Assessment of Lower Limb Neuromuscular Control in Prepubescent Athletes

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Background: Although neuromuscular indices have been extensively studied in adolescents and adults, limited data exist for prepubescent children.

Hypothesis: No differences exist between prepubescent boys and girls in lower limb strength, symmetry on single-legged hop testing, and limb alignment during drop-jump testing.

Study Design: Cross-sectional study (prevalence); Level of evidence, 1.

Methods: The authors tested 27 female and 25 male athletes who were aged 9 to 10 years and matched for both body mass index and years of organized sports participation. In a drop-jump screening test, the distance between the right and left hips, knees, and ankles was measured as an indicator of lower limb axial alignment in the coronal plane. The distance between the knees and ankles was normalized by the hip separation distance. Quadriceps and hamstrings strengths were measured isokinetically at 180 deg/s. Lower limb symmetry was determined from 2 single-legged hop function tests.

Results: Boys demonstrated greater mean absolute and normalized knee and ankle separation distances on the drop-jump test. Even so, 76% of boys had a normalized knee separation distance of 60% or less of the hip separation distance, as did 93% of girls, indicating a distinctly valgus alignment. There were no differences between the sexes in quadriceps and hamstrings peak torques, hamstrings/quadriceps ratio, time to peak torque, total work, or lower limb symmetry values.

Conclusions: A high percentage of the prepubescent athletes studied had a distinctly valgus lower limb alignment during the drop-jump test and a lack of lower limb symmetry during the hop tests. These same indices have been hypothesized to increase the risk for knee ligament injuries in older athletes. Neuromuscular training may be needed to address these issues in children.

Neuromuscular Retraining in Female Adolescent Athletes: Effect on Athletic Performance Indices and Noncontact Anterior Cruciate Ligament Injury Rates

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Abstract: While many anterior cruciate ligament (ACL) prevention programs have been

published, few have achieved significant reductions in injury rates and improvements in

athletic performance indices; both of which may increase compliance and motivation of

athletes to participate. A supervised neuromuscular retraining program (18 sessions) was

developed, aimed at achieving both of these objectives. The changes in neuromuscular indices

were measured after training in 1000 female athletes aged 13–18 years, and the noncontact

ACL injury rate in 700 of these trained athletes was compared with that of 1120 control

athletes. There were significant improvements in the drop-jump test, (p < 0.0001, effect size

[ES] 0.97), the single-leg triple crossover hop (p < 0.0001, ES 0.47), the t-test

(p < 0.0001, ES 0.64), the multi-stage fitness test (p < 0.0001, ES 0.57), hamstring strength

(p < 0.0001), and quadriceps strength (p < 0.01). The trained athletes had a significant

reduction in the noncontact ACL injury incidence rate compared with the controls (1 ACL

injury in 36,724 athlete-exposures [0.03] and 13 ACL injuries in 61,244 exposures [0.21],

respectively, p = 0.03). The neuromuscular retraining program was effective in reducing

noncontact ACL injury rate and improving athletic performance indicators.

Factors Used to Determine Return to Unrestricted Sports Activity After ACL Reconstruction

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Purpose: Anterior cruciate ligament (ACL) reconstruction is commonly performed in athletes, with

the goal of return to sports activities. Unfortunately, this operation may fail, and the rates of either

reinjuring an ACL-reconstructed knee or sustaining an ACL rupture to the contralateral knee range

from 3% to 49%. One problem that exists is a lack of information and consensus regarding the

appropriate criteria for releasing patients to unrestricted sports activities postoperatively. The purpose

of this study was to determine the published criteria used to allow athletes to return to unrestricted

sports activities after ACL reconstruction. Methods: A systematic search was performed to identify

the factors investigators used to determine when return to athletics was allowed after primary ACL

reconstruction. Inclusion criteria were English language, publication within the last 10 years, clinical

trial, all adult patients, primary ACL reconstruction, original research investigation, and minimum 12

months’ follow-up. Results: Of 716 studies identified, 264 met the inclusion criteria. Of these, 105

(40%) failed to provide any criteria for return to sports after ACL reconstruction. In 84 studies (32%)

the amount of time postoperatively was the only criterion provided. In 40 studies (15%) the amount

of time along with subjective criteria were given. Only 35 studies (13%) noted objective criteria

required for return to athletics. These criteria included muscle strength or thigh circumference (28

studies), general knee examination (15 studies), single-leg hop tests (10 studies), Lachman rating (1

study), and validated questionnaires (1 study). Conclusions: The results of this systematic review

show noteworthy problems and a lack of objective assessment before release to unrestricted sports

activities. General recommendations are made for quantification of muscle strength, stability,

neuromuscular control, and function in patients who desire to return to athletics after ACL reconstruction,

with acknowledgment of the need for continued research in this area. Level of Evidence:

Level IV, systematic review of Level I to IV studies.

2017 Course Dates Announced!

2017 Course Dates

February 11-12:  Cincinnati, OH
March 25-26:  Cincinnati, OH
April 22-23:  Cincinnati, OH
May 25-26:  Hilton Head Is, SC
July 15-16:  Cincinnati, OH
October 7-8:  Cincinnati, OH (tentative)
November 4-5:  Cincinnati, OH (tentative)

Save the Date!!

Join us at the Sonesta Resort, Hilton Head Is, SC in 2017:
Sportsmetrics Certification: May 25-26
32nd Annual Advances on the Knee, Shoulder & SportsMedicine Course: May 27-30
Details to follow…

Sportsmetrics Annual Course Hilton Head 2016

We weren’t sure what to expect this year with the Advances on the Knee and Shoulder/Sportsmetrics courses changing locations, but the Sonesta Resort turned out to be a very pleasant surprise!  Great staff, amenities and amazing food soon won over our faculty, staff and course attendees.  They handled our course roster of 40 with ease and made it one of the best (and largest) Sportsmetrics courses.  The addition of George Davies’ presentation on current research in ACL rehabilitation was an extra bonus.  We cannot thank George enough for being such a supporter of our program.  Help us thank George and welcome our new certified instructors:

Amanda Askey, PTA, CFT:  Flex Physical Therapy, Council Bluffs, IA

Susan Berland, DPT:  Catalyst Physical Therapy, Hamilton, MT

David Brcka, MD:  North Georgia Sports Injury & Performance, Bethlehem, GA

Xavier Brewer, CPT, FMS:  X Factor Performance, Ponte Vedra, FL

Shaun Buning, DPT, ATC, C/NDT:  GeorgiaLina Physical Therapy, Evans, GA

Brent Butler, PT:  Revere Health, Provo, UT

Rachelle Callahan, DPT:  Rusk Rehabilitation at NYU Langone Medical Center

Andrew Cantrell, PTA:  The Rehab Institute-NGHS, Braselton,

David Carroll, DPT:  Southeastern Orthopedics, Greensboro, NC

Donna Chisholm, PT:  Pro Sports Physical Therapy, P.C., Oyster Bay, NY

Dylan Chisholm, CPT-NETA:  Pro Sports Physical Therapy, P.C., Oyster Bay, NY

Larry Feldman, PT:  Five Star Physical Therapy & Sports Medicine, Ponte Vedra Beach, FL

Annmarie Garis, DPT:  Florida State University- Health & Wellness Center, Tallahassee, FL

Sam Gill, PT:  Troy, MI

Whittney Gomendi-Smith, DPT:  Fremont Therapy Group, Riverton, WY

Brittney Harrell, PT, OCS:  GeorgiaLina PT Associates, Grovetown, GA

Josh Hill, PT:  The Rehab Institute- NGHS, Braselton, GA

John Hill, DPT, MS, ATC, CSCS

Yuri Jean-Baptiste:  ATC, PES, CES:  University of North Carolina, Chapel Hill, NC

Penny Jones, MPT:  DeClaire LaMacchia Orthopaedic Institute, Rochester Hills, MI

Coby Jones, DPT:  Rocky Mountain Ortho, Grand Junction, CO

Vic Kaminski, PT:  TMC Rehab, Winder, GA

Christopher Lopez, MSPT, OCS, CSCS:  Physical Solutions, Mineola, NY

Melanie Lynn, ATC:  Auburn, AL

Mary Meadows, PT:  Inova Physical Therapy, Centerville, VA

Karen Purcell, PT:  Pro Sports Physical Therapy, P.C., Huntington, NY

Katherine Quayle, DPT:  Fremont Therapy Group, Riverton, WY

Michelle Ramirez, DPT, OCS:  Florida Hospital Sports Medicine & Rehabilitation, Orlando, FL

Mark Rau,  PT, ATC:  Liberty Sports & Physical Therapy, Fredericksburg, VA

Kimberly Schall, PT:  Advantage Rehab Physical Therapy & Sports Medicine, Denton, MD

Asa Shaffer, DPT:  SERC Physical Therapy, Lees Summit, MO

Ryan Sheedy, DPT:  Furnace Brook Physical Therapy, Quincy, MA

Richard Smith, PTA:  Evangelical Physical Therapy, Lewisburg, PA

Ashley Sneed, PT, ATC:  Piedmont Orthopaedics, Greenville, SC

Lauren Sperling, PTA:  Florida Hospital Sports Medicine & Rehabilitation, Orlando, FL

Meredith Stevenson, DPT:  Self Regional Healthcare, Greenwood, SC

Jerrica Thomas, DPT:  Campbell Clinic Orthopaedics, Southaven, MS

Corey Winn, DPT:  Brunswick County, NC

Michelle Yang, DPT:  Rusk Rehabilitation at NYU Langone Medical Center, New York, NY

Hunter Yard, CSCS:  Carolinas Health Care System, Charlotte, NC

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May Certification Group

On May 23rd, we made our annual trip to Hilton Head Island, SC for the 29th Annual Advances on the Knee and Shoulder and pre-conference Sportsmetrics course.  We certified 26 healthcare professionals from California, Florida, Michigan, Maryland, Mississippi, Maine, New Hampshire, North Carolina, Ohio, South Caroline, Virginia,  Wyoming, and Finland!  We welcomed the sports medicine staff from Tiffin University and Kenyon College in Ohio, University of Michigan and UCLA.  Sunny skies, a warm breeze and an enthusiastic class made for a picture perfect course.  We would like to thank our new certified sites for their commitment to ACL injury prevention!  We welcome:

Jean Beattie, DPT:  Sheepscot Bay Physical Therapy, Waldoboro, ME

Tyler Bolley, DPT:  University of Michigan @ Domino Farms, Ann Arbor, MI

Olivier Chassin, DPT:  Orthopedic Physical Therapy Associates, Wake Forest, NC

Lisa Friesen, ATC, CES:  UCLA, Los Angeles, CA

Christine Herriotts:  Health and Wellness, LLC, Glenwood, MD

Iain Langstone, USSF:  Fayetteville Orthopaedics & Sports Medicine, Fayetteville, NC

Jessica Kellum, DPT, ATC:  University of Michigan @ Domino Farms, Ann Arbor, MI

Martin Kerr, MS, PT:  Horizon Rehabilitation, Hilton Head Island, SC

Kyle Kissling, MBA, ATC:  Tiffin University, Tiffin, OH

Kirk Landrum, ATC, MPH:  South Central Regional Medical Center- Wellness Center, Laurel, MS

Vesa Linna, PT:  Fysioterapiakeskus Kunnon Klinikka, Tampere, Finland

Michael Maugeri, PTA:  Atlantic Physical Therapy, Virginia Beach, VA

Brett Mielnick, MHSc, PTA, CSCS:  Florida Orthopaedic Institute, Tampa, FL

Sean O’Connor, MD:  Concord Orthopaedics, Concord, NH

Lucas Phillips, MEd, ATC:  Tiffin University, Tiffin, OH

Sarah Proulx, DPT:  Atlantic Orthopaedic Specialists, Chesapeake, VA

Elizabeth Saulinas, MS, ATC:  Tiffin University, Tiffin, OH

Robin Scheimer, MS, ATC:  Kenyon College, Gambier, OH

Shane Shapiro, MD:  Mayo Clinic, Jacksonville, FL

Teri Skeen, BA:  Big Country Rehabilitation, LLC, Douglas, WY

Stephanie Smith, MAT, ATC:  Tiffin University, Tiffin, OH

Mark Teeples, AT:  Kenyon College, Gambier, OH

JT VanWey, DPT, ATC, CSCS:  Max Sports Medicine Institute, Columbus, OH

Andy Wheeler, ATC, CES:  Kenyon College, Gambier, OH

Lindsay Wiggins, DPT:  OrthoVirginia, North Chesterfield, VA

Emily Yorges, ATC, LAT:  North Platte Physical Therapy, Torrington, WY




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Evidence for Neuromuscular Retraining to Reduce Noncontact ACL Injuries in Female Athletes Continues to Mount

In the last two years, several meta-analyses and systematic reviews have been published that strongly support the need and rationale for neuromuscular training in young female athletes. These publications reported relative risk reduction rates for noncontact ACL injuries that ranged from 52-100%. Relative risk reduction refers to the estimate of the percentage of risk that is reduced for trained athletes compared with untrained athletes.

In the February 2014 issue of the journal Arthroscopy, we published our systematic review that included eight neuromuscular training programs. Our rigorous analysis found that three programs – Sportsmetrics, PEP, and KIPP – had a statistically significant impact in reducing the risk of ACL injuries in female soccer and basketball players. We believe it is important to understand that not all ACL prevention programs are effective, a concept that is not always made clear in both the scientific literature and in the media. This article is available for download on our website.

In the May 7, 2014 issue of the Journal of Bone and Joint Surgery, a unique article was published on the cost-effectiveness of ACL injury prevention training. The authors (Swart et al, from Columbia University Medical Center, New York) compared three strategies for young athletes who regularly participate in organized sports: 1) no neuromuscular training or ACL injury screening, 2) universal neuromuscular training, and 3) universal screening, with neuromuscular training only done in high-risk athletes. An analysis of the total costs and gains in quality-adjusted life years was conducted of these strategies, assuming that all ACL ruptures would be reconstructed. The neuromuscular training program costs were based on a protocol that included dynamic warm-up, plyometrics, strengthening, sport-specific agility drills, and flexibility and included programs such as Sportsmetrics and PEP. In addition, costs were based on personal and equipment needs for neuromuscular training and injury screening.

The study found that universal neuromuscular training would reduce the incidence of ACL injuries by an average of 63%, whereas screening would reduce the incidence by an average of 40%. The example was given that, in 10,000 athletes, ACL injuries would be sustained by: 1) 300 athletes in the no-screening or training group, 2) 180 in the screen-and-treat high-risk athletes only group, and 3) 110 in the train all group. The average cost of the universal training group was $100 lower than the no train group and $25 lower than screen-and-treat group. The authors concluded that universal neuromuscular training was the most cost-effective strategy for reducing costs and morbidity from ACL injuries. This article is also available for download on our website.


1.         Gagnier JJ, Morgenstern H, Chess L. Interventions Designed to Prevent Anterior Cruciate Ligament Injuries in Adolescents and Adults: A Systematic Review and Meta-analysis. Am J Sports Med. 2013;41(8):1952-1962.

2.         Noyes FR, Barber-Westin SD. Neuromuscular retraining intervention programs: do they reduce noncontact anterior cruciate ligament injury rates in adolescent female athletes? Arthroscopy. 2014;30(2):245-255.

3.         Paszkewicz J, Webb T, Waters B, Welch McCarty C, Van Lunen B. The effectiveness of injury-prevention programs in reducing the incidence of anterior cruciate ligament sprains in adolescent athletes. J Sport Rehabil. 2012;21(4):371-377.

4.         Sadoghi P, von Keudell A, Vavken P. Effectiveness of anterior cruciate ligament injury prevention training programs. J Bone Joint Surg Am. 2012;94(9):769-776.

5.         Stojanovic MD, Ostojic SM. Preventing ACL injuries in team-sport athletes: a systematic review of training interventions. Res Sports Med. 2012;20(3-4):223-238.

6.         Sugimoto D, Myer GD, Bush HM, Klugman MF, Medina McKeon JM, Hewett TE. Compliance with neuromuscular training and anterior cruciate ligament injury risk reduction in female athletes: a meta-analysis. J Athl Train. 2012;47(6):714-723.

7.         Swart E, Redler L, Fabricant PD, et al. Prevention and screening programs for anterior cruciate ligament injuries in young athletes. A cost-effectiveness analysis. J Bone Joint Surg Am 2014;96(9):705-71.

8.         Sugimoto D, Myer GD, McKeon JM, Hewett TE. Evaluation of the effectiveness of neuromuscular training to reduce anterior cruciate ligament injury in female athletes: a critical review of relative risk reduction and numbers-needed-to-treat analyses. Br J Sports Med. 2012;46(14):979-988.

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Sportsmetrics May Certification Course

On May 23rd, we made our annual trip to Hilton Head Island, SC for the 29th Annual Advances on the Knee and Shoulder and pre-conference Sportsmetrics course.

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