On Guard

Multiple-plane, multiple-joint workouts are the key to an effective defense against ACL injuries.

By Vern Gambetta

Vern Gambetta is the President of Gambetta Sports Training Systems in Sarasota, Fla. A frequent contributor to Coaching Management, he can be reached through his Web site: www.gambetta.com.

Coaching Management, 13.6, August 2005, http://www.momentummedia.com/articles/cm/cm1306/onguard.htm

Injuries to the anterior cruciate ligament (ACL) are among the most catastrophic in sport, and are especially prevalent in basketball. They always seem to happen when they’re least expected, and the long recovery that follows is nothing less than grueling.

While exercise physiologists and physicians continue to study the whys and hows of ACL injuries, coaches have been most interested in preventing them. The good news is that raised awareness to the problem has increased attention to strategies for injury prevention. From small studies to large-scale NCAA-funded research, clear guidelines are emerging on how to prevent these injuries.

I’ve reviewed the studies from the last few years and offer some suggestions here on developing ACL injury-prevention programs for your athletes, both male and female, high school and college. I also provide a warmup protocol that incorporates many of the most effective prevention exercises.

Studying the Studies
There are many theories as to why females suffer more ACL injuries than males. But there is no question that the knee is vulnerable regardless of gender. It is not designed for some of the movements athletes ask from it on a consistent basis.

The emphasis on ACL prevention needs to be on multiple-plane, multiple-joint work that puts a premium on balance and proprioception in functional, sport-specific positions. Instead of focusing on the knee alone, we need to address the entire kinetic chain to better reduce force on the joint. We must shift our thinking away from traditional exercises and training methods that emphasize force production to a more balanced program involving force reduction and proprioception. The emphasis needs to be on training integrated movements, not isolated muscles.

An important but often ignored fact is that 70 percent of knee injuries, regardless of gender, are non-contact. The typical mechanisms of these non-contact injuries are planting and cutting, straight-knee landing (no flexion on landing), hard one-step stops with the knee hyperextended, pivoting, and rapid deceleration. These are all movements that occur with high force and at high speed, and though they usually happen very quickly, athletes can be trained to make them more efficiently as part of a comprehensive prevention program.

There are two common threads in recent studies on ACL protection: first, that athletes need to improve balance, proprioception, and the mechanics of movement, and second, that plyometrics and strength training are effective preventatives of injury. In simpler terms, these studies show that almost anything that strengthens the muscles around the knee and develops proprioception will significantly reduce the incidence of ACL injury. The logical conclusion is that with more focused, longer-term, sophisticated intervention, the possibility of prevention and performance improvement should be even greater.

Making It Specific
With input from scores of other performance coaches, I developed the Lower Extremity Prevention & Performance Program™ to help address these types of injuries. The key to the success of this program is in how the exercises are adapted to the specific needs of your athletes, their positions on the court, and most importantly, the qualities of each individual athlete. (For a full program that can be used at any level of play, see “A Look at LEPPP” below).

How can you take the protocols for lowering ACL injuries and adjust them for your team? Depending on the level of play, time factors, and the athletes, you’ll want to adapt the program accordingly.

Let’s start by examining time factors, since this is the top concern of many coaches. The studies clearly show that a significant time commitment is a key factor in any ACL injury-prevention program. Spending 20 minutes on injury prevention two or three times a week is not enough—some form of training needs to be covered five days a week.

If it’s difficult for you to set aside half an hour of every practice for injury prevention, I suggest breaking down the training components into modules that can be completed at other times. These modules should be designed to fit within a time frame compatible with the other training components your athletes must accomplish. The logical place to begin is in warmup, because the warmup is a necessary component of every training session. Other exercises might be incorporated into drills done during the heart of practice, and athletes can also be given some of the simpler modules as “homework.”

After examining time factors, take a look at your individual athletes. What do they do on their non-training days? How active are they? What was their prior activity level and movement background before they started your sport? Athletes who have grown up playing youth basketball and spend weekends playing pick-up games with family and friends will have an advantage over those whose exposure to sport comes only through the team’s games and practices.

Injury history is also a key factor. If an athlete has a history of lower-extremity sprains and joint laxity, start with a more remedial program. In this case, initial stages should look more like a rehab program.

Another factor I’ve been looking at recently is style of play. Although I’ve seen no studies on this, anecdotal evidence suggests that athletes who play out of control are more likely to injure their ACLs. You may want to think about the difference between an athlete who hustles and an athlete who plays without regard to proper body positioning and mechanics.

Putting It All Together
All of the successful ACL-prevention programs share a few key components: mechanics of movement, proprioception, plyometrics, and strength training. They can be translated into the following five modules:

• strength/power, including basic strength, core strength, elastic/reactive strength (plyometrics)
• balance/proprioception
• agility, including body awareness, footwork, and change of direction
• dynamic flexibility
• sport-specific conditioning.

Here’s how I combine these modules and fit them into different parts of the year and different sections of practice:

Off-season: I recommend one hour, three to four times a week, with an emphasis on strength training and balance/proprioception work at first, followed by a gradual shift to include agility and plyometric training.

Preseason: Every day before practice, do 15 to 20 minutes of work as a warmup that includes balance/proprioception, agility, and plyometric training. After practice, do 20 to 30 minutes of strength training three times a week.

In-Season: Before practice, continue the preseason plan of 15 to 20 minutes of work as a warmup that includes balance/proprioception, agility, and plyometric training. Post-practice workouts can be reduced as the season progresses. In the early season, do 20 minutes of strength training three times a week; in midseason, 20 minutes of strength training twice a week is recommended; and during the late season and playoffs, do 10 to 15 minutes twice a week.

Here are some additional tips for designing your own program:

• Use minimal equipment to avoid equipment becoming a limiting factor.

• Use drills that are easy to teach and easy to monitor.

• Design a training program that is progressive and varied.

• Teach landing and stopping mechanics before plyometric and agility training.

• Focus part of your strength training on force reduction work, which can be accomplished through a heavy dose of strength training that emphasizes fast eccentric muscle action performed in postures and positions similar to sport movements.

• Remember that training is cumulative. There is no single workout or component that will ensure success, but rather the sum of all workouts and the interaction of all components.

One last tip is about communication: Educating your athletes in the importance of injury prevention is a crucial part of gaining their trust in your program. If you can teach the “why,” the “how” will follow as your athletes provide their own motivation and make compliance with the program a meaningful experience for your entire team.

Similar versions of this article have appeared in other editions of Coaching Management.

Table: A Look at LEPPP
The following details the portion of the Lower Extremity Prevention & Performance Program™ that I designed to be used as a warmup before practice. It can vary from 15 to 20 minutes in length.

Side step x 20
Forward walk x 20
Carioca x 20
Monster walk x 20

Single-leg squat
• Sagittal
• Frontal
• Transverse

Balance Shift
• Step to the side
• Step forward
• Step back
Note: do one rep at each position, hold 10 seconds.

Jackknife x 5
Creepy crawl x 5

Lunge A
• Lunge forward and reach up
• Lunge to the side and reach up
• Rotational lunge and reach up
Lunge B
• Lunge forward and reach out
• Lunge to the side and reach out
• Rotational lunge and reach out
Lunge C
• Lunge forward and reach across
• Lunge to the side and reach across
• Rotational lunge and reach across
Note: Reaches should be both to the right and the left. Do two reps with each leg in each plane. Combinations of A, B, and C should be varied from day to day.

Crossover skip
Side step
Carioca (low and long)
Carioca (short and quick)
Backward run
High-knee skip
High-knee skip w/rotation
Note: Do three reps of each exercise the length of the basketball court.

Jump in place (over line)
• Forward/back x 10
• Side to side x 10
• Rotational x 10 each side

Hop in place (over line)
• Forward/back x 10
• Side to side x 10
• Rotational x 10 each side

Multidirectional jump
• Forward/forward/side/side/opposite side/side/back/back x 2

Restart jump
• Forward/forward/back x 3
• Side/side/back x 3
• Opposite side/side/back x 3

Rotational jump
• Land facing 180 degrees opposite from start x 10 each side

Restart hop
• Forward/forward/back x 3
• Side/side/back x 3
• Opposite side/side/back x 3

Rotational bound
Off one foot onto opposite foot x 10 each side