KNEE HAB

Knee injury exercise and prevention has come a long way over the past 15 years since the first ACL prevention program was published in 1999 by Hewitt et al, with many clubs and institutions now including structured strengthening and flexibility programs.

 

Knee Hab

As we have seen from the literature, strength and flexibility are not only integral to injury prevention, but can also assist with performance enhancement. Ne-HAB-Intro-image-300x178Although there is a wealth of information
available on how to safely progress athletes or individual’s strength and flexibility, there needs to be a greater emphasis on how to educate quality movement patterns. Many young athletes are susceptible to injuries due to a lack of awareness of how to move well.

Incidence, Prevalence, and Benefits

  • 70% of ACL injuries occur in non-contact situations (Griffin et al 2000)
  • Young athletes 15-25 years old who participate in pivoting sports such as football, netball, soccer and basketball are at the highest risk, with females experiencing roughly 3 times greater incidence than males (Prodromos et al 2007)
  • A recent systematic review and meta-analysis by Gagnier et al (2013) found that neuromuscular and educational interventions can reduce the incidence of non-contact ACL injuries by 50%
  • In 2006 Hewett et al released a meta-analysis demonstrating that 4 out of 6 neuromuscular training and intervention programs reduce the incidence of knee injuries, and 3 out of 6 reduce the incidence of ACL injuries
  • The implementation of a neuromuscular training program saves each player over $100 per season (Swart et al 2014)
  • Strength training reduces sports injuries to less than 1/3 and overuse injuries to almost half (Laureson et al 2013)
  • In 2005, Myer et al found that injury prevention programs result in performance, with significant increases found in 1RM bench press, squat, single leg hop for distance, vertical jump, and speed
  • “There is now such good evidence to support injury prevention programs, that any clubs not performing them, should almost be held accountable.” Dr Peter Brukner

    Focused Program

    To safely facilitate an athlete’s progression through challenging tasks such as running, agility, jumping and landing, Health Sense Group have developed the kNee Education for Healthy
    Active Bodies (NE HAB) program. NE HAB is a means of providing internal (self-directed) and external (coach or therapist-directed) feedback and encouraging the athlete to assess their own technique to improve performance and reduce the likelihood of injury.

    NE HAB

    NE HAB consists of four phases of five different exercises focused on improving the athlete’s knee function and quality of movement. The NE HAB program is incorporated to educate the athlete about correct landing, cutting, running, hopping, and jumping techniques, neuromuscular control, and correct muscle activation; allowing them to assess their own functional performance.NE-Hab

    The NE HAB program is easy to facilitate, it is based on effective and proven interventions, and it can be modified to suit the needs of the team, club or individual. NE HAB can be conducted by a coach, therapist, or instructor at regular intervals to provide feedback on technique and areas to develop. This program is designed to teach the athlete about how to effectively recruit specific muscles such as lower fibers of gluteus maximus, how to avoid dynamic knee valgus, and how to critique their own jumping, landing and cutting patterns. Minimal equipment is required and all athletes are provided with and taught to use their own scoring sheet to assess and critique their movement patterns.

    The initial 2 phases of the program are designed to teach the athlete exercises that will help them to recruit and develop key muscles, which are fundamental to lower limb health. During the third and fourth phase both the athlete and the therapist independently and simultaneously evaluate the athlete’s ability to perform functional tasks.  By recording and reviewing the athlete performing specific drills and exercises, it is possible not only for the therapist to provide quality feedback, but for the athlete to learn better movement patterns. The NE HAB program will identify which areas athletes are deficient in and provide them with the education they need to overcome these barriers to performance enhancement.

    Example Program

    For optimal benefits it is best to have a program tailored specifically to the needs of the individual or team. The program below offers an excellent baseline and many of the principles can be applied to any sporting population that is either at high risk of knee injuries, or would benefit from improved biomechanics. For a personalised approach, please contact Campbell at Health Sense Group.

    Tables 1-4 outline exercises involved in each phase. Full videos of each exercise are available here. Tables 5-6 are used to analyse closed kinetic chain (the foot is fixed on the ground) and open kinetic chain exercises (the foot is free to move) in phases 3 and 4. Each exercise is scored out of 10, with a 1 being assigned to each body region for a correct movement pattern and a 0 for a compensatory movement pattern. For any scores less than 10, then athlete and therapist discuss discuss how the athlete can improve their movement patterns.

    TABLE 1: Phase 1 Correct muscle activation

    Exercise Description (see videos here) Focus Achieved (Y/N)
    Glut Bridges Lying on back, one knee bent, other leg bent to 90° with knee above hip. Push through heel to raise hips off ground. If hamstrings start working too hard, bring heel closer to body. Hold for 1 min each leg Lower fibers of gluteus maximus  
    Calf Raises Stand tall, resting both hands against wall at shoulder height. Keep your ribs down, no rocking forwards, no rolling out with the ankles. Push through big toe moving through full range. Repeat until fatigue Medial gastrocnemius  
    Wall Sits Sitting against a wall, knees and hips at 90˚. Keep your weight through the inside of your heels. Aim for >2:30. Vastus Medialis Oblique  
    Adductor Lifts Lying on your side with small towel between ribs and pelvis. Top leg bent to 90˚ resting on foam roller or other prop. Keep bottom leg straight and lift off ground. Hold for 1 minute Adductor magnus  
    Squats Standing tall with feet hip width apart, initiate squat from hips, hinging hips backwards. Knees go in line with your toes, but not beyond. Keep pushing through heels to maintain gluteal connection Trunk and lower limb alignment  

    TABLE 2: Phase 2 Strength and activation

    Exercise Description (see videos here) Focus Achieved (Y/N)
    Hangback Squats Holding onto rail or rack (fixed object), feet hip width apart, knees go in line with your toes, but not beyond your ankles. Sit back into squat position, focusing on using your gluts, then shift 90% of your weight to one leg, pushing through your heel. Lower fibers of gluteus maximus and deep lateral rotators  
    Lateral Step Downs Stand on 20 cm step, hands on hips. Reach one foot down beside step, touching ball of foot to ground. Knees go in line with your toes, but not beyond Eccentric VMO and lower gluteus maximus  
    Forward Lunge Stand tall, take a long stride with one leg. Keep front shin vertical, drop back knee towards ground. Push through front heel to walk forwards into next lunge. Alignment and control during forward motion  
    Single Leg Arabesque Stand tall, bend both knees then lift one leg off ground. Keeping knee bent, hinge forward from hips reaching other leg back. Keep your back straight! Push your weight back onto your heel, then come up slowly, pushing through your heel. Gluteus maximus  
    Plyometric Box Jump
    Standing on both legs, feet hip width apart. Jump up onto 30cm box or step. Land with feet hip width apart, folding through hips, knees pointing towards toes. Lower limb power and control  

    TABLE 3: Phase 3 Re-train the chain

    Exercise Description (see videos here) Therapist Points
    Athlete Points
    Eccentric Step Downs The subject stands on a 20 cm step on one leg and has 30 seconds to reach forward and touch the ground lightly with their heel and return to full knee extension.    
    Single Leg Squat Stand on one leg with arms crossed. Squat down to 60 then return to start position    
    Running Man with Calf Raise Stand on one leg, hands by side. Bend forward from hips while simultaneously bending knee. Reach one arm forward with torso parallel with the ground and same leg stretched behind you. Return to start position, finishing with a calf raise.    
    Bounding in Place Jump from one leg to the other straight up and down, progressively increasing rhythm and height    
    Cone Jumps Double leg jump with feet together. Jump side to side over cones quickly. Repeat forward and backward.    

    TABLE 4: Phase 4 Refining motor skills

    Test Description (see videos here) Athlete Points
    For scores <10 please give a reason
    Eccentric Step Downs on Foam The subject stands on a pillow or cushion on a 20 cm step on one leg and has 30 seconds to reach forward and touch the ground lightly with their heel and return to full knee extension.    
    Single Leg Squat Stand on one leg with arms crossed. Squat down to 90 then return to start position.    
    Star Excursion Balance Test Stand tall, hands on hips, mid-foot on centre of star. The athlete reaches as far forwards as they can without touching the foot down, then posterior medially, then posterior laterally.    
    Bound and Hold Jump from one leg to the other forwards and backwards, holding the landing for 3 seconds each time. Repeat side to side.    
    Single Leg Cone Jumps Single leg hop side to side over cones quickly. Repeat forward and backward.    

    TABLE 5: One Leg Assessment (OLA)

    OLA

    Closed Kinetic Chain Exercises

    Left

    Right

    Arm strategy

    Excessive arm movement to balance

     

     

    Trunk alignment

    Leaning in any direction

     

     

    Pelvic plane

    Loss of horizontal plane

     

     

     

    Excessive tilt or rotation

     

     

    Thigh motion

    WB thigh moves into hip adduction

     

     

     

    NWB thigh not held in neutral

     

     

    Knee position

    Patella pointing towards 2nd toe (noticeable valgus)

     

     

     

    Patella pointing past inside of foot (significant valgus)

     

     

    Steady stance

    Touches down with NWB foot

     

     

     

    Stance leg wobbles noticeably

     

     

     

    Total

     

     

    WB: Weight bearing. NWB: Non weight bearing.

    Modified from “Task based rehabilitation protocol for elite athletes following Anterior Cruciate ligament reconstruction: a clinical commentary” Herrington et al, 2013

    TABLE 6: Jump and Land Assessment (JALA)

    JALA

    Plyometric Exercises

    Left

    Right

    Arm strategy

    Excessive arm movement to balance

     

     

    Trunk alignment

    Leaning in any direction

     

     

    Pelvic plane

    Loss of horizontal plane

     

     

     

    Excessive tilt or rotation

     

     

    Thigh motion

    WB thigh moves into hip adduction

     

     

     

    NWB thigh not held in neutral

     

     

    Knee position

    Patella pointing towards 2nd toe (noticeable valgus)

     

     

     

    Patella pointing past inside of foot (significant valgus)

     

     

    Landing stance

    Touches down with NWB foot

     

     

     

    Noticeably wobbly during landing

     

     

     

    Total

     

     

    Modified from “Task based rehabilitation protocol for elite athletes following Anterior Cruciate ligament reconstruction: a clinical commentary” Herrington et al, 2013

    Example videos can be found in the resources section under the tab: Videos

    To receive the full program including scoring and assessing sheets, as well as more information on how your school, club, team, or family member can benefit from the NE HAB program, please contact us below