Will New Programs Stem the Epidemic of Knee Injuries?

Laird Harrison


July 08, 2014

In This Article

New Programs Focus on Prevention

Around the world, other regimens were cropping up as well, and they have proliferated. Sue Barber-Westin, Director of Clinical and Applied Research at the Cincinnati Foundation, counted 50 of them in a recent literature review.[4]

Many of these regimens have proved themselves in clinical trials, in which some teams do the exercises and other teams stick to their usual warm-ups. Noyes and Barber-Westin showed that Sportsmetrics reduced the risk for noncontact ACL injuries by 88%-100% in soccer, basketball, and volleyball.[4,5,6,7,8,9,10,11,12]

"It definitely works," Barber-Westin says. "You can see in 6 weeks that you really can change these dangerous movement programs that you see in female athletes."

PEP achieved similar success, reducing the risk for ACL injuries by 82% in soccer alone.[4]

But the success of a program depends partly on the outcome measured. The HarmoKnee Preventive Training Program, developed by Swedish researchers, reduced the combined incidence of all types of acute knee injuries, including contact injuries, by 90% in soccer.[13] And exercises developed by researchers at the Norwegian University of Sport and Physical Education in Oslo, Norway, reduced the combined risk for lower extremity injuries in team handball by 47%.[14]

Other programs have reduced injuries in male athletes as well. Mandelbaum went on to help develop FIFA11+, a program for soccer's governing body, the Fédération Internationale de Football Association (FIFA), which cut overall injuries -- not just knee injuries -- roughly in half for male soccer players.[15]

The number of competing programs can be bewildering. But they have a lot in common.[4] They train athletes to land softly on the forefoot and roll back to the rearfoot, engaging the knee and flexing their hips on landing and when making lateral cutting maneuvers. They demonstrate how to avoid excessive genu valgum ("knock knee") on landing, squatting, and running.

Most of the programs also feature jumping exercises (plyometrics), as well as hamstring, gluteus medius, core, and hip abductor strength exercises aimed at correcting imbalances.[4]

"Soccer athletes are quad-dominant," says Holly Silvers, MPT, who worked with Mandelbaum on the PEP and FIFA programs. "They don't use their hip adductors a lot. And if the quad pulls against the ACL, if they don't have enough hamstring co-contraction, that creates an imbalance."

Some of the programs include stretching exercises; others don't.

The programs work differently, and their developers are each ready with arguments for why theirs is the best. For example, Sportsmetrics differs from most of the other programs in offering a six-week program of training for 90 minutes, three times a week at the beginning of the season. The Cincinnati foundation certifies instructors in the program.

In contrast, most other programs are based on participation throughout the season -- for example, as a 15-minute warm-up before practices. Barber-Westin argues that repeating the exercises multiple times per week will lead to poor compliance. "The athletes get bored," she says.

Holly Silvers has the opposite perspective. If athletes don't keep up the exercises, they become less effective over time, she says. "The reality is you lose compliance," she notes. "If you abandon them, you get recidivism. There is a benefit to continuous development over the season."

To prevent boredom, the FIFA11+ program offers 3 levels of some exercises so that athletes can challenge themselves to improve.


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