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Prevelance of Anterior Cruciate Ligament Injury Prevention
Programs in High School Sports

presented by
Melissa A. Enlvin

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6/01 cJCIRCJDateDuepss-sz

PREVALENCE OF ANTERIOR CRUCIATE LIGAMENT INJURY PREVENTION
PROGRAMS IN HIGH SCHOOL SPORTS

By

Melissa A. Erwin

A THESIS
Submitted to
Michigan State University

in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE
Department of Kinesiology

2004

ABSTRACT

PREVALENCE OF ANTERIOR CRUCIATE LIGAMENT INJURY PREVENTION
PROGRAMS IN HIGH SCHOOL SPORTS

By
Melissa A. Erwin

Current literature supports the premise that female athletes have a higher
incidence of ACL injuries in competitive sports compared to male athletes. In response
to this issue several ACL injury prevention programs have been designed. The next issue
is whether coaches are implementing these prevention programs and are they being
informed that these programs are available?

This study was designed to survey coaches in the Capital Area Activities
Conference, in order to determine if they are aware of and/or implementing ACL injury
prevention programs. From the 105 coaches surveyed, 45 responded. Of those 45, 16
reported being aware of the ACL prevention programs, only 5 reported implementing an
ACL injury prevention program in their strength and conditioning regimen. From these
data it can be concluded that few coaches in the Capital Area Activities Conference are
aware of ACL injury prevention programs and significantly fewer are implementing an
ACL injury prevention program. It was also found from this study that 42 respondents
stated implementing one or more training techniques that were consistent with ACL
injury prevention programs. Future research directions should be aimed at educating the

public about ACL injury prevention programs.

ACKNOWLEDGEMENTS

I would like to thank my committee members, Dr. John Powell, Dr. Kavin Tsang, and Dr.
James Flore for the guidance, support, and time they put into making this Master’s Thesis

possible. I would also like to thank my family and friends for their continued support.

iii

TABLE OF CONTENTS

LIST OF TABLES .......................................................................... v
Chapter 1: INTRODUCTION ............................................................. 1
Chapter 2: REVIEW OF LITERATURE .................................................. 3
Anatomy of Knee Joint .................................................... 3
Mechanism of Injury ....................................................... 4
Incidence of ACL Injury in Female Athletes ........................... 5
ACL Injury Risk Factors ................................................... 5
ACL Injury Prevention Programs ........................................ 8
Coaches’ Education ....................................................... 14
Chapter 3: METHODS ....................................................................... 19
Subjects ........................... _ .......................................... l9
Instrumentation ............................................................ 19
Protocol ..................................................................... 19
Statistical Analysis ......................................................... 20
Chapter 4: RESULTS ....................................................................... 21
Chapter 5: DISCUSSION .................................................................. 36
Appendix A: Letter of Explanation and Informed Consent ........................... 43
Appendix B: Survey ........................................................................ 45
Appendix C: Second Letter of Explanation and Informed Consent .................. 49
Appendix D: Reference List of Current ACL Injury Prevention Literature ......... 51

Appendix E: Hunt Valley Consensus Conference on ACL Injury Prevention ...... 53

BIBLIOGRAPHY ........................................................................... 56

Table 4.1:

Table 4.2:

Table 4.3:

Table 4.4:

Table 4.5:

Table 4.6:

Table 4.7:

Table 4.8:

Table 4.9:

Table 4.10:

Table 4.11:

Table 4.12:

Table 4.13:

Table 4.14:

Table 4.15:

Table 4.16:

Table 4.17:

Table 4.18:

Table 4.19:

Table 4.20:

Table 4.21:

Table 4.22:

LIST OF TABLES

Years of Coaching Experience .......................................... 22
Coaching at High School Level ........................................ 22
Coaching at Elementary Level .......................................... 23
Coaching at Middle School Level ...................................... 23
Coaching at Junior High Level .......................................... 23
Coaching at Collegiate Level ............................................ 23
Coaching at Adult Level ................................................. 24
CPR Certification of Coaches ........................................... 24
Program of Athletic Coaches Education (PACE) .................... 25
Michigan State Youth Soccer Associations (MSYSA) ............. 25
Coaches’ Education ...................................................... 26
Number of Coaches Affected by ACL Injuries ...................... 26
Coaches’ Awareness and Belief of Reduction of ACL Injury. . ...27
ACL Injury Prevention Program Awareness ........................ 28
ACL Injury Prevention Program Implementation ................... 29
ACL Injury Prevention Technique Awareness ..................... 29
ACL Injury Prevention Technique Implementation... . . . . . . . . . . ...30
ACL Injury Prevention Technique Frequency ...................... 31
Plyometric Jump Training Implementation Timing ................ 32
Lower Extremity Training Implementation Timing ................ 32
Agility Running Implementation Timing ............................ 33
Proprioception and Balance Training Implementation Timing...33

Table 4.23: Differences Among Coaching Experience .......................... 35

vi

Chapter 1

INTRODUCTION

Female participation in sports has increased dramatically over the last decade. The
National Federation of State High School Associations’ data shows that there were just
under 2 million females participating in athletics at the high school level in 1993. There
has been an increase to just under 3 million in 2003. This is over a 30% increase in one
decade. Boys’ athletic participation over this same period has been less dramatic with
approximately a 14% increase. Participation in sports where anterior cruciate ligament
(ACL) injuries are more likely to occur, basketball, volleyball and soccer has also

increased. All three sports are among the top ten most popular girls’ athletic programs at

the high school level, with basketball ranking the most popular 1.

Along with this dramatic increase in female athletic participation has come an
increased awareness of the female ACL problem within the medical community. This
awareness has brought about extensive research in the area of female ACL injuries.

There is a general consensus that females have a higher incidence of ACL

injuries, and there are many ideas as to why this occurs. Some researchers focus on the
anatomical reasons 2 while others feel the causes are multifactoral and cannot be

considered independent in nature3. The research has also found that in soccer, basketball,

and volleyball, the rate of noncontact ACL injury is 2.4 to 9.5 times higher in women
than in men 4. In response to this, some researchers have developed prevention programs

5'10. The question is: are these researchers making this information available to

coaches? Also, if the coaches have been educated: are coaches aware of and
implementing programs as a result of this research?

In 1995, the National Association for Sport and Physical Education published

the National Standards for Athletic Coghes 1 1. Within the coaching community, there

 

are numerous formal coaches’ education programs available to coaches that want to
improve their coaching skills. This publication was developed because of the increase in
sport participation and in return the increased need for educated coaches. The publication
fostered an increase in the standards of coaching education and an increase in the amount
of coaching education available.

Despite the increase in coaching education availability the question still remains,
are the coaches being informed of the specific ACL injury prevention programs and
techniques these programs use to prevent injury? The objective of this study is to
determine the awareness and implementation of ACL injury prevention programs and
techniques in the Capital Area Activities Conference for the sports of boys’ and girls’
basketball, boys’ and girls’ soccer, and girls’ volleyball.

Hypothesis 1: Coaches are not aware of or implementing ACL injury prevention
programs.

Hypothesis II: Coaches are aware of and implementing ACL injury prevention

techniques unknowingly.

Chapter 2

REVIEW OF LITERATURE

Anatomy of the Knee Joint

The knee joint is classified as a diarthrodial joint with a subclassification as a
modified ginglymus or hinge joint. Its support structures include six ligaments, other soft
tissues, and the geometric constraints of the joint surfaces. The integrity of these
structures determines the movement of the knee joint. As long as each is intact and
fimctioning properly, the knee joint has six degrees of freedom, which includes three
rotations and three translations. There are three principle axes used to describe the
movement occurring at the knee joint: the tibial shaft axis, the epicondylar axis, and the
anterior-posterior axis, which is perpendicular to the other axes. The translations that
occur along these axes include: proximal-distal, medial-lateral, and anterior-posterior

translation respectively. The rotations that occur along these axes include: intemal-

external rotation, flexion-extension, and varus-valgus rotation, respectively 12.

The ligaments of the knee joint provide stability to the joint throughout its range
of motion. Each ligament restrains the knee motion in response to externally applied
loads as well as provides stability in more than one degree of freedom. The overall

stability of the joint depends on the contribution of all the ligaments both individually and

the interaction between ligaments 12.
The anterior cruciate ligament (AC L) prevents anterior translation, internal and
external rotation of the tibia on the femur. It also acts as a secondary restraint against

valgus and varus rotation of the tibia on the femur. A force applied in one or all of these

directions that exceeds the elastic limit of the ligament will cause injury. An
understanding of the forces applied to the ligaments during normal knee function plays a

role in injury mechanisms and aids in the development of ACL injury prevention

techniques 12.
Mechanism of ACL Injury

Research has shown that ACL injuries frequently occur during non-contact

situations such as pivoting, cutting or landing from a jump on one or both legs 13: 14.
The ACL is most at risk of injury during anterior tibial translation and valgus tibial

rotation. Activation of the hamstring musculature is thought to protect the ACL from
injury at knee flexion angles greater than 30 degrees 13.

It was theorized by Fagenbaum 13 that it is possible that ACL injuries in women
occur primarily during landings when the athlete intends to immediately change direction

or jump again, thus employing the internal tibial rotation component of injury. Arendt
and Dick 3 found that women land from jumps with smaller angles of knee flexion thus

predisposing them to ACL injury. The research done by Fagenbaum13 contradicted the
previous research in that women did not demonstrate lower hamstring muscle activity or
reduced knee flexion in response to fatigue. Their conclusions to this research indicated
that when speed is of most importance in a competitive situation, it is possible that female
athletes use less knee flexion when landing from a jump than male athletes and thereby
predispose themselves to injury. Under more controlled laboratory conditions as used in
their experiment, it may be that female basketball players landed in a manner that is

protective of the ACL.

Incidence of ACL Injury in Female Athletes
The preponderance of the research indicates that there is a higher number of ACL

injuries occurring in the female athletic population compared to the male athletic

population 1. Hewett reported that female athletes participating in jumping and cutting

sports demonstrate a four-to-six fold higher incidence of knee injury than do male

athletes participating in the same sports 9. Chandy and Grana reported that female high
school athletes had knee surgery nearly five times more often than their male peers and

that knee surgery accounted for almost 70% of all surgeries in the female athletic

population 15. Chandy and Grana reported that female high school athletes have an
occurrence of ACL injuries of 1 out of every 100 participants. With the larger numbers

of participants this translates to more than 20,000 knee injuries each year at the high

school level 9.

The increased risk of ACL injuries is also prevalent in the female collegiate
athlete population. A 1990 to 1993 injury survey done of approximately 15% of NCAA
member institutions reported that more than 1 out of every 10 female athletes
participating at the collegiate level will sustain a knee injury each year. Also from this

survey it was concluded that 2200 ACL ruptures are expected to occur in female

collegiate athletes each year 9.
ACL Injury Risk Factors

Many researchers have attempted to pinpoint risk factors, whether intrinsic or
extrinsic, that predispose an athlete to sustaining an ACL injury. Rather than pinpoint a
single risk factor it has been concluded that the increased risk of ACL injuries among

female athletes is likely multifactoral, with no single structural, anatomic, or

biomechanical factor solely responsible 3. Rozzi 2 stated, “Since women often incur
ACL injuries during routine noncontact activities, one might speculate that the
coordinated motor program that provides dynamic stability fails as a result of some
external influence such as fatigue or loss of motor control.” This concludes that an
intrinsic factor is influenced by an extrinsic factor. The factors that are of the most
concern are those that are reversible, allowing for injury prevention for example,
shoe-surface interface, neuromuscular deficits, and strength imbalances.

A group of sports medicine team members consisting of 22 orthopaedists, family
physicians, biomechanists, and athletic trainers met in Hunt Valley, Maryland in June
1999. These individuals met because they recognized a need to critically examine and
summarize existing data on prevention strategies and the implied risk factors for
noncontact ACL injuries. The goals of the 1999 Hunt Valley Consensus Conference on
Prevention of Noncontact ACL Injuries were to increase awareness in the at-risk
population and medical support personnel about prevention strategies for ACL injury and
to stimulate increased effort in ACL injury prevention research. During the conference,

participants carefully reviewed available data on injury risk factors and developed

consensus statements based on the research 16.

Environmental Risk Factors

There is no current research to support the use of knee braces to prevent ACL
injuries. By increasing the shoe-surface interaction the athlete may see performance
enhancement, but may be increasing their risk of ACL injury as well. It is undetermined
what the optimal shoe-surface interaction is for each playing surface in order to optimize

performance and decrease injury, therefore this topic warrants further investigation.

Anatomic Risk Factors

Anatomic risk factors that have been investigated by researchers include femoral
notch size, ACL size, and lower-extremity anatomic alignment and their role in ACL
injury. None of the research has proven any of these factors to be instrumental in ACL
injury, and there needs to be continued research and reliable measures developed for each
before a consensus on the role of these factors can be made.

Hormonal Risk Factors

Hormonal risk factors have been a topic in a lot of current ACL injury research.
There is no consensus as to what role sex-specific hormones play in the increased
incidence of ACL injury, therefore this area warrants further research.

Biomechanical Risk Factors

The research to date has shown that the biomechanical factors involved in many
injuries include impact on the foot rather than the toes during landing or changing
directions, awkward dynamic body movements, and biomechanical irritation prior to
injury.

According to Teitz 17, videotape analysis of ACL injuries revealed that athletes
contacting the ground in a flat foot position were noted in two thirds of the injured female
basketball players, all the soccer players, and all injured male players. The analysis also
showed that 100% of male basketball players were injured landing from a jump, whereas
roughly half the women were injured landing from a jump, and half were injured when
they stopped suddenly while running down the court. The lower limb position of the
injured athletes was frequently less than 30 degrees of knee flexion, knee valgus, and

external rotation of the foot relative to the knee.

It must also be kept in mind that the knee is only a single part of the kinetic
chain. The trunk, hip, and ankle may also have a role in ACL injury. 'From the video
analysis it also appeared that the center of gravity was behind the knee in two thirds of
the injuries. If an athlete makes ground contact at the toes rather than in a flat-foot
position it is nearly impossible for the center of gravity to be behind the knee. When one

lands with the center of gravity behind the knee, the rectus femon's contracts to bring the

trunk over the leg, thus placing a large anterior force on the tibial tubercle 17.
Most non-contact ACL injuries occur when the athlete cuts, changes direction or

lands from a jump. The deceleration portion of these actions places a large anterior force

on the tibia thus also placing a strain on the ACL 17.
ACL Injury Prevention Programs
Available risk factor data suggests that a change in a biomechanical risk factor is

the most likely link to decreasing the risk of ACL injuries. The following hypothesis that

Teitz 17 made from video analysis should be considered when designing an ACL
prevention program. “A neuromuscular training program to aid the prevention of
noncontact AC L injuries sustained in pivoting sports should include the following
elements; a kinesthetic program to keep the center of gravity forward and the athlete on
his or her toes, and a program to encourage better lower extremity rotational and angular
control. The first portion of the program would include strength and endurance training
of the rectus abdominis, iliopsoas, and gastrocnemius-soleus muscles while the second

portion would include strength and endurance training of hip abductor and external

rotator muscles" 17.

There have been several ACL injury prevention programs developed that are
based on altering the biomechanical risk factors through neuromuscular training. Frank
Noyes and Timothy Hewett from Cincinnati, Ohio developed Sportsmetrics, a three-part
ACL injury prevention program consisting of stretching, plyometrics, and strength

training activities designed to address the potential deficits in neuromuscular strength and

coordination of stabilizing muscles around the knee joint 18.

From a 1996 study, Hewett, et al found striking neuromuscular imbalances
between young female athletes prior to training. When landing from a jump, male
athletes activated their knee flexors at three times the level of the female athletes in this

study, and it was discovered that jump training corrected hamstrings and quadriceps

imbalances, decreased impact forces, and increased strength and jump height 18.

In 1999, Hewett, et al did an additional study in order to test the effectiveness of
the program developed previously. There were 1263 athletes from 43 soccer, volleyball,
and basketball teams from 12 high schools participating in the program, and they were
monitored over their entire sports season. The program is a six week, three time weekly
regimen that consisted of 20 to 25 minutes of stretching exercises, a 30 minute
plyometrics jump training program, and 30 minutes of upper and lower extremity
strength training. The plyometric jump training portion was broken up into 32 week
phases. Phase 1, Technique, focuses on teaching the athlete the proper jumping
techniques. It instructs the athlete to “land soft as a feather”, “recoil like a spring”, and

“jump straight as an arrow”. Phase II, Fundamentals, is a phase that adds specific

techniques to build a base of strength, power and ability. Phase III, Performance, is

aimed at increasing the athlete’s vertical jump height, coordination, and balance while
landing from a jump 9.

In this study, it was found that the use of this program reduced the risk of a
serious knee injury significantly. It was also concluded that the decreased injury

incidence in trained athletes might be due to increased dynamic stability of the knee joint

after training 9.

The late Chuck Henning developed another ACL injury prevention program, The
Henning Program. Henning was a well-known orthopaedist that focused his sports
medicine research on what he called the “quad-cruciate interaction” and its role in
noncontact ACL injuries. Henning’s research was halted at his untimely death in 1991.
Just before his death, he had found in his study of videotaped ACL injuries that the most
common mechanisms were planting and cutting (29%), straight knee landing (28%), and
one step stop with knee hyperextended (26%). Only 7% of the injuries were caused by a
direct hit on the knee. He also found that the most common play situations in the
noncontact group of injuries included shifting while on defense, jumping for a loose ball,
dribbling to avoid a defender, going up for a layup, jumping and landing for a rebound,
and attempting to block a shot. From his research endeavors, Henning believed that the
ACL acts as a major restraint of forward movement of the tibia on the femur when the
knee is straight while weight bearing. He believed the ACL provides 86% of the total
resistive force, and when the quadriceps contract they cause more strain on the ACL. 1f
the knee is flexed to 60 degrees or greater the contraction of the quadriceps causes a

smaller anterior tibial translation and smaller load on the ACL.

10

From these conclusions, Henning developed his ACL injury prevention program.
Henning’s program consisted of drills in which he had athletes practice substituting an
accelerated rounded turn off a bent knee for the plant and cut, landing on a bent knee
instead of straight knee landing, and three-step st0p with knees bent instead of one-step
stop with knees straight. Prior to his death, Homing was able to make an instructional
video of these three techniques and conduct a pilot study. In the study, he instituted his

program at two division one basketball programs in Witchita, Kansas. The pilot study

showed an 89% decrease in the rate of occurrence of ACL injuries 5.

Carraffa Orthopedic Clinic in Temi, Italy developed another program in 1996.
This program is a five-phase proprioceptive program based on increasingly difficult skills
performed initially without a balance board and progressing through the use of a series of
balance boards. The study, a prospective study on the effect of proprioceptive training on
noncontact ACL injury rates in soccer players, was published in 1996 by Caraffa and
associates. The idea behind this study was that proprioception training is essential during
the rehabilitation process of a knee ligament injury and the role that prophylactic
proprioception training would have in preventing knee ligament injury? To test their
program, Caraffa and associates implemented their balance training program to the
standard training routine for 300 from 20 semiprofessional and amateur Italian soccer
teams. The controls were 300 players from 20 teams that continued their normal training
routine. The results showed a significant decrease in injury rate for the trained group,

0.15 injuries per team per season, compared to 1.15 injuries per team per season for the

untrained group 8.

ll

The program consisted of five phases of progressively difficult balance exercises.
During phase one, the athlete balances on a single leg with no board. They then progress
to a rectangular board in phase two, a round board in phase three, and alternates between
rectangular and round boards in phase four. Finally in phase five, the athlete uses a
multiplanar board, also called a biomechanical ankle platform system, BAPS. These

exercises were recommended to be done 20 minutes each day for 30 days prior to the

season and continue the program three days a week during the regular season 8.
Anterior cruciate ligament injury is not only common among basketball,

volleyball, and soccer players, but also among female skiers. There has been an

ongoing case control study at the Sugarbush Ski Area in Vermont. The data in 1998

showed that ACL injuries accounted for 19.3% of all injuries sustained on the slopes, a

notable increase from the 4.5% in 1972 10.

The Vermont Safety Research based in Underhill, Vermont recognized the
increased risk and described what is known as the “phantom foot”. Phantom foot is a
phenomenon that occurs when the following elements occur: (1) skier off balance to the
rear; (2) uphill arm back; (3) hips below the knees (knees flexed greater than 90 degrees);
(4) uphill ski unweighted; (5) weight on the inside edge of the downhill ski tail; and (6)
upper body generally facing the downhill ski. From their awareness of this phenomenon
the researchers designed an injury awareness program to address and minimize these
actions. The program was developed into a videotape that describes the mechanism of
phantom foot and several ways to prevent being in the position of injury. An interesting
point about ACL injuries in the ski population is that the risk of sustaining an injury does

not appear to be effectively reduced by improvement in the skier’s ability or by increase

12

in the skier’s strength or experience. Ski instructors and patrollers who devised

prevention programs after viewing videotapes of ACL injury and near-injury situations

sustained fewer ACL injuries than those in the control group 10.

In response to the Hunt Valley Consensus Conference the Santa Monica ACL
Prevention Project was developed. Their goal was to develop a program that could be
done as part of the normal practice and that would also decrease the number of ACL
injuries in female soccer. They developed PEP, Prevent Injury and Enhance
Performance. PEP consists of a warm-up, stretching, strengthening, plyometrics, and

sport specific agilities. The program is designed to take 15 minutes plus a cool down and

stretching. It is recommended that athletes perform this program 2-3 times per week 7.
Girls’ Can Jump is an 8-week training program, which focuses on addressing four
problem areas for female athletes: flexibility differences, strength imbalances, balance
deficits, and jumping technique error. The program includes a dynamic warm—up, correct
jumping technique that includes posture, take off, and landing. Plyometric jumps will
also be done progressing from less difficult to more difficult exercises, beginning with
double leg jumps progressing to single leg jumps, and finishing with multi-directional
jumps. The program also addresses balance deficits by translating balance into a
functional strength training program including strengthening for the arms, legs, and core.
This program was developed by Laura Ramus PT, ATC, CSCS for the Detroit Shock, and
has been implemented in the Detroit Shock strength and conditioning program for the last
three years. Since the implementation of the program the athletes on the Detroit Shock

team have suffered no ACL injuries, and report improved performance in vertical jump

height 6.

13

Coaches’ Education

As previously stated, there are numerous opportunities for coaChes’ education.
Several associations have developed credentialing programs for coaches in order to
increase the level of education that occurs between coach and athlete. It is estimated that
2.5 million coaches are involved in non-scholastic sports, and approximately 400,000 are
involved in scholastic sports in the United States. The Institute for the Study of Youth
Sports at Michigan developed PACE, Program for Athletic Coaches’ Education, in

response to the increased number of youth participating in organized sports and the

increased demand for educated coaches 19.

Michigan High School Athletic Associations, Michigan Interscholastic Athletic
Administrator Associations, and the Youth Sports Institute designed and endorsed the
PACE program. PACE provides interscholastic coaches with information about their
daily coaching responsibilities, and credentialing through PACE has been made a
requirement for several school districts as part of their coaching continuing education.

PACE is offered in two levels, Level I and Level II, and is not sport specific therefore is

ideal for all coaches 20.

Another education program that is not sport specific is ASEP, American Sport
Education Program, and NFHS, National Federation of State High School Associations’
Coaches’ Education Committee. The ASEP develops and delivers online and
instructor-led courses and resources for coaches, officials, sport administrators, athletes,
and parents of athletes. ASEP consists of two levels of certification, the Volunteer
Education Program and the Professional Education Program. The Volunteer Education

Program is designed for those working with the less competitive, recreational sports

14

 

program with athletes 13 years of age and younger. The Professional Education Program

allows coaches working with athletes 14 years of age and older to increase their skills and

enhance their careers 2].

The National Federation of State High School Coaches’ Education Committee
also has coaches’ education programs in place. Their mission is “to assist member state
associations by providing a coaches’ education program which will enhance the skills and

knowledge necessary to teach meaningful life-long lessons to all student participants and

to support the achievement of educational goals” 22.

The NFHS encourages coaches to earn professional credentials and they have

partnered with the ASEP to provide the Bronze, Silver, and Gold level courses 22. The
NFHS has also developed a Sports Medicine Handbook in response to the need expressed
by state organizations for a publication focused on Sports Medicine. This publication
includes information on administrative issues like coaches training, emergency planning,
guidelines for lightening safety, and pre-participation examinations. In the section
regarding medical issues the topics covered include: cold illness, heat-related illness,
infectious disease, skin disorders, nutritional concerns: female athlete triad, supplements,
weight control, mild head injury, asthma, and fluid replacement. The final section

discusses equipment issues and covers the topics of helmet removal and mouthguard

use 23.

In addition to the non-sport specific programs, there are also sport specific
education programs available to coaches. The Michigan State Youth Soccer Association,
MSYSA, provides educational courses for coaches working with youth soccer. Coaches

can receive credentialing for all levels of coaching experience. According to the

15

 

Michigan State Youth Soccer Association’s website, the U6, U8, U10 modules are
three-hour courses, recommended for parents, new coaches, and those working with
children under the age of ten. The E license is a 16 hour course that consists of
theoretical and practical instruction on the teaching of techniques and tactics of small-
sided games between 1V] and 6V6. The emphasis is to build on the player’s technical
development by applying tactical concepts with game situations. The D license is a 36
hour course that consists of theoretical and practical instruction on teaching the four
components of soccer: technique, tactics, fitness and psychology, as they relate to games
from IV] to llvl 1. This level of certification is recommended for all travel level coaches
working in the 1 1-a-side game. To obtain this certification coaches are required to pass
two written tests and a practical field test. When taking this course, there are three
possible outcomes.

1. Coaches can pass outright and become National D and proceed to the next
national level courses, C, B, and A after a mandatory one year wait.

2. Coaches can earn a restricted pass, State D, which requires a two year wait, or

3. Coaches can fail the course 24.

Along with the certification coaches are required to attend Continuing Education
Program, CEP, in order to maintain their “A” License. According to the US. Soccer
website coaches that are currently “A” Licensed must accumulate eight credits within

every four-year cycle in order to maintain their “A” License. Coaches that do not obtain

enough Continuing Education, CE, credits will revert into a “B” License 25.
According to the Basketball Coaches Association of Michigan, they are

promoting the new Graduate Certificate in Coaching offered online through Michigan

16

 

State University’s Department of Kinesiology and Youth Sports Institute. Upon
completion of the three 3-semester hour courses that address legal, administrative,
psychological, sociological, and biological issues as they relate to the coaching of

amateur athletes, a Certificate of Completion will be awarded by the Department of

Kinesiology 26, 27.

According to the US. Volleyball website, they provide the CAP Cadre Program
for their coaches’ education. This program consists of six levels: Home Equivalency
Course, Level 1, Level 11, Level III, Level IV, and Volleyball Conditioning Specialist
(VCS) Course. The Home Equivalency Course is aimed toward the well experienced
coaches who have taken prior coaching education foundation course work and possess
established competencies in facilitating athlete development. The Level I certification is
targeted towards coaches of all coaching and teaching levels, especially those who have
had no or limited formal coaching education courses. The Level II follows Level I, and
puts an emphasis on team offense/defense systems, blocking and setting development,
problem solving, social issues, and drill development. The Level III course follows Level
II and focuses on critical thinking about the sport of volleyball. It also includes peer
presentations and an Outreach Project to coach in the community. The Level IV
certification is granted on an honorary basis to those individuals who have been head
coaches for an official USA National Volleyball Team. The VCS course is a course
provided by the USA Volleyball’s Sports Medicine and Performance Commission and
Performance Conditioning for Volleyball. The course is designed to help those that have

a large role in their team’s strength and conditioning program. The course covers on and

17

 

off the court conditioning, court movement, evaluation, individualization, jump

improvement, over-training and injury prevention 28.

18

 

Chapter 3
METHODS

Subjects

The subjects in this study included the coaches from the 21 schools participating
in the Capital Area Activities Conference, CAAC the sports of boys’ and girls’
basketball, boys’ and girls’ soccer and girls’ volleyball will be mailed questionnaires
pertaining to their knowledge in the area of ACL prevention. The schools in Division 1
inlcude: East Lansing, Eastern, Everett, Grand Ledge, Holt, Jackson, Okemos, and l

Sexton. The schools in Division 2 include: Charlotte, Eaton Rapids, Ionia, Lumen

 

Christi, Mason, Northwest, and Waverly. The schools in Division 3 include: Catholic
Central, Dewitt, Fowlerville, Haslett, Lakewood, and Williamston.
Instrumentation

A survey was designed to answer questions regarding coaches’ demographics,
their awareness of ACL injuries, awareness and implementation of ACL injury
prevention programs and techniques. (See Appendix B)
Protocol

Survey materials were distributed by mail, addressed to each of the varsity
coaches for the sports of boys’ and girls’ basketball, boys’ and girls’ soccer, and girls’
volleyball at each of the schools listed above. It included a letter (see Appendix A)
explaining the research being conducted, an informed consent statement, and a request to
return the survey within two weeks. Also included with the survey was information on
obtaining a reference list of current research in the area of ACL injury prevention. At

three weeks, the participants that had not returned their survey were mailed a second

19

survey and a second letter (see Appendix C). In response for their participation, each
respondent was mailed a reference list of current prevention programs and relevant
articles (see Appendix D).
Statistical Analysis

The statistical analysis was done by entering the raw data into an excel file. The
data was then processed using SPSS 10.0 software (SPSS Inc, Chicago, IL) to determine

the descriptive statistics. Frequencies, percents, and simple comparisons were made.

20

 

Chapter 4

RESULTS

There were 105 surveys mailed to coaches participating in the Capital Area
Activities Conference. Of these 45 (42.8%) were returned. Table 4.1 shows which sport
the respondents coached, and how many years they have been coaching their sport.
Coaches were able to answer multiple sports coached. Of the 45 respondents, 15 (33.3%)
had coached boys’ basketball, 13 (28.9%) had coached girls’ basketball, 7 (15.6%) had
coached boys’ soccer, 10 (22.2%) had coached girls’ soccer, and 9 (20%) had coached
volleyball.

For the boys’ basketball respondents the majority, 9 (20%) had 216 years of
coaching experience. For girls’ basketball, 4 (8.9%) respondents had s5 years
experience, 4 (8.9%) respondents had 6-10 years experience, and 4 (8.9%) respondents
had 11-15 years of coaching experience. For the boys’ soccer respondents the majority, 5
(11.1%) respondents had 6-10 years boys’ soccer coaching experience. For the girls’
soccer respondents the majority, 7 (15.6%) respondents had 6-10 years girls’ soccer
coaching experience. For the volleyball respondents the majority, 4 (8.9%) respondents
had 11-15 years volleyball coaching experience.

There are three divisions within the Capital Area Activities Conference. Schools
are placed into a division based on the number of students enrolled in their school. There
were 16 out of 40 possible respondents (40%) from the Division I level. 14 out of 35
possible respondents (40%) from the Division 11 level, and 15 out of 30 possible

respondents (50%) in the Division III level.

21

 

Table 4.1

Years of Coaching Experience

 

 

Boys’ Basketball 55 yrs 6-10 yrs 11-15 yrs 216 yrs Total
Frequency 1 3 2 9 15
Percent 2.2% 6.7% 4.4% 20.0% 33.0%
Girls’ Basketball
Frequency 4 4 1 4 13
Percent 8.9% 8.9% 2.2% 8.9% 28.9%
Boys’ Soccer
Frequency 1 5 0 1 7
Percent 2.2% 11.1% 0% 2.2% 15.6%
Girls’ Soccer
Frequency 2 7 0 1 10
Percent 4.4% 15 .6% 0% 2.2% 22.2%
Volleyball
Frequency 1 2 4 2 9
Percent 2.2% 4.4% 8.9% 4.4% 20.0%

 

 

 

Percentages indicate percent of total respondents (45).

Tables 4.2-4.7 show the coaching level of the 45 coaches that participated in the
survey. All coaches were involved in coaching at the high school level. The interesting
piece of data is the number of coaches that were involved at other levels besides
scholastic high school. Twenty-eight percent of the total respondents also coached at the
elementary school level, 37.8% also coached at the middle school level, 46.7% also
coached at the junior high level, 24.4% also coached at the collegiate level, and 24.4%

also coached at the adult recreational level.

 

Table 4.2
Coaching at High School Level
Frequency Percent
Scholastic 9 - 12th grade 39 86.7%
Non-Scholastic 0 0%
Both Scholastic and Non-Scholastic 6 13.3%
Total 45 100%

 

 

 

Percents are based on the total respondents (45).

22

Table 4.3
Coaching at Elementary Level

 

 

 

 

 

 

 

 

 

 

Frequency Percent
Scholastic K - 4th grade 5 11.1%
Non-Scholastic 5 - 9 years of age 8 17.8%
Total 13 28.9%
Percents are based on the total respondents (45).
Bile—4:1
Coaching at Middle School Level
Frequency Percent
Scholastic 5 - 6th grade 7 15.6%
Non-Scholastic 10 - 11 years of age 9 20.0%
Both Scholastic and Non—scholastic l 2.2%
Total 17 37.8%
Percents are based on the total respondents (45).
Table 4.5
Coaching at Junior High Level
Frequency Percent
Scholastic 7 - 8th grade 14 31.1%
Non-Scholastic 12 -13 years of age 6 13.3%
Both Scholastic and Non-scholastic l 2.2%
Total 21 46.7%
Percents are based on the total respondents (45).
Table 4.6
Coaching at Collegiate Level
Frequency Percent
Intercollegiate 4 8.9%
C lub/ Intramural 5 1 1 . l %
Both Intercollegiate and Club/ Intramural 2 4.4%
Total 11 24.4%

 

 

Percents are based on the total respondents (45).

23

 

 

 

 

Table 4.7

 

Coaching at Adult Level
Frequency Percent
Yes 8 17.8%
No 3 6.7%
Total 1 1 24.4%

 

 

 

Percents are based on the total respondents (45).

Table 4.8 shows the number of coaches that are currently or have been
certified in CPR. It is interesting to note that 62.2% of total respondents were currently
CPR certified and of those that were not current, 58.8% had been certified but were not

maintaining these credentials.

 

Table 4.8
CPR Certification of Coaches
Currently CPR Certified Yes No Total
Frequency 28 1 7 45
Percent 62.2% 37.8% 100%
Previously CPR Certified
Frequency 10 7 17
Percent 58.8% 41.2% 100%

 

 

 

Coaches that responded to the survey held very few coaching credentials, which
the pattern of their responses are portrayed in Tables 4.9-4.10. Ten (22%) reported
taking the PACE program. Five (11.1%) of the respondents reported credentialing
through Michigan State Youth Soccer Association (MSYSA). No one reported having
credentialing through the American Sport Education Program (ASEP), and only 1 (2.2%
respondent was credentialed through National Federation of State High School

Associations (NF HS).

24

Table 4.9
Program of Athletic Coaches Education (PACE) '

 

Frequency Percent

 

 

 

 

Level 1 1 2.2%
Level 2 7 15 .6%
Both Level 1 and 2 2 4.4%
Total 10 22.2%
Percentages indicate the percent of total respondents (45).
Table 4.10
Michigan State Youth Soccer Associations (MSYSA)

Frequency Percent
U6, U8, or U10 Module 0 0%
E License 0 0%
D License 5 11.1%
Multiple Certifications 5 11.1%
Total 10 22.2%

 

 

 

Percentages indicate the percent of total respondents (45).

Table 4.11 shows the number of respondents involved in education courses
related to coaching. The majority of respondents reported taking coaching seminars for
their continuing education with 41 (91%) of total respondents answering in the
affirmative. Only 13 (28%) have taken injury prevention courses.~ There were 28
(62.2%) of the respondents that have taken a strength and conditioning course, 27 (60%)
of the respondents that have taken a coaching education course, and 15 (33.3%) of the

respondents have taken an athletic training course.

Table 4.11

Coaches’ Education

 

Coaching Education Course
Frequency
Percent
Coaching Seminars
Frequency
Percent

Frequency

Percent

Athletic Training Course
Frequency

Percent
Injury Prevention Course
Frequency

Percent

 

Strength and Conditioning Course

Yes
27
60.0%

41
91.1%

28
62.2%

15
33.3%

13
28.9%

No
18
40.0%

4
8.9%

17
37.8%

30
66.7%

32
71.1%

Total
45
100%

45
100%

45
100%

45
100%

45
1 00%

 

Coaches that have been affected by an ACL occurrence within the athletic

 

population they coach may be more likely to investigate ACL injury prevention. Table
4.12 shows the number of coaches affected by an ACL injury in their coaching career.
The majority, 29 (64.4%) of respondents have had 1-5 ACL injuries in their athletic
population. It is also interesting to note that 15 (33.3%) of the respondents reported zero

ACL injuries in the population they coach.

 

Table 4.12
Number of Coaches Affected by ACL Injuries
0 1-5 6-10
Number of ACL In juries Injuries Injuries Injuries Total Respondents
Frequency 15 29 l 45
Percent 33 .3% 64.4% 2.2% 100%

 

 

 

26

Coaches must know that ACL injuries occur, and believe they can be prevented
before they implement a program to reduce the injury rate. Table 4.13 shows the number
of respondents that are aware of ACL injuries, and how many feel that ACL injuries can
be reduced. All coaches that responded to the survey are aware of ACL injuries and
97.8% report believing that the occurrence of ACL injuries can be reduced. There was
one missing data point and this was from a coach that did not respond negatively or

affirmatively to the question.

 

Table 4.13
Coaches’ Awareness and Belief of Reduction of ACL Injury
Awareness of ACL Injuries Yes No Total
Frequency 45 0 45
Percent 100% 0% l 00%
Reduction of ACL Injuries
Frequency 44 0 45
Percent 97.8% 0 100%

 

 

 

Table 4.14 shows how many respondents were aware of ACL injury prevention
programs. Sportsmetrics was the most commonly recognized prevention program at 9
(21.9%) of the respondents being aware. The PEP program and RIF A were the next most
common with 5 (12.2%) responses each. Henning’s and Caraffa were tied for the least
awareness with 1 (2.4%) response each.

Table 4.15 shows how many respondents are implementing ACL prevention
programs in their strength and conditioning programs. Sportsmetrics was the most
commonly implemented program with 5 (12.2%) respondents saying they use
Sportsmetrics in their strength and conditioning program. Reduce Injury in Female

Athletes (RIFA) was implemented by 2 (4.9%) of respondents. One respondent

27

implements the program Girls Can Jump. No other program was being implemented by

any of the respondents.

Few coaches were aware of specific ACL injury prevention programs. They were

more familiar with the techniques used in these programs. Table 4.16 shows that

plyometric jump training and agility running were the prevention techniques that the

respondents were most aware of with 42 (95.5%) saying they were aware of these

techniques. Lower extremity strengthening had a frequency of 36 (81.8%) affirrnative

responses. Proprioception and balance training was the technique that respondents were

least aware of with 18 (40.9%) of the respondents answering in the affirmative.

 

Table 4.14
ACL Injury Prevention Program Awareness
Sportsmetrics Yes No Total
Frequency 9 32 41
Percent 21.9% 78.1% 100%
Prevent Injury and Enhance Performance - PEP
Frequency 5 36 41
Percent 12.2% 87.8% 100%
Henning's Program
Frequency 1 40 41
Percent 2 .4% 97.6% 100%
Reduce Injury in Female Athletes -— RIFA
Frequency 5 36 41
Percent 12.2% 87.8% 100%
Caraffa Program
Frequency 1 40 41
Percent 2.4% 97.6% 100%

 

 

Four respondents did not answer the question, so the percentages are based on the 41 respondents.

28

 

Table 4.15

AC L Injury Prevention Program Implementation .

 

Sportsmetrics

Henning's Program

Caraffa Program

 

Frequency
Percent

Prevent Injury and Enhance Performance — PEP

Frequency
Percent

Frequency
Percent

Reduce Injury in Female Athletes — RIFA

Frequency
Percent

Frequency
Percent

Yes
5

12.2%

0%

0%

2
4.9%

0
0%

No
36

87.8%

41
100%

41
100%

39

95.1%

41
100%

Total
41
1 00%

41
100%

41
100%

41
100%

41
100%

 

Four respondents did not answer the question, so the percentages are based on the 41 respondents

Table 4.16

AC L Injury Prevention Technique Awareness

 

Agility Running

Plyometric Jump Training

Frequency
Percent

Lower Extremity Strengthening

Frequency
Percent

Frequency
Percent

Proprioception and Balance Training

Frequency
Percent

Yes
42
95.5%

36
81.8%

42
95.5%

18
40.9%

No '
2
4.5%

8
18.2%

2
4.5%

26
59.1%

Total
44
1 00%

44
100%

44
100%

44
100%

 

 

One respondent did not answer this question, so percentages are based on the 44 respondents.

Few coaches’ implemented ACL injury prevention programs, but a significant

amount implements the techniques used in these programs. Table 4.17 shows that agility

running was the most common prevention technique being implemented by the

 

 

respondents with 42 (95.5%) saying they use it in their strength and conditioning
regimen. Plyometric jump training and lower extremity strengthening were the next most
common techniques being used with 33 (75.0%) of the respondents saying they use these
techniques. Proprioception and balance training was the least implemented technique
with 12 (27.2%) of the respondents implementing the technique.

Table 4.18 shows how many times per week the coaches implemented the ACL
prevention technique. Of the 42 respondents implementing the agility running technique,
the majority, 30 (71.4%) of them are doing this 1-2 times per week. Of the 33
respondents implementing the plyometric jump training technique the majority, 29
(87.9%) are doing this 1-2 times per week. Of the 33 respondents implementing the
lower extremity strengthening technique, the majority, 23 (69.7%) are doing this 1-2
times per week. Of the 12 respondents implementing the proprioception or balance

training technique, the majority, 9 (75%) are doing this 1-2 times per week.

 

Table 4.17
ACL Injury Prevention Technique Implementation
Plyometric Jump Training Yes No Total
Frequency 33 11 44
Percent 75.0% 25.0% 1 00%
Lower Extremity Strengthening
Frequency 33 l 1 44
Percent 75 .0% 25.0% 1 00%
Agility Running
Frequency 42 2 44
Percent 95.5% 4.5% 100%
Proprioception and Balance Training
Frequency 1 2 32 44
Percent 27.2% 72.7% 100%

 

 

 

One respondent did not answer this question, so percentages are based on the 44 respondents.

30

Table 4.18
ACL Injury Prevention Technique Frequency

 

 

Plyometric Jump Training 1-2 times/wk 3-4 times/wk Total
Frequency 29 4 33
Percent 87.9% 12.1% 100%
Lower Extremity Strengthening
Frequency 23 l 0 33
Percent 69.7% 30.3% 100%
Agility Running
Frequency 30 1 2 42
Percent 71.4% 28.6% 100%
Proprioception and Balance Training
Frequency 9 3 12
Percent 75.0% 25.0% 100%

 

 

The percents are reflective of the total respondents implementing each technique.

Table 4.19 shows during what part of the season the coaches implemented
plyometric jump training. Of the 33 respondents implementing the plyometric jump
training technique all are implementing this technique during their preseason
conditioning. There were also 25 (75.8%) that reported implementing this technique
during the season, and 11 (33.3%) implementing it postseason.

Table 4.19 shows during what part of the season coaches are implementing lower
extremity strengthing. Of the 33 respondents implementing the lower extremity
conditioning technique, the majority, 31 (93.9%) are implementing this technique during
their preseason conditioning. There were also 25 (75.8%) that reported implementing
this technique during the season, and 15 (45.5%) that implemented this technique
postseason.

Table 4.20 shows during what part of the season coaches are implementing agility
running. Of the 42 respondents implementing the agility running technique, the majority,

38 (84.4%) are implementing this technique during their preseason conditioning.

31

Table 4.21 shows during what time coaches implemented proprioception and

balance training. Of the 12 respondents implementing the proprioception and balance

training technique the majority, 10 (83.3%) are implementing this technique during their

preseason conditioning. There were 9 (75%) implementing this technique during season,

and 4 (33.3%) implementing it postseason.

Table 4.19

Plyometric Jump Training Implementation Timing

 

 

 

 

 

Plyometric Jump Training Preseason Yes No Total
Frequency 33 0 33
Percent 1 00% 0% 100%
Plyometric Jump Training During Season
Frequency 25 8 33
Percent 75.8% 24.2% 100%
Plyometric Jump Training Postseason
Frequency 1 l 22 33
Percent 33.3% 66.7% 100%
Table 4.20
Lower Extremity Training Implementation Timing
Lower Extremity Strengthening Preseason Yes No Total
Frequency 31 2 33
Percent 93.9% 6.1% 100%
Lower Extremity Strengthening During Season
Frequency 25 8 33
Percent 75.8% 24.2% 100%
Lower Extremity Strengthening Postseason
Frequency 15 18 33
Percent 45.5% 54.5% 100%

 

32

 

 

 

Table 4.2]

Agility Running Implementation Timing

 

 

 

 

Agility Running Preseason Yes No Total
Frequency 38 4 42
Percent 90.8% 9.2% 100%
Agility Running During Season
Frequency 35 7 42
Percent 83.3% 16.7% 100%
Agility Running Postseason
Frequency 1 1 31 42
Percent 26.2% 73.8% 100%
Table 4.22
Proprioception and Balance Training Implementation Timing
Proprioception and Balance Training Preseason Yes No Total
Frequency 10 2 12
Percent 83.3% 16.7% 100%
Proprioception and Balance Training During Season
Frequency 9 3 12
Percent 75 .0% 25 .0% 100%
Proprioception and Balance Training Postseason
Frequency 4 8 12
Percent 33.3% 66.7% 100%

 

 

When the respondents were regrouped according to boys’ versus girls’ coaching

experience there were 23 (51.1%) respondents coaching only girls’ sports, 13 (28.9%)

respondents coaching only boys’ sports, and 9 (20%) respondents coaching both boys’

and girls’ sports. Table 4.23 shows the data separated between coaches with boys’ only,

girls’ only, coaches with both boys’ and girls’ experience, and a combination of girls’

only experience and both girls’ and boys’ coaching experience. There were 4 (17.4%)

girls’ coaches, zero boys’ coaches, and 2 (22.2%) of coaches with both boys’ and girls’

coaching experience that reported implementing an AC L injury prevention program.

33

 

 

All of the individuals that had girls’ coaches and 11 (84.6%) of the individuals
that had boys’ coaches reported implementing one or more ACL injury prevention
techniques. There were 8 (34.8%) individuals with both boys’ and girls’ coaching
experience who reported implementing one or more ACL injury prevention technique.

Four (30.8%) of those individuals that had coaching experience for only boys’
sports had some type of coaching credential, while 13 (56.5%) of the individuals that
coached only girls’ sports reported a coaching credential. There was only one (11.1%)
coach that had both boys’ and girls’ coaching experience that reported a coaching
credential.

All coaches reported taking a strength and conditioning course more frequently
than an athletic training or injury prevention course. Strength and conditioning course
was reportedly taken by 7 (53.8%) of coaches with boys’ only experience, 15 (65.2%) of
coaches with girls’ only experience, and 5 (55.6%) of coaches with boys’ and girls’

coaching experience.

34

Table 4.23

Differences Among Coaching Experience

 

Number of Respondents

ACL Injury Prevention Program
Implementation
Frequency
Percent

Implementation
Frequency
Percent
Currently CPR Certified
Frequency
Percent
Previously CPR Certified
Frequency
Percent
Coaching Credentials
Frequency
Percent
Athletic Training Class
Frequency
Percent
Strength and Conditioning Class
Frequency
Percent
Injury Prevention Class
Frequency
Percent

 

Boys' Only Girls’ Only Boys' and Girls’ Only

Coaching Coaching Girls’ and Girls’

Experience Experience Coaching and Boys'
Experience Coaching

ACL Injury Prevention Technique

Experience
13 23 9 32
0 4 2 6
0% 17.40% 22.20% 18.80%
11 23 8 31
84.60% 100% 88.80% 96.90%
12 13 3 16
92.30% 56.50% 33.30% 50%
1 5 4 9
7.70% 21.70% 44.40% 28.10%
4 13 6 19
30.80% 56.50% 66.70% 59.40%
4 8 l 9
30.80% 34.80% 11.10% 28.10%
7 15 5 20
53.80% 65.20% 55.60% 62.50%
1 7 3 10
7.70% 30.40% 33.30% 31.30%

 

35

 

Chapter 5

DISCUSSION

Anterior cruciate ligament injuries are more common in female athletes who
participate in sports where jumping, cutting and pivoting are essential. The researchers
have identified possible risk factors, some of which can be changed in order to decrease
the risk of ACL injury. In response, some researchers have developed prevention
programs, and demonstrated improvements in the biomechanical risk factors that can
reduce the incidence of ACL injuries. At the Hunt Valley Conference on ACL injury
prevention, all the ACL injury research was taken into consideration and consensus
statements were made regarding risk factors, current prevention programs, and future
research directions. The conference concluded that “there is a pressing need to improve

public and participant awareness of the risk of ACL injury and the possibilities of

prevention”29.

This research study was done to identify Capital Area Activity Conference
coaches’ awareness and implementation of specific ACL injury prevention programs or
techniques. The results support the hypothesis that coaches are not aware of or
implementing specific ACL injury prevention programs, but they are unknowingly
implementing ACL injury prevention techniques.

It was found that few coaches participating in the Capital Area Activities
Conference are aware of ACL injury prevention programs. Coaches were most
commonly aware of Sportsmetrics with only 21% reportedly being familiar with the

program. The majority of coaches reported being aware of one or more ACL injury

36

prevention technique. Ninety-five percent of respondents said they were aware of agility
running and plyometric jump training. These finding support the hypothesis that coaches
were not aware of specific ACL injury prevention programs, but they are aware of the
techniques that have been used in these programs.

From the results of this study it was found that few coaches in the Capital Area
Activities Conference are implementing ACL injury prevention programs, but the
majority of these coaches are implementing one or more of the techniques included in the
programs. It is interesting to note that the majority, 42 (95.5%) of coaches reported
implementing agility running as part of their strength and conditioning program. This
technique is used in the Prevention injury and Enhance Performance (PEP) program,
which was recognized by only five coaches and implemented by zero. Plyometric jump
training and lower extremity strengthening were the next most commonly implemented
techniques and these are the basis of Sportsmetrics and Girls Can Jump. Nine coaches
reported being aware of Sportsmetrics and only five were implementing it. There was
only one coach that reported being aware of and implementing Girls Can Jump.
Proprioception and balance training was the least likely to be implemented by the
coaches and is the foundation of the Caraffa program. Only one respondent was aware of
the Caraffa program and none reported implementing it. These results support the
hypothesis that coaches were unknowingly implementing techniques used in ACL injury
prevention.

No relationship could be made between holding a coaching credential and
implementing an ACL injury prevention program or technique. There was also no

relationship found between occurrence of ACL injury and implementation of and ACL

37

injury prevention program. This result was surprising because it would be logical to
think that coaches that have been affected by an ACL injury would be more likely to seek
out information on ACL injury prevention. These results may be distorted because of the
small number of respondents.

The most interesting findings from this survey came when the respondents were
divided into boys’ versus girls’ coaching experience. The ACL injury research has
focused on the female athlete, thus the focus of ACL injury prevention has also been on
the female athlete. It was found that coaches that had experience coaching girls’ were
more likely to implement ACL injury prevention programs. There were no coaches with
boys’ only experience that implemented ACL injury prevention programs versus the
17.4% with girls’ only experience and 11.1% of coaches with both boys and girls’
coaching experience.

There was no notable difference between boys’ and girls’ coaching experience
and ACL injury prevention technique implementation. All coaches with girls’ only
coaching experience implemented one or more ACL injury prevention technique and all
but two coaches with boys’ only experience implemented a technique.

Coaches involved in girls’ sports implement ACL injury prevention programs
and techniques more often than those with only boys’ coaching experience. When
considering the literature, it makes sense that girls’ coaches would be more likely to
implement ACL injury prevention programs and/or techniques in the strength and

conditioning program. The incidence of ACL injuries is 2-8 times higher in girls’ sports

compared to boys’ sports7-9. It is more likely that a coach involved in only girls’ sports

will be affected by an AC L injury than a coach involved in only boys’ sports, which

38

could cause them to seek out prevention for such a devastating injury. As was evident in
the results of this study coaches involved in girls’ sports were more likely to be affected
by an ACL injury.

The results of this survey also show that coaches involved in girls’ sports were
more likely to hold coaching credentials, take an athletic training, strength and
conditioning, and injury prevention course. It was evident that coaches involved in
female sports tend to seek continuing education courses more often than coaches that
work with only boys’ sports. . If ACL injury prevention was discussed in any of these
courses it is more likely to reach the female athletic population.

One program that was reportedly being implemented by one respondent is Girls
Can Jump (GCJ). This program is available on video, and during her off season from the
WNBA Detroit Shock, Laura Ramsus performs a GCJ community outreach program.
This program is designed for coaches involved in the sports of girls’ basketball,
volleyball, and soccer. In the outreach program Ms. Ramsus will personally present the
Girls Can Jump athletic training and knee care program to the group of community
members. The goal of the program is to reach as many female athletes and those

involved in female athletics as possible, and help the athletes, parents, and coaches

understand ways to prevent ACL injury 30. This outreach program is an excellent way to
do exactly what needs to be done to increase the public and participant awareness of ACL
injury and ACL injury prevention.

Another program that has attempted to increase the public and participant
awareness of ACL injury and ACL injury prevention is Sportsmetrics. Sportsmetrics was

highlighted on the ABC’s Wide World of Sports, “Game for Anything-The Strength in

39

Women’s Sports”. It was also featured on the US. News and World Report’s health
section, “News You Can Use”. There has also been remarkable coverage in the
Cincinnati area over the last couple years with the continued research at the Cincinnati
Sports Medicine Research and Education Foundation.

Those at Cincinnati Sportsmedicine have recently made available a certification
program for Sportsmetrics. There are several ways to go about performing the program
with a certified trainer. Those in the local Cincinnati area can train with Cincinnati
Sportsmedicine where they perform a Sports Injury Test Report to assess the athlete’s

needs prior to and at the completion of the program. They will also be supervised during

all training sessions with a Certified Sportsmetrics instructor 31.
Athletes can also train in a Sportsmetrics Certified Clinical Site, which are located
all over the country, with four locations in northern Michigan. These locations can

provide the latest in Sportsmetrics testing, training, and educational consultation for

coaches, athletes, and patients in their local community 31. For those athletes that do not
have a site within the locale, Cincinnati Sportsmedicine has developed an instructional

video series. This series includes a step-by-step instructional video as well as a follow

along video for group or individual training“.

There has been an obvious attempt to increase the public and participant
awareness of ACL injury and ACL injury prevention by both of these programs. From
the results of this study, the awareness is low among coaches involved in the Capital Area
Activities Conference. Hosting a Girls Can Jump Community Outreach or gaining a
Certified Clinical Site in the Lansing area could dramatically change the awareness level

of ACL injury and ACL injury prevention for those participating in the Capital Area

40

Activities Conference. This would in turn decrease the number of ACL injuries sustained
by athletes participating in this conference.

The findings of the current project support the recommendation made at the Hunt
Valley Consensus Conference. One of their key findings was that “there is a pressing

need to improve public and participant awareness of the risk of ACL injury and the

possibilities of prevention”29. The low number of coaches that were aware of ACL
injury prevention programs indicate a strong need to enhance public awareness of the
ACL injury prevention programs.
Considerations for Future Research

Michigan does not have requirements for coaches’ education. It would be
interesting to distribute this survey in a state where coaches’ education is a requirement.
Limitations of the Study

The population surveyed included only coaches within a single Mid-Michigan
high school athletic conference. The return was better than expected for the type of study
done. Regardless the numbers were still too low to make any generalizations outside the

population studied.

41

APPENDIX A

42

ACL Injury in High School Sports
Participant Informed Consent Form
Dear Coach,

My name is Missy Erwin and I am a Graduate Student at Michigan State University. I
am doing my Master’s Thesis in the area of ACL injury prevention. I am surveying
coaches in the Capital Area Activities Conference regarding my topic and I ask that you
please complete the survey that is enclosed.

Participation in the survey is voluntary, and you may chose not to participate, or you may
refuse to answer certain questions. Your participation will contribute to the research in
the area of ACL injury prevention, and it should take less than 15 minutes to complete
and return the survey. A self addressed stamped envelope is included for you to return
the survey to me. I ask that you please return it within two weeks of its receipt.

Your privacy will be protected to the maximum extent allowable by law. In return for the
surveys completion you will be sent a reference list of current research in the area of
ACL injury prevention.

Thank you for your participation; it is greatly appreciated. If you have any questions or
concerns about this study, please contact Missy Erwin, Secondary Investigator by phone:
(517)-214-4054, by regular mail: 2910 Beau Jardin Dr. Apt #208, Lansing, MI 48910, or
by email: enx'inmclflmsuedu. You may also contact Dr. John Powell, Principle
Investigator by phone: (517)-432-5018, by regular mail: 105 IM Sports Circle, E.
Lansing, MI 48824, or by email: powelli4@msu.edu.

 

If you have any questions or concerns regarding your rights as a study participant, or are
dissatisfied at any time with any aspect of this study, you may contact — anonymously, if
you wish — Peter Vasilenko, Ph.D, Chair of University Committee on Research Involving
Human Subjects (UCHRIS) by phone: (517)-355—2180, fax: (517)-432-4503, email:
uchris@msu.edu, or regular mail: 202 Olds Hall, East Lansing, MI 48824.

Again, I thank you for your time and participation.

Sincerely,

Missy Erwin, Certified Athletic Trainer
Graduate Assistant Michigan State University

43

APPENDIX B

44

ACL Injuries in High School Sports
Missy Erwin, Certified Athletic Trainer
Graduate Student Michigan State University

Please answer all questions to the best of your knowledge. Please use a dark pen and clearly
mark each response. You may answer as many responses to each question as is appropriate.

1.
0 Boys’ Basketball 0 5 5 0 6-10
0 Girls’ Basketball 0 5 5 0 6—10
0 Boys’ Soccer 0 5 5 0 6-10
0 Girls’ Soccer 0 g 5 0 6-10
0 Girls’ Volleyball 0 g 5 0 6-10

2. What level have you coached?

5 — 9 years of age

10 — 11 years ofage
12 — 13 years ofage
l4 — 18 years ofage

Collegiate

OOOOOO

Adult

Scholastic K - 4th
Scholastic 5th — 6‘h
Scholastic 7’" - 8’h
Scholastic 9’h - 12th
Intercollegiate

Yes

0
O
0

000000

Which sport do you coach? And how many seasons have you coached the sport?

 

11-15 0 >16
11-15 0 >16
11-15 0 216
11-15 0 >16 ..
11-15 0 316 i
Non-scholastic i

Non-scholastic
Non—scholastic
Non-scholastic
Club/Intramural
No

3. Are you currently certified in American Red Cross or American Heart Association

CPR and First Aid?
0 Yes O No

4. If no, have you ever been certified in American Red Cross or American Heart
Association CPR and First Aid?

0 Yes 0 No

5. Do you have credentialing or certification from any of the following?

Program of Athletic Coaches
Education (P A. C. E)

American Sport Education Program
(A.S.E.P)

National Federation of High School
Associations (NFHSA)

Michigan Youth Soccer Association
(M.Y.S.A)

O Level 1

0 Volunteer

0 Bronze

Module

0 Level 2

0 Professional
0 Silver 0 Gold

0 U6, U8, or U10 0 “meme

 

O D License

 

Other, Please Specify

45

 

6. Have you participated in any of the following coaches education classes?
Coaching education courses (University or Collegiate)
Coaching seminars
Strength and Conditioning courses
Athletic Training course

Injury Prevention course

000000

Other, please specify

7. Are you aware of anterior cruciate ligament (ACL) injuries?

Yes 0 No

O

8. Do you believe the risk of ACL injury can be reduced?

0 Yes 0 No

9. Are you aware of any of the ACL prevention programs below?

Sportsmetrics 0 Yes 0 No
Prevent Injury and Enhance Performance: PEP 0 Yes O No
Henning’s Program 0 Yes O No
Reduce Injury in Female Athletes: RIF A 0 Yes O No
Caraffa Program 0 Yes O No

Other, please specify

 

10. Are you implementing any of the following ACL injury prevention programs in
your strength and conditioning programs?

Sportsmetrics 0 Yes O No
Prevent Injury and Enhance Performance:

PEP 0 Yes 0 N0
Henning’s Program 0 Yes O No
Reduce Injury in Female Athletes: RIF A 0 Yes O No
Caraffa Program 0 Yes O No

Other, please specify

 

46

11. Are you aware of the following ACL injury prevention techniques?

Plyometric jump training 0 Yes O No
Lower extremity strengthening 0 Yes O No
Agility running 0 Yes O No
Proprioception/balance training 0 Yes O No

12. Are you implementing any of the following ACL injury prevention techniques in
your strength and conditioning programs?

Plyometric jump training 0 Yes O No
Lower extremity strengthening 0 Yes O No
Agility running 0 Yes 0 No
Proprioception/balance training 0 Yes O No

If you answered yes to any part of question 12 please answer questions I 3 and I 4. If you

answered no to all parts of question 12 please move on to question 15.

13. How frequently do you perform each of the following techniques?

Plyometric jump training 0 1_2 times/week O 3.4 times/week
Lower extremity strengthening O 1_2 times/week O 3.4 times/week
Agility running 0 1-2 times/week O 34 times/week
Proprioception/balance training 0 1_2 times/week O 3.4 times/week

14. During what time of season do you perform each of the following techniques?

Plyometricjump training 0 Preseason 0 During season 0 Post season
3:123:3ng O Preseason 0 During season 0 Post season
Agility running 0 Preseason 0 During season 0 Postseason
qusgcgceptlon/balance O Preseason 0 During season 0 Post season

15. How many of the athletes you have coached sustained an ACL injury?

0 o 0 11-15
0 1-5 0 15—20
0 6-10 0 >20

47

APPENDIX C

48

ACL Injury in High School Sports
Participant Informed Consent Form
Dear Coach,

My name is Missy Erwin and I am a Graduate Student at Michigan State University. I
am doing my Master’s Thesis in the area of ACL injury prevention, and I am surveying
coaches in the Capital Area Activities Conference regarding my topic. Recently you
should have received a packet from me. I am resending the information because I have
not received a copy of your survey. If you are willing to participate I ask that you please
fill out this survey and return it to me as soon as possible.

Participation in the survey is voluntary, and you may chose not to participate, or you may
refuse to answer certain questions. Your participation will contribute to the research in
the area of ACL injury prevention, and it should take less than 15 minutes to complete
and return the survey. A self addressed stamped envelope is included for you to return
the survey to me. I ask that you please return it within two weeks of its receipt.

Your privacy will be protected to the maximum extent allowable by law. In return for the
surveys completion you will be sent a reference list of current research in the area of
ACL injury prevention.

Thank you for your participation; it is greatly appreciated. If you have any questions or
concerns about this study, please contact Missy Erwin, Secondary Investigator by phone:
(517)-214-4054, by regular mail: 2910 Beau Jardin Dr. Apt #208, Lansing, MI 48910, or
by email: erwinmefifzmsu.edu. You may also contact Dr. John Powell, Principle
Investigator by phone: (517)-432-5018, by regular mail: 105 IM Sports Circle, E.
Lansing, MI 48824, or by email: powelli4€rllnsu.edu.

 

 

If you have any questions or concerns regarding your rights as a study participant, or are
dissatisfied at any time with any aspect of this study, you may contact - anonymously, if
you wish — Peter Vasilenko, Ph.D, Chair of University Committee on Research Involving
Human Subjects (UCHRIS) by phone: (517)-355-2180, fax: (517)-432—4503, email:
uchrisfriamsuedu, or regular mail: 202 Olds Hall, East Lansing, MI 48824.

 

Again, I thank you for your time and participation.

Sincerely,

Missy Erwin, Certified Athletic Trainer
Graduate Assistant Michigan State University

49

APPENDIX D

50

ACL Injuries in High School Sports
Reference List
Missy Erwin, Certified Athletic Trainer
Graduate Student Michigan State University

Dear Coach,

Thank you for taking the time to participate in my study. In appreciation, I have included
a reference list that will guide you to the prevention programs that have been developed
to address the ACL injury problem.

Prevention of Noncontact ACL Injuries

Edited by Letha Y. Griffin MD, PhD
This book can be ordered through the following website:
http://www4.aaos.org/product/prtiitcm.cfm?code=02533

 

Sportsmetrics
Cincinnati Sportsmedicine Research and Education Foundation
311 Straight Street
Cincinnati, Ohio 45219
Information about this program can also be found at:
http:Nwww.speltsmetrics.llet/

 

Prevent Injury and Enhance Performance: PEP
Santa Monica Orthopaedic and Sports Medicine Group
Holly Silvers, MPT Hollvpt‘wfiixaolcom
(310) 315-0292 ext. 1283
Information about this program can also be found at:
llltp:waw.aclprevcnt.com/protccted/pepfieldmf

Henning Program

Dean Griffis

240 South Forest View Court
Wichita, Kansas 67235

Caraffa Program

A. Caraffa Orthopedic Clinic
S. Maria Hospital

University of Perugia
1-05106 Temi, Italy

Again, thank you for your participation. If you have any further questions feel free to
contact me through email erwinmelQi msuedu

Sincerely,

Missy Erwin, ATC

51

APPENDIX E

52

 

HUNT VALLEY CONSENSUS CONFERENCE ON ACL INJURY PREVENTION
(Adapted from Griffin 16)

During the Hunt Valley Consensus Conference participants carefully reviewed available
data on injury risk factors and their associated prevention programs. They then
formulated the following consensus statements.

Environmental Risk Factors

1. At present there is no evidence that knee braces prevent ACL injury.

2. Increasing the shoe-surface coefficient of friction may improve performance
but also may increase the risk of injury to the ACL. Because shoe-surface interaction is
modifiable, this area merits further investigation.

Anatomic Risk Factors

1. There is much literature on the role of the femoral notch size and ACL injury,
but because of the difficulty of obtaining valid and reliable measurements, no consensus
on the role of the notch in ACL injury has been reached as yet.

2. At present, there are insufficient data on AC L size (absolute or proportional) to
support the concept that ligament size is related to the risk of injury.

3. There are insufficient data to relate lower-extremity anatomic alignment to
ACL injury; therefore, further research is needed.

Hormonal Risk Factors

1. At present, there is no consensus in the scientific community that sex-specific
hormones play a role in the increased incidence of AC L injury, but filrther research in
this area is encouraged.

2. Hormonal intervention for ACL injury prevention cannot be justified.

53

3. There is no evidence to recommend modification of activity or restriction from
sport for females at any time during menstrual cycle.
Biomechanical Risk Factors

1. The knee is only one part of a kinetic chain; therefore it must be borne in mind
that anatomic sites other than the knee, including the trunk, hip, and ankle, may have a
role in ACL injury.

2. Common biomechanical factors involved in many injuries include impact on
the foot rather than the toes during landing or changing directions, awkward dynamic
body movements, and biomechanical perturbation prior to the injury.

3. The common at-risk situation for noncontact ACL injuries appears to be
deceleration, which occurs when the athlete cuts, changes direction, or lands from a
jump.

4. Neuromuscular factors are important contributors to the increased risk of ACL
injuries in females and appear to be the most important reason for the differing ACL
injury rates between males and females.

5. Strong quadriceps activation during concentric contraction was considered to
be a major factor in injury to the ACL.

Prevention
After reviewing the existing neuromuscular training prevention programs, participants
agreed on the following statements regarding prevention strategies:

1. Early data show that specific training programs that enhance body control

reduce ACL injury rates in female athletes and may increase athletic performance.

54

 

2. Training and conditioning programs for male and female athletes in the same
sport may need to be different.

3. Those involved in the care of athletes should identify sport-specific at-risk
motions and positions and encourage athletes to avoid these situations when possible.

4. Strategies for activating protective neuromuscular responses when at-risk

situations are encountered should be identified

55

 

 

BIBLIOGRAPHY

1. Powell J, Barber-Foss KD. Sex-related injury patterns among selected high school
sports. American Journal of Sportsmedicine. 2000;28:385-391.

2. Rozzi S, Lephart SM, Fu FH. Effects of muscular fatigue on knee joint laxity and
neuromuscular characteristics of male and female athletes. Journal of Athletic Training.

1999;34:106-114.

3. Arendt E, Dick R. Knee injury patterns among men and women in collegiate
basketball and soccer: NCAA data and review of literature. American Journal of
Sportsmedicine. 1995;23:694-701.

4. Garrick JG, Requa RK. Anterior Cruciate Ligament Injuries in Men and Women:
How Common Are They? In: Griffin LY, ed. Prevention of Noncontact ACL Injuries:
American Academy of Sports Medicine; 2001:1-9.

5. Griffin LY. The Henning Program. In: Griffin LY, ed. Prevention of Noncontact
ACL Injuries: American Academy of Orthopaedic Surgeons; 2001 :93-96.

6. Ramus L. Girls Can Jump. http://wwwgirls’gmiump.com/.

7. The PEP Program: Prevent injury and Enhance Performance.
http://www.coach.org/pep.htm.

8. Mandelbaum BR. The Caraffa Program. In: Griffin LY, ed. Prevention of
Noncontact ACL Injuries: American Academy of Orthopaedic Surgeons; 2001:97-99.

9. Hewett TE, Lindedfeld T, Riccobene JV, Noyes FR. The effect of neuromuscular
training on the incidence of knee injury in female athletes. American Journal of
Sportsmedicine. 1999;27:699-706.

10. Johnson RJ. The ACL Injury in Female Skiers. In: Griffin LY, ed. Prevention of
Noncontact ACL Injuries: American Academy of Orthopaedic Surgeons; 2001:107-1 1 1.

11. Sulliva P. National Standards for Athletic Coaches. Journal of Physical
Education, Recreation, and Dance. 1996.

12. W00 S, Debski R, Withrow J, Janaushek M. Biomechanics of Knee Li gaments.
American Journal of Sports Medicine. 1999;27:533-543.

56

 

13. Fagenbaum R, Darling WG. Jump landing strategies in male and female college
athletes and the implications of such strategies for anterior cruciate ligament injury.
American Journal of Sportsmedicine. 2003;31:233-240. ’

14. Orchard J, Sward H, McGivem J, Hood S. Intrinsic and extrinsic risk factors for
anterior cruciate ligament injury in Australian Footballers. American Journal of
Sportsmedicine. 2001;29:196-200.

15. Chandy TA, Grana WA. Secondary School Athletic Injuries in Boys and Girls’.
The Physician and Sportsmedicine. 1985;13:106-111.

16. Griffin LY. Consensus Statements on ACL Prevention Strategies. In: Griffin Ly,
ed. Prevention of Noncontact ACL Injuries: American Academy of Orthopaedic
Surgeons; 2001:113-114.

17. Teitz CC. Video Analysis of ACL Injuries. In: Griffin LY, ed. Prevention of
Noncontact ACL Injuries: American Academy of Orthopaedic Surgeons; 2001:87-92.

18. Hewett TE. Plyometric Jump Training in Female Athletes. American Journal of
Sports Medicine. 1996;24:765-772.

19. Institute YS. Program for Athletic Coaches' Education: PACE Certification.
http://edweb6.educ.msu.edu/kin/Academics/Certificarte/PACEhtm.

20. Institute YS. Program for Athletic Coaches' Education: PACE. http://www.ed-
web3.educ.msu.edu/ysi/SpotlightWin97/pace.html. .

 

21. American Sport Education Program. http://wwwasgrcom/ .

22. National Federation of State High School Associations: NFHS.
http://www.nflrs.org/ScriptContent/V A custom/va_cm/contentpagedisplav.cfm?conterL
ID=41.

23. Shultz SJ, Valovich TC, Zinder SM. Sports Medicine Handbook. . Indianapolis:
National Federation of State High School Associations; 2002294.

24. Michigan State Youth Soccer Association; MSYSA.http://www.msysa.net/.
25. United States Soccer Federation. http://wwvw.ussoccer.com/.
26. Basketball Coaches Association of Michigan. http://wwwbcamorg/ .

27. MSU Graduate Coaching Certification. http://online-
continuedmsu.edu/program.asp?program=46 .

 

28. United States Volleyball Association.
http://www.usavollevball.orfieducation/programs.asp.

57

29. Griffin LY, Agel J, Abohn M. Prevention of Noncontact ACL Injuries: Risk
Factors and Prevention Strategies. Journal of the American Academy ofOrthopaedic
Surgery. 2000;8zl41-150.

30. Ramus L. Girls Can Jump Presentation.
httrfl/wwwgfirls’caniump.com/presentation.html.

31. Sportsmetrics Certification. http://www.sportsmetrics.net/ .

58

   

lllllllllltill

547—.