| | ACL Injury Prevention: Neuromuscular Reeducation

Author / Christopher McQuilkin

Change-of-direction-ACL-Injury-Prevention-Power-AthleteThe first article in this series, Injury Mechanisms, focused on identifying neuromuscular imbalances present in non-contact anterior cruciate ligament (ACL) tears, one of the most common non-contact injuries to the knee joint.  While many bio-markers for this injury are beyond an athlete’s control, the mechanisms discussed are not.  Left unnoticed, they introduce faulty bio-mechanics that put an athlete at risk every time they lace up.

That said, identification is only one piece of the puzzle.

Neuromuscular reeducation is the next line of defense against ACL non-contact injuries.

What is the neuromuscular system?
Simply put, the neuromuscular system is the combination of the nervous system and the muscles working together to permit movement.  These processes are fundamental to not only force production, but force reduction.  While this definition may grossly oversimplify the actual biology, textbook knowledge of these intricacies is not required for a coach or parent to empower an athlete with the following information.

Why reeducation?
Given a movement, muscle groups may be controlled by different parts of the brain, depending on the speed of the movement. Neuromuscular reeducation develops neuromuscular efficiency: how efficiently and intensively one recruits appropriate muscle fibers to produce the movement pattern accurately, powerfully and safely (4).

However, the neuromuscular imbalances discussed in Injury Mechanisms resulted from faulty dissipative motor actions and reflexes the body adapted over countless of reps, practices and games.  Inefficient, incorrect movement patterns are difficult to erase, much like a quarterback learning new throwing mechanics.  As the adage goes, it’s hard to teach an old dog new tricks.

Amanda-Ruller-Power-Athlete-LFL-ACL-Prevention-TrainingAny attempt to change faulty technique initially feels awkward creating an inability to perform as comfortably as before, since the body has already adapted to inefficient movement patterns.  The emotional distress from struggling with new techniques can prevent the athlete from implementing any changes.

This is where Power Coaches earn their money.

We will provide key insights into attacking ACL injury mechanisms with strategies, proper positions and movements for reeducating an athlete’s neuromuscular system and create an instinct for a strong, stable knee.
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Posterior Chain Dominant Strategy

Reeducation for ligament and quadriceps dominant athletes focuses on teaching the posterior chain to always be in a position to control knee flexion and absorb forces. While the posterior chain are often present in these athletes, they are under-recruited.  These include the glutes, hamstrings and the calf complex.

The gluteus maximus, the biggest, strongest muscle in the body, is the only triaxial controller of hip and knee position through all three planes of motion (3).  Without activating this big ass muscle, the leg can catch in a vulnerable position that will not allow the posterior chain to dissipate force.

The hamstrings, also known as the synergists of the ACL, increase flexion at the knee, which provides a better mechanical advantage for using muscles to absorb forces instead of ligaments.  The ‘bicep of the legs’ has both medial and lateral tendons stiffen and stabilize the knee joint in the opposite direction of the quadriceps at low knee flexion angles, and pulls the tibia posteriorly decreasing the stress on the ACL.  Lastly, the hamstrings have tendons that insert on either side of the knee joint that offer frontal plane motion control at the knee that is vital for injury prevention during change of direction (3).

Symmetry Strategy

Athletes are asymmetrical in nature; just look at tennis, baseball, and the other specialists throughout the sporting spectrum.  This specialization allows them to perform at the highest level, but also puts them at risk for injury.  Fortunately, the neuromuscular system possesses amazing, complex neurologic mechanisms that attempt to achieve balance between sides.  This is especially true when performing single leg tasks like those featured in Plyometric Training: Assessment and Preparation.  The body uses neuromuscular feedback loops and bilateral neurological systems to influence symmetry during dynamic control tasks in training (3).

According to Hewet, T.E., et al, maximum cross-over effects are achieved when both lower extremities are utilized in alternating single limb activities such as lunges and step ups. They also noted that single leg hop activities may influence synergistic recruitment of the posterior chain musculature (3).  This makes way for not only the neuromuscular control of unilateral tasks, but potentially decreases quadriceps dominance during bilateral dynamic tasks!

The symmetry strategy integrates training that combines plyometric and dynamic stabilization to improve leg-to-leg symmetry during dynamic tasks.  The more single leg activities an athlete performs, the more side to side symmetry is restored.  Many single leg movements have been introduced in previous plyometric articles, with more on the way in the forthcoming article, Plyometric Training: Programming.

ACL-Prevention-Power-Athlete-Lacrosse-TrainingTrunk Strategy

The four neuromuscular imbalances covered in Injury Mechanisms comprise the formula for an ACL tear, and all are affected by trunk position.  A common mistake made in trunk training is a sole focus on the prime movers (like the rectus abdominis) and as a means of showing off them abzzzz.

Instead, develop a comprehensive strategy of challenging posture and position. Connect iso-stability work (as seen in Field Strong) with dynamic movements that challenge stability of the local musculature (such as transversus abdominis and multifidus) and pelvic/hip stabilizers through all axis of rotation and planes of motion.

The trunk strategy carries over to all movements and training days.  There’s little potential for skill transfer without it.  No exceptions.

Reeducation:

The following phases should be applied to every athlete as an initial assessment, and integrating into warm ups and plyometric training. Never move an athlete beyond a phase before mastering the basics.  These phases will not only assess their readiness  for the forces on the field, but will be the corrective exercises for developing neuromuscular efficiency of the knee joint where they are inefficient.

Phase 1: The Universal Athletic Position

Purpose:
Establish posture and position of the body and posterior chain loading that will be challenged throughout athlete’s development, injury prevention training and beyond.

Before stressing an athlete, they must first find their most neuromuscualr-efficient athletic position set up.  This is a standing, ready position, balanced among the quad, hamstring and hips, allowing the athlete to be ready for action in any direction.  The proper alignment is shown below.  Heels are set just outside the shoulder, knees above the in-step of the foot and toes pointing forward.  The weight in the mid-foot over the arch, butt pushed back to load the posterior chain to what feels like a slight hamstring stretch.  The athlete’s center of mass is over the mid-foot/arch.

Athletic-Position-Power-Athlete-plyometricsThe athlete is capable of moving left, right, forward, back, up or down – perfect for a field sport athlete who needs to catch jumps or react to a play.  Many quad and ligament dominant athletes may find this butt back set up awkward and inefficient at first, but the following movements will help demonstrate the value of a loaded posterior chain.

Phase 2: Athletic Position Through Space

Purpose:
Challenging an athlete’s ability to maintain posture and return in and out of athletic position while moving through all planes of motion.

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Lateral Step Catch
This is a fundamental movement of the body through the frontal plane that challenges an athlete to maintain loading of the knee joint sagittally, through the posterior chain.  Do not let any deviation from a perfect universal athletic position go when coaching this movement, whether it’s hip external rotation, knees shifting forward, chest drifting upward, or stepping feet inside A-frame.  None.

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Rotational Jacks
This movement challenges an athlete’s footwork while moving through space, and tests their ability to efficiently load the posterior chain, all while the body moves through the transverse plane.  The athlete should minimize vertical displacement throughout the movement, and if there is a misstep, simply fix the position before continuing onward.

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Athletic Position Lateral Jump + Vertical Jump
Here we are challenging the athletic position through the frontal and vertical planes.  This challenges replication of posterior chain activation moving through two different planes, much like the athlete will see on the field.  Make sure the athlete catches in their universal athletic position after the lateral and especially after the big vertical jump.

Phase 3: Unilateral Movements and Primals

Purpose:
Attack asymmetry, challenge of posture through triaxial hip movement and educate each leg to dissipate force efficiently in the proper position.

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Leg Cradle Lateral Lunge Twist
There are many benefits to this exercise, but here we are primarily focusing on the athlete’s placement of the lateral step and loading of the posterior chain as the hips moves from the Z-axis to the X-axis through the frontal plane.  Notice how the athlete lands toes forward, knee inside the instep and pushes their hips back loading their hamstring and glute.

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See Saw Walk to Vertical Jump
This the perfect education tool for training posterior chain loading because of the dynamic movement that follows the See Saw Walk.  Notice how the landing athletic position was the same hip and hamstring action as the slow and steady See Saw Walk!

Phase 4: Resistance

Purpose:
The athlete must be stressed to progress.  Once they have mastered posterior chain dominant movement moving through all axes and planes of motion, it is time to add resistance.  The integrity of the athletic position and knee must be PERFECT when adding the following stresses.

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Jam Squats
The purpose of the jam squat is to train the posterior chain to load and load quickly.  This is an incredibly challenging movement for quad and ligament dominant athletes.  Always be sure to observe from the front angle for any external rotation or valgus knees, and from the side view to ensure the quad isn’t doing all the work by the knees driving forward.  Posterior chain should be doing all the work here, pulling into position and pushing out of it.

Resistance Band Complex
This complex for moving through all planes of motion is hard to beat at any level.  Banded Walks, Banded Reverse Walks, and Banded Lateral Walks need to be a stable in any field sport athlete’s training.  Here we introduce one new movement to the band complex to attack the transverse plane: Banded Rotational Jacks

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Standards
The standard for all of the above movements is perfection, not completion.

Neuromuscular reeducation is extremely difficult, given an athlete’s rich history of incorrect movement. Even so, any deviation from perfection is wrong, and if there are 2-3 missed reps with no correction, the athlete is done with that movement for the day.   Remember, we are not strengthening muscles, we are teaching them to efficiently dissipate force in the most optimal, stable and safe way.

Perfect Practice Makes Perfect (Old Habits Die Hard)
Whether it is a high schooler requiring constant reeducation because their body is changing daily, or a weekend warrior who has done these movements wrong their whole training life, mastering the universal athletic position through repetition and calculated stress will help the athlete with other tasks.

Initially, reeducation will demand cognitive effort and focus on execution in the face of many lingering technical flaws.  Always return to phase 1, getting into a strong, stable athletic position, regardless of their abilities in phase 2, 4 or any of the drills to be introduced in ACL Injury Prevention: Anti-Rotation.  As an athlete improves their neuromuscular control and bio-mechanics, they will gain neuromuscular control of the lower extremities and create a learned skill that can be transferred to their sporting arena.

Sources:

1) Myer, G. D., Brent, J. L., Ford, K. R., & Hewett, T. E. (2011). Real-time assessment and neuromuscular training feedback techniques to prevent ACL injury in female athletes. Strength and Conditioning Journal, 33(3), 21–35.
2) Myer, G. D., Chu, D. A., Brent, J. E., & Hewett, T. E. (2008). Trunk and Hip Control Neuromuscular Training for the Prevention of Knee Joint Injury. Clinics in Sports Medicine, 27(3), 425–ix.
3) Hewett, T. E., Ford, K. R., Hoogenboom, B. J., & Myer, G. D. (2010). Understanding And Preventing ACL Injuries: Current Biomechanical And Eepidemiological Cconsiderations – Update 2010. North American Journal of Sports Physical Therapy : NAJSPT, 5(4), 234–251.
4) Verkhoshansky, Y., & Siff, M. (2009, pg. 472). Supertraing: 6th Edition. Rome: Ultimate Athlete Concepts.

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AUTHOR

Christopher McQuilkin

MS, CSCS, SCCC, CHES
Book a consult with me regarding coaching, training, life, education... anything your heart desires. Click below:
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Former collegiate lacrosse defensive midfielder, 4-year letter winner and 3-year team captain. Coached strength and conditioning collegiately with Georgetown University football, Men's and Women's lacrosse and Women's Crew, as well with the University of Texas at Austin's football program. Apprenticed under Raphael Ruiz of 1-FortyFour-1 studying proper implementation of science based, performance driven training systems. Head coached CrossFit Dupont's program for two years in Washington D.C. Received a Master's in Health Promotion Management from Marymount University in 2010, and has been a coach for Power Athlete since October, 2012.

5 Comments

  1. Rukas on February 3, 2015 at 6:19 am

    As always, great article.

  2. Ingo B on February 3, 2015 at 10:21 am

    I’ve been doing it all wrong! You’re supposed to smile in the athletic position.

  3. honeybadgernick on February 3, 2015 at 4:28 pm

    Outstanding article as usual Tex

  4. […] One of the primary mechanisms for a torn ACL in contact sports is the inability to control the body at top end speed.  Learn more about the connection of change of direction and neuromuscular coordination here. […]

  5. […] One of the primary mechanisms for a torn ACL in contact sports is the inability to control the body at top end speed.  Learn more about the connection of change of direction and neuromuscular coordination here. […]

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