This post is especially for coaches and parents who help athletes as it highlights some of the best ways to improve skills to help knee stability, rather than just doing strength training
Personally, one of the biggest arguments I have against highly structured sessions for athletes overall is because the program should reflect on a number of factors, and there is no such thing as a one size fits all approach for athletes. Generally, the more an athlete trains, then the more variety that is required within cycles of training to see improvement, as you need to change the stimulus provided to the body regularly to seek physiological and psychological adaptations.
In a perfect world, I like to monitor people over a daily period, however this becomes very difficult when you are in a private setting as the time taken to do this sort of monitoring is extensive and not something that is possible to do very well, if you have a number of athletes and programs to run. So, we try to monitor over a weekly period where you might write a program structure for 4-8 weeks but monitor some key variables over a weekly setting with the athlete.
With the changing landscape of activity levels due to more sedentary occupations, and the decrease in activity overall across our younger generations in particular, it is important sometimes to “TEACH” people HOW to train and then what to do, so that when you are not there, they will train as specified.
In the world of ACL Injury Prevention, and by all accounts, within our industry there is so much research that has been done on this topic that it is like having your own world when you start reading about it, there are a few different ways to get work done. You have strength training, classic work that has been done for years, but it is boring, and it does require concentration. AND… motor learning (skill acquisition) is another way we can work to decrease ACL injury risk.
To look at this in one way, this is an example of breaking a commonly done exercise down and looking at all the reasons why people do this exercise poorly… This is a break down of the key components of a push up.
- Scapula stability – to help control the eccentric pathway to let the body go all the way down to the ground. Then to control the power produced in the concentric phase.
- In conjunction with Scapula stability – you need the appropriate amount of stability through your trunk to stop your lower back “sinking” into the ground either during the concentric phase or during power production in the concentric phase.
- Then you need the arm, shoulder and front plane strength to push yourself up repeatedly.
The unfortunate thing is that we see the most simple of exercises done really poorly by children, adolescents and adults which leads to injuries to the lower back, shoulders, elbows and wrists due to too many being done in a poor mechanical position.
So, in a strength context, you could take this feedback, then go away and strengthen all the minor bits and pieces such as core stability, scapula stability and strength in isolation of arms and shoulders, and then come back 6 weeks later and ask the person to do the push up, and still you get the SAME mistakes! Why? Because we had an internal focus of feedback to the athlete, we broke apart the skill, strengthened pieces of the whole skill and then unfortunately there was no translation to the push up.
So, skills such as the primal movement patterns, such as crawling, jumping, squatting, lunging and rolling are sometimes a lot more “fun” way to do exactly the same thing, which is to help make the body listen to your brain in a more automatic sense and therefore make good movement an automatic function, rather than a chore. Especially when relating to a visual cue, such as an animal movement, rather than “just a push up.”
The exact same thing happens with landings and the strength components such as a squat and one-leg squat. If we break everything down and then try to put it back together with no real focus on HOW the skill itself needs to be done, then much of the time, we just spend time improving strength WITHOUT gaining any better skill knowledge or performance.
So, we need to externally focus feedback instead and drive athletes to improve basic skills like landings, jumping, hopping, side lunging and stopping by getting them to think about something that relates the skill to the sport they are playing. A cue in landing, like sit back like you are sitting in a chair and STOP, rather than keep your knees out will work better for some players as they can relate the external cue to their body better than the internal cue, which is about the process that is happening.
The specific Gluteal strength exercises utilised were:
The Skill acquisition program included:
Another article that talks about trying to reduce the likelihood of a second ACL injury after the first repair talks about the assessment of a range of factors especially including range of motion at the knee, rotation of the knee during handguns, asymmetries especially at the saggital plane knee movements at initial contact and postural stability are all strong predictors of secondary ACL injury.
From my experience, I would say that it comes to what each athlete is going to prefer. Some athletes will be happy to work on strength and work with that, as that is what they like to do, and what makes them feel like they are doing “work.” Some athletes will really get the concept of the skill acquisition work, and will work really hard in front of a mirror so they come back to a physiotherapist or coach and say “look at me, I can do what I could not last week now.”
We have to remember first and foremost that what we are trying to prevent is rotation at the knee joint on landings and in cutting actions. This is how many of the non-contact ACL injuries happen. So, when we are looking at athletes, this is what we try to work on. Whatever works with each athlete, we just do!
What I have found works really well for strength work for ACL prevention, when I relate that back to the skill acquisition work that I expect athletes to do is:
- Clams – side lying OR Banded Crab Walks
- Floor – banded lying back bridge – with focus on Glute activation FIRST then explosive hip drive with slow eccentric phase. You can progress this exercise to your shoulders on a bench to increase the range and instability of the exercise.
- Single leg Back Bridge on the floor – with toes pull off the floor to decrease the involvement of the hamstring.
- Half Single leg squat with pause.
- Single leg balance eyes open and eyes closed
- Single leg squat in a mirror focusing on breaking at the hip first.
- Jumping and landing in a mirror focusing on a “tight” position in landing with Co-Contraction JUST BEFORE landing of all lower limb muscles.
- Hopping on the spot in front of a mirror, progress away from the mirror and then progress to eyes closed to work on proprioceptive input more.
- Jumping and hopping forward and backwards in controlled – sticking landing and then rebounding for 3 then with a stop landing.
- Lateral Bounding – or Ice-skaters, where the cue is given to PUSH off the stance leg to bound laterally onto the other leg, stick the landing on ONE leg and then push back again.
With all my athletes who jump, run and stop, I try to have athletes doing at least part of their session whether in active warm up or in the session doing at least a few of these exercises EVERY session to focus them on the habit of doing simple things very well.
I hope this makes sense of the strength versus skill acquisition argument in how to prevent ACL injuries. For some, this will be the first time you read this sort of argument and for others it will invigorate you to think more deeply about HOW you do things.