arms in sagittal plane. Land softly in squat position with proper mechanics.

Depth Jump: Begin on a 6-inch box in proper squat position. Step off box and land softly on both feet in squat position. Increase height of box as athlete progresses.

Bent Knee Touch: Begin in standing. Shift weight to right leg and bend at right hip and knee. Slowly raise inside of left foot to touch right hand at the height of right knee while maintaining an upright trunk. Maintain proper mechanics throughout exercise. Repeat on other side.

Step Down: Begin with a 6-inch box. Stand with inside of right foot on outside of step. Slowly bend at right hip and knee and softly touch left heel to ground. Extend right hip and knee to return to starting position. Maintain proper mechanics throughout exercise. Repeat on other side. Increase height of box as athlete progresses.