When an athlete hits the ground, current data tells us the ACL will tear within the first 60 milliseconds.
That’s why I’ve completely reframed my thinking of ACL injury as a sensorimotor integration issue, not a strength/biomechanical issue.
🧵
4 recent ACL papers all coming to a very similar conclusion.
Measures of dynamic knee valgus during common jump-landing assessments are poor indicators for future ACL injury.
Reminder…
It takes approximately 3 hours/week of consistent weight room training to reduce the risk of ACL injury by 50-60% in the youth female athlete
Is ACL injury really a biomechanics issue? Or perhaps "risky biomechanics" are really a downstream product of neurocognitive errors🤔
Note all 4 papers are from the past 3 years. Beginning to see a much needed paradigm shift in ACL injury risk...
Neuromuscular training programs reduce the risk of non-contact ACL injury by 64% in youth female athletes.
Main components:
- Strength and plyometric training
- 2-3x per week
- Training completed at pre-season AND in-season
ACL injury risk reduction..
🚫 Monster walks and hopping off boxes
✅ Heavy single-leg training and exposure to intense decelerations under conditions which stress visual attention, decision-making, and working memory
Spot the differences?
Further evidence supporting visual performance to be a risk factor for ACL injury.
Low visual fusion range (the ability to merge images from each eye into a single image) was the strongest internal ACL risk factor.
Non-contact ACL injuries = sensorimotor integration deficits.
Recent evidence indicates the primary biomechanical mechanism of non-contact ACL injury is axial compression (provokes tibial translation)
Knee valgus may be a secondary MOI, perhaps even occurring AFTER the ACL has already ruptured.
Major implications for risk reduction…🤔
Early aerobic activity post-concussion continues to be the strongest intervention for enhancing recovery trajectories in athletes, even when compared to usual care.
Figure from Hutchison (2022)
Watch enough video & you’ll come across a common theme in non-contact ACL injuries…
Athletes are visually distracted. Their attentional focus is on the stimulus in front / to the side of them (eg, opponent).
ACL injury = sensorimotor integration issue
The best summary for this paper is likely...
"A comprehensive warm-up performed multiple times per week is associated with a 60% reduction in ACL injury risk in adolescents"
Comprehensive = increase tissue temp + dynamic stretching + plyometrics + jump-landings / decelerations
This 2005 paper is perhaps the most cited ACL injury prediction research to date.
I figured it was past time to perform a deep analysis on this paper, especially given the information we’ve learned over the past 17 years.
Let’s kick this off…
🧵
Highly recommended read for practitioners working with athletes during ACL injury return-to-performance.
Really enjoyed how the authors considered multiple areas:
- Energy system reacquisition
- Objective load monitoring
- Sensorimotor/perceptual challenges
- Athlete-feedback
What is decision-making in team sports?
This article does a fantastic job overviewing a few different perspectives of decision-making. A heavy read, but worth it for those interested in sensorimotor performance.
Everything comes back to manipulating time & space!
Any "ACL screening" test must incorporate a neurocognitive component to have any sort of utility.
Otherwise, it's a large waste of time and resources.
Non-contact ACL injuries occur because of time and space constraints...
This 2016 paper has been a major influence on our Olympic sports science team.
If you want to get your athletes faster I would highly recommend giving this one multiple reads!!
I found this passage about the ACL to be very interesting (Duthon, 2006).
An ACL tears 40-60 ms after landing / cutting, way before an athlete consciously processes what occurred.
Those "bad biomechanics" you see = an athlete not having enough time & space.
🧵incoming...
20 year trends in ACL injury rates suggest continued exponential growth (Maniar, 2022).
Perhaps time to move away from laboratory-based research and allow clinicians / practitioners to lead ecologically valid investigations?
An updated list of the macro-level risk factors believed to be associated with ACL injury.
There are 34 listed here. Highly likely this list is missing some with further research.
This should give you an idea of the true complexity of ACL injury...
I was told a symbiotic relationship between academics & athletics was a pipe dream at the D1 university level.
“Too many silos”
Well, at the month 1 checkpoint we’re now providing a platform for our STEM students to engage in sports science initiatives.
Stay tuned… 🐅
How do ACL injuries occur?
To develop effective risk reduction strategies, we need to reverse engineer ACL injury.
Common ACL injury components include...
- Primarily non-contact
- Single-leg deceleration
- 40 - 80 milliseconds after ground contact
- Unanticipated conditions
To my knowledge, there are 24 papers that have examined the relationship between concussion and subsequent lower extremity injury.
96% of those papers have demonstrated a greater risk for lower extremity injury post-concussion.
This is across a wide variety of populations.
When researching a new topic, I always start with a literature summary table. Best thing I ever did in grad school.
Super simple and effective way to accumulate relevant literature. Also makes writing literature reviews and manuscripts super easy.
Highly recommend!
Interesting findings here...
Athlete attention was on the ball or the opponent in nearly 75% of these second ACL injury events.
Movement screenings without cognitive load or external attentional focus have little utility for determining ACL injury risk.
A few ACL nuggets…
- Injury occurrence is estimated at ~60ms after ground contact, likely before valgus
- Approx. 50% of non-contact ACLs don’t present knee valgus
- Overwhelming majority of prospective studies have not found knee biomechanics predictive of future ACL injury
Updated graphic (Oct '22) on the relationship between sports-related concussion and lower extremity injury.
90% of published studies have indicated a greater risk for LE injury after SRC.
Millions of research dollars have been spent targeting ACL injury reduction over the last 15 years.
Data from Koy (2023) indicate ACL injury incidence has increased over this time period.
ACL injury is a sensorimotor integration error.
Most common non-contact ACL injury scenario you see?
The athlete’s attentional focus is fixated toward external environmental stressors.
The error comes in judging when and how much muscular force is required to decelerate.
The bilateral drop vertical jump test has dominated the ACL injury risk screening literature for 20 years.
And yet, most data indicates this test is not associated with ACL injury.
Here’s a few of my thoughts as to why that is, as well as opportunities to advance ACL screening.
93% of published studies have demonstrated an increased risk for lower extremity injury post-concussion in athletes and military populations.
Practitioners should consider monitoring sensorimotor and psychological behavior beyond return-to-performance after concussion.
The more I read/study about ACL injury, the more I question my own knowledge about it.
Once you depart from thinking of ACL injury as a pure biomechanical injury, you gain a true appreciation for its unbelievable complexity.
New ACL paper... very interesting findings 👀
- Differences in knee valgus between injured & non-injured athletes detected 67 msec after ground contact, beyond estimated time injury occurs (17-50 msec)
- Knee valgus occurred in ~50% of injured athletes
New paper alert! 🚨
Sneak peek into recent data indicating visual-spatial attention identifies lower extremity injury risk in 400+ adolescent athletes.
Every 10ms ⬆️ in reaction time = 15% ⬆️ risk for injury.
These findings were independent of any biomechanical testing 🤔👀🧠
Full look into the very first Clemson Olympic Sports Science intern curriculum!
Mentorship is a big rock for our sports science program. Very 🔥'd up for this semester!! 🐅
Sports science can be generally thought of in two ways:
1) Research sports science
2) Applied sports science
Having been on both sides, here are the differences between the two…
Consider a few findings about the ACL...
1) Non-contact ACL injury occurs approx. 40-60ms after ground contact
2) Neuromuscular "ACL reflex" occurs approx. 110ms after ACL loading
ACL injury is a sensorimotor integration issue. Must consider the neurocognitive aspects🧠
Thoroughly enjoyed this article about incorporating cognitive load into ACL return-to-sport testing.
A largely untapped area that has tons of potential to better gauge athlete readiness throughout the rehab process.
Train the brain! 🧠
Important point for the next wave of sports scientists…
While GPS and other load monitoring devices provide valuable insights, the richest data comes from you actually attending training and competitions.
Important paper when considering ACL injury risk profiling and return-to-performance.
1) Reaction time, anticipation, and decision making heavily influence lower extremity biomechanics
2) Isolated movement tasks largely fail to elicit biomechanical deficiencies
🧠
Creating research summary tables were the best thing I did during graduate school.
Super effective way to stay organized and actually recall the most important aspects of the literature. Highly recommend for sports scientists.
Force-velocity and load-velocity sprint profiling are major points of emphasis for our Olympic sports science and S&C teams.
Pairing with high-speed video provides even greater insight.
Shoutout to
@BVNiznansky
for the awesome work on this! 🏃♂️🏃♀️💨
The first iteration of the Clemson Olympic Sports Science playbook is complete!!!
200 pages of technology and sports science goodies for our interns and staff. I anticipate this playbook will grow and evolve with our program.🐾
Findings from 7 different recent studies have come to a similar conclusion...
Knee biomechanical measures during laboratory-based jump-landing tasks have poor association with future ACL injury risk.
Seeing more evidence for single-leg RSI measures being great indicators of neuromuscular readiness post-ACL injury.
This recent study demonstrates RSI to be sensitive to residual deficits even though all athletes cleared LSI hop and gross strength tests.
The CMJ is one of the most common assessments in sports science.
Based off McHugh (2020), I'm starting to examine movement efficiency during the CMJ (done easily with
@HawkinDynamics
).
Example of a biomechanically efficient (left) and inefficient (right) CMJ.
Data on approx. 600 patients indicate anterior tibial translation is the primary biomechanical mechanism for ACL injury.
Max knee valgus likely occurs after the ACL tear. These findings should make you re-consider your risk reduction strategies...🤔
Each week I'll share a few slides / discussion points from our Clemson Olympic Sports Science internship program.
Week 1: What is sports science? Why are sports scientists needed?
There’s really not too many secrets in sports science.
Everyone is jumping on a force plate, collecting GPS data, etc.
It comes down to who can best contextualize the data and better inform the decision-making process. This where sports science groups separate themselves.
It's likely you're looking at too many GPS metrics to quantify external demands.
96% of the variance in Total Player Load is explained by total distance!
Data from ~1700 data points in WSOC.
Updated collection of research on the relationship between concussion and lower extremity injury.
96% of studies have demonstrated an increased risk for lower extremity injury post-concussion.
This relationship is often demonstrated well beyond clinical clearance.
There appears to be a relationship between visuomotor reaction time and non-contact lower extremity injury.
Below is a brief infographic on the topic.
Targeted visuomotor training may have substantial effects in athletes 👀 🧠
The Fall 2023 Clemson Olympic Sports Science playbook is here! 🐾🐅
418 pages (!) of sports science information and resources for our staff and students, including...
- Technology overviews
- Data dictionary
- Intern curriculum
- Research articles
...and much more
A lot of previous research attempts to "predict" ACL injury based upon an isolated risk factor.
The issue? It's much more complex than any single factor.
Here's 34 different variables I've come across that have demonstrated an association to ACL injury. Likely, there are more.
Very interesting findings in a fairly large athlete cohort at post-ACL injury.
- Passing thresholds of self-reported symptoms / knee function and psychological readiness = 3-4x more likely to return-to-sport
- Hop and strength tests = no association to return-to-sport
If often concluded that “bad biomechanics” = ACL injury risk
Example: peak ACL strain occurs within the first 30 degrees of knee flexion, so athletes have to avoid “stiff landings”
But we have to consider the unanticipatory nature of which ACL injuries occur…
🧵
GPS data provides an accurate representation of sport- and position-specific demands (velocity, acceleration, mileage).
It's a valuable tool for progressing an athlete through various stages of return-to-performance.
@BVNiznansky
has done a great job visualizing our GPS KPIs!
How does a sports scientist function within a collegiate setting?
Here’s a real-time look into a typical day.
6:15am…
- Breakfast
- Daily 2min HRV/subjective wellness measures and planned training load
- Checking all comms (email, slack, AMS, DevOps)
The drop-vertical jump (DVJ) is arguably the most researched assessment for ACL injury risk.
Brand new paper demonstrating knee kinematics and kinetics are influenced by a secondary cognitive task during the DVJ!
Think about the 🧠...
FWIW, this is all coming from someone trained in mechanical engineering with a masters and PhD in lower extremity biomechanics.
And I don’t believe ACL injury is a primary biomechanics issue. 🎤
While velocity and acceleration are valuable attributes in any field-based sport, I’d argue that deceleration is more important.
Elite deceleration ability is a performance enhancer and injury risk mitigator.
Some of the most elite-level athletes are elite-level decelerators.
Over the last few weeks I’ve seen more and more collegiate-level sports science positions become available.
The question becomes…
“What does a collegiate sports scientist do?”
Here’s a little deeper insight into this new and exciting position 🧵
As a sports scientist you'll likely read quite a bit of research.
I highly recommend creating personalized literature summary tables for each article you read.
This saved me tons of time throughout grad school and allowed me to aggregate similar research in a single location.
ACL injury risk + motor learning 🧠
Although the sample size was small, preliminary results indicate traditional linear learning methods (practice to achieve the "ideal" movement) was the least effective.
Manipulating task constraints can enhance athlete robustness.
FYI: There isn’t strong evidence to suggest female athletes are at greater risk for ACL injury due to anatomical and/or hormonal factors compared to males.
Those are cop out rationalizations not addressing the real issue in exposure to similar long-term training opportunities.
Interesting study examining how indirect contact influence ACL loading. Upper body contact was the most influential to ACL biomechanics.
Individuals landed 30-40 ms earlier on the contralateral limb after upper body contact, the initial time we think ACL injury actually occurs.
When examining biomechanical parameters related to non-contact ACL injury, it's likely best to start at the trunk/hip.
Excessive posterior and lateral shifts of the trunk/hip can heavily influence knee joint loading.
Brilliant figures from Sipprell (2012) and Powers (2010).
There is no strong evidence that dynamic knee valgus is predictive of future ACL injury.
Consider - approx. 50% of injured athletes do not demonstrate valgus during the first 60 ms of ground contact, the time in which we believe ACL injury occurs (Boden, 2021).
Neuropsychological readiness post-ACL injury should be a major component of return-to-performance.
- Fear of re-injury
- Anxiety
- Rumination
Often these measures outperform objective tests (eg, hop distance) in terms of having a greater association with subsequent injury.
Question I ask during every interview…
“How would you describe the role of a sports scientist?”
Answer I got this morning…
“A liaison to all staffs to help make the pieces fit together and tell the right story”
Best response I’ve gotten from a student!!
Want to be a better ACL injury practitioner?
Put down the same old drop-landing biomechanics paper that’s been published thousands of times.
Pick up some neuroscience research and learn more about the underlying sensorimotor processes that facilitate human movement.
🚨 Brand new paper 🚨
More evidence to suggest that sensorimotor performance (particularly visual-spatial attention) is associated with non-contact lower extremity injury in football and soccer athletes.
Ask your athletes to perform cuts under anticipated & unanticipated conditions. Film it.
You’ll likely see biomechanical changes at the trunk & knee.
What happened? Did the hamstring & glute med suddenly become weaker?
No - you’ve just introduced the 🧠 into the equation.
Athletes post-ACL injury are up to a 15x greater risk for re-injury (Paterno, 2012).
During return-to-performance, it’s important to consider the psychological & sensorimotor aspects of ACL injury.
Consider
- Anxiety/confidence
- Attentional focus
- Environment (drill design)
The secret of sports science is that it’s actually not driven by the field itself.
Sports science is driven by intuitive practitioners (S&C, sports med, nutrition, coaches) with questions and observations that are then answered by sports science.
This week our sports science team is examining GPS!
GPS is a powerful tool for many purposes
- training & game model description
- worst-case scenarios
- return-to-performance
- benchmarking
Below is a must read paper for practitioners and researchers utilizing GPS 📡🏃♀️
Millions of dollars have poured into ACL research, grants, and technology over the last 25 years.
Yet, ACL injury rates continue to climb.
This is demonstrated across all sporting populations, but particularly in adolescents.
The CMJ is likely the most frequent assessment in sports science.
- Preparedness
- Fatigue profiling
- Return-to-performance
We examined every CMJ in our 6 year
@HawkinDynamics
database to explore team normative values across a variety of metrics!
Read a lot of research in 2021 attempting to better understand my three main areas of interest (sensorimotor performance, ACL injury, and concussion).
A little 🧵 on some of my favorite reads on the year...
Sports science is a unique field that can be pursued by those with a diverse range of backgrounds and skill sets.
Below is a list of disciplines that may fall under the umbrella of sports science.
My own research (along with others’ awesome work) suggests vision, attention, anticipation, pattern recognition, & overall perception directly influence movement related to ACL injury.
The reason biomechanical studies fail to “predict” ACL injury? The above isn’t accounted for.
Vision is a hot topic in high-performance.
Here are a few reads I've found particulary enlightening.
Elite-athletes certainly demonstrate outlier visual abilities. The question becomes... how trainable are these qualities in the context of the sport environment?
Getting youth and adolescent athletes frequent exposure to strength training is the most beneficial thing that can be accomplished to reduce ACL injury risk. We have 20 years of data to support this.
Everything else is secondary during those crucial developmental years.
If you're in the business of collecting sports science and performance data, I'd recommend a data dictionary.
Helpful for onboarding /educating staff and students.
Our data dictionary describes macro-level metrics commonly communicated with each Olympic sports team.
Beginning to wonder if many non-contact ACLs stem from an athlete not being able to properly initiate a horizontal deceleration… 🤔
Visual stimulus overload (perception-action mismatch) 👀
⬇️
Delayed limb stiffness 🦵
⬇️
Rapid ligament loading 🩼
This article was a culmination of about 6 years of intense ACL research.
Greater understanding of how neurocognition & sensorimotor performance affects non-contact ACL injury will be the biggest leap forward of the past 25 years of ACL work.
My current research has led me to believe that perhaps we are somewhat ignoring another important contributor to ACL injury—the brain, says
@JasonAvedesian
. via
@SimpliFaster