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13th September 2018


Anterior cruciate ligament remains a common orthopaedic injury (Sanders et al., 2016), possessing multiple factors that are seen to elevate risk (Weber et al., 2017). Therefore, what factors can be modified so as to infinitely delay the time point at which injury happens? Hug and Tucker (2017) identify some individuals display ‘kinematic signatures’ which may well be linked to pain, compromised function and injury, such as anterior cruciate ligament (ACL) injury. The question arises as to which of these movement patterns relate to ACL for any individual. Over the past decade and a half, biomechanical measures related to hip flexion, adduction, internal rotation, and knee flexion, abduction, internal rotation and external rotation have all been proposed to be markers of elevated ACL injury risk (Hashemi et al., 2011; Hewett et al., 2005; Shimokochi et al., 2008). In response to these movement related risk factors, movement retraining interventions have been established which are seen to positively impact ACL risk factors (Labella et al., 2011; Taylor et al., 2015). These interventions are seen to influence what have been described as ‘high-risk movement strategies’, such as stiff-legged landings and dynamic lower extremity valgus (Ford et al., 2015; Hashemi et al., 2011; Hewitt et al., 2005; Shimokochi et al., 2008).


A recent study by Taylor et al. (2018) employed an ACL injury risk reduction protocol developed by Labella et al. (2011) on a group of female team multi-directional team sport players. Delivered 2–3 times per week, for 6 weeks, the intervention focussed on ‘soft-landings’ and attention to frontal plan knee alignment during a wide variety of exercises. Yet, at the end of the 6-week trial, only minimal changes had been observed in the biomechanical measures suggested to be linked to ACL risk. The study highlighted that 6 weeks appears to be an insufficient duration of time to make the large- scale changes on kinematic risk factors. Additionally, the authors identified that ‘no a priori compliance threshold was set for exclusion from the study prior to training so as to best replicate current clinical practice’. This element of study highlighted the importance of compliance. Without sufficient exposure to the training stimulus, surely no movement retraining intervention can be expected to be ‘successful.’


Let’s go back to kinematic signatures; if everyone moves different, the high-risk movement patterns of one person are likely to differ to another. There is then the need to profile individuals as individuals. A battery of tests is required so as to identify the distinctions between one person and another. This individualised set of results can then steer a very specific movement retraining intervention, reducing the need for lots and lots of exercises, a factor increasing efficiency, reducing time burden and likely to enhance compliance. Within a TPM Pro clinic environment there is then the need to consider who would benefit from an ‘improved’ ability to be more robust during single leg landings; frequently the task associated with elevated risk. There is the need to consider which sites and directions, which threshold and which retraining strategies will achieve this aim, for this client. As highlighted by Taylor (2018), targeting everything, over a 6-week period, is probably not going to change kinematic risk factors when we consider individuals as a group. There is indeed the need to get ‘personal’, using site, direction and threshold ® to change risk.



· Ford KR, Nguyen AD, Dischiavi SL, Hegedus EJ, Zuk EF, Taylor JB (2015) An evidence-based review of hip-focused neuromuscular exercise interventions to address dynamic lower extremity valgus. Open Access J Sports Med 6:291–303

· Hashemi J, Breighner R, Chandrashekar N, Hardy DM, Chaudhari AM, Shultz SJ et al (2011) Hip extension, knee flexion paradox: a new mechanism for non-contact ACL injury. J Biomech 44:577–585

· Hewett TE, Myer GD, Ford KR, Heidt RS Jr, Colosimo AJ, McLean SG et al (2005) Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med 33:492–501

· LaBella CR, Huxford MR, Grissom J, Kim KY, Peng J, Christoffel KK (2011) Effect of neuromuscular warm-up on injuries in female soccer and basketball athletes in urban public high schools: cluster randomized controlled trial. Arch Pediatr Adolesc Med 165:1033–1040

· Sanders, T. L., Maradit Kremers, H., Bryan, A. J., Larson, D. R., Dahm, D. L., Levy, B. A., ... & Krych, A. J. (2016). Incidence of anterior cruciate ligament tears and reconstruction: a 21-year population-based study. The American journal of sports medicine, 44(6), 1502-1507

· Shimokochi Y, Shultz SJ (2008) Mechanisms of noncontact anterior cruciate ligament injury. J Athl Train 43:396–408

· Taylor JB, Waxman JP, Richter SJ, Shultz SJ (2015) Evaluation of the effectiveness of anterior cruciate ligament injury prevention programme training components: a systematic review and metaanalysis. Br J Sports Med 49:79–87

· Taylor, J. B., Ford, K. R., Schmitz, R. J., Ross, S. E., Ackerman, T. A., & Shultz, S. J. (2018). A 6-week warm-up injury prevention programme results in minimal biomechanical changes during jump landings: a randomized controlled trial. Knee Surgery, Sports Traumatology, Arthroscopy, 1-10

· Weber, A. E., Bach, B. R., & Bedi, A. (2017). How Do We Eliminate Risk Factors for ACL Injury?. In Rotatory Knee Instability (pp. 465-472). Springer, Cham


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