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SPORTS REHABILITATION

ACL prevention in
female football
– Written by Kathrin Steffen, Roald Bahr and Grethe Myklebust, Norway

“TARPLEY TEARS RIGHT ACL, WILL MISS could have been prevented and in this players have a two to three times higher
WOMEN’S WORLD CUP paper we will tell you how. ACL injury risk compared to their male
United States Women’s National Team counterparts. Females also tend to sustain
midfielder Lindsay Tarpley tore her right HOW BIG IS THE PROBLEM? an ACL injury at a younger age than males1.
anterior cruciate ligament in the 75th minute Severe knee injuries, such as ACL injuries, Protecting the health of the athlete by
of Saturday night’s 2-0 win over Japan and constitute a serious problem. Unfortunately, establishing prevention routines early is the
will miss this summer’s Women’s World Cup they are frequent in many sports. Treatment responsibility of everyone involved in sports
in Germany. She is expected to miss six-to- is costly and it often takes 12 months or including coaches, medical personnel,
eight months. more to return to sport or in worst case, lead referees and the athletes themselves. To
This is the same ACL that Tarpley tore in to early retirement. The long-term outcome maximise the health benefits for players
the final game of the 2009 WPS season with is also a concern. A majority of athletes and to minimise the direct and indirect costs
the Chicago Red Stars. She slowly recovered will develop osteoarthritis within 15 to associated with injuries, early identification
from that and made a strong comeback in 20 years after an ACL injury, regardless of of players at high injury risk is key.
2010 with Saint Louis Athletica and, more treatment. Consequently, injuries represent
notably, with the Boston Breakers. Tarpley a considerable problem for the athlete, their RISK FACTORS
was recalled to the US team in November and team and, given the popularity of sport, for As for most other types of injury, recent
had scored two goals in just four appearances society at large. studies have suggested that a history of knee
with the team in 2011.” In football, as in other team sports ligament injury is the predominant risk
– equalizersoccer.com characterised by sudden changes of factor for a subsequent injury2,3. However,
direction, pivoting accelerations and the reasons for the obvious gender gap in
Unfortunately, we hear of numerous sad decelerations, ACL injuries are a particular the risk of ACL injury are not completely
stories like this, especially among women concern, especially for female athletes. clear. Various researchers have suggested
competing in pivoting sports. Many of these A recent literature review, including 23 differences in anatomy, hormonal and
anterior cruciate ligament (ACL) injuries studies, demonstrated that female football neuromuscular function as potential

178
reasons for the higher injury risk in women no direct player contact to the knee, many factor in many cases. This implies that
than in men. To date, however, there is little cases involve some sort of perturbation by avoiding valgus knee motion is important
evidence linking all these potential intrinsic an opponent (e.g. being pushed slightly for preventing injuries5,7.
risk factors to noncontact ACL injuries and off-balance just before landing). The
a great deal of controversy exists on the mechanisms for non-contact ACL injuries PREVENTION
relative importance of the different factors4. are widely debated. What seems clear from A variety of injury-specific and sport-
The main external risk factor that has several studies from various team sports specific preventive exercise programmes
been advanced is the effect of friction and even alpine skiing is that knee valgus exist. Also, a growing number of
between shoes and the playing surface. (where the knee collapses inwards into programmes have been developed to reduce
Investigations from Australian Rules a ‘knock-knee’ position) is an important the risk of knee injuries in general and ACL
Football and European handball suggest injuries in particular. Studies from various
that a high shoe surface friction is associated sports typically show that establishing
with an increased risk of ACL injury. For such programmes as standard warm-up
example, when friction is high, the foot can majority of athletes programmes for teams can reduce the risk
abruptly stop while the athletes are out for
a cutting or turning manoeuvre. This will
will develop of injury by as much as 30 to 50%8-14.
Typically, these programmes consist of
cause the knee to twist suddenly at foot osteoarthritis exercises focusing on core stability, balance,
strike and collapse5,6. dynamic stabilisation and muscle strength
within 15 to 20 years of the lower extremities. The exercises are
MECHANISMS often designed as structured warm-up
ACL injuries usually occur without after an ACL injury programmes to ensure that all players use
contact between players and typically the programme regularly. One essential
during cutting and turning or when landing part is to emphasise the ‘hip-knee-toe in
on one foot after a jump. Even if there is line position’ in all types of exercises, both

SPORTS MEDICINE IN FOOTBALL TARGETED TOPIC 179


SPORTS REHABILITATION

Figure 1: Proper and poor knee


lower limb alignment.

in plyometric, co-ordination and strength Balance training alone and home-based To identify the minimal effective dose
exercises. The primary goal of this strategy training without instruction and feedback to reduce ACL injury risk is a daunting task.
is to maintain posture and lower limb on proper movement technique (i.e. lower Also, we question: Which exercises are the
balance in an attempt to teach players limb alignment, two-leg landings) is key exercises in a programme: strength,
how to control their knee position as far as probably ineffective16,17 unless combined balance, plyometric or agility are actually all
possible in all situations (Figure 1). with other types of exercises for core and of them?
A recent comprehensive review of lower-limb strength, perturbation and
the scientific literature15 focused on jumping, with a continuous focus on knee When to start?
neuromuscular training programmes control. Most clinicians and researchers suggest
developed to alter risk factors associated Another important challenge is to that focus on injury prevention should start
with an ACL injury and to reduce injury risk convince coaches and athletes to use the as soon as children start participating in
in football players. The authors conclude programmes. “Are the exercises really organised sports. Generally, injury risk is low
that neuromuscular training appears to worth doing?” “The programme takes 20 under the age of 1218. Even so, from a motor
be effective in reducing ACL injury risk minutes; do we need to do this programme learning perspective, including exercises
and that lower extremity strength and every training session?” These are common to prevent injuries early can help develop
balance exercises, in combination with core questions. And the answers are yes and yes! ‘good habits’ and less vulnerable movement
and trunk control, seem to be necessary If done properly, as many as every second patters, in addition to establishing correct
components of a successful ACL injury injury can be prevented. Perhaps one day, playing technique and fair play attitudes.
prevention programme. Since Alentorn-Geli through continued research, programmes
et al15 finished their thorough review, new can be developed which take less time and
studies in football have been published are even more effective. (Continued on page 184)
which reinforce their message: injuries can
be prevented9,11-13. Figure 2: Prevention of ACL injuries
We have selected three knee/ACL injury in team sports (Page 181)
prevention programmes to present all have
been proven to prevent 30 to 50% of all
injuries (Figures 2 to 4). Two of the exercise A 5-phase 15 min programme with 3 different balance exercises focusing
programmes presented here have been on neuromuscular control and planting/landing skills was developed and
developed for football9,12, while the other is introduced to female elite handball players. Injury risk was significantly reduced
for handball10. These and other successful for those players who highly complied with the exercises10. Balance exercises
knee/ACL injury prevention programmes are usually done on a balance board or on an unstable balance pad, with the
have several key aspects in common and knees and hips slightly flexed. Ball or partner exercises may also be included
keeping these in mind, they can easily be to make the training more challenging and fun. While proper hip and knee
adapted to other sports. control is always emphasised, the exercises for balance, jumping and landing
can be adjusted to suit all sports that are characterised by cutting and landing
PRACTICAL IMPLICATIONS - HOW, WHAT, movements. These exercises can also be incorporated into a warm-up program.
WHEN? Though this programme seems to focus much on balance, there are also strength
What type of exercises? elements included, such as two and one-leg squats. Remember, always use proper
ACL injury prevention works. However, hip - knee – toe control. During an initial training period of at least 5 weeks,
we still do not know how to optimise injury the exercise should be done a minimum of 3 times per week, training for 10–15
prevention programmes to make them time minutes per session. Maintenance training once or twice a week should continue
efficient, which exercises are the ‘right ones’ throughout the competitive season.
or if such a thing exists at all.

180
Right Wrong
Prevention of ACL injuries
in team sport athletes

Level 1
Floor exercises Mat exercises Wobble board exercises
Running and planting, Two players standing on one Two players standing two
partner running backwards leg on the mat throwing to legged on the board
and giving feedback on the each other. throwing to each other.
quality of the movement,
change position after 20 s.

Level 2 R
R
L

Floor exercises R Mat exercises Wobble board exercises


Jumping exercise—right leg– L Jump shot from a box Squats on two legs,
right leg over to left leg–left (30–40 cm high) with a then on one leg.
L
leg and finishing with a two- two-foot landing with
foot landing with flexion in L flexion in hip and knees.
both hips and knees. R L

Level 3
Floor exercises Mat exercises Wobble board exercises
Running and planting “Step” down from box with Two players throwing to
(as in week 1), now doing a one-leg landing with flexion each other, one foot on the
full plant and cut movement in hip and knee. board.
with the ball, focusing on
knee position.

Level 4
Floor exercises Mat exercises Wobble board exercises
Two and two players together two-
Two players both standing One foot on the board,
leg jump forward and backwards,
on balance mats trying to bounding the ball with their
180° turn and the same movement
push partner out of balance, eyes shut.
backwards; partner tries to push
first on two-legs, then on
the player out of control but still
one leg.
focusing on landing technique.

Level 5
Floor exercises Mat exercises Wobble board exercises
Expanding the movement The players jump on a mat Two players, both standing
from week 3 to a full plant catching the ball, then take on balance boards trying to
and cut, then a jump shot a 180° turn on the mat. push partner out of balance,
with two-legged landing. first on two legs, then on
one leg.

Squats: Imagine that you are sitting down on a chair. Perform squats by bending your hips and knees
to 90 degrees, do not let your knees cave inward. Bend slowly and straighten up more quickly.

Nordic Hamstrings: Your body should be completely straight from the shoulder to the knee. Lean forward as far as
you can by using the hamstring muscles to resist the forward falling motion.

Squat–walking lunges: As you lunge forward, bend your lead leg until the hip and knee are bent to 90 degrees.
Do not let your knee cave inward. Keep your upper body and hips steady.

Lateral jumps: Jump approx. 1m sideways from one leg to the other, like a skater. Land gently on the
ball of your foot. Bend your hips and knees slightly and do no let your knee cave inward.

Sprunglauf: Spring as high and far as possible off the supporting leg. Bring the knee of the trailing
leg up as high as possible and the opposite arm in front of the body.

©www.skadefri.no

Figure 2: Prevention of ACL injuries in team sport (Myklebust et al10).


Plakat Forebygging korsbåndskader.indd 1 01.06.10 16.02

SPORTS MEDICINE IN FOOTBALL TARGETED TOPIC 181


SPORTS REHABILITATION

Figure 3: Knäkontroll (Waldén et al12).

182
Figure 4: FIFA 11+ (Soligard et al9).

SPORTS MEDICINE IN FOOTBALL TARGETED TOPIC 183


SPORTS REHABILITATION

Who should be targeted?


Figure 3: Knäkontroll (knee control) (Page 182) Most prevention programmes today are
created as ‘one-size fits all’ package to be
performed by all athletes. Perhaps future
studies will give more specific knowledge
The neuromuscular warm-up program “Knäkontroll” (“knee control”) about which type of exercises different
significantly reduces the rate of ACL injuries among adolescent female football sports and different athletes should
players (Waldén et al.12). “Knäkontroll” contains of exercises focusing on knee perform. Further evidence is needed to
control and core stability similar to other programs in, for example, handball. determine whether a pre-season functional
The 6 exercises are one-legged knee squat, pelvic lift, two-legged knee squat, test e.g. by a drop-jump or single-leg squad
the bench, lunge, and exercises on jump/landing technique. Each exercise is
test, can be used to identify athletes with
subdivided into 4 steps of progressive difficulty and a pair exercise (Table 1).
higher risk. A study by Soligard et al19 showed
The exercises are to be preceded by 5 minutes of low intensity running and take
that across different skill attributes, players
about 15 minutes to complete after familiarisation. In the project, the teams were
with high levels of football skills were at
instructed to conduct the exercises during the warm-up at 2 training sessions
greater risk of sustaining injuries than their
a week throughout the whole season. All players started on the first level of
difficulty and proceeded to the next level when exercises were performed with less skilled teammates. In other words, there
good control as assessed by the coach. are direct and indirect performance benefits
from keeping players free of injury.

The Coach is the key!


Winning and performance are the key
factors for coaches and players. Therefore,
Figure 4: The FIFA 11+ (Page 183) motivating coaches and players to follow
exercise programmes is easier if they do not
only to prevent injuries but also is provide
direct performance benefit20. It might be
In a randomised controlled study by Soligard et al9, the objective was to examine
expected that by implementing a 15 to
the effect of a comprehensive warm-up program designed to reduce the risk
of lower extremity injuries among female soccer players. Approximately 1900 20 minute injury prevention programme,
players participated in the study. The 15-20 min warm-up program, called physical performance should also improve.
“The FIFA 11+” includes exercises to improve lower extremity and core strength, However, there is limited research on this
awareness and neuromuscular control during static and dynamic movements. with conflicting outcomes20.
After 8 months of training, the intervention group had a significantly lower Coach education is the key. Well-
risk of injuries overall (32%), of overuse injuries (53%) and of severe injuries trained coaches can deliver a new exercise
(45%) compared with the controls. The “11+” exercises, as in many of the other programme in the correct way. Knowledge
neuromuscular exercise programs, compose a multifaceted program, provide of sports injuries, injury prevention,
variation and progression of exercises, and address many training components attitudes and beliefs to the importance of
that are thought to be related to ACL and lower extremity injury risk. injury prevention training is quite varied
among coaches. Without doubt, injury
prevention should be mandatory as part of
the coach education and certification at all
levels.
Key Aspects of Successful Injury
Prevention Programmes TAKE HOME MESSAGE
It is possible to prevent ACL injuries,
however, much research is still needed to
Multi-component warm-up programmes, including a combination of balance/ make the current programmes even better
co-ordination, technique, lower limb and core strength, plyometric and agility and maybe more athlete-specific. We know
exercises. that exercise programmes need to include
a combination of balance, co-ordination,
Focus on technique:
strength, plyometric and agility exercises.
• two-leg landings.
A better understanding of ACL injury
• a more narrow cutting technique.
risk factors and mechanisms will help
• proper balance with hip, knee and toe in line.
us to optimise current injury prevention
Include a variety of exercises with a progression from easy to more difficult to programmes. In the meantime, our best
continually pose a challenge to athletes (important for motivation!). recommendation is to establish warm-up
Include exercises in pairs to make training more fun, but also to maximise routines and put the existing knowledge on
movement quality. ACL injury prevention into practice. Spread
Include ball exercises when basic exercises are well-established. this knowledge and convince coaches and
athletes that ACL prevention works!

184
15. Alentorn-Geli E, Myer GD, Silvers HJ,
Samitier G, Romero D, Lázaro-Haro C et
al. Prevention of non-contact anterior
cruciate ligament injuries in soccer
players. Part 2: a review of prevention

players with high programs aimed to modify risk factors


and to reduce injury rates. Knee Surg

levels of football skills


Sports Traumatol Arthrosc 2009; 17:859-
879.

are at greater risk of


16. Söderman K, Werner S, Pietila T, Engström
B, Alfredson H. Balance board training:
prevention of traumatic injuries of

sustaining injuries
the lower extremities in female soccer
players? A prospective randomised
intervention study. Knee Surg Sports
Traumatol Arthrosc 2000; 8:356-363.
17. Engebretsen AH, Myklebust G, Holme
I, Engebretsen L, Bahr R. Prevention of
injuries among male soccer players: a
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SPORTS MEDICINE IN FOOTBALL TARGETED TOPIC 185