2001 Proprioceptive Training and Prevention of Anterior Cruciate Ligament Injuries in Soccer

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Journal of Orthopaedic Sports Physical Therapy

2OOl;3l(ll):655-66O

n

Proprioceptive Training and Prevention of

Anterior Cruciate Ligament injuries

G.

Cerulli

MD s

D.

I Benoit

MScl

A.

Caraffa

MD1s2

Ponteggia

MD3

--- - --,,- 7 *-. , ..-.

-*.,-. .

This commentary describes a program developed to help reduce the incidence of anterior

cruciate ligament injuries in soccer players The basic principles underlying the injury

prevention protocol are described with respect to the proprioceptive control mechanisms at

the knee joint This is followed by a detailed description of the program Orthop Sports

Phys Ther .?OOl;3 :655 660.

ey

Words: injury prevention knee joint proprioception

n our experience, the anterior cruciate ligament (ACL) injury

rate of soccer players not trained in injury prevention is 1.15 per

team per season compared to players trained with a propriocep

tive training program (0.15; < 0.001) in groups matched for

practice and game exposure over 3 years.' Not surprisingly, the

ACL injury causes the greatest financial expense and highest number of

player days missed in the sport.'*JJ s in most sports, ACL injuries in

soccer occur from both contact and noncontact situations. Most ACL

injuries occur between 0 and 30 knee flexion,SzJ primarily in noncon-

tact situations during running and jumping. In running, the move-

ments associated with the injury include change of direction, rapid de-

celeration, spontaneous stopping, and torsional movements. In j u m p

ing, the movements include landing with varus and internal rotation

stress or valgus and external rotation stress.

Currently there is little research that identifies the critical phases of

these movements that cause injury. However, recent advances with in

vivo ACL strain measurement during rapid deceleration have confirmed

that the rapid deceleration movement, such as when a player unexpect-

Let People Move Biomechanics Laboratory Perugia Italy.

Department of Orthopaedic Surgery University Hospital of Perugia Italy.

Lecturer Physical Medicine and Rehabilitation University of Florence Italy.

Send correspondence to Daniel Benoit Let People Move Via G.B. Pontani

9

Perugia Umbria

06

128

Italy. E-mail: [email protected]

edly stops, causes a high level of

strain on the ACL, which initiates

at foot contact when the leg is

most e~ te nd ed .~lthough this

study confirms that the ACL will

be

in high stress situations during

sports, the point at which injury

may occur is still unknown. The

injury mechanism is triggered

through an interaction of kine-

matic and kinetic variables that, by

definition, can only be altered by

changing either the external or

internal forces acting on the body.

In a noncontact injury situation,

the external forces may be altered

by shoe-playing surface interface,

as this is the only point at which

an external force may act on the

body. The internal forces are gov-

erned by bone on bone forces, lig-

ament and soft tissue, and mus-

cles. Muscle contractions generate

the forces acting on the bones,

which alters the position of body

segments and also greatly affects

joint stiffness. When referring to

alterations of postural control or

body position, it thus implies an

associated alteration in neuromus-

cular control.

C o p y r i g h t © 2 0 0 1 J o u r n a l o f O r t h o p a e d i c & S

p o r t s P h y s i c a l T h e r a p y ® . A l l r i g h t s r e s e r v e d .



PROPRIOCEPTION ND THE KNEE JOINT

In ord er to describe the proprioceptive system, we

must first discuss the issue of proprioception. A pro-

prioceptor may be described as a sensory receptor

that can detect stimuli generated by the system it-

self. Many authors have demonstrated the existence

of mechanoreceptors and free nerve endings in sev-

eral parts of the knee joint. These receptors provide

the basis for the proprioceptive feedback system that

would allow adaptive changes to occur during pre-

ventive training programs, thus helping in the pre-

vention of knee injuries during sports. For a proprio-

ceptive training program to function, the premise is

that adaptations will take place based on the stimuli

the proprioceptors receive during or prior to initia-

tion of the deleterious movement. This information

will alter the possibly programmed response in a

manner that modifies the mechanical conditions act-

ing on the ACL. For this to occur, the injury mecha-

nism, or pattern of movement, must be recognized

by the sensory control system as deleterious. A cor-

rective response must then be initiated to modify the

movement of the involved limbs in a way that reduc-

es or alters the stresses applied to the ACL by apply-

ing a different movement strategy. This implies an al-

tered neuromuscular response, as the only way to al-

ter a movement pattern is to modify the internal

forces applied to the system, that is, by changing

muscle activation patterns.

Currently in the literature, the evidence supports 2

main views of where the corrective response may be

initiated:

(1)

via peripheral feedback from sensory

receptors or (2) based on preplanning through the

central nervous system.Vt is beyond the scope of

this commentary to discuss these views; however, a

theme common to both views is that training may al-

ter the neuromuscular response to unexpected per-

turbations. This indicates that, in some way, the feed-

back derived from sensory input may be modified to

alter neuromuscular response. It is possible that the

structures within the ACL9.'R.242H.x'nd soft tissues

within and around the knee jointl.H.10.1W. .2(i.27.21) may

provide sensory information that could contribute to

the proprioceptive system.

PROPRIOCEPTION ND THE NKLE JOINT

Along with the knee, the ankle is an important

joint to consider in the prevention of ACL injuries,

as it will have a direct influence on tibial orientation

and, thus, the position of the ACL. Freeman and

Wyke14 found type I, 11, and receptors in ankle

joint capsules and type I, 111, and receptors in an-

kle ligaments in cats. Lynch et al tested 10 unin-

jured subjects with a tilt platform to reproduce quick

ankle inversion and plantar flexion by recording

muscle contraction latency with surface electromyog-

raphy. The results showed that increasing the range

of motion of plantar flexion-inversion augments the

latency response of the peroneus muscles, while in-

creasing inversion velocity reduces the latency time

in these same muscles. Sheth et alJ1used surface

electromyography to investigate the effect of proprio-

ceptive training on the activation pattern of ankle

muscles during simulated ankle sprains in nonim-

paired subjects. They concluded that 8 weeks of exer-

cises on an ankle disk (15 minutes per day) led to

selective modulations in the sequence of muscle con-

traction. The pretrained athletes showed simulta-

neous activation of anterior and posterior tibialis,

peroneus longus, and flexor digitorum longus mus-

cles, whereas in posttraining there was delayed activa-

tion of the inversion muscles, thus allowing the pero-

neals to counteract the sprain.

These studies demonstrate the importance of using

ankle disk exercises in an injury prevention training

program. Exercises on a disk cause quick ankle

movements that may be similar to those occurring

prior to or at the time of injury. This sensory input

may lead to improved kinesthesia (sense of move-

ment) and proprioception (sense of position), fac-

tors that may be important for injury prevention.

Based on the information described here, we de-

fine a preventive proprioceptive training program as

a series of exercises o r situations that will elicit a re-

sponse from the nervous system in order to counter-

act external stimuli. The program must be progres-

sive and include both situations controlled by the

athlete and those that change based on extrinsic fac-

tors. For example, directional changes elicited by

coaching instructions or bases of support disturbed

at random intervals are both situations that necessi-

tate a neuromuscular response to effectively counter

the stimuli.

TR INING ND PREVENTION

Knee joint alignment is directly affected by the

kinematics of the hip and ankle joints. For example,

sensory feedback and motion control at the foot and

ankle will directly affect tibial loading and orienta-

tion, thereby predetermining the condition in which

the ACL will be loaded. It is, thus, possible for knee

injury prevention to be initiated not at the knee but

at the ankle. The same situation is present with re-

spect to the hip and femoral loading and orienta-

tion. Postural control following a perturbation or in

preparation for movement of a nonrelated segment

is not limited to the lower limb; instead, it is con-

trolled by a complex interaction of anticipatory and

preparatory contractions also seen in the arms and

trunk muscle^ ^^^ Horak and Nashner17 have found

that altering the base of support from a normal sur-

face to one that is short in relation to foot length

will cause the control strategy to shift from the ankle


p o r t s

P h y s i c a l T h e r a p y ® . A l l r i g h t s r e s e r v e d .



TABLE

Proposed training program.

Training

level lmtructiom Frequency

Level 1 Balance training without a 2.5 min 41d 3lwk

board 1-legged stance on the

ground)

Level

2

Balance training on a rectangu- 2.5 min 41d 3lwk

lar balance board each leg

alternately)

Level 3

Training on

a

round board 2.5 min 4/d 3lwk

Level 4 Training on a combined round 2.5 min 4ld 3/wk

and a rectangular board

Level 5 Training on a multiplanar board 2 5 min 4ld 3lwk

to the hip, respectively, as well as the base of s u p

port. Therefore, any training for the prevention of

knee injuries must take into consideration these oth-

er links in the kinetic chain of the lower limb, s

well

s

upper body postural control mechanisms.

Muscle fatigue seems to induce proprioceptive de-

teriorat i~n.~. ' ~herefore, the training program

must also include enough exercise sequences to elicit

fatigue and train these responses. Hamstring activity

appears to help reduce anterior tibia1 displacement

at certain joint angles and should also be stressed

during the training program. Further evidence of the

important role of the hamstrings may be deduced

from the fact that there is a greater latency of muscle

contraction in ACMeficient knees compared not

only with control groups of nonimpaired subjects,

but also with the uninjured contralateral side in the

same patient. The correlation between latency and

functional instability (frequency of giving way) in pa-

tients with ACL deficiencyJ insinuates that this func-

tion could play a protective role. Evidence that the

reflex hamstring contraction latency time can be re-

duced by performing proprioceptive exercises with

the aim of improving speed and facility of hamstring

contractions further supports the principles of injury

prevention training. A training program including

weight-bearing exercises and a progressive reduction

in stability (wobble board, eyes open and then

closed) with increasing repetitions and rate of con-

tractions appears better than a traditional program

of muscle strengthening (non-weight-bearing and

graduated weight-resisted exercises) in improving re-

flex hamstring contraction latency and dynamic joint

stability2 A functional exercise program (training of

leg muscles while bearing weight and of trunk mus-

cles to improve coordination, postural reactions, and

endurance) also appears to improve standing balance

in patients with ACL deficiency.%

Proprioceptive training must be performed

throughout the range of joint motion; this is impor-

tant because the mechanoreceptors seem to be acti-

vated selectively at specific angles.20Muscle receptors

play a primary role in the intermediate range of mo-

tion, while joint receptors and muscle receptors are

FIGURE

1. Step-downs off of the training board.

more important in the extreme ranges of motion.

Muscle training focused on building endurance,

strength, and power is important along with the pro-

prioceptive programs. Hewett et all demonstrated

the importance of plyometric training in preventing

knee injuries in female athletes, reducing the injury

rate from 0.43 per 1000 exposures to 0.12 P

0.05), following a &week jump training program. A

Swedish study by Tropp et al,3%owever, demonstrat-

ed that coordination training might help to prevent

functional instability, reducing the frequency of ankle

sprains in athletes with previous ankle injury. The

training program was composed of exercises per-

formed on a disk with a spherical undersurface, with

one leg straight and the other raised and flexed at

the knee while the arms were placed over the chest.

The training time was 10 minutes

5

times weekly for

10 weeks, then 5 minutes 3 times weekly; the length

of the study was 6 months. Comparing proprio cep

tively trained and control groups, both composed of

players with previous ankle problems, the difference

in reinjury was significantly lower in the trained

group (5% vs. 25%;

P

0.01).

Following these same principles, our group applied

similar methods to determine if it is possible to re-

duce the incidence of ACL lesions in soccer players

by adding proprioceptive exercises to traditional train-

ing programs. In a prospective controlled study by

Caraffa et a17 of 600 soccer players (semiprofessional

or amateur teams), we evaluated the possible preven-

tive effect of gradually increased proprioceptive train-

ing during 3 soccer seasons. A control group of 300

J Orthop Sports Phys Ther Volume

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.Number l .November 2 1





FIGURE

2. Example of the proprioceptive neuromuscular facilitation ex

ercises.

players w s trained traditionally, without specific bal-

ance exercises, while the experimental group of 300

players followed a proprioceptive training program.

During 3 soccer seasons, 10 arthroscopically verified

CL

lesions occurred in the proprioceptively trained

group , while 70 were recorded in the traditionally

trained group P 0.001). The training program

used in this study, and today, is described below.

The experimental gro up was instructed to train 20

minutes per day, with 5 levels of difficulty (Table).

Each phase of training was performed for 3 to

6

training days, depending on proficiency, and all

FIGURE 4.

Use of multiplanar board along the oblique axis.

training sessions lasted for a t least 30 days. The ath-

letes had to demonstrate proficiency in each phase

before progressing to the next level. This was selfde-

termined based on the instruction that they could

perform the exercises without the need for addition-

al support (the other foot or hand) in a consistent

manner and without fear of falling.

In addition, the subjects were instructed to per-

form anterior and posterior u ps te p exercises while

standing on the training board. F this exercise, the

subjects used the free leg to step off of the board,

barely touching the floor with the free foot, and

then returned to the standing position (Figure

1 .

This was repeated in a controlled manner and forced

the subject to maintain balance over a wide range of

knee joint angles. All subjects also took part in p r e

prioceptive neuromuscular facilitation exercises for

the lower limb, assisted by a trained technician (Fig-

ure

2).

These proprioceptive neuromuscular facilita-

tion exercises were performed as part of the regular

FIGURE 3.

Multiplanar board configuration.

stretching routine during practice sessions. The tech-

nician performed these knee and hip exercises on

J Orthop Sports Phys Ther-Volume 3 Number -November 2 1





FIGURE 5 Increased training difficulty with 2 boards.

the subjects with the subjects in a supine position,

and the exercises included passive movements of

flexionextension, internal-external rotation, abduc-

tion-adduction movements, and combinations there-

of. The subjects were then asked to reproduce these

same movement patterns unassisted active move-

ments). These exercises were meant to increase sub-

ject awareness of limb position; however, this effect

was not measured or quantified.

The subjects were also instructed to follow a modi-

fied version of the neuromuscular facilitation pro-

gram described by Hervkou and Mksskan.I5 This con-

sisted of using both a circular and a rectangular

board. The rectangular board, with

spheres placed

obliquely o r along its longitudinal axis, allowed for

movement along 3 axes Figure 3) , depending on

the patient starting position and sphere placement.

The subject was instructed to perform forward lung-

es with deep knee bends using the rectangular board

along all 3 axes. The subject had to maintain the po-

sitional alignment of the knee above the foot no in-

ternal or external rotation of the hip and control of

foot pronation and supination) Figure

4).

The de-

gree of difficulty was increased by stepping off of a

raised height eg, a stair) ont o the board and per-

forming the lunge to maximal knee bend. The sub-

ject would then perform the exercise by stepping off

of the circular board, keeping the trailing leg on it,

ont o the rectangular board, or vice-versa Figure

5).

Although not part of the original prevention pro-

gram, additional tests may be added to further in-

crease the degree of difficulty. These movements

could place the athlete in safe but unstable situations

that mimic the movement patterns known to cause

injury, such as hopping onto the training board, thus

training the athlete to adapt to unexpected situations

Figure

6).

FIGURE 6 Increased difficulty by hopping onto the training board.

CONCLUSIONS

Our previous results have indicated the potential

to reduce the incidence of CL injuries in soccer

players; however, more work is necessary to optimize

these prevention protocols. multifaceted approach

should be applied and customized based on the

needs of the athlete. The goal is to provide an inter-

esting and challenging routine that puts the athlete

in situations that force a reaction to expected and

unexpected changes in the environment. Using the

techniques described, along with other innovative a p

proaches, we believe that the incidence of CL inju-

ries in soccer players can be reduced.

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Orthop Sports Phys Ther Volume 31 Nu mb er 11 November 2001



2001 Proprioceptive Training and Prevention of Anterior Cruciate Ligament Injuries in Soccer

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Transcript of 2001 Proprioceptive Training and Prevention of Anterior Cruciate Ligament Injuries in Soccer