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[Physio Explained] Preventing ACL injuries: evidence-based strategies with Dr Brooke Patterson

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In this episode with Brooke Patterson we explore the prevention of ACL injuries. We explore:

  • What is involved within ACL injury prevention programs
  • The role of Nordic Hamstring Curls within ACL prevention
  • Importance of sports specific PREhabilitation and rehabilitation
  • Top recommendations for risk reduction of ACL injuries

This episode is closely tied to Brooke’s Practical she did with us. With Practicals you can see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster.

👉🏻 Watch Brooke’s Practical here with our 7-day free trial: https://physio.network/practicals-patterson

Brooke is physiotherapist and Australian Research Council Early Career Industry Fellow at the La Trobe University Sport and Exercise Medicine Research Centre. She completed her PhD in 2020 at the La Trobe Sport and Exercise Medicine Research Centre under the supervision of Professor Kay Crossley, investigating the impact of anterior cruciate ligament reconstruction (ACLR) on the lives of young adults (early osteoarthritis, symptoms and quality of life), and how potentially modifiable factors are associated with knee joint health changes over time. Her research program aims to prevent sports-related knee and head injuries, and reduce their burden, with a focus on women’s/girl’s Australian Football. 

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Our host is @sarah.yule from Physio Network

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SPEAKER_02:

ASL injury risk can be reduced by 40 to 50 percent and so you know getting out there and myth busting a little bit that they're not just a part of sport and they're not all contact a lot of them are non-contact and a lot of them can be prevented.

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Music

SPEAKER_01:

Can ACL injuries actually be prevented? And if so, what does the evidence tell us about the most effective strategies? To help us explore these questions, we're joined today by Brooke Patterson, physiotherapist and Australian Research Council Early Career Industry Fellow at the La Trobe University Sport and Exercise Medicine Research Centre. Brooke has published 46 peer-reviewed articles, secured more than$4.5 million in research funding, and combines her work as a researcher with lived experience as a former elite player, current coach, physiotherapy in academy level Australian football and someone who has personally sustained an ACL injury. She has also created a practical with Physio Network where you can explore this topic in even greater depth than we're able to in today's episode. Be sure to click the link in the show notes to access the practical for free with our seven day trial. You're going to love today's episode. I'm Sarah Yule and this is Physio Explained. Welcome to the podcast, Brooke. Thanks for joining us. Thanks for having me. We'll dive straight into the first question. We obviously see ACL injuries as something that every physio in sport encounters. Can ACL injuries actually be prevented? Well, what I probably would

SPEAKER_02:

say is the risk can be reduced is probably the phrase a lot of people in the field like to use, and this goes for all injuries. I don't think we're ever going to get to zero, but definitely there's really good evidence from lots of different clinical trials around the world across lots of different, mostly team sports, but even things like skiing as well, that you can reduce ACL injury risk by around 30 to 60, sometimes 70% in some trials. And then there's been systematic reviews that basically collate all the trials and evidence around the world that's ever been done. And there's lots of those systematic reviews of hundreds of thousands of athletes. And normally the estimate comes out around 40 to 50%. So for clinicians listening in, that's the stat I would take away. ACL injury risk can be reduced by 40 to 50%. And so, you know, getting out there and myth busting a little bit that they're not just a part of sport and they're not all contact. A lot of them are non-contact and a lot of them can be prevented.

SPEAKER_01:

That's a fantastic stat to be able to give. And it's probably worth our audience noting that as you've seen, prevention versus injury risk reduction.

SPEAKER_02:

And I guess the other thing probably clinicians and the teams that maybe hear these stats that we always say is you're starting to implement an injury prevention program this season, it doesn't mean that next season you're going to go down 50%. It's kind of a lot of these studies, it's the data collated over many seasons and many athletes. So over like a 10-year period, one year you as a team might have like three ACLs and then you might have like none for four years kind of thing. So I think it's also good for clinicians to put that disclaimer on a little bit, but also not being too hard on yourself as a clinician because injuries do happen and are a part of sport as well.

SPEAKER_01:

Fantastic. So when we actually look at the ACL injury prevention interventions, what do they typically include? Yeah, so

SPEAKER_02:

they typically include some warm-up and I'm going to say strength activities, but I'll come back to that term. And if we go through the warm-up activities, they typically are lots of multi-directional movements, lots of jumping and landing, changing direction, single leg balance, squatting. So things to, one, to get the body prepared for the session, but it's also the cumulative training effect of doing those types of movements. And maybe I thought going into prep to play, which was shown in the practical as an example of just a few more specific examples of the activities. So we have eight activities. The first one's going for a little bit of a jog and doing some dynamic mobility. A lot of typical warmups we would see in community sport in particular would be teams going for one or two laps, big long jog around doing a few leg swings. And we really want to try and get away from that and doing a little bit of that to get warmed up. But then if time is an issue, and we know that's the biggest barrier, getting a lot more focus on things like jumping and landing on one leg, single leg balance, changing direction, deceleration. In prep to play, we also have some contact-specific warm-up activities, so some grappling or tackling technique and also some falling and rolling and kind of some instructions on how to fall and roll. High-speed running is also really important, so we've got some sprints in there. And a lot of the other programs have very similar activities. activities in terms of the strength activities sometimes in the other programs these have done as part of the warm-up we recommend that teams replace their traditional cool down which again can be that typical lap around sit around and stretch at the end of training but we actually our motto is strength over stretch so get rid of some of the stretching not to say that it might work for some people but there's better evidence behind the strengthening a lot of community players aren't doing strengthening outside of sport their sports was a bit training so it's a really good opportunity for clinicians to empower their coaches to get a little bit of a dose of strength in and they aren't exercises that require equipment they can be all done as a team typically some kind of quad focused exercise so in prep to play we have the options of doing a lunge a partner single leg squat with a ball in between the ankles or a reverse nordic and then we have a hamstring focused exercise we really try and encourage them to get into the nordic hamstring lowers in that but we also have some bridge options as well and then Most of the programs also have a core component. So we have a part on the wheelbarrow in that kind of front plank position, side plank. And then we also have in that section, which is a little bit of a ductor as well, the Copenhagen adductor holds, which you get a little bit of core and obviously the adductor as well. So they're typically exercises that if you're choosing the Nordic, so we really try and encourage them to do the reverse Nordics, Nordic hamstring lowers, which you are actually getting a true kind of strength dosage if you're doing kind of two exercise they'd challenge it for most people whereas if you're doing like a squat or a lunge without any weight so maybe for some people you wouldn't actually be getting like at a strength dosage so we try and push people towards those eccentric exercises that are really quick and effective and they're not often things that probably people are doing as part of their normal gym program so often culturally it's really hard to get people to do the strength because they come to sport training to play sport not to be punished with playing some things so it is really hard to get by with this stuff so The education that we give coaches and players is that these things are actually really good to do on your training night because they're also like quite high load when you're doing these sprinting and kicking. And you're better off to probably do them on the same night and get that longer recovery and then do your like slower, heavier stuff on the other days of the week. And I think that's covered off like I think the main activities. Probably the only thing I wanted to add, Sarah, was that we don't really know what the critical ingredients are. So again, time is the biggest issue when sprinting. is often the thing that's not done. But at the moment, we don't really know the evidence. Is it the stream? Is it the warm-up? Is it particular activities that show those 40% to 50% reductions? And a recent systematic review that we did in BGSM, if you just Google making football safer for women, it shows that the multi-component programs were better. So compared to the programs that only focused on one particular type of activity. Some of the programs do include sport-specific activities. So the Warm-up and strength. But probably where we've got the most work to do in the field is trying to get that transfer of what we're doing in the warm-up and practicing those movements into our sport-specific situations because that's where the injuries happen in training and in games. So that was a big focus of us developing prep to play. We've got tackling, being tackled ground balls and aerial contests. And a big focus of that was more on the concussion piece that we also tried to time some of the deceleration and change your direction teachings from the warm-up into, say, a tackling drill. So across all kind of sports, a lot of ACL injuries happen on approach to a tackle. So in soccer, it's about when they're going up and pressing. It's very similar in Australian football, basketball, it's driving in and having to suddenly change direction. So I think trying to empower coaches, so you as a clinician, and having a look at the coach's training plan, are they actually designing drills that are going to expose the players to those more complex situations where they're happy to, in a real competitive situation, a few more different things going on, decelerate, change direction and trying to bring in some of those learnings from chopping your steps. So getting quick, but, you know, decelerate, chop your steps and not lunging and reaching for that tackle is where we get a big load on the lower limb, especially. And the coaches can try and tie in some of their skill efficient, like technical kind of cues as well that might help with this. So for tackling, for example, we were trying to get the coaches to encourage them to tackle with their body, not lunge and reach with their hands, which that really works for coaches. And in turn, if they're tackling with their body, they're not actually lunging and reaching with their hand and their leg. And you would get maybe some better preventative effects by trying to lean into more some of the coaching external cues than trying to, I think as physio, if we get a bit focused on that, you know, don't put your foot here, don't put your knee here. But if we can go, what cue, like actually ask the coaches, like what they do and is that going to achieve the same outcome that we want. The other thing is, yeah, like the ACL injuries don't happen in the warmup. So it's trying to challenge them in those more complex situations.

SPEAKER_00:

Thank you.

SPEAKER_01:

Fantastic tangible advice there, particularly for physios that are in that sporting environment. And it sounds like there's great value there in knowing when the ACL injuries actually do occur in each specific sport to be able to replicate it in programs.

SPEAKER_02:

Yeah, it's a good point. And that's part of the education that we would often give to coaches in our workshops so they understand, okay, oh, why aren't we doing jogging and stretching anymore? Why are we doing all this landing on one leg and change direction?

SPEAKER_01:

And it sounds like in terms of back Hopefully that education component of both players and coaches overcomes that perceived time barrier.

SPEAKER_02:

Yeah, 100%. I think the other, yeah, the time is the biggest barrier. The lack of relevance to the sport is probably the other number one. And just the coach confidence and skills, which is, I think, where we might get to chatting about these physios really have a role to get involved with because they're just a bit unsure that they have the skills. So just empowering them to go and give these programs a go and provide I think a bit of practical training is where I think clinicians have a big impact.

SPEAKER_01:

I'm curious to tease that out a little bit more. For the physios that are listening who want to really nail their ACL risk reduction, what would be your top recommendation?

SPEAKER_02:

The first thing I had written down was just to get involved. And what that might look like is to begin with, it might just be with individual patients within the clinic. They might have come in for a mild ankle sprain or some patellofemoral pain. It should be maybe part of your subjective assessment and return to train return to play planning and trying to understand what they do as part of their individual team warm up and strengthening and if they're not hitting what we would say is evidence-based and what we've talked through today then it might be one providing the links to that individual athlete or it might be offering to come down to their club and provide some practical training and workshops and what we've done in our trial and others around the world is yeah go down and it might be anywhere from kind of 60 minutes to a couple of hours depending on the team's preferences and yeah 10-15 minutes of education and then a lot of like actually going out on the field and practicing the activities and yeah really just empowering the coaches that they can't really stuff it up they're pretty low risk things to implement and just doing something is better than nothing and it's definitely better than that too slowed laps around the field so get involved to increase your confidence and knowledge and skills if you're listening to this podcast you're probably halfway there but there's obviously lots of research articles out there but we're reaching out to any of the authors that are on those papers that have developed the sport-specific program. We're always really happy to share resources. You don't have to reinvent the wheel and come up with all the education points. We've got so many PowerPoint slides and handouts and cheat sheets and things that we could share with clinicians who want to go out and give this stuff a go. So do, yeah, I'm happy to share contact details. Do reach out if you're interested in this space. You could give an in-service. A lot of clinics will do journal clubs and things like that. So you might want to just start practicing in front of your peers and delivering some of the education and showing the activities because it is a very different skill set to talking one-on-one with a patient to get in front of a whole team of, I think the other week I had under 12 boys and that was organized chaos. So don't be disheartened if they're not all listening to you either. And then probably just understanding the context and tailoring and adapting to the context. So that might be age group, competition level, the sport, the individual your coach and their attitudes and beliefs. And then just get some feedback. Every time I do it, you learn something and you're like, oh, I should have done that. And you get better each and more confident each time and do it.

SPEAKER_01:

And that's sort of the best component of zooming out on our roles as physios, isn't it? We're always learning and always adjusting and adapting to what we've done.

SPEAKER_02:

100%. So

SPEAKER_01:

it's sounding like in terms of resources and tools that physios can check out to perhaps provide to teams, obviously reaching out to authors like yourself Are there any other resources that you would usually send them or direct them towards?

SPEAKER_02:

Yeah, I mean, you can normally get to things on the internet pretty quickly. If you know the sport and want to type into it, you should get into the right spot. But I do have a big long list of all different sports and the links to all their sports specific programs. I'll give a shout out the new edition of the Clinical Sports Medicine, the Bruckner and Kahn is going to have a table of all the different programs and how they're linked to the different sports in there. So maybe keep an eye out for that. I mean, on our The Trope Her a sport website we've got a page with different links to different programs as well and I mean not every sport has like their own program and like I said the core components of them are quite similar so you can probably look at one look at what they're already doing they might be ticking off like a lot of the things already and then it might be just providing some advice oh you're just missing these kind of things like add these two or three things into your warm-up get some strengthening

SPEAKER_01:

well Brooke thank you so much for your wisdom today and helping us unpack what risk reduction actually looks like and hopefully prompting some swapping out of stretching with some strengthening. And for all those listening, you can absolutely dive deeper on this topic with Brooke's Practical with Physio Network. So if you click the link in the show notes to access the practical for free with our seven-day trial, you can dive a whole lot deeper. But thank you, Brooke. That was very helpful. Thanks so much, Sarah.