Note: The below combines several previously-published articles related to ACL injuries and training. At the bottom are links to a presentation from 2011 at the Boston Sports Medicine and Performance Group conference, as well as a paper published in the Strength & Conditioning Journal on the same topic.
I first investigated ACL injuries because I met four girls from a single high school who had ruptured their ACLs within the same year. I imagined something about their training must have contributed to the frequency of injuries in one program, and I wanted to avoid this with my athletes.
I recently watched 10 girls’ basketball games, and girls should not play basketball. Their movement skills were so poor the basic actions of basketball put nearly every player at risk for severe injury. Many could not bend to a half-squat when shooting free throws without some movement abnormality. Most had knee valgus (knock-kneed), which is cited as a factor in ACL injuries. What happens when they jump stop or land from a rebound with much higher forces when they display knees valgus on a free throw, a closed skill with few forces to control? Other players showed limited ankle range of motion, as they were unable to bend to shoot without their heels coming off the ground. Limited ankle mobility and flexibility may contribute to ACL injuries, but almost certainly contributes to patellar tendinopathy or “Jumper’s Knee.“
Basketball is a high impact sport, and the body must control and use high forces in actions such as jumping, sprinting, stopping and landing. The body breaks down, either through acute or chronic injury, when it cannot control these forces — when the load exceeds the capacity.
We currently do little to improve basketball players’ capacity to handle the loads. Players risk injury every time they step on the floor, evidenced by the approximately 7000 ACL ruptures in high-school female basketball players in the United States annually (Ford et al., 2003). Season-ending knee injuries can occur at a rate as high as 1 in 10 athletes annually at the intercollegiate level, which can account for 15,000 female athletes lost each year to athletic participation (Ford et al. 2003). Injuries to the knee can account for up to 91% of season ending injuries and 94% of injuries requiring surgery in female basketball players (Agel, 2005). These are not minor injuries, as the cost of reconstructing and rehabilitating the ACL has a conservative cost of $17,000 per patient, which amounts to $119 million annually spent on female high-school basketball players alone (Ford et al., 2003).
The prevalence, financial costs, and psychological and physical toll associated with the injuries are too high to continue supporting women’s basketball participation if we — coaches, administrators, parents, athletic trainers, and strength & conditioning coaches — cannot teach proper movement and develop adequate levels of strength to handle the forces inherent in basketball.
Two issues heavily influence the ACL injury epidemic: (1) Lack of education and dissemination of information to coaches; and (2) the Peak by Friday mentality (see Cross Over: The New Model of Youth Basketball Development for more).
Lack of Education
I sat with the athletic trainer at Cal’s Elite Basketball Camp years ago as they played a dumb camp game called land-see-air. The trainer pointed to girl after girl who was at-risk as the girls played. I asked why she did not do anything. She said she asked the staff, but was told there was not enough time. The staff valued a game of land-see-air over a frank discussion or presentation on movement skills and injury prevention. It is this attitude which hurts youth sports the most.
The popular perception is girls lack the requisite strength to resist the forces and play safely. I saw movement issues yesterday with a college player who has well-developed strength and a 28-inch vertical jump. Strength is not the only issue.
ESPN analysts made a big deal during the NCAA Final Four of UConn’s Geno Auriemma no longer teaching the jump stop for fear of ACL injuries. Stanford’s Tara Vanderveer told me the same thing several years ago. This approach misses the point. Jump stops do not cause ACL injuries. Deceleration, in general, along with changes of direction are the actions most associated with injuries, but it is the inability to decelerate properly and handle one’s body weight at game speeds, not the specific technique choice.
I coached in a women’s league in Sweden years ago. I had an older player (late 30s) who had had a previous knee injury and wore a bulky knee brace, but throughout the season I was there, not one player injured her ACL among the 12 teams.
I mocked the warmups of some opponents, as they hardly touched the ball, opting instead for various hops, jumps, skips and more. I had never seen a dynamic warmup in the USA; I am sure teams used them, but I had never used one as a player or coach. The concept was foreign to me. We jumped rope, then began shooting drills. Previous teams, when I was an assistant, static stretched for 10-15 minutes and moved to layup/transition passing drills.
I returned home, reflected on the lack of injuries, and thought more about these warmups. I began to incorporate them with my teams and players. That experience and reflection in Sweden changed my coaching.
Many teams use dynamic warmups today, but their effort is wasted because the players’ attention and techniques are poor. They laugh and talk throughout the warmup. There is no concentration on the correct execution of the movements. Coaches ignore the warmup and use the time to set up the next activity. We must be more aware and more proactive in our approach to coaching and training athletes, especially female basketball players.
The drills and programs are not magic. Dozens of neuromuscular training programs and ACL injury prevention programs have been developed over the last decade, yet the injury rate has not declined (Agel, 2005). Going through the motions will not reduce or prevent injuries. The exercises are fine. It is the coaches’ lack of attention (feedback) to the programs, and the players’ lack of concentration to the proper execution preventing the programs from positively impacting injury rates.
Personal trainers do not take a seven-year-old who weighs 60 pounds and put her in a squat rack and have her squat 300 lbs. That trainer would be sued for malpractice when the bar crushes the poor girl. Some studies have shown females land with the force of three to five times their body weight, yet nobody questions the coach who tells the same seven-year-old with poor movement skills to jump stop and rebound over and over.
Players should learn to bend and squat properly before learning to shoot. They need to run and stop before they dribble. They need to know how to shuffle and change directions before playing defense. They need to develop landing skills before they rebound. These are skills: Running, stopping, jumping, landing, squatting, and bending are skills, and should be approached in a similar manner as coaches approach sport-specific skills such as shooting.
Peak by Friday
Good coaches win; bad coaches lose. We cannot differentiate one’s coaching ability from their record, so coaches use a Peak by Friday approach: They concentrate on the next game, not on development. They are too busy to spend 10-15 minutes at practice on movement skills, which enhance performance as well as reduce injury risk. No coach is fired because he or she has too many players suffer ACL injuries, but plenty are fired for losing too many games.
I mentioned to a coach that his entire team was at risk of serious knee injury because of their undeveloped strength and poor movement skills. He said he knew they needed strength and laughed. He also blamed a disappointing season last year on his best player tearing her ACL, yet nothing changes.
Coaches throw up their hands and curse their fate, but do not analyze their players’ movements, teach basic movement skills, or incorporate strength training. The offseason program at this high school is run by a P.E. teacher who has every out-of-season athlete training together running laps around a track while he rides his bicycle. What are these athletes preparing to play besides cross country?
These coaches should invest more time in general movement skills and dynamic warmups because winning teams tend to be the biggest and fastest teams (or players). Ignoring the warmup because it does not affect the outcome is foolhardy because few teams have the depth to sustain an injury to its best player or two, and the best players tend to stand out because they move well. This wasted time is the time to improve performance. Would ten minutes each practice to perform these exercises really make a team any less competitive?
Some children develop movement skills naturally. Some develop skills by watching others, although the amount of mirror neuron activation correlates positively when the athletes are already proficient in the skill, suggesting it may not be wise to rely on beginners to learn by watching others (Benjaminse & Otten, 2011). Other children develop flaws in their movement patterns and need feedback to correct these patterns.
Children need to play basic games where they have to solve movement problems; games such as hop-scotch and tag. Once they reach a formal team, they should be screened with a Fundamental Movement Screen or similar tool. Any weaknesses or abnormalities should be addressed before these children engage in practicing and training for a specific sport. By starting young, when these patterns are varied and inconsistent, athletes can learn the proper movement patterns and practice those, creating the desired patterns. We need athlete preparation before focusing on sports participation.
Each year, players should be screened for their movement skills to catch any issues that may have developed as children mature, grow, and develop. Tests could include various single-leg balance tests, overhead squats, hopping, and more to get a baseline for the athlete’s general capacities to perform the tasks in the game.
I was asked at a recent coaching clinic what I would do with five and six-year-olds. I said martial arts. Children who start in martial arts or gymnastics learn to move, learn body awareness, and develop general strength before playing a team sport. These are all positives, especially because few youth coaches train general skills. Players who start basketball at five and only play basketball have a shallow foundation of athletic skills. Playing other sports, especially martial arts or gymnastics, develops athletic skills that all sports incorporate and gives players a head start toward performance and injury prevention.
The game becomes too risky for girls’ and women’s basketball players if we are unprepared to develop athletes first and basketball players second. These athletes need better coaching and training at the youth, high school, and college levels focused beyond just sport-specific techniques and strategy and emphasizing the basic motor skills at the foundation of each sport skill. Until these athletes develop these motor skills, and develop the requisite strength, season-ending injuries will remain the norm, not a freak occurrence, and the game may no longer be worth the risk.
Task Complexity and Jump Landing
References
Agel, J., Arendt, E.A., & Bershadsky, B. (2005). Anterior cruciate ligament injury in national collegiate athletic association basketball and soccer: A 13-year review. The American Journal of Sports Medicine, 33(4), 524-31.
Benjaminse, A. & Otten, E. (2011). ACL injury prevention, more effective with a different way of motor learning?. Knee Surgery, Sports Traumatology, Arthroscopy, 19, 622-27.
Ford, K. R., Myer, G. D., & Hewett, T. E. (2003). Valgus knee motion during landing in high school female and male basketball players. Medicine & Science in Sports & Exercise, 35(10), 1745-50.
Most of the article is 15 years old...I’d probably choose jujitsu. The problem is now without an organized activity, there is no play ( a bit of an oxymoron I know). So it’s lesser of two evils...
Hi Brian,
I agree with all your observations and recommendations in this article, except for 5 year olds doing Martial Arts. I have a 4th Dan in Shotokan Karate, boxed and did judo in the Army and trained in MMA for 18 months: I would not put children into the sterile MA environments that involve a lot of 'instruction', pseudo-religious waffle and sitting/standing in lines performing one kick/punch at a time.
I would recommend: outdoor/indoor play from 2-6. Maybe gymnastics 6-9, then a rolling/grappling MA like judo or wrestling from then. Plus, roughhousing with adults who can control the pace/tempo.
As to Hopscotch, this has to be taught nowadays, here's a video that shows some progressions. https://youtu.be/Pw-Bctz47rc?si=Q7vbsVcbDVwByYWa