ACL Injuries No Longer a Career - Ender

This post originally appeared on the TD Athletes Edge blog on January 24, 2018 - my first guest post!  Special thanks to Tim DiFrancesco for the invitation and the learning opportunity.  

When it comes to scientific research, anecdotal evidence is lowest on the hierarchy of resources.  As a clinician, it is vital to review higher levels of evidence, but sometimes it’s impossible to ignore what you witness.  There are numerous publications reporting higher incidence of ACL injury in females compared to males, and there are also studies that outline the outcomes to these athletes.

When I was the manager for the Cheshire High School (Connecticut - GO RAMS!) Girls’ Basketball Team, my friend tore her ACL going for a breakaway layup and landing in a heap on the floor.  A few years later, as a team manager for UConn Women’s Basketball (Go Huskies!), I was standing three feet away from a player when she changed directions during a drill and dropped to the floor with a yelp…torn ACL. After an ankle sprain you're back to playing in a week or two… but with these injuries mean you're out for almost a year. 

Rosemary Ragle was the Athletic Trainer for UConn Women’s Basketball for 18 seasons.  She was kind enough to share with me that in her tenure, 6 athletes (average of 1 every 3 seasons) tore their ACL and she also treated several others, at least 6 more, who had the injury prior to arriving on campus needing rehab.  Of the six that were injured at UConn, all of them returned to the team roster and most moved on to play professionally. 

James Doran, the current Men’s Basketball Athletic Trainer at UConn has been there for 12 seasons.  He confirmed what I had read in this Hartford Courant Article that he had worked with two athletes (average of 1 every six seasons) who tore their ACL in a Husky jersey. AJ Price, later played eight years in the NBA and Terry Larrier is currently the team’s 2nd leading scorer.

After UConn, I spent four seasons with the Connecticut Sun WNBA team.  During that time, four Sun players (average 1 per season) tore their ACL either in a Sun jersey or while playing overseas.  All four recovered and played again at an elite level including one winning a 2016 Olympic Medal.  I asked Tim DiFrancesco how many Lakers guys had torn their ACL in his six seasons in the NBA: Zero! Basically – there’s a boatload of anecdotal evidence with a small sample size that demonstrates females are injured more often than males. At the end of the day, though, most of these injured athletes ultimately made it back to their previous level of competition.

My graduate research studied lower extremity injuries in the WNBA and (former) Big East Conference Women's Basketball Teams. Previous studies showed that ACL injury was uncommon: 3-5% of basketball players, but that was because it was looking at how many athletes were injured in a season.  From that perspective, sure, it's rare to tear an ACL. But my research looked at a large sample of women’s basketball players (246) over their whole career and showed that almost 25% of these athletes had experienced the injury, some of them multiple times.  25% doesn't sound so rare to me. These athletes were all currently playing in Division I College Basketball or in the WNBA at the time of their participation having overcome an ACL injury. 

To my knowledge, a study of this type has never been conducted in the NBA, but based on this 2006 article, the WNBA experiences more ACL tears than the NBA. A CBS Sports7 report from 2013 outlined that in each NBA season, up to 5 players (out of 491 roster spots) tear an ACL which is about 1% of all the players in the league. At that time, this was an increase to previous NBA seasons. If a set of teammates don't both experience the injury, 25 teams out of 30 will go through the season unharmed. I wish I had the access and approval to do my study in the NBA to see how many of these guys have ever torn their ACL in their whole career – and then made it back.  My suspicion is significantly less players have been injured in the NBA than in the 25% in the WNBA, and the majority have made it back to playing.

Twenty years ago, and sometimes still today, an ACL tear was considered a career-ending injury. It’s still devastating because of the time lost from sports and school for the injured athletes, lost work time for parents, costs, extensive rehabilitation, pain and potential long term physical and mental consequences.  Though it is easy to see the gender disparity, these injured athletes mostly return to basketball and are able to excel at a high level of competition.  Why these outcomes have improved is largely speculative, but since we started out anecdotally, why not suggest reasons for the improvement?

Perhaps surgical techniques such as physeal sparing in the youth population and the trend towards more bone-patellar tendon-bone grafts over hamstring grafts or allografts is a contributor to better outcomes.  When there is not additional internal derangement to the meniscus, it is likely that more accelerated protocols for early range of motion and weight bearing in rehabilitation are getting these athletes back into shape quicker.  There is research on return to sport protocols which have improved the process of assessing injured athletes to make sure they’re ready for return, hopefully preventing recurrence of injury.  There have been studies examining mechanical faults during ACL injuries as well as muscular imbalances that increase risk of injury which can be treated by physical therapy.  The development of more ACL Injury Prevention programs has been increasing and groups are working hard to get them disbursed that this may be improving outcomes.

Why does any of this matter?  It matters because even though these injured athletes make it back to their sports, there are a large percentage of them that could be preventable.  There is now ample research showing that ACL injury prevention programs reduce the risk of injury.  Newly released in January 2018 is the National Athletic Trainer’s Association Position Statement on ACL Injury Prevention which is the most up-to-date data on evaluating the levels of evidence that support the importance of participation in these programs.  It outlines that participation in an ACL injury prevention program can reduce the risk of ACL injury 52-61% but it can also reduce risk of other injuries, too. If your child, particularly middle-school or high-school aged is participating in a sport, ask their coaches if they’re doing a program with their team.  If they’re not, have your child independently examined by a physical therapist, a skilled strength and conditioning team such as at TD Athletes Edge, or consider some of the following resources which may be helpful:

1) Seattle Pediatric Sports Medicine ACL Injury Prevention Program: http://seattlepediatricsportsmedicine.com/injury-prevention/injury-prevention-warm-up-program/injury-prevention-routine/

2) FIFA 11 ACL Injury Prevention Program: https://www.kort.com/uploadedFiles/KORT/Content/Services/Sports_Medicine/Concussion_Management/FIFA-the-11-Booklet.pdf

3) Cincinnati’s Sportsmetrics ACL Injury Prevention Program: http://sportsmetrics.org/

4) As a parent or coach, watching an ACL Injury Prevention Program and trying to implement it with your child/team is not enough.  A skilled clinician should be implementing it or checking the movement patterns.  This is imperative.  Ask a local physical therapist or skilled strength coach to watch your child’s movement to assess their risk for injury and to develop a program tailored to their needs to decrease their risk.

References 

1)      Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: Summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42(2):311–319. PubMed

2)      Deitch JR, Starkey C, Walters SL, Moseley JB. Injury risk in professional basketball players. A comparison of women’s national basketball association and national basketball association athletes. Am J Sports Med. 2006;34(7):1077–1083. PubMed doi:10.1177/0363546505285383 7. https://www.ncbi.nlm.nih.gov/pubmed/16493173

3)      Renstrom P, Ljungqvist A, Arendt E, Beynnon B, Fukubayashi T, Garrett W, et al. Non-contact ACL injuries in female athletes: An international Olympic Committee current concepts statement. Br J Sports Med. 2008;42:394–412. PubMed doi:10.1136/bjsm.2008.048934 http://bjsm.bmj.com/content/42/6/394

4)      Gordon AI, DiStefano LJ, Denegar CR, Ragle RB, Norman JR. College and Professional Women’s Basketball Players’ Lower Extremity Injuries: A Survey of Career Incidence. IJATT. 19:5 (22-35). September 2014.  http://journals.humankinetics.com/doi/pdf/10.1123/ijatt.2014-0020

5)      Padua DA, DiStefano LJ, Hewett TE, Garrett WE, Marshall SW, Golden GM, Shultz, SJ, Sigward SM, National Athletic Trainers’ Association Position Statement: Prevention of Anterior Cruciate Ligament Injury. Journal of Athletic Training. 2018; 53(1).

6)      Hartford Courant Article: Dom Amore. UConn Men’s Insider: Doran is a trainer with patience, but too many patients. January 31, 2017.  Accessed January 9, 2018. http://www.courant.com/sports/uconn-mens-basketball/hc-uconn-men-insider-james-doran-0201-20170130-story.html

7)      CBS Sports Article: Ken Berger. ACL Injuries Once Were Rare Occurrences in the NBA But No More: October 4, 2013. Accessed January 12, 2018. https://www.cbssports.com/nba/news/acl-injuries-once-were-rare-occurrences-in-nba-but-no-more/

Book Alert: Deep Nutrition By Dr. Catherine Shanahan

I just finished reading Deep Nutrition by Dr. Catherine Shanahan.  Fascinating stuff.  And if Kobe Bryant endorses it, as one of the few who was able to play NBA elite level hoops for 20 years, it has to be worthy of a few weeks of my reading time, right?

A few snippets that I found fascinating from this book:

1) Nutrition can affect genetics in later on generations but these may not be permanent changes.  The idea that DNA and genes are a series of light switches turned on or off by what is available is novel to me.  One example in the book describes a 1930 study conducted using pigs that were deprived of vitamin A before they reproduced.  The litter of these deprived pigs were born without eyeballs because the mother had no supply available and vitamin A is essential to formation of the eye.  The blind piglets, however, were fed normal diets that contained vitamin A and they were able to give birth to pigs with eyeballs. Unreal!

2) The science of food is considered with respect to the biochemistry of oils and how certain ones (particularly vegetable oils) are dangerous for consumption. Dr Cate shows how vegetable oils have multiple double bonds in their chains which break apart when heated leaving reactive compounds in our bodies that can wreak havoc on the system. My inner chemistry nerd loved trying to comprehend the complexity that she simplified here.  Additionally, there is a lengthy discussion of the science of all the ways vegetable oils can affect the body- and none of them sounds good!  This book is a challenging read- even with boat loads of science learning behind me, I had to really work to gain full understanding of some of the biochemistry going on- but it is definitely making me think about my food in a new way.

3) Following oil, the book went on to discuss the negative effects of sugar consumption. After completing five rounds of the whole 30, I'm positive that my body hates sugar... though my mind continues to crave it and give in to the temptation of its deliciousness. Discussions of how sugar influences cholesterol levels, diabetes, migraines, erectile dysfunction, and cardiac issues were outlined. I doubt I’ll ever be able to completely exclude my favorite treats from my diet, but the anecdotes and research outlined in this book will certainly make me think more about the treats I’m consuming and whether or not they’re worth it. 

4) Consider food as medicine. If you focus on what we eat as the problem, it might be hard to realize that food is also the solution.  The book looks at a few conditions - particularly concussion, Alzheimer’s, and autism- and discusses how oxidative stress contributes to these diagnoses. Did you know that what you eat after a concussion can impact your potential recovery because certain foods increase oxidative stress on the brain which it is already overloaded with from the injury? I had never thought about it from that perspective, and I treat people who have experienced concussions!  The book outlines "The Human Diet" with the four key components of what you should be eating. 

Overall, I definitely recommend the book but think it’s only fare to mention it felt like hard work to get through some of the heavy science portions. Ultimately I’m so glad I did and will definitely be applying some of the principles I learned to how I eat and cook.

Check it out!  Next up to read: "The Origin of Species."

Hip Hinge 101 Course

On November 12th, I had the opportunity to attend a Hip Hinge 101 Course presented by Matthew Ibrahim (@MatthewIbrahim_) from TD Athletes Edge (@TDAthletesEdge) and Zak Gabor (@SimpleStrengthPhysio from Boston PT and Wellness (@BostonPTWellness).  These fellas were kind enough to bring the East Coast to the West Coast!

How did they fill the day?  They started with a focus on pain science - vitally important in the physical therapy/rehabilitation world as well as to be considered for strength and conditioning coaches.  They followed up with discussions around the word selection we use with patients.  The conclusion was lifting some heavy stuff in various ways.

Pain Science:
Zak presented a thorough discussion of the basics of pain science a la Adriaan Louw and several others.  It was a great summary and he used some excellent analogies to help drive his points across.  My personal favorite was a slide with two photos of USA Soccer Player Clint Dempsey - in one he's got his arms up and he's screaming with joy from a big goal to win a game and in the other he's looking down at the ground following the ball bouncing off the post and losing the game... No World Cup for USA Soccer.  But let's say that Clint had broken his ankle taking both of those shots.  Would his pain be the same if he was in a moment of elation as if he was in a moment of sadness and disappointment?  Based on pain science - the likely outcome would differ based on the emotional overlay.

The definition of pain has been evolving.  Zak presented the 1994 definition of Pain by Merskey and Bogduk: "Pain is an unpleasant sensory and emotional experience which follows actual or potential tissue damage, or is described in such terms." which has been updated in 2016 by Williams and Craig to "Pain is a distressing experience associated with actual or potential tissue damage with sensory, emotional, cognitive, and social components."  Both of these definitions highlight that pain is an experience but the new definition opens the gates for the psychosocial components that impact pain.

Recently in the clinic I've been seeing more chronic pain patients.  My focus on learning with regard to chronic pain and pain science has been a new topic of focus for me - but without understanding pain, these patients cannot be properly educated sufficiently to get them back to full function.  I'm looking forward to reading more resources about chronic pain to include that information here, and I'm grateful that this course took the opportunity to begin their presentation with this lens.

As for the hip hinging and deadlifting - it was really great to see various ways to break down the hip hinge in differing positions and using different equipment.  I had never tried using TRX bands for the upper body as a component of a hip hinge.  I'd previously never seen the "Squat-Hinge Continuum" the spectrum of exercises that range from hip dominance to quad dominance.  There's certainly benefit to training the front and the back sides of the legs - and to properly learning the patterns.  But for me, the biggest take away of the program was the importance of the pain science.

Anybody else taking  any classes I should check out?

More soon...