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Prevention of Anterior Cruciate Ligament Injuries Dr Ivan Popoff MBChB BPhEd FRACS (Orth) Knee, Shoulder
Prevention of Anterior Cruciate
Ligament Injuries
Dr Ivan Popoff
MBChB BPhEd FRACS (Orth)
Knee, Shoulder and Elbow Surgeon
Dr Ivan Popoff
Knee , Shoulder and Elbow Surgery
History of Injury 80% non-contact Pivoting / side stepping Landing on single leg
History of Injury
80% non-contact
Pivoting / side stepping
Landing on single leg
Injury 80% non-contact Pivoting / side stepping Landing on single leg Dr Ivan Popoff Knee ,

Dr Ivan Popoff Knee , Shoulder and Elbow Surgery

Mechanism of Injury
Mechanism of Injury
Mechanism of Injury Dr Ivan Popoff Knee , Shoulder and Elbow Surgery

Dr Ivan Popoff Knee , Shoulder and Elbow Surgery

Prevention of ACL Injuries • Not a random event • Preventable • Extrinsic and Intrinsic
Prevention of ACL Injuries
• Not a random event
• Preventable
• Extrinsic and Intrinsic Factors
Not a random event • Preventable • Extrinsic and Intrinsic Factors Dr Ivan Popoff Knee ,

Dr Ivan Popoff Knee , Shoulder and Elbow Surgery

Extrinsic Factors • Competition vs. Practice • Footwear and Playing Surface • Protective equipment •
Extrinsic Factors
• Competition vs. Practice
• Footwear and Playing Surface
• Protective equipment
• Meteorological conditions
Dr Ivan Popoff
Knee , Shoulder and Elbow Surgery
Intrinsic Factors • Anatomical – Small femoral notch Posterior tibial slope Neuromuscular Strength, proprioception
Intrinsic Factors
• Anatomical – Small femoral notch
Posterior tibial slope
Neuromuscular
Strength, proprioception
Coordination, Technique, Fatigue
Sex – Female 4 – 6x risk c.f. Males
Dr Ivan Popoff
Knee , Shoulder and Elbow Surgery
ACL Injuries in Females • Small Notch • Small Ligament • Hormonal factors ACL oestrogen
ACL Injuries in Females
• Small Notch
• Small Ligament
• Hormonal factors
ACL oestrogen receptors
Increased risk preovulatory phase of
menstrual cycle
Ligamentous laxity
Dr Ivan Popoff
Knee , Shoulder and Elbow Surgery
ACL Injuries in Females • Ligaments different mechanically – less stiff, lower elongation to failure,
ACL Injuries in Females
• Ligaments different mechanically – less
stiff, lower elongation to failure, lower load
to failure
• Lack of neuromuscular /proprioceptive
“growth spurt”
Dr Ivan Popoff
Knee , Shoulder and Elbow Surgery
Biomechanical Factors • Complex interaction between knee, hip, foot/ankle and trunk
Biomechanical Factors
• Complex interaction between knee, hip,
foot/ankle and trunk
• Complex interaction between knee, hip, foot/ankle and trunk Dr Ivan Popoff Knee , Shoulder and

Dr Ivan Popoff Knee , Shoulder and Elbow Surgery

Knee • Dynamic Valgus • Low flexion Angle – Increase d ACL elevation angle, defxns
Knee
• Dynamic Valgus
• Low flexion Angle – Increase d ACL
elevation angle, defxns hamstrings,
Increased PT – tibial shaft angle, decreased
force absorption
• Tibial Internal rotation
• Quads >> Hamstrings
• Tibial Internal rotation • Quads >> Hamstrings Dr Ivan Popoff Knee , Shoulder and Elbow

Dr Ivan Popoff Knee , Shoulder and Elbow Surgery

Hip • Adduction / internal rotation – dynami c valgus at the knee • Low
Hip
• Adduction / internal rotation – dynami c valgus
at the knee
• Low flexion angle – decreased ability to
absorb force
• Weak abductors
flexion angle – decreased ability to absorb force • Weak abductors Dr Ivan Popoff Knee ,

Dr Ivan Popoff Knee , Shoulder and Elbow Surgery

Foot / Ankle • Pronation / eversion • Internal tibial rotation • heel landing posture,
Foot / Ankle
• Pronation / eversion
• Internal tibial rotation
• heel landing posture, dorsiflexion
• Internal tibial rotation • heel landing posture, dorsiflexion Dr Ivan Popoff Knee , Shoulder and

Dr Ivan Popoff Knee , Shoulder and Elbow Surgery

Trunk • Center of mass passes laterally over the foot
Trunk
• Center of mass passes laterally over the
foot
Trunk • Center of mass passes laterally over the foot Dr Ivan Popoff Knee , Shoulder

Dr Ivan Popoff Knee , Shoulder and Elbow Surgery

Other Factors • Perturbance / unplanned movement • Fatigue
Other Factors
• Perturbance / unplanned movement
• Fatigue
Other Factors • Perturbance / unplanned movement • Fatigue Dr Ivan Popoff Knee , Shoulder and

Dr Ivan Popoff Knee , Shoulder and Elbow Surgery

Identification of Athletes at risk • Double Jump Test
Identification of Athletes at risk
• Double Jump Test
Identification of Athletes at risk • Double Jump Test Dr Ivan Popoff Knee , Shoulder and

Dr Ivan Popoff Knee , Shoulder and Elbow Surgery

Identification of Athletes at Risk Single leg Squat
Identification of Athletes at Risk
Single leg Squat
Identification of Athletes at Risk Single leg Squat Dr Ivan Popoff Knee , Shoulder and Elbow

Dr Ivan Popoff Knee , Shoulder and Elbow Surgery

Prevention ACL Injuries • Education – Downhill skiers 62% decrease • Proprioception training – Socce
Prevention ACL Injuries
• Education – Downhill skiers 62% decrease
• Proprioception training – Socce r 10 ACL c.f.
70 in control group n 600 (Caraffa et al
1996)
• Neuromuscular training – Basketball 89%
reduction in ACL tears over 8 years (
Henning 1990) knee flexion, multiple step
deceleration, rounded cutting
• 4 ‐ 6 weeks to gain benefit
Dr Ivan Popoff
Knee , Shoulder and Elbow Surgery
PEP Program • Prevent Injury and Enhance Performance • Santa Monica Ortho & Sports Med
PEP Program
• Prevent Injury and Enhance Performance
• Santa Monica Ortho & Sports Med
(Mandelbaum et al)
• No specialised equipment, 20min 3x /week
• Warm up
• Focus on avoiding movement patterns of
risk
• 6 – 8 weeks to gain benefit
Dr Ivan Popoff
Knee , Shoulder and Elbow Surgery
PEP Program • 14 ‐ 18 yo female soccer players 1041 PEP program 1902 control
PEP Program
• 14 ‐ 18 yo female soccer players
1041
PEP program
1902
control
First year 2 ACL c.f. 32 in control (88%)
Second year 4 ACL c.f. 35 in control (74%)
Age and skilled matched , not randomised
(Mandelbaum, Silvers,Watanabe Am J Spts
Med 2005)
Dr Ivan Popoff
Knee , Shoulder and Elbow Surgery
PEP Programme • NCAA womens soccer 1 season • Randomised 575 PEP programme 854 control
PEP Programme
• NCAA womens soccer 1 season
• Randomised
575
PEP programme
854
control
7 ACL in PEP group c.f. 18 in control
With increasing difference in second half of
season
(Gilcrest, Mandelbaum , Silvers 2004)
Dr Ivan Popoff
Knee , Shoulder and Elbow Surgery
Avoid ACL Injury • Avoid hip adduction/ IR • Increase hip flexion angles • Avoid
Avoid ACL Injury
• Avoid hip adduction/ IR
• Increase hip flexion angles
• Avoid dynamic valgus at the knee
• Increase knee flexion angles
• Balance Quads and Hamstrings
• Forefoot landing
• Hip, knee, ankle in line
• Multiple step deceleration
• Rounded cutting
Dr Ivan Popoff
Knee , Shoulder and Elbow Surgery
Avoiding ACL injury • Do something else Dr Ivan Popoff Knee , Shoulder and Elbow
Avoiding ACL injury
• Do something else
Dr Ivan Popoff
Knee , Shoulder and Elbow Surgery
Thank You Dr Ivan Popoff Knee , Shoulder and Elbow Surgery
Thank You
Dr Ivan Popoff
Knee , Shoulder and Elbow Surgery