I did not write this title to scare you. I wrote it to get your attention. There is a dirty little secret in sports that statistically you cant hide from. There are between 100,000 and 200,000 ACL tears in the united states annually and right around 70% of those are sports related (1). Although there are more total ACL tears in males, females are 2-8x more likely to tear their ACL's than males.
Several factors are speculated to increase risk of ACL injury in females including lower extremity alignment (wider pelvis, knee valgus, foot pronation), joint laxity, hamstring flexibility, muscle development, hormonal differences, and ACL size (4,6). These are the facts stated in the research, but that is not what I want to discuss here in this post.
What needs to come to the forefront is a phenomenon in sports that we refer to as benign neglect. We see this in a number of sports and it is essentially the acceptance of certain injuries as "just a part of the process", as opposed to trying to change the situation for the better. I have given talks in the past about this benign neglect in the sport of hockey when it comes to groin pulls and sports hernias. For years it has been forged into the culture of hockey that groin pulls will happen, and so much so that they are commonly referred to as "training camp injuries", but this topic is for a future post. Creating change oftentimes takes people who are outside the culture of the sport to stand up and call out a situation of benign neglect.
Today I will discuss this topic in the sport of high school girls basketball, and I'm sure you have already figured out that the injury topic will be ACL tears. This discussion was sparked by a meeting I had last week with a local girls basketball player who tore her ACL this past season and her mother. This was a very open and honest conversation and we discussed her recovery process, but there needed to be more this time. I said "this time" because Andrea has been here before. Last year at this time Andrea had just finished up her post-rehab program with me at Lewis Fitness & Performance. During the spring of 2014 she tore her left ACL during the AAU basketball season, she began her recovery program with us in August of 2014.
By April she was cleared to play basketball and began another grueling AAU schedule full of tournaments and travel. Her schedule did not allow for her to continue in a strength & conditioning program of any kind, and when her basketball team began their pre-season work here at LFP she was tied up in her golf season. She managed to get 3 or 4 sessions with the team, despite having a great golf season where her team won the state championship. She displayed that her strength was still being maintained and things were looking great heading into the fall. But as a strength & conditioning coach you always worry about the athletes you have guided through their recovery when they haven't been able to work consistently with our program. And what you worry about most is the knee on the opposite side of the surgery, as that knee is statistically more at risk then the surgically repaired one.
As the season begins more bad news as one of the freshmen, Addy, tears her ACL in the first game of the season.
Several factors are speculated to increase risk of ACL injury in females including lower extremity alignment (wider pelvis, knee valgus, foot pronation), joint laxity, hamstring flexibility, muscle development, hormonal differences, and ACL size (4,6). These are the facts stated in the research, but that is not what I want to discuss here in this post.
What needs to come to the forefront is a phenomenon in sports that we refer to as benign neglect. We see this in a number of sports and it is essentially the acceptance of certain injuries as "just a part of the process", as opposed to trying to change the situation for the better. I have given talks in the past about this benign neglect in the sport of hockey when it comes to groin pulls and sports hernias. For years it has been forged into the culture of hockey that groin pulls will happen, and so much so that they are commonly referred to as "training camp injuries", but this topic is for a future post. Creating change oftentimes takes people who are outside the culture of the sport to stand up and call out a situation of benign neglect.
Today I will discuss this topic in the sport of high school girls basketball, and I'm sure you have already figured out that the injury topic will be ACL tears. This discussion was sparked by a meeting I had last week with a local girls basketball player who tore her ACL this past season and her mother. This was a very open and honest conversation and we discussed her recovery process, but there needed to be more this time. I said "this time" because Andrea has been here before. Last year at this time Andrea had just finished up her post-rehab program with me at Lewis Fitness & Performance. During the spring of 2014 she tore her left ACL during the AAU basketball season, she began her recovery program with us in August of 2014.
By April she was cleared to play basketball and began another grueling AAU schedule full of tournaments and travel. Her schedule did not allow for her to continue in a strength & conditioning program of any kind, and when her basketball team began their pre-season work here at LFP she was tied up in her golf season. She managed to get 3 or 4 sessions with the team, despite having a great golf season where her team won the state championship. She displayed that her strength was still being maintained and things were looking great heading into the fall. But as a strength & conditioning coach you always worry about the athletes you have guided through their recovery when they haven't been able to work consistently with our program. And what you worry about most is the knee on the opposite side of the surgery, as that knee is statistically more at risk then the surgically repaired one.
As the season begins more bad news as one of the freshmen, Addy, tears her ACL in the first game of the season.
As we have been blessed with working with a number of basketball teams and countless individual basketball stars from the area, this was a lightbulb moment as it was seen as just a normal accepted step in the process of girls high school basketball. Then January rolled around and Andrea tore her right ACL, just as we talked about the "other knee" is the one to be concerned with (3).
So Addy and Andrea have started down the road to recovery. These are two of the hardest working young ladies that we have worked with here at LFP so I have no doubt that they will do fantastic. Here are some of the activities that these two have started back doing in there first week.
So Addy and Andrea have started down the road to recovery. These are two of the hardest working young ladies that we have worked with here at LFP so I have no doubt that they will do fantastic. Here are some of the activities that these two have started back doing in there first week.
 Cook Band SL Glute Bridge |  USB Bench Hip Raise |  Valslide Eccentric Leg Curl |
But I want to shift gears here as when it comes to the talk I had with Andrea and her Mom we went to a different place. I've worked with Andrea in the past and her Mother obviously knows her better than anyone, we both have no doubt that she will persevere and leave here everyday better than she arrived; that's how she rolls. The question came up as to why Andrea was back in the same situation she was a year and a half ago?
I was completely open and transparent with them. I told them how I felt when Addy hurt her knee, and how I was heading down the road of "benign neglect" thinking that you should probably expect 1 ACL per year, and a freshman who is being exposed to a top notch high school girls basketball program for the first time would be more prone to it. Plus her injury was not a complete non-contact related tear. Then when Andrea went down my heart sank. She had worked so hard.
The first thoughts were that of self reflection. I put our program in front of the mirror and dissected it, ripped it apart for answers as to why this would happen to a young lady that did so well in our program. Had the program changed since she went through it...YES. I will never be able to look back through 7 months of programming and say we haven't changed anything in our program because it is always evolving and improving. But there was nothing to question that was not right on point with those leading the industry in both rehabilitation and sports performance training. The program was not/is not the issue... consistency was.
I was completely open and transparent with them. I told them how I felt when Addy hurt her knee, and how I was heading down the road of "benign neglect" thinking that you should probably expect 1 ACL per year, and a freshman who is being exposed to a top notch high school girls basketball program for the first time would be more prone to it. Plus her injury was not a complete non-contact related tear. Then when Andrea went down my heart sank. She had worked so hard.
The first thoughts were that of self reflection. I put our program in front of the mirror and dissected it, ripped it apart for answers as to why this would happen to a young lady that did so well in our program. Had the program changed since she went through it...YES. I will never be able to look back through 7 months of programming and say we haven't changed anything in our program because it is always evolving and improving. But there was nothing to question that was not right on point with those leading the industry in both rehabilitation and sports performance training. The program was not/is not the issue... consistency was.
"ACL return to play protocols are broken! When the doctor fully clears you what it need to state is you are cleared to PREPARE TO PLAY."
When it comes to ACL recovery programs the plan follows a very conservative protocol that if followed will return the athlete to full activity typically between 40 and 50 weeks. We have been successful getting athletes cleared to return to play as early as 26 weeks. This is not typical and a case that bares mentioning because it is an extreme case and it brings about a change that MUST be made in the ACL recovery protocols. In this case the athlete was CLEARED to return to play at 26 weeks. We had been working with this athletes from 14 weeks post surgery. In three month there was tremendous progress made but only the beginnings of change of direction and higher intensity eccentric loading from a jumping/landing standpoint. She was cleared to PLAY and the season began. She did not continue with her program and (luckily) did not have a setback during her season. If this was my daughter who was CLEARED to return to play at 26 weeks, she would not have returned to the basketball court full time. The criteria to be cleared are often times only based upon a bilateral isokinetic strength comparison of rapid contractions of the quadriceps and hamstrings within 90% of the non-surgically related limbs strength out put. What this tells you is she is cleared to PREPARE TO PLAY.
This is the most important point of this post, and is the missing step in all return to play protocols. When you get CLEARED from your doctor it is now time to fully immerse yourself in a sound strength & conditioning program with no restriction. As a strength & conditioning professional we can now set a progression that will teach an athlete to control their body in a controlled environment to relearn to change direction and then progress to and open, reactionary environment, that is as close to the basketball
court as we can get as far as mimicking the sport environment. At this point we can give the athlete complete confidence that they are fully rehabilitated. At LFP we will have completed a thorough movement evaluation, including the Functional Movemet Screen, to determine movement competency and compensation patterns to aide in the development of their program. But this program must continue, even in-season, as any backtracking in strength/stability/mobility or compensation away from the previously injured ACL will put the other leg statistically in jeopardy.
This is the most important point of this post, and is the missing step in all return to play protocols. When you get CLEARED from your doctor it is now time to fully immerse yourself in a sound strength & conditioning program with no restriction. As a strength & conditioning professional we can now set a progression that will teach an athlete to control their body in a controlled environment to relearn to change direction and then progress to and open, reactionary environment, that is as close to the basketball
court as we can get as far as mimicking the sport environment. At this point we can give the athlete complete confidence that they are fully rehabilitated. At LFP we will have completed a thorough movement evaluation, including the Functional Movemet Screen, to determine movement competency and compensation patterns to aide in the development of their program. But this program must continue, even in-season, as any backtracking in strength/stability/mobility or compensation away from the previously injured ACL will put the other leg statistically in jeopardy.
One of of the biggest areas of concern when it comes to correcting the benign neglect in the sport of girls basketball is in the springtime. Most coaches see the value of pre-season programs in the fall for their teams. Get their bodies physically prepared for the demands of the high school season. This includes practice or games 5-6x/week from November through the end of March (if you're good). But then immediately comes the AAU season. Not as notable as the high school season but a very close second, especially when it comes to recruiting. This season places an even bigger physical/mental demand on the athletes as they don't practice as much and if successful play weekend tournaments with sometimes 5-6 games in a weekend! This culminates in the month of July, which is an open recruitment period that sees these ladies travel the country playing tournament after tournament with the added stress of recovery. You can call the travel environment a team bonding experience, which I agree with, but it also disrupts the natural recovery strategies that we preach (sound sleep schedules, proper nutrition) and this on top of a huge physical demand can produce the perfect storm for potential injury. This time period is just, if not more, important that the high school pre-season to include a physical preparation program to ensure safety of the athletes.
Consistency is the linchpin in this equation. Getting back to the conversation with Andrea, I told her she can never stop her training. She has 4 Division I offers and 2 ACL surgeries under her belt. I was up front with her and told her the truth... If she tears another the potential to increase her offers will be gone and the 4 offers would likely decrease. I gave her my honest opinion but she already knew. I also told her she must be consistent and I would do whatever was needed to continue her development. This will lead to decreased sleep for us at LFP because I am almost certain we will see her at 5:00am this fall during golf season, because she is a fighter and she knows now that the fight can never stop.
I titled this post the way I did to get your attention, but I also titled it because I never want to enter one of MY daughter's sporting events and have that question cross my mind. And I also don't want anyone to have to console their daughter/son the way that Scott is for Addy in the picture above. I know that won't happen, injuries will always be a part of sports. But I also know we can decrease the likelihood of that happening through scientifically based programming, sound coaching technique, and consistency.
Consistency is the linchpin in this equation. Getting back to the conversation with Andrea, I told her she can never stop her training. She has 4 Division I offers and 2 ACL surgeries under her belt. I was up front with her and told her the truth... If she tears another the potential to increase her offers will be gone and the 4 offers would likely decrease. I gave her my honest opinion but she already knew. I also told her she must be consistent and I would do whatever was needed to continue her development. This will lead to decreased sleep for us at LFP because I am almost certain we will see her at 5:00am this fall during golf season, because she is a fighter and she knows now that the fight can never stop.
I titled this post the way I did to get your attention, but I also titled it because I never want to enter one of MY daughter's sporting events and have that question cross my mind. And I also don't want anyone to have to console their daughter/son the way that Scott is for Addy in the picture above. I know that won't happen, injuries will always be a part of sports. But I also know we can decrease the likelihood of that happening through scientifically based programming, sound coaching technique, and consistency.
- American Academy of Orthopaedic Surgeons, July 2007, Anterior Cruciate Ligament Injury: Surgical Considerations, http://orthoinfo.aaos.org/topic.cfm?topic=A00297#A00297_R4_anchor (July 11, 2008).
- Griffin LY. Noncontact Anterior Cruciate Ligament Injuries: Risk Factors and Prevention Strategies. Journal of the American Academy of Orthopaedic Surgeons. 2000;8:141-150.
- Hewett TE, Myer GD, Ford KR. Anterior cruciate ligament injuries in female athletes: Part 1, mechanisms and risk factors. American Journal of Sports Medicine. 2006 Feb; 34(2):299-311.
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