My sections of lecture given to regional ATCs as part of Signature Healthcare's SportSmart program presented on March 31, 2016. Complete lecture included presentations by orthopedic surgeon Marshal Armitage, MD, FRCSC and athletic trainer Evan Chandra, LAT, ATC. -their sections not included here.

1. Understanding the Mechanics
for Prevention of Knee Injuries
Amy E. Goren, PT, DPT

2. Tibiofemoral Joint
Hinge Joint Movement: Flexion & Extension
•Close Packed Position: Nearly Full EXT
– Screw Home Mechanism: 0-20°
• Rotation of the Knee Itself
•Open Packed Position: 25° FLEX
Rotation and Alignment of the Knee are Controlled
by the Hip and Ankle

3. The Knee During Gait
http://www.utdallas.edu/atec/midori/Handouts/walkingGraphs.htm
http://www.oandp.org

4. Rotation of the Knee During Gait
• Knee FLEX during Loading Response
– CKC: Screw-Home Mechanism Reverses
• Anterior Femoral Glide and Femoral ER
– Tibia IR
• Pelvic Rotation of Loading
• Subtalar Pronation at Heel Strike
• Knee EXT during Mid-Stance
– CKC: Screw-Home Mechanism
• Posterior Femoral Glide and Femoral IR
– Tibia ER
• Pelvic Rotation of Stance
• Subtalar supination for Toe-Off

5. Reaction from the Ground
Movement Up the Kinetic Chain
•At Heel Strike: Lateral calcaneous everts
– causing Subtalar pronation
•Subtalar Pronation
– causes Tib-Fib Pronation (IR and ADD)
•Attributes to increased Knee Valgus
•Which continues up the chain to the Hips

6. Hip & Core Control Pronation
Need for appropriate Recip- and Co- CON and ECC
contractions of the whole LE
•Hip should decelerate the femur
– Decrease knee valgus moment
•Eccentric control for deceleration of gravity &
forces going to the ground
– Decrease Pronation
Muscles to Focus On:
Glut Max, Glut Med, Hamstring, Core (TA)

7. Image: https://www.pinterest.com/pin/280419514273905287/

8. The Hip and Patellofemoral Pain
Souze RB, Powers CM7
. January 2009
– Controlled Laboratory Study using cross-sectional design
•Hip Kinematics & Activity Level of Ms.
– Running, Drop Jump, Step Down
•Strength: Isometric torque production
With all activities Pt’s with PFP had:
Greater peak hip IR
Diminished hip torque production
14% Less Hip ABD and 17% Less Hip EXT strength
Significantly greater glut max recruitment

9. Gluteal Muscle Activity & PFPS
Barton, CJ et al1
. February 2013.
– A Systematic Review
•Ten case-control studies: Gluteal EMG with PFPS
•Gluteus Medius activity delayed & shorter duration
– Mod-Strong Evidence: During Stair Negotiation
– Limited Evidence: During running
•Gluteus Maximus activity increased
– Limited Evidence: During stair descent
“Delayed and shorter duration of Glut. Med. EMG may
indicate impaired ability to control frontal & transverse
plane hip motion.”

10. Exercise for PFPS
Clijen R. et al2
. December 2014
– Systematic Review and Meta-Analysis
•15 studies, 748 Participants
•Exercise Therapy
– Strong pain-reducing effects
– Decreases activity limitations & participation
restrictions
Which exercise is best at reducing pain and
limitations?

11. Effects of Neuromuscular Warm Up
LaBella C, et al.5
November 2011
– Cluster Randomized Controlled Trial
•90 Coaches and 1492 Athletes
•20min NM vs Usual Warm Up
– Intervention coaches used prescribed warm-up in 1425 of 1773
practices (80.4%)
•Significant Results!
“Coach-led neuromuscular warm-up REDUCES
noncontact LE injuries…”

12. LaBella5
Results
Injury Intervention Control P value
Gradual-Onset LE
Injury
0.43 1.22 <.01
Acute-Onset
NonContact LE
Injury
0.71 1.61 <.01
Noncontact Ankle
Sprain
0.25 0.74 = .01
LE Injuries Treated
Surgically
0 17 =.04
Rate per 1000 Athletic Experiences
Total of 28,023 Intervention AEs & 22,925 Control AEs

13. LaBella5
Results
Injury Rate 95% CI
Acute-Onset
NonContact LE
Injury
0. 33 0.17-0.61
Noncontact Ankle
Sprain
0.38 0.15-0.98
Noncontact Knee
Spains
0.30 0.10-0.86
Noncontact ACL
lnjuries
0.2 0.04-0.95
Regression Analysis Showed Significant Incidence Rate Ratios

14. Mechanics Screen
• Single Leg Hop & Hold (SLH) for Distance
– Dominant Leg vs. Non-Dominant Leg
• 3 Trails and Measured in cm
• Symmetry Index
– Mean DL/Mean NDL x100 = ___%
• Hands behind back?
• Able to hold landing for 2-3seconds?
• Limb Symmetry ≥ 85% ?

15. Mechanics Screen
• Drop Vertical Jump (DVJ) From 18”
– Do both feet hit the ground at the same time on initial
contact?
– Pronation of the feet on initial contact?
– Evidence of increased (M-L) knee motion during initial
contact?
– Evidence of increased (M-L) knee motion during the
final landing?
– Additional Comments or Observations?

16. Mechanics Screen
• Single Leg Squat (SLS)
– Pronation or Supination of the foot?
– Hip Internal Rotation or External Rotation?
– Knee Valgus or Varus?
– Able to maintain balance?
– Able to perform a set of 10 reps?

17. What we need to incorporate
• Dynamic Warm Up: At least 10-15min in length
• Balance Activities
• Tri-planar Exercises
– Hip Strength and Coordination
• Hops: Uni- and Bilateral
• Jump Landing Training
• Sport Specific Drills

18. References
1. Barton CJ, Lack S, Malliaras P, Morrissey D. Gluteal muscle activity and patellofemoral pain
syndrome: a systematic review. JOSPT. 2013. 47: 207-214. doi: 10.1136/bjsports-2012-090953
2. Clijsen R, Fuchs J, Taeymans J. Effectiveness of Exercise Therapy in Treatment of Patients With
Patellofemoral Pain Syndrome: Systematic Review and Meta-Analysis. PHYS THER. 2014; 94: 1697-
1708
3. Garrison C. The Hip and Knee Complex. Therapy Network Seminars. October 17-18, 2009.
4. Kim HY, et al. Srew Home Movement of the Tibiofemoral Joint during Normal Gait: Three-
Dimensional Analysis. Clinics in Orthopedic Surgery. 2015; 7: 303-309.
5. LaBella CR, Huxford MR, et al. Effect of Neuromuscular Warm-Up on Injuries in Female Soccer &
Basketball Athletes in Urban Public Schools: A Cluster Randomized Controlled Trial. ARCH PEDIATR
ADOLESC MED. 2011. 165, 1033-1040
6. McWilliams K. Evidence-Based Sports Enhancement Programs: From ACL Injury Prevention to Speed
and Agility Coaching. Cross Country Education. July 23-25, 2015.
7. Souza RB, Powers CM. Differences in Hip Kinematics, Muscle Strength, and Muscle Activation
Between Subjects With and Without Patellofemoral Pain. JOSPT. 2009. 39:12-19

19. ACL Rehabilitation
Amy E. Goren, PT, DPT

20. ACL Rehabilitation
No less than 6 month period
•ROM & Flexibility
•Muscular Strength & Endurance
•Gait Retraining
•Neuromuscular & Proprioception
•Return to Sport
Always Follow Protocol Provided by Pt.’s
Surgeon

21. 0-2 Weeks
Pt. education for weight-bearing status
Decrease pain & swelling
Increase ROM & restore full EXT:
Maintain hamstring and calf flexibility
Quadriceps activation:
Ex. Isometric and Quad/Ham co-contraction
Proprioceptive/balance re-ed:
Ex. SLS, Weight Shift and Wobble c Support
Gait:
2-1 Axillary Crutches maintaining normal walking pattern
Maintain cardiovascular fitness

22. 3-6 Weeks
Achieve near to full ROM
Full Bike, Prone Knee Stretch, Standing Stretches
Progress flexibility and strength
Ex. Fwd/Lat Step Ups 2-4”
Strengthen bilaterally
Ex. Wall Squats 40-60°
Proprioception progressions
Ex. Decrease Support
Gait: Full WB
Maintain cardiovascular fitness
May Start elliptical or Stair Master-No Hip Hiking

23. 6-9 Weeks
Full pain free ROM
Functional quad strength
Ex. ECC Lat Step Downs 2-6” & Static Lunge ¼ - ½ Range
Isokinetic quad strengthening
ONLY if full ROM, no swelling, adequate control, no meniscal or PFJ
pathology
Address quad deficits
High/Low Velocity, CON/ECC, 0-95°
Strengthening LE without pain
Ex. Full Wall Squat
Advance proprioception
Ex. BOSU Marches & Squats 60-90°
Increase cardiovascular fitness
Ex. Swim- Pool Jogging & Flutter Kick ONLY

24. 9-12 Weeks
Continue with flexibility
Mobilizations PRN
Quad strength progression
Ex. Static LungeDynamicWalking Lunge
Address hamstring deficits
High Speed, ECC 95-60°
Continue lower chain CON/ECC strengthening of quad and hams:
60-95° and Full ROM
Progress proprioception
Ex. Catch & Throw on Various Surfaces
Sport specific cardiovascular fitness
Ex. Treadmill +/- Incline  Quick Walk

25. 12-16 Weeks
Continue flexibility & strengthening
Sport Specific quad & ham strengthening
CON and ECC Ham & Quad- Full and Inner Range
Sport Specific proprioception training
Ex. Ladder Drills, 2 Legged Jumping
Sport Specific cardiovascular fitness
Ex. Jogging: Straight on flat ground NO cutting or downhill
STOP: If swelling, loss of motion or patellofemoral pain
Initiate 2 Legged Hop Tests:
Hop for Distance, 6m Timed Hop, Triple Hop, Crossover Hop

26. 16-20 Weeks
Sport specific quad, ham and lower chain strengthening
Ex. Plyometric and Agility Training with 2 1 LE progressions
*Watch Landing Mechanics*
Proprioception training
Ex. Maintaining balance for 5sec on Landing from Hops
Sport specific cardiovascular training
Ex. Running (Normal Painfree Stride) & Jogging c Turns
Hop Test:
Single Hop, 6m timed hop, triple hop, crossover hop

27. 20-24 Weeks
Adequate Fitness, Strength, Power, Agility and
Neuromuscular Control
Minimize Compensations
Back to sport practice for upper skills
Return to sport skills on own at practice
Minimal risk of re-Injury
Gradual return over 6-9months- NO PAIN or SWELLING
All Hop Tests within 15% of uninvolved side

28. Rehab. Compliance Improves Outcomes
Han F, et al. 3
2015
– Cohort Study, Level 3
•93 Recreational Athletes prescribed PT for 20 visits Post OP
•Outcome Measures: Knee Injury and OA Outcomes Score
(KOOS), Lysholm Scale and Short-Form Health Survey (SF-36)
– Pre and 1-yr Post OP
•Compliance: Fully >15, Moderate 6-15, Non <6 sessions
Greater compliance correlates with greater chance of return to
sport and improved knee function

29. OKC vs CKC Exercises
Ucar et al.2
2014
•58 Pts into Group 1: CKC and Group 2: OKC
•Outcome Measures: Pain VAS, Thigh Circumference, Knee FLEX
ROM and Lysholm Scale
– Pre-Op, 3month and 6months
•Values of CKC group were statistically significantly high
between groups in Lysholm and ROM scores
“CKC exercises are more effective than OKC at providing
mobilization & enabling a quicker return to daily and sporting
activities”

30. Neuromuscular vs. Strength Training
Risberg MA, et al4
, 2007
– Randomized Clinical Trial
•NT Protocol vs. ST Protocol
•Measurement taken at 3 & 6months Post-OP
– Primary: Cincinnati Knee Score
– Secondary: VAS for pain and function, 36-Item Short Form Health
survey, Hop Tests, Isokinetic Muscle Strength, Proprioception, and
Static and Dynamic Balance Tests
NT significantly better at 6month:
Cincinnati Knee Score & VAS Function

31. Neuromuscular Training Program

32. Strengthen Training Protocol

33. Common Compensations
Ernst GP, et al1
, 2000
•Scoring within normal on SL hop test but quad weakness?
•Evaluated LE kinetics during
– SL Vertical Jump (VJ)
– Lateral Step Ups (LSU)
•Examined hip, knee and ankle EXT moments
– Motion analysis and Force platform system
•Matched during LSU, VJ take-off and landing
•No difference in sum EXT moment
HIP and ANKLE EXT COMPENSATIONS

34. References
1. Ernst GP, et al. Lower- Extremity Compensations Following Anterior Cruciate Ligament
Reconstruction. PHYS THER. 2000; 80: 251-260
2. Fowler Kennedy Sport Medicine Clinic.. Physiotherapy ACL Protocol. Revised March
2009.
3. Han F, et al. Increased Compliance With Supervised Rehabilitation Improves
Functional Outcome and Return to Sport After Anterior Cruciate Ligament
Reconstruction in Recreational Athletes. OJSM. 2015; 3(12). doi:
10.1177/2325967115620770
4. Risberg MA, Holm I, Myklebust G, Engebretson. Neuromuscular Training Versus
Strength Training During First 6 Months After Anterior Crucuiate Ligament
Reconstruction: A Randomized Clinical Trail. PHYS THER. 2007; 87: 737-750. doi:
10.2522/ptj.20060041
5. Ucar M, et al. Evaluation of Open and Closed Kinetic Chain Exercises in Rehabilitation
Following Anterior Cruciate Ligament Reconstrunction. J.PHYS. THER. SCI. 2014; 26:
1875-1878. doi: 10.1589/jpts.26.1875