On Saturday January 20, 2007, Pilates instructors from around the Bay Area met at Los Gatos Pilates to attend the Physical Therapy of Los Gatos Train-the-Trainer seminar: “Assessment for Pilates Instructors.” The purpose of the seminar was to present key physical assessment tools that Pilates instructors can use to customize exercise programs to meet the specific  needs of individual clients.

“Given the many similarities between Physical Therapy and Pilates, the move to more prescriptive exercise provides greater long term results for clients,” said Rob Naber, founder of Physical Therapy of Los Gatos.   The seminar included an instructional lecture and hands-on practice to assess client’s posture, spinal lumbopelvic range of motion and rhythm, flexibility and core strength.  At the conclusion, case studies were presented with “home work” for the attendees.  Answers to the assignment are provided at the end of the presentation.

Physical Therapy of Los Gatos thanks Nancy Chin and Marcie Ryken at Los Gatos Pilates for hosting the seminar.

Download “Physical Assessment for the Pilates Professional” (7.5 MB pdf)

The Spring 2006 West Valley College Sports Medicine Symposium was held May 5th. The symposium was organized by John Kao MD for an audience consisting of physical therapists, athletic trainers, and physicians. The purpose of the Sports Medicine Symposia series is to continue improving the standard of orthopedic medicine here in the Bay Area by providing orthopedic professionals an opportunity to share their knowledge with one another and with other medical practitioners. This year’s spring symposium focused on current challenges of treating the lower extremities.

The following local professionals gave presentations:

• John T. Kao, M.D.

• Grady L. Jeter, M.D.

• Robert S. Nishime, M.D.

• Thomas Elardo, D.P.M.

• Paul Christensen, DPT, OCS, ATC

• Rob Naber PT, OCS, ATC

• Ross Nakaji PT, OCS, ATC, CSCS

• Fabrice Rockich, DPT, OCS, CSCS

• Paul Starks, MA, ATC, PTA, CSCS

Physical Therapy of Los Gatos principal Rob Naber spoke about the evaluation and treatment of problems affecting the knee. Rob began by noting the value of recent knee research and the bearing of research findings on the practitioner’s approach to knee conditions and injuries:

“The knee is often the weakest link that defines and limits an athlete’s total competitive capacity. The knee is needed for speed, power and strength, but is also vulnerable to injury. A knee injury not only means missing practice or competition but may also lead to the loss of scholarship support and potential professional opportunities. Extensive research of the knee, and improved diagnostic, rehabilitation, and surgical methods have brought new hope to athletes and clinicians dealing with the challenges of the injured knee.”

– from Current Issues in Sports Medicine: The Knee presented by Rob Naber PT, OCS, ATC

One of the key takeaway messages from Rob’s presentation was the importance of quantifying the capability and condition of the knee while the joint is in motion. In the evaluation and treatment of anterior knee pain, for instance, measuring the concentric vs. eccentric torque capacities of the knee is critically important as a diagnostic aid and as a reliable indicator of treatment progress. In rehabilitation following surgical reconstruction of the anterior cruciate ligament, videographic analysis of lower extremity angles during landing and jumping provides data the therapist needs to design and carry out a course of treatment that brings about rapid restoration of function and corrects neuromuscular control deficiencies that would otherwise invite re-injury.

Using the links below, interested individuals can view visuals and handouts from Rob Naber’s presentation to the Spring 2006 West Valley College Sports Medicine Symposium. For more information about Physical Therapy of Los Gatos’ approach to the evaluation and treatment of knee problems, please call the clinic at (408) 358-6505.

Current Issues in Sports Medicine: The Knee (view presentation visuals)
Current Issues In Sports Medicine: The Knee (download text)

Jump Strength Training Program (download program description)

Jump Strength Training Glossary (download glossary)

You know the feeling. You’ve put in the miles, the hills, the interval training. Now it’s race day and you’re having a good one. You feel balanced, light, and fast. You press the pace one more click and leave another pack of runners behind.

Then it happens. Your foot comes down on a rock and rolls painfully inward. You hear a sickening “pop,” you go down, and the runners you just passed thunder past you. Nauseating pain overwhelms your interest in the torn skin on your hands and stays with you throughout the long limp back to town.

Here in Los Gatos we’re fortunate to have miles of unpaved recreational trails and utility roads, such as the Los Gatos Creek Trail, the Flume Trail, the Jones Trail, and the Limekiln Trail, offering a variety of terrain through our open space preserves. The race described above could well be our own late-summer annual event, the Dammit Run. If you suffer an ankle sprain while running in competition or in training, here’s what you need to know to get back on the trail and back up to speed.

A Few Definitions
A ligament is a band of fibrous tissue in a joint connecting bone to bone. Each joint has several ligaments. Ligaments are distinct from tendons, which connect muscle to bone. Ligaments support and strengthen joints and make joints stable by limiting joint motion from movements in unwanted directions.

A sprain occurs when a ligament is stretched beyond its normal limits. Sprains are classified according to degrees of severity. A Grade I sprain involves damaging a ligament but not compromising its function of restraining unwanted motion. In a Grade II sprain, the ligament is partially torn and allows some unwanted motion. In a Grade III sprain, the ligament is completely torn and cannot stop unwanted motion, and joint stability and function are lost. Grade III sprains cause diffuse swelling and bruising around the affected joint.

A sprain is more than a simple mechanical injury. Sprains affect proprioception, the neural feedback mechanism that enables us to know the angles of our joints, and the positions of our limbs and extremities, without looking. Good proprioception is what enables us to run in the dark without thinking about where to put our feet, or land a jump shot when focusing on the hoop.

First Aid for Sprains
First Aid for sprains can be remembered by the acronym  “RICE,” (Rest, Ice, Compression, Elevation). For Grade I sprains, First Aid treatment alone is often adequate. Grade II and III sprains require rapid administration of First Aid, plus medical evaluation and treatment including some external support, such as a McDavid ankle brace , to protect the ligament while healing. Complete recovery from a Grade II or Grade III sprain is unlikely to occur without medical attention.

Recovery from Sprain
Recovery from a sprain involves promoting the healing of the ligament, elimination of swelling and bruising, increasing strength, and restoring proprioception. At Physical Therapy of Los Gatos the goal of treatment is returning the individual to their pre-injury level of activities and sports, without elevated risk of re-injury. If our runner returns to training on the Los Gatos Creek Trail without fully restored proprioception, he or she will find intense concentration is needed on the exact placement of each foot-fall to prevent the injured ankle from rolling inward again. Longer term, residual changes in joint forces and mechanics, due to incomplete recovery, can accelerate degenerative changes and conditions, such as arthritis.

Restoring Proprioception
Proprioception is based on neural feedback loops that carry and compare information from the eyes and middle ear, and from the stretch receptors of muscles and connective tissues. Following a sprain injury, proprioception is restored by thoroughly rehabilitating neuromuscular control over the affected joint with facilitory techniques such as compression, vibration, and biofeedback. This must be accomplished in a way that promotes, rather than impairs, healing of the injured ligament, and trains the surrounding muscles to assist the injured ligament in supporting the joint while it heals.

Elements of Therapy for Sprain
Therapy begins with a thorough evaluation of the sprain injury. If a Grade III sprain is suspected, the injury should be evaluated by an orthopedic specialist, who will order and evaluate X-ray or MRI images to detect any damage to the underlying bone structure of the affected joint and to obtain a clear picture of soft tissue injuries. Evaluation of a sprain performed by a physical therapist or a physician will also include stress tests to measure the extent of abnormal joint motion caused by the injury, and the progressive tightening of the joint as the injured ligament heals, as compared to the stress-bearing characteristics of the opposite joint and normative values.

In addition to specific, individualized strengthening exercises aimed at re-establishing neuromuscular control and joint strength, physical therapy for sprain should also include evaluation and training of muscles affecting the entire limb of the injured joint. For instance, when ankle pain, weakness, or injury compromise proprioceptive cues, the hips and low back muscles will compensate by altering the injured individuals’ walking and running patterns. Because the goal of therapy is complete recovery, including normal or improved function, specific, progressive exercises are prescribed over the course of rehabilitation to restore motion, strength, and control throughout the entire limb.

If you suspect you have a joint injury involving ligament sprain, please contact us for expert advice by calling (408) 358-6505. For additional information about ankle sprain, see the related article “Foot and Ankle Injuries of Ballet Dancers.”

Injuries arising from inadequate or incorrect neuromuscular control during practice or performance, or poor management of an existing orthopedic injury, can sideline a ballet dancer for a season or for an entire career. In a recent workshop on the diagnosis, treatment, and prevention of foot and ankle injuries, Physical Therapy of Los Gatos physical therapist Ariel Lehaitre showed members of a local studio how to avoid and manage specific problems for which ballet dancers are at increased risk due to the physical challenges of their art.

With years of experience as a student of ballet, and specialized training in body mechanics and motions, Ariel brings a unique and valuable body of essential health information to the Bay Area ballet dance community. Though the workshop is incomplete without Ariel’s comments, explanations, and demonstrations, the presentation visuals available below provide useful information on specific dance injury types, causes, and degrees of severity. Additional visuals cover elements of effective treatment designs that enable dancers to return to practice without pain or elevated risk of re-injury.

The clinical staff at Physical Therapy of Los Gatos has the specialized training and direct experience required to understand the unique orthopedic challenges of ballet and provide care that produces complete recoveries from dance injuries. To discuss an individual concern, please contact us by calling (408) 358-6505.

Presentation visuals from workshop presentation “Foot and Ankle Injuries of Ballet Dancers” by Ariel Lehaitre (12 MB .pdf download)

At the September 2005 Western Occupational Health Conference, Physical Therapy of Los Gatos principal Rob Naber delivered presentations on anterior knee pain and lumbar active range of motion. At the same conference, Rob also gave a somewhat more technical presentation for physicians on the topic of lumbar spine stability. This web site article was adapted from his presentation notes and materials.

Lumbar spine stability is an important concept in orthopedic medicine because its absence is often identified as the cause of lower back pain. When the lumbar spine is insufficiently stable, the motion between the joints of the lower back is exaggerated and abnormal. A patient with lumbar spine instability will experience lower back pain when the joints of the lumbar spine “wobble” in use rather than transferring forces with the smooth, synchronous movements of a healthy spine.

If lumbar spine instability is identified as the cause in a case of lower back pain, lumbar spine stabilization must be the cure. Too often this simplistic view of the relationship between lumbar spine stability and lower back pain is used as the basis for handing out “core strengthening” exercise instructions as a treatment for lower back pain. Few cases of lower back pain caused by lumbar spine instability are relieved by pre-printed handouts of abdominal and paraspinal, or “core,” strengthening exercises.

While we encourage our patients toward any healthy form of exercise, including those forms that address core strength, we are critical of physical therapists and other health care providers who prescribe pre-printed, generic strengthening exercises to patients suffering from lower back pain. In most cases, these exercises will fail to provide any relief. And unfortunately, the most motivated patients receiving these instructions will succeed in strengthening their abdominal and paraspinal muscles. Greater strength will cause untreated lumbar spine joint wobbling to occur with greater force and velocity, and the patient will feel much worse.

In the maintenance of healthy lumbar spine stability, muscle endurance is more important than muscle strength. Furthermore, muscle endurance, the condition of ligaments, and motor control of the structures supporting the spine must be in balance if lumbar spine stability is to be achieved. Generic muscle strengthening regimes that disregard initial measures of paraspinal and abdominal wall muscle endurance, and do not aim to restore correct, specific, balanced, and sustainable force vector ratios around the lumbar spine will fail to produce measurable improvements and will likely increase the patient’s pain and disability.

At Physical Therapy of Los Gatos, our physical therapists are trained to evaluate lumbar spine instability using effective methods and clinical precision. Measurements taken during the evaluation phase of therapy and at key intervals over the course of treatment include timed isometric holding exercises in right and left “side plank” positions, a sixty degree sit-up position, and the Biering-Sorensen position (pictured). The results of these tests are compared with normative time values determined in research studies and are used to design individualized treatment protocols to restore correct force vector ratios around the lumbar spine. These individualized treatment protocols produce complete and rapid recoveries from lower back pain caused by lumbar instability.

Lumbar Spine Stabilization presentation by Rob Naber to the 2005 Western Occupational Health Conference (765 KB .pdf

Conference Program Abstract (76 KB .pdf download)

This entry is adapted from a talk presented by Physical Therapy of Los Gatos principal Rob Naber at the Western Occupational Health Conference 2005, held September, 2005 in Monterey, California:

Active Range of Motion (AROM) refers to the range of motion for a specific movement that a patient can achieve without assistance, such as a measurement of how far the back moves when a patient bends forward to touch his or her toes. The distance or angle between the starting and finishing position is the AROM. A reduction in AROM can impair routine, vocational, and athletic movements and overall functional capability. Restoring AROM following injury, surgery, or the effects of an illness on the musculoskeletal system is often the goal of physical therapy and the principal reason that many patients are referred to physical therapy.

In the past, physical therapists used goniometers to quantify lumbar AROM. Though practical for AROM measurements around knees and shoulders, the goniometer was of of very limited clinical utility as a means of measuring motions of the spine and surrounding joints. Other tools and methods, such as flexible rulers and measuring tapes, suffered from a lack of precision and reference values, and were also of little diagnostic value.

In 1984, Mayer, et al. proposed a method using specific inclinometer measurements to enable quantification of lumbar forward bending AROM and discrimination between the contributions of the hip and spine to the overall motion. In 1986, Keeley, et al. published a follow-up article that validated the reliability of the inclinometer-based technique and presented the reference values needed to make measurements made in the clinic meaningful.

While necessary as components of a complete evaluation, individual inclinometer measurements of lumbar AROM offer little information of clinical value and should not be used to report degrees of impairment. Multiple inclinometer measurements are necessary to determine the effects of the patient’s starting posture and the relative contributions of hip, pelvis, and lumbar joints to forward and backward bending. A patient can present with a normal lumbar AROM but still suffer from a “weak back” and recurring back pain and disability.

Physical therapy to restore a diminished lumbar AROM is not simply a matter of achieving a specific AROM value. A more nuanced therapeutic goal of restoring ideal ratios between the contributions of involved joints to composite lumbar motions will lead to more rapid and sustained reductions in impairment and more complete and satisfying recoveries.

Lumbar Spine Active Range of Motion: Significance and Relevance in Rehabilitation presentation by Rob Naber to the Western Occupational Health Conference 2005
Western Occupational Health Conference 2005: New Horizons in Occupational Medicine

Tennis elbow, also known as “lateral epicondylitis,” often affects active adults between the ages of 30 and 60 years, and causes pain on the outside of the elbow joint where the forearm meets the elbow. Internally, tennis elbow pain is localized where the muscles of the forearm merge into tendons and attach to end of the upper arm bone. A patient with tennis elbow will typically feel pain upon extending (unbending) the wrist (think of the wrist motion required to rev a motorcycle). As an aid to evaluation, a therapist can reproduce the pain by resisting the patient’s wrist motion. Sometimes tennis elbow can be so painful that the patient cannot raise his or her hand, even when no resistance is applied.

Although the condition is known by two names, neither is very accurate. You don’t have to play tennis to get tennis elbow! In addition to the high tensile stresses of the backhand tennis stroke, any other activity involving a firm grip, such as using a hammer or screwdriver, or heavy lifting, such as lifting suitcases away from the body with the palm facing the ground, can cause tennis elbow. And the “-itis” suffix of the name “lateral epicondylitis” signifies that the condition is characterized by inflammation, which is not the case. Factors normally associated with inflammation, such as certain white blood cells, cytokines, and chemokines, are not found at the site of the lateral epicondyle of the elbow. What surgeons do find, however, upon opening and examining an affected elbow, is disorganized connective tissue in the form of a characteristic yellow-brown scar. By contrast, healthy tendon tissue is glistening white and is composed of cells organized in neat rows along the axis of tension between the muscles of the forearm and the lateral epicondyle of the elbow.

Palliative measures for tennis elbow include rest and anti-inflammatory medication. Tennis elbow patients are also sometimes instructed to use a tight band around the upper forearm to help rest the painful area and protect it from damaging tensile loads. Although these measures are effective at reducing pain while they are used, they rarely result in full recovery, because they do not restore proper connective tissue alignment.

Fortunately, there are more effective measures. Twenty years ago, exercise physiologists discovered that eccentric exercise is a necessary component of rehabilitation from tendinitis. Eccentric exercise occurs when a muscle generates tension as it is lengthening. For instance, when you place a coffee cup down on a table, you are performing eccentric exercise: your biceps muscles must lengthen in a controlled manner to lower your forearm and place the cup down gently. You may think of eccentric exercise as the braking force needed to slow down the motion. The opposite of eccentric exercise is concentric exercise, which involves active muscle shortening.

Although the exact way in which eccentric exercise improves tendinitis is not known, researchers have discovered that muscle elasticity is a key feature of eccentric muscle contraction, and that eccentric exercise increases muscle elasticity. The leading hypothesis is that muscle tissues that have been made elastic by eccentric exercise effectively distribute and absorb forces that would otherwise lead to fraying of the tendon, formation of disorganized scar tissue, and tennis elbow pain.

At Physical Therapy of Los Gatos, treatment for tennis elbow begins with a thorough evaluation of the problem and a discussion of the patient’s rehabilitation goals. Movements associated with the activities that cause tennis elbow pain must be identified and analyzed. If the patient began having tennis elbow pain after playing tennis on rainy days, perhaps he or she needs only a short course of treatment and to stop hitting wet, heavy tennis balls. In other cases, we may find that improper use or involvement of the neck, shoulder, or wrist during sports or other activities has caused excessive loading of the elbow. In these cases, therapy includes instruction and retraining to balance the physical forces required for the chosen activity correctly.

However, regardless of the other required elements of effective treatment, rehabilitation of tennis elbow will include progressive, eccentric muscle training. Eccentric muscle rehabilitation involves using wrist motion to lower a weight over the edge of a table while the forearm is supported. The patient uses his or her forearm muscles to raise the weight and then lower the weight in a controlled manner. The greatest eccentric muscle force occurs when the patient changes the weight’s direction of motion from downward to upward. Therefore, the amount of weight and the speed at which the weight is moved downward and upward can be varied to increase or decrease the intensity of training. As training progresses, the amount of weight and the speed of weighted movements are both increased. Effective eccentric muscle rehabilitation can also be accomplished using elastic resistance bands.

When going over the instructions for eccentric muscle training, patients might be surprised to hear that their tennis elbow pain should increase towards the end of each exercise session. This is a case where “no pain, no gain” applies. Insufficient loading of the tendon (inadequate intensity) or loading along the wrong axis, will delay recovery.

Progressive, eccentric muscle training is the only type of exercise known to increase muscle elasticity and tendon strength and is the process by which disorganized connective tissues associated with tennis elbow pain are remodeled to become functional once again. In the treatment of tennis elbow, progressive eccentric muscle training as prescribed by a qualified physical therapist is a reliable and effective means of achieving specific recovery goals. The precise method, intensity, frequency, and duration of eccentric muscle training must match the recovery goals of each patient, allowing the tennis player to return to playing tennis and getting the carpenter back to work swinging a hammer without pain.

Anterior Knee Pain, also known as “runner’s knee,” is the second most common reason for joint pain related physical therapy office visits. Patients with anterior knee pain complain of a dull ache at the front of the knee that feels like it’s coming from behind the patella (kneecap). Patients feel pain most strongly after sitting for a long time with their knees bent, as in a long meeting or at the movies, and when walking downstairs or bending down into a crouching or squatting position. In almost all cases, anterior knee pain can be relieved temporarily by simply straightening the leg. Untreated anterior knee pain is often severe enough to limit knee function, requiring sufferers to discontinue sports activities, avoid stairs, and seek out seating that allows frequent full leg extension.

The exact cause of anterior knee pain is not known, and the condition is considered difficult to treat. Most interventions for anterior knee pain are based on one or the other of two popular theories: “chondromalacia” of the cartilage behind the patella, and “malalignment” between the patella and femur.

Chondromalacia in the context of anterior knee pain refers to softening and degradation of cartilage behind the patella. Chondromalacia is so commonly considered the cause of anterior knee pain that the word is often used incorrectly as a synonym for anterior knee pain.

Cartilage behind the patella is thought to allow the patella and the end of the femur to slide smoothly relative to each other when the knee joint is in motion. Chondromalacia theory says that anterior knee pain occurs when the cartilage is softened or degraded. Chondromalacia is treated by surgery aimed at encouraging new cartilage to grow inside the knee joint or by separating intact cartilage from its original location and moving it to sites where the surgeon believes it will be more useful.

Surgery to correct chondromalacia has not been shown in rigorously designed, statistically valid studies to provide long-term relief from anterior knee pain. This lack of effect is consistent with what we know about joint cartilage: joint cartilage does not have nerve endings and can therefore not be a source of pain. The absence of pain receptors in knee cartilage was confirmed in an unusual experiment carried out on orthopedic surgeon Scott Dye, MD, who reported no sensation during direct probing, without anesthesia, of the cartilage behind his patella.

The presence or absence of chondromalacia does not predict whether someone does or does not have anterior knee pain. Many individuals with advanced chondromalacia do not have anterior knee pain, and many individuals with anterior knee pain do not have chondromalacia.

Malalignment theory proposes that the patella is somehow crooked or is located too far to one side or the other of the knee, causing excessive friction and pain. A number of therapies aimed at correcting malalignment have been developed, including:

• using tape applied to the skin to try to hold the patella in a “medial glide” position
• specific muscle training exercises aimed at changing the position of the patella
• “lateral release” surgery to change the position of the patella

None of the non-surgical treatments for patellar malalignment have been shown to change the position of the patella for any clinically meaningful duration of time. Therefore, it has been difficult to detect a statistical correlation between malalignment and anterior knee pain. In addition, none of the non-surgical or surgical treatments based on correcting malalignment have been shown statistically to provide long-term relief of anterior knee pain.

Like chondromalacia, patella alignment or malalignment does not predict whether an individual will experience anterior knee pain. Chondromalacia theory and malalignment theory are also similar in that they are both based on observations made when the knee is not moving.

At Physical Therapy of Los Gatos, we view the knee as a dynamic process, and we believe that anterior knee pain must be evaluated while the knee is in motion.

Our approach to understanding and treating anterior knee pain is influenced by the work of Bennet and Stauber, who in 1986 noticed that, in individuals with anterior knee pain, the amount of torque produced around the knee joint by the quadriceps muscles during dynamic, eccentric exercise (when the quadriceps muscles are lengthening to allow the knee to bend) was not normal in its distribution around the axis of rotation of knees affected by anterior knee pain. Contrary to the differences normally observed between eccentric and concentric muscle strength, torque measured around affected knees was less than torque measured around the same knees during concentric exercise. Bennet and Stauber also found that specific exercises could restore eccentric torque and torque distribution to normal, and when that was accomplished, anterior knee pain went away.

Analyzing the relative torque-producing capabilities of the quadriceps muscles during eccentric and concentric exercise is a critical aspect of our approach to evaluating patients with anterior knee pain. In our experience, re-defining the eccentric and concentric torque profiles of the quadriceps can be readily accomplished by a motivated patient using specific exercises that emphasize eccentric muscle strength. This approach provides long-term relief from anterior knee pain and allows our patients to return to sports and other activities requiring normal knee function.

Low back pain is a vexing medical and personal problem. Almost everyone has to deal with it sooner or later. Low back pain can interfere with almost every aspect of daily living and causes more days lost from work than any other malady except the common cold. Low back pain can make finding a comfortable sleeping or sitting position impossible, and due to the central position of the lower back and its key mechanical role in supporting and enabling movement, resting the painful spine during waking hours is very difficult.

A clear physical evaluation and focused goals are imperative when solving enigmatic health problems such as low back pain. At Physical Therapy of Los Gatos, evaluation for low back pain includes objective measurement of the patient’s function, mobility of the spine, neurological assessment, dynamic strength, flexibility, and gait analysis. In our experience, the outcome of physical therapy that begins with a comprehensive evaluation is more likely to be successful than one that passes over the opportunity to use up-to-date diagnostic instrumentation and methods for precise patient evaluation.

One of many tools and methods we use to evaluate low back pain is the Oswestry Low Back Pain Disability Questionnaire. Originally published in 1980, the Oswestry questionnaire measures how one’s low back pain affects a variety of daily activities. Patients usually complete the questionnaire in less than five minutes. The answers patients select from the multiple-choice questionnaire provide useful information about the behavior, mechanical cause, and severity of the patient’s low back pain. This information, combined with other responses and measures used in our evaluation, help us to design a personalized, effective course of treatment, and prognosticate the duration of treatment.

If you’d like to take the Oswestry Low Back Pain Disability Questionnaire, you can pick up a copy at Physical Therapy of Los Gatos, or call to have us fax or mail it to you, or download the questionnaire. You can find our location and contact information near the top right-hand corner of this web page. Afterwards, we’ll be happy to discuss the results with you and, depending on your score, discuss our recommendations for more precise evaluation of your low back pain.

An unintended consequence of the increase in sports participation by girls and young women over the past thirty years has been an extraordinary rise in the incidence of anterior cruciate ligament (ACL) injuries in young female athletes. At the college level, one in ten young female athletes participating in sports such as soccer, volleyball, and basketball will suffer an ACL tear injury. These girls are typically unable to practice or compete for one or more seasons and face potential loss of scholarship funding and significant psychological trauma. A widely cited 1985 study found that at the high school level, the knee injury rate among female athletes is one per 100 participants, and noted the need for preventative measures.

In 1983, sports medicine researchers determined that four-fifths of ACL injuries are non-contact injuries, that is, they are caused by the athlete’s own motions rather than collisions with other players. To the researchers, this finding meant that the high incidence of ACL tear injuries in young female athletes might be greatly reduced if those motions could be identified and avoided.

The ACL is one of four major ligaments that connect the upper and lower leg at the knee. The ACL provides joint stability and supports cutting and pivoting motions. Oftentimes, the ACL will tear with a “pop” that can be heard by spectators and other players. Pain and immediate swelling follow. ACL tears require surgical reconstruction using tendon grafts from other areas of the knee or from cadavers, followed by a long period of rehabilitation.

The frequency and seriousness of ACL tears in young female athletes has led to research studies aimed at understanding the problem. These studies are now yielding valuable data. Three major hypotheses to account for the higher number of ACL tears in female athletes versus male athletes have been examined: hormonal differences causing laxity of the female athlete’s ACL, a smaller and more narrow space within the knee for the female athlete’s ACL, and sex-based differences in lower extremity strength and coordination. The last of these three hypotheses is receiving the most scientific support from study data.

Certain aspects of lower extremity strength and coordination can be captured and measured by videotaping athletes while they perform athletic movements in the research lab. While video recordings do not capture complex three-dimensional movements and the rotational stresses that these movements place upon the knees, the recordings do enable researchers to make close measurements of joint and limb positions in a single plane. These measurements were found to have predictive value.

In one well-designed study of 205 young female athletes, researchers found that athletes with a specific way of posturing their lower extremities, known as “valgus” (or “knock-kneed”) alignment, during certain athletic movements were more likely to suffer ACL injury than athletes with more “neutral” or straighter lower extremity alignment. This valgus alignment can be seen by analyzing the angles formed between the ankles, knees, and hips when the athlete lands from a jump off a small box and when she jumps vertically from a crouched position. A separate study that included videographic analysis of 325 young female athletes showed that a six-week neuromuscular training program corrected the lower limb valgus alignment associated with injury during jump landing and takeoff.

It is already well-known to physical therapists that muscular strength stabilizes the knee by helping to maintain the correct relative positions of knee structures during sports movements and by allowing muscles in the legs to absorb forces that would otherwise subject the joint to potential injury. But physical therapists treating young female athletes must now consider the implications of the new studies. Physical therapists familiar with these studies infer that rehabilitation from ACL injury should, in addition to conventional strength training treatment methods, include specific neuromuscular training aimed at improving the athlete’s ability to avoid valgus alignment of the lower extremities during high-risk sports.

It is no longer acceptable to reconstruct the ACL but leave neuromuscular control deficient.

The jump strength training program at Physical Therapy of Los Gatos is an element of rehabilitation from surgical reconstruction of the ACL as well as a standalone performance improvement module. The program includes jump analysis, strength conditioning, and neuromuscular training designed to improve power and acceleration. The neuromuscular training methods employed include visual, auditory and proprioceptive cues to train athletes to use muscular strength to absorb jump impacts in a controlled fashion, and, if necessary, to correct jumping, landing, and pivoting techniques in order to avoid forces associated with injury. For additional information about prevention of ACL injury, rehabilitation from surgical ACL repair, and jump strength performance training for athletes, please call Physical Therapy of Los Gatos at (408) 358-6505.