Sports Physiotherapy

1. Sports Physiotherapy Seminar Presentation Chan Hon Yan 99060146D Chan Man Leung Sunny 99946540D Choi Chor Kei Leo 99199765D Fung Mo Ching Ivy 99023277D

2. Topic 2 • Mary, a 21 years old University student, belongs to Hong Kong Basketball Team. • She twisted her (L) knee while landing from a rebound during competition 3 months ago. • Her doctor informed her that she had suffered from a grade II ACL injury, and recommended Mary to have intensive rehabilitation with special emphasis on functional training.

3. Outline of Presentation Sports Skill Gender Pathology Psychology Rehabilitation Program Return to Sports

4. Introduction • In a 5 year study, knee injuries accounted for 15% of total basketball injuries in National Collegiate Athletic Association (NCAA). • Almost 20% of the knee structure injuries are ACL injury. • The ACL injury rate in women was 4.1 times greater in basketball. (Arendt & Dick, 1995)

5. Injury mechanism • Non-contact • planting & cutting • straight-knee landing • one-step landing with the knee hyperextended • pivoting & sudden deceleration

6. Effects on Structures after ACL injury • Static stabilizer • Medial menisci --- increase cross sectional area and volume, thickening at its attachment • Posterior capsule --- thickening (Jackson et al., 1999) • Decrease Bone Mineral Density (BMD) in the periarticular cancellous bone of femur and tibia (Boyd et al., 2000).

7. Effects on Structures after ACL injury • Dynamic stabilizer • Hamstrings • Quad • Gastrocnemius Increase demand

8. Non-copers vs Copers • Non-copers • had instability with activities of daily living. • They stiffened their knees by landing in less flexion and accepting weight with less flexion in both walking and jogging. • May lead to excessive joint contact forces which have potential to damage articular structure. (Rudloph et al., 1998)  cannot return to previous performance

9. Non-copers vs Copers • Copers • return to all pre-injury activity without limitation. • Copers demonstrated increased hamstrings EMG, may be a compensation mechanism. (Tibone & Antich, 1993 and Boerboom et al., 2001) • It has been suggested that Quadriceps and Gastrocnemius are also important for compensatory dynamic knee stabilization. (Nyland et al., 1997 and Kivist & Gillquist, 2001)

10. Why are women more susceptible? • Intrinsic factors (Huston LJ. et al, 2000) • Q-angle • femoral notch • joint laxity • hormonal influence - need more research to prove irreversible

11. Why are women more susceptible? • Extrinsic factors • Proprioception • muscle strength • neuromuscular control • knee stiffness

12. Risk Factors • Proprioception (Rozzi SL. et al, 1999) • Female took longer than male to detect joint motion moving in the direction of knee joint extension • May be less sensitive to potentially damaging force Increase risk for ligament injury

13. Risk Factors • Muscle strength (Huston LJ. & Wojtys EM. 1996) • Female athletes has weaker knee extension & flexion strength than male

14. Risk Factors • Neuromuscular control • Muscle recruitment pattern response to anterior tibial translation (Huston LJ. & Wojtys EM. 1996) • Female athlete – quad-dominant • Male athlete, men and female control subjects – hamstrings-dominant • quad-dominate pattern: more strain on the ACL than cocontraction or contract the hamstrings first

15. Risk Factors • Knee stiffness • Important component to knee stability and injury prevention • Mm increase the joint contact force & decrease tibiofemoral displacement, dissipating potentially dangerous loads, lowering the force carried by the ACL and other passive structure

16. Risk Factors • Knee stiffness • Valgus & Varus stiffness (Brant JT. & Cooke TD.,1988) • knees in female rotate 66% more than males & 35% less stiff • Ability to voluntarily stiffen the knee (Wojtys EM et al, 1999) • Men: 4 times • Women: 2 times

17. Basic Skill in basketball • Running • Cutting • Pivoting • Rebounding • Shooting • (adapted from R J Emerson 1993)

18. Running • Change of speed and direction • To get away from opponents • To guard the route of offending opponent • require slide-steps, backward steps • Sudden deceleration & stopping prior to change of direction  knee almost fully extended + twisted

19. Cutting • Use of technique such as fake, stops and pivot to get away from opponent • Cutting method • Side-step Cut • Cross-over Cut • Require sudden change of • Speed • Direction

20. Pivoting • Use of technique getting away from opponent by moving body and step one or more steps on one foot while keeping the other stationary  Produce tibia torsion to knee

21. Points to consider in return to sport • Position • Habits in performing skills

22. Position Center • Perform much pivoting under net for scoring • Require more strength in jumping • Many collision and body contact under net • Need more proprioceptive training for balance during landing • May consider any uses of brace to prevent re-injury

23. Position Wing & Guard • Perform many high speed cutting and shooting with 2-steps stop • Perform much dribbling • Abilities required: • High power in initiating movement • High agility with sudden change of cutting direction or pace • need to stabilization of knee & agility

24. Habit in Skills Kirkendall DT et al (2000) • Cutting maneuver with less knee & hip flexion with knee valgus  Higher injury rate of ACL • training to perform cutting with knee  flexion  ACL injury reduced by 89%

25. Psychological Support • Explain to player • nature and severity of the injury • prognosis for recovery • recommended courses of therapy • estimate time frame of rehabilitation • Reassurance and support • Peer support

26. Visual-Motor Behaviour Rehearsal (VMBR) • Rehearse an entire performance • e.g. Landing with proper foot placement • Review and correct a specific performance • e.g. Remind herself the wrong habit in sport • Practice approaching the crowd or competition with confidence

27. Goals of rehabilitation • Gender aspect: • To minimize possible risk factors for recurrence of ACL injury in female basketball player • Sports aspect: • To restore physical capacity in competing in basketball games • Psychological aspect: • To overcome fear associated with the injury movement

28. Functional Training • Perturbation training • Plyometric training • Agility training • Sport-specific training

29. Perturbation Training • Techniques involving perturbation of support surfaces • roller board • tilt board • roller board & stationary platform • Induce compensatory muscle activity

30. Advantages of Perturbation Training Fitzgerald et al., 2000: • Enhance the probability of successful return to high-level physical activity • perturbation group with greater long-term success • Improve knee stability • reduce the risk of continued episodes of giving way of knee during athletic participation

31. Plyometric Training • Neuromuscular training • Develop power, strength & coordination • involve a prestretching of muscle  induce the stretch-shortening cycles

32. Plyometric Training • Goal: • Decrease reaction time between eccentric lengthening of mm and concentric mm contraction • Increase power

33. Advantages of Plyometric training Hewett et al, 1996 &1999: • Decrease landing forces • Increase vertical jump height • Improve knee stabilization • Improve hamstring-to-quadriceps strength ratio • Decrease incidence of knee injury in female athletes

34. Examples of Plyometric Training Hewett et al, 1996 &1999: • Cone jump • Jump, jump, jump, vertical

35. Agility Training • Allow pt to adapt to: • quick changes in direction • quick starting and stopping • cutting & pivoting • improve proprioception • Agility training significantly improves mm reaction time in response to anterior tibial translation (Wojtys et al, 1996)

36. Figure-of-eight Drills • gradual change of direction • allow adaptation to cutting activity • Longer distances  shorter distances (smaller surface area  tighter “8” ) • backward “8”

37. Cutting Maneuver Drills • Sidestep cut • Crossover cut • half-speed  full-speed • 45o 60o  90o cutting • Carioca

38. Shuttle Run • Involve straight plane running, acceleration, deceleration, cutting & pivoting

39. Others • SEMO drill • incorporate forward, backward, diagonal acceleration and lateral movt Start

40. Sport Specific Training • Start when full speed agility training was achieved • sport specific tasks are added during the agility training • For basketball player: • Dribbling skills • Ball catching • Ball passing

41. Sport Specific Training • Started w/o being opposed • Progressed to one-on-one opposition • Progressed to real competition

42. Question & Answer Session

43. References • Arendt E. Dick R. Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. American Journal of Sports Medicine. 23(6):694-701, 1995 • Baratta R. Solomonow M. Zhou BH. Letson D. Chuinard R. D'Ambrosia R. Muscular coactivation. The role of the antagonist musculature in maintaining knee stability. American Journal of Sports Medicine. 16(2):113-22, 1988. • Boden BP. Dean GS. Feagin JA Jr. Garrett WE Jr. Mechanisms of anterior cruciate ligament injury. Orthopedics. 23(6):573-8, 2000 • Boerboom AL. Hof AL. Halbertsma JP. van Raaij JJ. Schenk W. Diercks RL. van Horn JR. Atypical hamstrings electromyographic activity as a compensatory mechanism in anterior cruciate ligament deficiency. Knee Surgery, Sports Traumatology, Arthroscopy.9(4):211-6, 2001 • Boyd SK. Matyas JR. Wohl GR. Kantzas A. Zernicke RF. Early regional adaptation of periarticular bone mineral density after anterior cruciate ligament injury. Journal of Applied Physiology. 89(6):2359-64, 2000 • Bryant JT. Cooke TD. Standardized biomechanical measurement for varus-valgus stiffness and rotation in normal knees. Journal of Orthopaedic Research. 6(6):863-70, 1988. • Colby S. Francisco A. Yu B. Kirkendall D. Finch M. Garrett W Jr. Electromyographic and kinematic analysis of cutting maneuvers. Implications for anterior cruciate ligament injury. American Journal of Sports Medicine. 28(2):234-40, 2000

44. Fitzgerald GK. Axe MJ. Snyder-Mackler L. Proposed practice guidelines for nonoperative anterior cruciate ligament rehabilitation of physically active individuals. Journal of Orthopaedic & Sports Physical Therapy. 30(4):194-203, 2000 • Fitzgerald GK. Axe MJ. Snyder-Mackler L. The efficacy of perturbation training in nonoperative anterior cruciate ligament rehabilitation programs for physical active individuals. Physical Therapy. 80(2):128-40, 2000 • Huston LJ. Greenfield ML. Wojtys EM. Anterior cruciate ligament injuries in the female athlete. Potential risk factors. Clinical Orthopaedics & Related Research. (372):50-63, 2000. • Huston LJ. Wojtys EM. Neuromuscular performance characteristics in elite female athletes. American Journal of Sports Medicine. 24(4):427-36, 1996 • Hewett TE. Lindenfeld TN. Riccobene JV. Noyes FR. The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. American Journal of Sports Medicine. 27(6):699-706, 1999 • Hewett TE. Stroupe AL. Nance TA. Noyes FR. Plyometric training in female athletes. Decreased impact forces and increased hamstring torques. American Journal of Sports Medicine. 24(6):765-73, 1996 Kirkendall DT. Garrett WE Jr. The anterior cruciate ligament enigma. Injury mechanisms and prevention. Clinical Orthopaedics & Related Research. (372):64-8, 2000 • Jackson DW. Schreck P. Jacobson S. Simon TM. Reduced anterior tibial translation associated with adaptive changes in the anterior cruciate ligament-deficient joint: goat model. Journal of Orthopaedic Research.17(6):810-6, 1999 • Kvist J. Gillquist J. Anterior positioning of tibia during motion after anterior cruciate ligament injury. Medicine & Science in Sports & Exercise. 33(7):1063-72, 2001.

45. Kvist J. Gillquist J. Sagittal plane knee translation and electromyographic activity during closed and open kinetic chain exercises in anterior cruciate ligament-deficient patients and control subjects. American Journal of Sports Medicine. 29(1):72-82, 2001 • MacWilliams BA, Wilson DR, DesJardins JD, Romero J, Chao EYS. Hamstring cocontraction reduces internal rotation anterior translation, and anterior cruciate ligament load in weight-bearing flexion. Journal of Orthopaedic Research. 17(6):817-822,1999. • Rozzi SL. Lephart SM. Gear WS. Fu FH. Knee joint laxity and neuromuscular characteristics of male and female soccer and basketball players. American Journal of Sports Medicine. 27(3):312-9, 1999. • Rudolph KS. Eastlack ME. Axe MJ. Snyder-Mackler L. 1998 Basmajian Student Award Paper: Movement patterns after anterior cruciate ligament injury: a comparison of patients who compensate well for the injury and those who require operative stabilization. Journal of Electromyography & Kinesiology. 8(6):349-62, 1998 • Rudolph KS. Axe MJ. Buchanan TS. Scholz JP. Snyder-Mackler L. Dynamic stability in the anterior cruciate ligament deficient knee. Knee Surgery, Sports Traumatology, Arthroscopy. 9(2):62-71, 2001 • Tibone JE. Antich TJ. Electromyographic analysis of the anterior cruciate ligament-deficient knee. Clinical Orthopaedics & Related Research. (288):35-9, 1993 • Wojtys EM. Huston LJ. Taylor PD. Bastian SD. Neuromuscular adaptations in isokinetic, isotonic, and agility training programs. American Journal of Sports Medicine. 24(2):187-92, 1996