The Effect of Training Interventions on Change of Direction Biomechanics Associated with Increased Anterior Cruciate Ligament Loading: A Scoping Review

Abstract

Change of direction (COD) manoeuvres are associated with anterior cruciate ligament (ACL) injury risk due to the propensity to generate large multiplanar knee joint loads. Given the short-and long-term consequences of ACL injury, practitioners are interested in methods that reduce knee joint loads and subsequent ACL loading. An effective strategy to reduce ACL loading is modifying an athlete's movement mechanics to reduce knee joint loading. The purpose of this scoping review was to critically appraise and comprehensively synthesise the existing literature related to the effects of training interventions on COD biomechanics associated with increased knee joint loads and subsequent ACL loading, and identify gaps and recommend areas for future research. A review of the literature was conducted using Medline and Sport DISCUS databases. Inclusion criteria consisted of pre-post analysis of a COD task, a minimum 4-week training intervention, and assessments of biomechanical characteristics associated with increased ACL loading. Of the 1,027 articles identified, 22 were included in the scoping review. Based on current literature, balance training and COD technique modification are the most effective training modalities for reducing knee joint loading (small to moderate effect sizes). One study reported dynamic core stability training was effective in reducing knee joint loads, but further research is needed to definitively confirm the efficacy of this method. Perturbation-enhanced plyometric training, the F-MARC 11 + soccer specific warm-up, Oslo Neuromuscular warm-up, and resistance training are ineffective training modalities to reduce COD knee joint loads. Conflicting findings have been observed for the Core-Pac and mixed training programme. Consequently, practitioners should consider incorporating balance and COD technique modification drills into their athletes' training programmes to reduce potentially hazardous knee joint loads when changing direction. However, training intervention studies can be improved by investigating larger sample sizes (> 20), including a control group, acknowledging measurement error when interpreting their findings, and considering performance implications, to confirm the effectiveness of training interventions and improve adherence.

Biomechanical Determinants of Knee Joint Loads Associated with Increased Anterior Cruciate Ligament Loading During Cutting: A Systematic Review and Technical Framework

“…It should be noted that insufficient evidence is available at the moment to provide technical models for CODs between 110° and 180°. These identified determinants influence the moment arm, GRF, or a combination of the two, therefore elevating KAMs; however, it appears that these biomechanical deficits are modifiable with appropriate training, feedback and conditioning [ 76 – 78 ]. Particularly, technical characteristics associated with safer side-stepping are as follows: reduced lateral foot-plant distances, thus lower hip abduction and orientating the foot closer to neutral with a mid-foot or forefoot placement strategy; minimising knee valgus and hip internal rotation angles and motion at IC and WA; avoiding and limiting lateral trunk flexion and attempt to maintain an upright trunk position or trunk lean into the intended direction; reducing the magnitude of GRF during WA in the plant foot, potentially by attenuation through increased knee flexion and emphasising a greater proportion of braking in the penultimate foot contact.…”

Age differences in selected measures of physical fitness in young handball players

“…The higher COD deficit in the U15 group could be related to the fact that faster (and heavier) athletes possibly have greater “inertia” and, therefore, need to apply higher breaking forces over longer ground contact times [ 14 ], not being capable of handling these forces efficiently. As a result, and based on recent research [ 14 , 34 , 35 ], the inclusion of training practices combining not only physical elements, but also cognitive and technical skills (e.g., unanticipated COD tasks) more related to sport specificity, may increase the magnitude and efficiency of external training loads, which could be useful for these athletes [ 36 ]. Moreover, the use of training methods focused on increasing eccentric strength is suggested to improve the ability to tolerate high braking forces during deceleration prior to directional changes.…”

The Cutting Movement Assessment Score (CMAS) Qualitative Screening Tool: Application to Mitigate Anterior Cruciate Ligament Injury Risk during Cutting

“…Additionally, creating "injury-risk profiles" through the identification of "high-risk" biomechanical and neuromuscular control deficits is considered important in terms quantifying relative injury risk [59][60][61]. For example, "high-risk" postures include knee abduction angles (KAA-synonymous with knee valgus angles) [33,40,42,62,63], lateral trunk flexion [31,42,[64][65][66], extended knee postures [24,67,68], and hip internal rotation [40,41,63,69] are related to greater multiplanar knee joint loads and subsequent ACL loading [46,70,71].…”

“…This can be used to inform and help develop individualised training programmes to modify the specific deficits and mitigate potential ACL injury risk [59,60,140]. Readers are encouraged to read specific reviews regarding training strategies to mitigate non-contact ACL injury [45,46,48,141,142]; thus, a brief overview is presented in the CMAS training recommendations decision tree (Figure 9).…”

“…[1,[31][32][33][41][42][43]. Importantly, neuromuscular control and biomechanical deficits are modifiable through appropriate training and conditioning [31][32][33]41,42,44,45], which may reduce knee joint loading during high-impact actions and subsequent risk of non-contact ACL injury [1,[43][44][45][46]. As such, the mechanism of ACL injury, from a knee joint loading perspective, has been stated as "multiplanar" [6]; highlighting the importance of reducing multiplanar joint loading during high-risk activities to mitigate ACL injury risk [9,47,48].…”