untitled

The Scientific Basis for Prevention of Anterior Cruciate Ligament Injury Nagano, Yasuharu

1 1 1 2 2 3 3 27 2 29 1 30 1 30 2 31 3 32 4 35 3 37 1 38 1 38 2 40 3 44 4 48 2 ACL 52 1 52 2 54 3 58 4 61 3 65 1 65 2 67 3 71 4 78

4 82 1 83 1 83 2 85 3 90 4 93 2 96 1 96 2 98 3 107 4 110 5 113 1 ACL 114 1 114 2 115 3 116 4 124 2 130 1 130 2 132 3 135 4 139 6 143 7 148 1 151 2 Point Cluster Technique 153 154 175 177

1

1 21 ( ACL) ACL 1 20 ACL 20 ACL ACL 20 ACL 2005 1 2008 2 ACL van Mechelen [1] 4 4 ACL ACL

2 1 ACL ACL 3000 1 ACL 8 10[2] 15 45 1750 1 [3] ACL 2 8 [2-10][4, 6, 8-10] [4, 6, 9][7] ACL [11] ACL 70%[2, 3] 70%[3, 4, 12]ACL [3, 12, 13]ACL 2 ACL ACL

2 ACL ACL ACL ACL ACL 3 ACL ACL ACL ACL ACL ACL ACL ACL ACL ACL ACL 4 [7, 12, 14, 15] McNair [14] 20 Boden [12] 70% Myklebust [7] Olsen [15]

32 20 ACL ACL 4 [12, 15-17]Teitz [16] 14 30 Boden [12] 23 Olsen [15] 20 2 1 1 Krosshaug [17] 28 17ms 50ms 2 [18] Krosshaug [19]

ACLMRI (bone bruise)acl MRI [20-24]Mink [20] T2 ACL 72% Rosen [21] ACL 85%83%Graf [22] 1/3 ACL Kaplan [23] 215 MRI ACL Viskontas [24] ACL MRI ACLCipolla [25] ACL 1103 ACL ACL Bellabarba [26] ACL 20 ACL Nishimori [27]ACL ACL

ACL ACL ACL ACL (strain)(force) ACL 1980 Arms [28] ACL ACL 30 40 10 15 Berns [29] ACL Markolf [30] ACL 10 ACL 10 30 ACL Kanamori [31] pivot shift () ACL ACL 30 ACL [32] ACL ACL Renstrom [33] in-vitro ACL ACL 45 ACL Durselen [34] ACL 20 60 ACL

Li [35] ACL 0 30 ACL ACL ACL ACL ACL ACL ACL Withrow [36-38] ACL ACL [36] ACL [37] ACL 30%[38]Weinhold [39] ACL ACL ACL ACL ACL Henning [40] ACL 22 ACL Beynnon [41] ACL ACL 15 30 ACL 60 90 Fleming ACL [42][42-44]

Closed Kinetic Chain ACL 15 ACL ACL Cerulli [45] ACL ACL MRI ACL Li [46]Li [46]ACL 0 90 60 ACL ACL ACL ACL ACL ACL ACL ACL Q Q

[47]Q [47-50]Q [51] Q Q ACL ACL ACL Navicular drop [52](calcaneal angle) Navicular drop ACL Navicular drop [53-55]Smith [56]ACL ACL [56][54]ACL Nguyen [50]Navicular drop ACL Yoshioka [57] Braten [58] Nguyen [50] Craig ACL Dejour [59] Meister [60]ACL

Brandon [61]ACL Stijak [62] ACL ACL ACL ACL 1980 Notch width index [11] Notch width index [63-67] [68-70]ACL Notch width index [68, 71, 72][73, 74] ACL ACL [71, 72]ACL ACL [75][50] [76]Ramesh [77] ACL ACL Uhorchak [71] ACL ACL Myer [78] ACL ACL [79] ACL

Q ACL ACL ACL ACL ACL Huston [80] ACL Chu [81] ACL ACL Dyhre-Poulsen [82]ACL 90ms ACL 100ms [17, 45] 40ms [82] ACL 1970 Markolf [83] (stiffness) 2

4 Lloyd [84] Wojtys [85][86] [85, 86] ACL ACL ACL ACL Colby [87] ACL ACL Fagenbaum[88] Cowling [89] Sell [90] Chappell [91] ACL Sell [92]

ACL Sigward [93] Landry [94] [95] ACL Kellis [96] Fagenbaum [88] Sigward [97] ACL ACL ACL ACL [3, 12, 13]

[12, 15-17] ACL ACL ACL Grood [98] Wu [99] [100-102] [103][104-106] [103-105] McLean [105] Salci [102] Ford [104]McLean [105][103, 105] [105] [103, 105] [102, 103] [105] [103]Hewett [107] ACL ACL

ACL [108, 109][88] [89, 106, 110] [106, 110]Lephart [108] [89, 110, 111] [106, 110][111] Hewett [111] Lephart[108] [106, 109]Pappas [106] ACL 40

Jacobs [112] ACL ACL Chappell [113] [91] [114] ACL [39]Sell [90]

[114] ACL ACL ACL ACL 45 [115-117] [93-95, 118-120] McLean [121] ACL ACL [115-118][119, 120, 122] McLean [116] McLean [117]Pollard [120] Sigward [93] [93][94, 95, 116, 117]

[95, 117] [116, 120] [117, 120] [94, 116] [117][95, 118, 119] [122][94, 120][95] [120] [93, 94] [95, 123] [94, 95] [120] Hawkins [124] ACL

ACL [96, 110, 125] [110][110, 112, 125][112] [88] McLean [105] Moran [126] Chappell [127] ACL ACL Borotikar [128] ACL 15 45 [3] (Maturation) ACL

Hewett [129] (1214 ) (15 ) Quatman [130] Yu [131] 12 ACL Hewett [129] ACL ACL Houck [132] Dempsey [133]

[134][135] Chaudhari [136] ACL ACL McLean [137] (r 2 =0.58, r 2 =0.64) McLean Noyes [138] Barber-Westin 9 10 [139]9 17

[140] Noyes ACL

3 ACL ACL ACL ACL 1 ACL ACL 1990 Henning [141] [142-152] 4 1 ACL ACL ACL ACL ACL Bencke [153] Hewett [154] Chimera [155] Lephart

[156] Hurd [157] Wojtys [158] ACL Lephart [156] Pollard [122] Hewett [154] Noyes [138] Irmischer [159] Myer [160]

Myer [161] ACL [162][156] [154, 163, 164] [163][165] [162, 166] ACL

3 ACL ACL ACL 4 [1] 2 ACL 3 ACL 1 2 ACL 3 4 1 2 5 ACL 1 ACL 2 1 ACL 6 2 5 ACL

7 (Knee rotation)(tibial rotation)

2

1 1 ACL 2 8 [2-4, 7] ACL 70%[3, 4, 12] [3] ACL ACL [167] [8, 10]

2 13 (W 8 W1 5 ) 2005 8 2006 3 (2005-2006 ) 2006 4 2007 3 (2006-2007 ) Injury Report Form ( 1: IRF) Exposure Sheet ( 1) Injury Report Form () Exposure Sheet 15 Injury Report Form Exposure Sheet Player-Hours Player-Hours( PH)()[10] 1000PH ACL ()

3 20052006 10 137 20062007 12 158 PH 20052006 49021PH( 1059PH)20062007 118646PH( 2809PH) 167667PH( PH 3868PH) 20052006 80 2006-2007 135 215 1.282 /1000PH 20052006 22 2006-2007 39 61 15.771 /1000PH Table 2-1-1 () Table 2-1-2 3 ACL () Table 2-1-3 ACL ACL 12 10 7 6 3 5 2 2

Table 2-1-1 Injury location by incidence and injury risk Location Incidence (%) Injury risk Ankle, foot 76 (35.3) 0.453 Knee 46 (21.4) 0.274 Low Back 28 (13.0) 0.167 Thigh 21(9.8) 0.125 Upper limb 13 (6.0) 0.078 Shank 10 (4.7) 0.060 Shoulder 7 (3.3) 0.042 Head 7 (3.3) 0.042 Neck 3 (1.4) 0.018 etc. 4 (1.9) 0.024 Injury risk are presented by incidence/1000 Player-hours Table 2-1-2 Injury diagnosis by incidence and injury risk Diagnosis Incidence (%) Injury risk Ankle lateral sprain 50 (23.3) 0.298 Low back pain 18 (8.4) 0.107 ACL injury 12 (5.6) 0.072 Hamstrings strain 9 (4.2) 0.054 Achilles tendinitis 4 (1.9) 0.024 Low back sprain 4 (1.9) 0.024 Contusion 4 (1.9) 0.024 Medial meniscus injury 4 (1.9) 0.024 Metatarsal stress fracture 4 (1.9) 0.024 Elbow MCL injury 4 (1.9) 0.024 Ankle medial sprain 3 (1.4) 0.018 Ankle sprain etc. 3 (1.4) 0.018 Femoral cartilage damage 3 (1.4) 0.018 Adductor muscle strain 3 (1.4) 0.018 Lateral meniscus injury 3 (1.4) 0.018 Injury risk are presented by incidence/1000 Player-hours

Table 2-1-3 ACL injury by incidence and injury risk Injury situation Incidence Injury risk ACL injury 12 0.072 contact 2 0.012 non-contact 10 0.060 (game) 7 1.810 contact 1 0.259 non-contact 6 1.551 Injury risk are presented by incidence/1000 Player-hours

4 Player-hours(PH) PH Athlete Exposure 1 PH 1.282 /1000PH 15.771 /1000PH Messina [10] 3.6 /1000PH 16.0 /1000PH Deitch [8] WNBA WNBA Messina [10] Fong [168] () ACL Deitch [8] WNBA 12.7% 3.6%ACL

0.9% WNBA [8] ACL WNBA ACL 6 ACL 12 ACL Messina [10]ACL 0.09 /1000PH 0.09 /1000PH[169] 0.31 /1000PH [7] ACL 83%(12 10 )[3, 4, 12] 70% ACL ACL 0.072 /1000PH

3

1 1 ACL ACL 1 [3, 4, 12]ACL 2~8 [2-4, 6, 147] ACL ACL [7, 12, 14] Olsen [15] ACL [104, 107, 113, 115, 116, 119] ACL [87, 100, 101, 115, 116]ACL [116] [93, 120] [170]() ACL [33, 171] [115][91][93, 115] ACL

ACL ACL ACL

2 18 (19.8±4.6 175.0±7.6cm68.7±16.2kg; ±) 19 (19.4±0.9 166.0±7.5cm59.8±7.5kg) 37 10 11 8 8 6 1 (Figure 3-1-1) 30cm 30cm (Figure 3-1-2) 3

30cm Figure 3-1-1 Landing position and arrangement of makers Subjects performed a single limb landing from a 30cm platform. Twenty four reflective markers of 9 mm diameter were secured to the limb. Figure 3-1-2 Experiment setup and test task Subjects landed with their right foot 30cm away from the platform. A seven camera VICON 370 motion analysis system was used.

24 10 6 (Figure 3-1-1)[170] Point Cluster Technique(PCT)[170]PCT PCT Andriacchi [170] 7 (VICON 370; Oxford Metrics Ink., Oxford, UK) 200Hz 1000Hz PCT [170] (PCT 2 )PCT 10 6 Grood [98] (DelSys Bagnoli-8 EMG system) 1/3 1/3

1000Hz 3 60 3 (Intraclass correlation coefficients; ICC)(1, 3) Root Mean Square (RMS) RMS 3 1 1 %MVC (Hamstrings Quadriceps Ratio: HQR)HQR [153] %MVC 50ms 50ms 50ms 50ms [172] 50ms [153] 46ms [173] 3 t U 5%

3 ICC(1, 3) 0.96 0.97 0.96 0.97 0.96 0.80 0.76 0.99 60ms Figure3-1-3 Table3-1-1 Table3-1-2 (p<0.05) (p<0.01; male 38.1±7.6ms, female 43.7 ±8.1ms) Table 3-1-1 Mean (SD) of knee position at foot contact Position at foot contact Flexion (deg) Adduction (deg) External tibial rot. (deg) Ant. translation (mm) Males 15.9 (6.4) 2.0 (2.9) 1.2 (6.0) 2.0 (4.9) Females 18.0 (6.3) 1.8 (2.7) 2.2 (6.0) 3.2 (5.7) Table 3-1-2 Mean (SD) of knee motion during at landing Degree or displacement during the landing Flexion (deg) Adduction (deg) Abduction (deg) Internal tibial rot. (deg) Ant. translation (mm) Males 27.8 (7.2) 1.4 (1.3) 1.7 (1.4) 9.4 (3.7)* 5.9 (2.3) Females 31.2 (6.5) 1.6 (1.1) 2.3 (1.7) 12.6 (5.1)* 7.5 (3.8) *: p < 0.05 between males and females

Figure 3-1-3 Gender-based comparisons of joint motion and GRF data (Mean and SD) Data are presented for Knee Flexion (a), Knee Abduction (b), Internal Tibial Rotation (c), Anterior Tibial Translation (d), and GRF (e).

Figure3-1-4HQR Figure3-1-5 50ms (p<0.001, Figure3-1-4a) 50ms (Figure3-1-4b)HQR 50ms (p<0.001, Figure3-1-5a) 50ms (Figure3-1-5b) Figure 3-1-4 %MVC of the rectus femoris (RF) and the hamstrings (Ham) during the 50 ms time period before foot contact (a), and during the 50 ms time period after foot contact (b) Boxes denote the middle 50% of the range and the median. The whiskers show the extent of the rest of the data. ***p<0.001 between males and females.

Figure 3-1-5 Ham/quad-ratio (HQR) before foot contact (a), and after foot contact (b) Boxes denote the middle 50% of the range and the median. The whiskers show the extent of the rest of data. ***p<0.001 between males and females

4 ACL [3, 12] ACL ACL ACL ACL ACL ACL Cerulli [45] ACL ACL PCT Andriacchi [170] PCT Lafortune [174] PCT [174] 2 PCT Andriacchi [170] ACL [28, 29][30, 32] Graf [22] ACL MRI 1/3 ACL ACL [26]

Waite [175] PCT ACL ACL ACL Screw home mechanism Asano [176] Screw home mechanism 30 Screw home mechanism Asano [176] 30 30 10 15 Asano [176] 0 15 15 20 30 ACL (stiffness)wojtys [86] HQR [91, 93, 115] [177] [178, 179]. [173]

ACL ACL ACL [104, 107, 115, 118, 119] 2 PCT ACL [30, 31] ACL [101, 115, 116][88][118] ACL [116, 180]PCT PCT [170, 181]

[174] ACL ACL ACL

2 ACL 1 ACL ACL ACL [12, 15-17]Olsen [15]ACL ACL ACL ACL ACL ACL ACL [12]- [15]Sell [90] -ACL - ACL Pappas [106] ACL Olsen [15]ACL - - - ACL

ACL ACL -ACL ACL

2 24 (21.1±1.3 166.1±8.3cm59.3±8.2kg; ±) 12 12 6-1 (Figure 3-2-1a)30cm 30cm 3 -(Figure 3-2-1b) 30cm 45 45 3 3 (Figure 3-2-1c) 5 5 1 5 2 4 3

Figure 3-2-1 Sequential photographs of experimental tasks: Single-limb landing (a), plant and cutting (b), and both-limb jump landing.

25 10 6 7 (Hawk; Motion Analysis Corp., Santa Rosa, CA, USA) 200Hz 1000Hz PCT [170] 200ms 3 ICC(1, 3) Bonferroni 5%

3 ICC(1, 3) 0.96 0.98 0.93 0.89 0.97 0.98 200ms Figure3-2-2 Table3-2-1 - (p<0.01)- (p<0.01) - ( p<0.01) (p<0.05)- - ( p<0.01) (p<0.01) Table 3-2-1 Mean (SD) for tasks of joint angle at the time of foot contact. Knee flexion Knee abduction Internal tibial rotation Single limb landing 15.8 (5.0) -4.0 (2.6) -9.0 (3.4) Plant and cutting 19.2 (7.0) -8.2 (3.1) -12.4 (4.3) Both limb jump landing 32.8 (7.1) -2.2 (3.4) 3.0 (5.2) *; p <0.05, ; p <0.01 Table3-2-2 - (p<0.05) - (p<0.01p<0.05)- - (p<0.05p<0.01) Table 3-2-2 Mean (SD) for tasks of peak joint angle. Knee flexion Knee abduction Internal tibial rotation Single limb landing 72.5 (6.7) -1.2 (5.2) 12.3 (5.5) Plant and cutting 70.4 (8.5) -2.6 (6.1) 14.4 (6.0) Both limb jump landing 80.3 (16.4) 7.1 (5.5) 14.9 (5.5) *; p <0.05, ; p <0.01

Table3-2-3 - ( p<0.01) - ( p<0.01) (p<0.01)- ( p<0.01) Table 3-2-3 Mean (SD) for angular excursion (deg) and rate of excursion (deg/ms). Knee abduction Internal tibial rotation Excursion Rate Excursion Rate Single limb landing 6.6 (3.6) 0.12 (0.05) 21.4 (6.4) 0.15 (0.06) Plant and cutting 9.8 (3.8) 0.13 (0.04) 26.8 (6.8) 0.22 (0.07) Both limb jump landing 11.2 (3.6) 0.14 (0.05) 12.1 (4.9) 0.14 (0.05) *; p <0.05, ; p <0.01

Figure 3-2-2 Task-based comparisons of joint motion Data are presented for Knee Flexion (a), Knee Abduction (b), and Internal Tibial Rotation (c).

4 ACL - - - [90, 113, 182] ACL Chappell [113] Sell [90] ACL ACLBesier[182] ACL ACL - - [28, 29][30, 32] ACL

- ACL - -- -ACL [12, 15-17]ACL [90, 113, 182] ACL ACL [38] ACL ACL [30, 32] ACL - - ACL ACL [104, 105, 129] ACL [107][138, 139] Pappas [106] ACL ACL ACL [106]Pappas

ACL ACL [28, 33, 41]ACL ACL ACL ACL ACL ACL ACL [17] ACL ACL [139, 140] PCT ACL

- ACL PCT ACL -ACL - 5 3 ACL ACL ACL

3 1 ACL [4] [15] ACL [100, 101, 108, 115, 116][104, 105, 129] McLean [123]Sigward [183] ACL ACL [16]Zazulak [184][185] Houck [132]45 Blackburn [134] ACL ACL

ACL 1 ACL ACL

2 10 (20.7±1.3 175.0±5.4cm66.9±6.2kg; ±) 10 (20.1±1.4 161.4±5.5cm56.8±7.4kg;) 20 10 7 3 6 (Shuttle run cutting) 1 5m 180 5m (Figure 3-3-1) 3

z y x Foot contact 5m Original motion direction Figure 3-3-1 Shuttle run cutting Subjects ran straight ahead for five meters, planted their cutting foot vertically and then changed direction to move 180 degrees to their original direction of motion.

37 2 10 6 [136, 170] 2 8 (Hawk; Motion Analysis Corp., USA) 200Hz Point Cluster [136, 170] x z ()(+: -: )y z (+: -: ) Andriacchi [170] Grood [98] 50ms 150ms 75ms150ms 150ms 3 ICC(1, 3)

t 5%

3 ICC(1, 3)0.860.8475ms 0.91 0.85 150ms 0.94 0.82 0.92 0.78 Figure 3-3-2 Table 3-3-1 (p<0.05) 75ms (p<0.05) (p<0.05) 75ms 150ms (p<0.05p<0.01p<0.05) (p<0.05) 75ms (p<0.01p<0.01)

Figure 3-3-2 Comparisons of joint motion Data are presented for Knee Flexion/Extension (a), Knee Abduction/Adduction (b), Internal/Internal Tibial Rotation (c), Trunk Forward/Backward Inclination (d), and Trunk Lateral Inclination (e)

Table 3-3-1 Mean (SD) of knee motion and trunk inclination (deg) Knee flexion Trunk forward inclination Trunk lateral inclination a Males Females Males Females Males Females Foot contact 37.5 (10.5) 29.2 (8.0) 38.4 (6.8)* 31.2 (4.8)* 7.3 (6.9)** -5.2 (9.2)** 75ms 56.0 (7.8)* 47.7 (6.4)* 45.1 (8.3)** 35.5 (5.4)** 8.3 (10.8)** -5.6 (9.9)** 150ms 66.5 (9.0) 58.9 (8.5) 51.5 (10.5)* 41.1 (6.4)* 7.8 (16.5) -5.4 (11.3) Excursion 29.0 (5.1) 29.6 (7.7) 13.1 (7.4) 9.9 (3.6) 0.5 (11.1) -0.2 (4.7) Males Females Males Females Foot contact 4.8 (3.7) 5.0 (4.3) 7.8 (5.2) 8.8 (6.8) Minimum peak 3.3 (4.4) -0.6 (5.2) 3.8 (5.6) 0.1 (5.4) Maximum peak 12.9 (5.3) 9.3 (6.7) 19.0 (5.3) 18.6 (4.2) Excursion 9.6 (2.3) 10.0 (3.7) 15.2 (5.9) 18.6 (5.8) a : positive value indicate the direction of original motion *: p < 0.05 between males and females **: p < 0.01 between males and females Knee abduction Internal tibial rotation

Table 3-3-2 75ms 150ms (r=0.60-0.79; p<0.01; Figure 3-3-3: ) 75ms 150ms (r=0.47-0.53; p<0.05) 75ms 150ms (r=-0.53 - -0.60; p<0.01, p<0.01, p<0.05; Figure 3-3-4: ) 150ms (r=-0.49, -0.49; p<0.05; Figure 3-3-5:) (r=-0.48; p<0.05; Figure 3-3-6: )

Table 3-3-2 r values for the association with trunk inclination and knee motion Knee flexion Knee abduction Trunk forward inclination FC b 75ms 150ms Exc. c FC b Min peak Max peak Exc. c FC b Min peak Internal tibial rotation Foot contact 0.76** 0.78** 0.65** -0.25 0.12 0.47* 0.27-0.24-0.12 0.28-0.41-0.60** 75ms 0.72** 0.79** 0.64** -0.19 0.12 0.49* 0.34-0.13-0.07 0.36-0.32-0.60** 150ms 0.64** 0.73** 0.60** -0.13 0.15 0.53* 0.41-0.05-0.01 0.42-0.16-0.53* Excursion 0.21 0.37 0.28 0.07 0.11 0.36 0.39 0.19 0.12 0.38 0.21-0.20 Max peak Exc. c Trunk lateral inclination a FC b 75ms 150ms Exc. c FC b Min peak Max peak Exc. c FC b Min peak Foot contact 0.36 0.44* 0.23-0.23-0.19 0.32 0.16-0.21 0.05 0.42-0.09-0.48* 75ms 0.18 0.29 0.08-0.17-0.24 0.21 0.12-0.10-0.04 0.34-0.05-0.36 150ms -0.01 0.08-0.12-0.16-0.18 0.18 0.15 0.01-0.10 0.27 0.01-0.25 Excursion -0.49* -0.40-0.49* -0.02-0.09-0.07 0.08 0.27-0.25-0.23 0.12 0.12 a : positive value indicate the direction of original motion, b : foot contact, c : excursion *: p < 0.05, **: p < 0.01 Max peak Exc. c

60 Knee flexion at foot contact (deg) 50 40 30 20 10 R = 0.76 0 0 20 40 60 Trunk forward inclination at foot contact (deg) Figure 3-3-3 Associations between trunk forward inclination at foot contact and knee flexion at foot contact 30 Excursion of internal tibial rotation (deg) 25 20 15 10 5 0 R = -0.60 0 20 40 60 Trunk forward inclination at foot contact (deg) Figure 3-3-4 Associations between trunk forward inclination at foot contact and excursion of internal tibial rotation

60 Knee flexion at foot contact (deg) 50 40 30 20 10 R = -0.49 0-20 -10 0 10 20 30 Excursion of trunk lateral inclination (deg) Figure 3-3-5 Associations between excursion of trunk lateral inclination and knee flexion at foot contact Excursion of internal tibial rotation (deg) 30 25 20 15 10 5 0 R = -0.48-40 -20 0 20 40 Trunk lateral inclination at foot contact (deg) Figure 3-3-6 Associations between trunk lateral inclination at foot contact and excursion of internal tibial rotation

4 ACL ACL ACL ACL Blackburn [134] Farrokhi [186] Farrokhi [186] ACL Olsen [15] ACL ACL

ACL Boden [12] ACL ACL 30 ACL [33, 41] ACL [28]Kanamori [32] ACL ACL [115, 116] Chappell [91] ACL ACL [4] ACL [4] ACL

() ACL ACL ACL Point Cluster Technique [170]

1 1 ACL

4

1 1 ACL ACL [107]ACL ACL [121] ACL [104, 115, 119] ACL [30, 31][29] ACL [147, 148, 152] ACL ACL [138, 139, 187] McLean [137]

McLean [137] [107, 131, 138]

2 28 (20.9±1.4 166.0±7.8cm58.8±7.7kg; ±) 16 12 6 (Figure 4-1-1) 5 (continuous jump test: ) 5 1 5 2 4 3

Figure 4-1-1 Continuous jump test All subjects performed five vertical jumps with maximum effort using both legs and landing.

24 10 6 6 (Hawk; Motion Analysis Corp., Santa Rosa, CA, USA) 200Hz 1000Hz PCT [170] 3 1.8cm () (30Hz; Sony Product, Japan) 3.8m (Dartfish software, Dartfish Japan Co., Ltd. Japan) (Figure 4-1-2)

Knee valgus angle Figure 4-1-2 Measurement of knee valgus using the 2D method The angle between the line formed from the marker on the ASIS to the mid point of the patella and that formed from the mid point of the patella to the midpoint of the ankle joint was recorded as the knee valgus angle.

y = a + b x y = a + b x + c x y = a + b ln(x) 2 3 LSD Coorevits [188] (1, 2) 5%

3 (1, 2) 0.73 8 20 (: r 2 =0.34, p<0.01; Figure 4-1-3A, : r 2 =0.40, p=0.01; Figure 4-1-3B, : r 2 =0.41, p<0.01; Figure 4-1-3C) (Figure 4-1-4)

r 2 r 2 r 2 Figure 4-1-3 Associations between 2D valgus and 3D knee abduction during the continuous jump test for the linear model (A), the quadratic model (B), and the logarithmic model (C) The R2 values of all models between 2D valgus and 3D knee abduction were significantly different from zero.

Figure 4-1-4 Associations between 2D valgus and 3D internal tibial rotation during the continuous jump test The R2 values of all models between 2D valgus and 3D internal tibial rotation were not significantly different from zero.

4 ACL ACL McLean [137]( ) McLean [137] McLean [137] ACL 7.036.766.60 ACL Hewett [107]ACL 7.6 ACL Hewett [107]ACL

9 ACL 35%30%30% 0%10%10% ACL ACL 10 15 15 25 4 ACL

ACL [29][30, 32] ACL ACL ACL

2 1 ACL ACL [12, 15, 16] ACL [107] ACL ACL ACL [143, 145, 147, 148] Plisky [189] ACL ACL ACL ACL Navicular drop [54, 56, 190](calcaneal angle) [54, 56]ACL Q ACL [191]

2 61 122 (19.4±1.2 169.1±6.6cm62.8±6.5kg; ± ) 5 (continuous jump test: )(Figure 4-2-1)() 5 1 5 2 4 3 90 12 1.8cm () (30 Hz; Panasonic Inc., Japan) 3.5m ( 55cm)(Figure 4-2-2) (Dartfish software, Dartfish Japan Co., Ltd. Japan) 4 1

Figure 4-2-1 Continuous jump test All subjects performed five vertical jumps with maximum effort using both legs and landing. Figure 4-2-2 Setting for continuous jump test The trial was recorded using digital video cameras from the frontal plane and sagittal plane. Each digital camera was placed 3.5 m distant from the landing point at the knee joint height.

Plisky [189]Star Excursion Balance Test (Figure 4-2-3) [192] ()3 3 3 ( )

Figure 4-2-3 Star Excursion Balance Test procedure While maintaining a single-leg stance, the player was asked to reach with the free limb in the anterior, posteromedial, and posterolateral directions in relation to the stance foot. The device comprises a footplate and three measure cords with a slider spreading to anterior, posteromedial, and posterolateral directions.

Q Navicular drop Leg heel Q Q [47] 90 (Figure 4-2-4)(Multi Level A-300; Shinwa Sokutei K.K., Japan) 1/3 (mid-point of hip rotation: MPR) MPR = ( IR ER) 2(deg) MPR

Figure 4-2-4 Measurement of hip rotation In the prone position with knee flexed 90 deg, the angle between the tibia and the vertical was measured using an inclinometer.

Denegar [193] 1/3 0 Navicular drop Navicular drop [194] Brody [52] (mm) Leg heel Leg heel Woodford-Rogers [54] 1/3 Leg heel ()() Pearson (F=2.0)

5%

3 6 8 59 114 5.5±2.2 47.2±7.7 r Table 4-2-1 Navicular drop (p < 0.05)(p < 0.05)MPRNavicular drop Leg heel (p < 0.01, p < 0.05, p < 0.01, p < 0.01, p < 0.05) Table 4-2-2 Navicular drop Navicular drop (p < 0.01) r 2 0.079 Table 4-2-3 Navicular drop Navicular drop (p < 0.01) r 2 0.290 (r = 0.340, 0.258, p < 0.01)

Table 4-2-1 Mean (SD) of lower limb alignment (deg or mm) and balance abilities (% leg length), and r values for the association with knee valgus angle and knee flexion angle Q-angle Hip IR Hip ER Mid point Ankle DF Navicular ROM ROM of rotation ROM drop Mean (SD) 20.1 (4.6) 49.9 (10.5) 33.5 (8.4) 8.2 (7.4) 34.5 (8.7) 5.7 (3.7) Knee valgus r -0.05 0.20* -0.03 0.16 0.06 0.19* Knee flex r -0.06 0.25** -0.05 0.21* 0.42** 0.29** LH-angle AT Bal. PM Bal. PL Bal. 5.2 (4.5) 72.6 (5.7) 110.1 (7.2) 108.1 (9.2) Composite Balance 96.9 (6.1) Mean (SD) Knee valgus r 0.05 0.06 0.07 0.04 0.07 Knee flex r 0.19* 0.35** 0.08 0.03 0.16 *: p<0.05, **: p<0.01 AT bal., anterior balance; PM bal., posteromedial balance; PL bal., posterolateral balance

Table 4-2-2 Results of step-wise regression model for peak knee valgus angle Model r r 2 Adj. r 2 SE of Est 1 0.205 0.042 0.033 2.195 2 0.281 0.079 0.063 2.162 Equation 1: Knee valgus = 0.043(IR ROM) + 3.042 Equation 2: Knee valgus = 0.044(IR ROM) + 0.116(ND) + 2.369 IR ROM, ROM of hip internal rotation; ND, navicular drop Table 4-2-3 Results of step-wise regression model for peak knee flexion angle Model r r 2 Adj. r 2 SE of Est 1 0.424 0.180 0.172 7.017 2 0.484 0.234 0.220 6.812 3 0.526 0.277 0.257 6.648 4 0.539 0.290 0.264 6.618 Equation 1: Knee flexion = 0.375(DF ROM) + 34.228 Equation 2: Knee flexion = 0.347(DF ROM) + 0.486(ND) + 32.453 Knee flexion = 0.282(DF ROM) + 0.456(ND) + 0.300(AT) Equation 3: + 13.056 Knee flexion = 0.261(DF ROM) + 0.471(ND) + 0.264(AT) Equation 4: + 0.089(IR ROM) + 11.889 DF ROM, ROM of ankle dorsiflexion; ND, navicular drop; AT, anterior balance; IR ROM, ROM of hip internal rotation

4 ACL [12, 15, 16] ACL [107] ACL ACL [12, 15, 16] ACL [28, 33, 41] ACL

[189] Navicular drop ACL ACL Cincinnati Sportsmetrics [145]PEP [148]Myklebust [147] ACL ACL ACL

ACL

5

1 ACL 1 ACL ACL ACL

2 ACL Pubmed ACLPrevention 251 (2007 5 ) ACL ACL [195-199]12 ACL 10

3 12 Henning ACL Henning [200]Henning Quad-cruciate interaction () ACL ACL ACL 1 3 2 ACL 0.33 / 0.25 / Henning ACL Vermont Vermont [142] ACL ACL ACL Phantom-foot 1 2 1) 2) 3) 4) 5)

20 ( 4700 )( 4000 ) ACL 2 ACL ACL 2 (26.6 / 10 /) Caraffa Caraffa [143] 5 3 20 3 ACL (20 300 ) 0.15 /season/team (20 300 ) 1.15 /season/team [143] Cincinnati Sportsmetrics Hewett [145] Cincinnati Sportsmetrics 6 3 6 2 Technique phasefundamentals phase Performance phasetechnique phase Fundamentals phase Performance phase ACL

ACL (463 ) 0.12 /1000Athlete exposure(ah)(366 ) 0.43 /1000AE 0.09 /1000AH [145] [154] ACL [138] Dynamic Neuromuscular Analysis (DNA) Hewett [152, 201, 202] Sportsmetrics Training Dynamic Neuromuscular Analysis program( DNA ) Ligament dominancequadriceps dominanceleg dominance 3 Ligament dominance ACL [154]31 wall-jumptuck-jumpbroad-jump and hold180jumpsingle-leg hop-and-hold Quadriceps dominance [101, 108]

ACL [80] 55 Quadriceps dominance squat-jump broad-jump and hold Leg dominance X-hop DNA ACL DNA ACL Hewett [161, 203]DNA 3 Soderman Soderman [144] 5 10 15 1 [144] ACL (: 4 : 1 )ACL (0.12/1000Play Hours (PH) 1.36/1000 PH, RR: 10.96) (62 ) Frappier Acceleration Training

Heidt [146]Frappier Acceleration Frappier Acceleration Trainng 7 (258 ) 33.7%(42 ) 14.3%ACL 3.0% 2.4% [146] Myklebust Myklebust [147] ACL 3 5 3 15 ACL ( 1 58 855 2 52 850 ) 2 [147] 3 1 2 ACL 0.09 /1000PH, 0.14 /1000PH ( (OR): 0.64) (OR: 0.37)

(OR: 0.06) [162] Prevent Injury, Enhance Performance (PEP) Mandelbaum [148] ACL Prevent Injury, Enhance Performance ( PEP)PEP 20 (without side to side movement) (soft landing) (opposed to landing with a flat foot) 14 18 3 2 ACL (1041/844 ) 0.09 /1000AH (1902/1913 : 00/01) 0.49 /1000AH ACL [148] Olsen Olsen[149] 20 (Knee over toe) (61 958 ) 6.9%(59 879 ) 13.1%(RR: 0.51)

3 (ACL 3 ) 14 (ACL 10 PCL 3 MCL 1 )(RR: 0.20) Petersen Petersen [150] Myklebust. [147] knee over toe 3 1 ACL ACL (134 ) 0.04/1000AH (142 ) 0.21/1000AH ACL (OR: 0.17) Knee Ligament Injnury Prevention (KLIP) Pfeiffer [151] Knee Ligament Injury Prevention ( KLIP) 4 Hewett [145]20 KLIP [159] ACL 2 ACL KLIP (577 ) 0.167/1000exposure(862 ) 0.078/1000exposure (OR: 2.05)[151]

4 ACL 12 ACL 10 ACL Table 5-1-1 10

Table 5-1-1 Details and effects of the 10 ACL prevention programs Year Author Sports Strength Flexibility Agility Jump Balance Feedback 1995 Ettlinger et al. Ski 1996 Caraffa et al. 1999 Hewett et al. 2000 Soderman et al. 2000 Heidt et al. 2003 Myklebust et al. 2005 Mandelbaum et al. Male soccer Female basketball, volleyball, soccer Female soccer Female soccer Female handball Female soccer PNF) treadmill 2005 Olsen et al. Handball Effects (control vs intervention) 26.6 vs 10/season a 1.15 vs 0.15/team/season 0.43 vs 0.12/1000AE b 1 vs 4 injuries (ACL) 0.12 vs 1.36/1000PH cd 3.0% vs 2.4% 0.14 vs 0.09/1000PH d (OR e : 0.64), (OR e : 0.37) f 0.49 vs 0.09/1000AE (RR g : 0.18) 14 vs 3 injuries RR g : 0.20 h a 2005 Petersen et al. 2006 Pfeiffer et al. Female handball Female basketball, volleyball, soccer 0.078 vs 0.167/1000AE b (OR e : 2.05) vs past 2 years b AE: Athlete Exposure c Severe knee injury d PH: Play Hour e OR: Odds Ratio f in top league g RR: Rerative Risk Including 3 PCL injuries and 1 MCL injury in control h 0.21 vs 0.04/1000AE b (OR e : 0.17)

ACL (Feedback) 6 ACL 1990 Ettlinger [142] Caraffa [143] Soderman [144] Hewett [145] [146-151] 7 [145-151] Heidt [146] 6 ACL [12]ACL 7 5 7 3 Hewett [145]

7 4 Mandelbaum [148] Olsen [149] ACL 7 3 10 ACL 3 [145, 147, 151]Hewett [145] [154]Myklebust [147] 1 35 [162]Pfeiffer [151] [159] ACL

Randomized control trial ( RCT) (Prospective cohort study: PCS) 10 RCT Olsen [149] Soderman [144] 2 Olsen [149]RCT Soderman [144] PCS [142, 143, 145, 146][142, 143, 145, 148] [146, 150] ACL Olsen [149] RCT Olsen [149] PCS [145, 147, 148, 150] Caraffa [143]Soderman [144] [147, 149, 150] Heidt [146]Pfeiffer [151]ACL

ACL ACL 12 10 ACL ACL

2 1 ACL ACL 1 [204] [205] ACL ACL ACL [145, 147-151] ACL [145, 147-150] ACL ACL [122, 156, 160, 206] [156, 160][160][206] Myer [160] [122, 156] ()() ACL ACL [15] [153, 155, 156] [153, 155, 156]

DeMorat [207] ACL Colby [87] ACL ACL ACL

2 8 (19.4±0.7 169.5±4.9cm64.1±7.8kg; ±) 6 3 1 ( 3 1 ) 3 1 (Pre-tarining1)5 2 (Pre-training2) 2 5 1 3 (Post-training) 3 1 ( 3 1 ) 1 20 3 5 [147, 154, 201, 202](Table 5-2-1) 5 3 3 (1) (2) (3) 2

Table 5-2-1 Jump and balance training Exercise Time or Repetitions Exercise Time or Repetitions Phase1: Technique Phase2 :Performance 1. Squat jumps 20sec 1. Squat jumps 20sec 2. 180 jumps 20sec 2. Scissors jumps 20sec 3. Single leg balance 20sec 3. Single leg balance and pass 20sec 4. Hop jump (both leg) 20sec 4. Hop jump (single leg) 20sec 5. Broad jump and hold 28m 5. Single-leg hop and hold 14m/leg 6. Crossover hop, hop, hop, stick 28m 6. Crossover hop, hop, hop, stick 28m Squat jumps: Drop into deep knee, hip, and ankle flexion and then take off into a maximal vertical jump. On landing, immediately return to the starting position and repeat the initial jump. 180 jumps : Initiates a 2-footed jump with a direct vertical motion combined with a 180 rotation in midair, keeping arms away from the body to help maintain balance. When landing, immediately reverses this jump to the opposite direction. Single-leg balance (and pass): This drill is performed on a balance device that provides an unstable surface. Begin by stanging on one foot on the device. After the subject has improved, the training drills can incorporate ball catches and passes. Hop jumps: Start by standing next to a small square balance board. Hop onto the board and then hop off on the opposite side. Repeat hopping on and off the board. Broad jump and hold: Begin by swinging arms forward and jumping horizontally and vertically at approximately a 45 angle to achieve a maximum horizontal distance. The athlete lands with her knees flexed to approximately 90. Crossover hop, hop, hop, stick: Start on a single limb and jump at a diagonal across the body landing on the opposite limb with the foot pointing straight ahead and immediately redirect the jump in the opposite diagonal direction. Scissors jumps: Start in a stride position with one foot well in front of other. Jump up, alternating foot positions in midair. Single-leg hop and hold: Initiate the jump by swinging the arms forward while simultaneously extending at the hips and knees. The jump should carry the athlete up at an angle of approximately 45 and attain maximal distance for a single-leg landing. The subject is instructed to land on the jumping leg in deep knee flexion.

3 1 ( 3 1 ) 50ms 50ms (%MVC)(Hamstrings Quadriceps Ratio: HQR) 3 Bonferroni Friedman Wilcoxon Pre-training1 Pre-training2 Pre-training2 Post-training 5%

3 60ms Figure 5-2-1 3 1 Table 5-2-2 Pre-training2 Post-training (p<0.01) Pre-training1 Pre-training2 Pre-training2 Post-training (p<0.01, p<0.05) Table 5-2-3 Pre-training2 Post-training (p<0.001) Table 5-2-2 Mean (SD) of knee position at foot contact Position at foot contact Flexion (deg) Adduction (deg) External tibial rot. (deg) Ant. translation (mm) Pre-training1 19.5 (7.3) 1.3 (2.7) 1.9 (5.3) 0.9 (5.5) Pre-training2 19.3 (7.0) 0.1 (3.3) 0.6 (7.1) 5.0 (3.9) ** ** Post-training 24.4 (5.9) 0.6 (3.2) 1.1 (5.7) 1.6 (5.0) * *: p < 0.05, **: p < 0.01 Table 5-2-3 Mean (SD) of knee motion during at landing Degree or displacement during the landing Flexion (deg) Adduction (deg) Abduction (deg) Internal tibial rot. (deg) Ant. translation (mm) Pre-training1 31.6 (7.3) 1.5 (1.0) 2.8 (2.0) 12.3 (3.8) 9.4 (3.2) Pre-training2 34.3 (7.1) 1.3 (0.8) 3.7 (2.0) 13.8 (5.1) 9.2 (4.2) Post-training 40.3 (5.4) *** 1.3 (1.1) 4.1 (1.7) 13.3 (5.6) 9.1 (3.6) ***: p < 0.001

Figure 5-2-1 Mean joint motion during the single limb drop landing for pre-training 1, pre-training 2, and post-training. Data are presented for knee flexion (a), internal tibial rotation (b), knee valgus (c) and anterior tibial translation (d).

Figure 5-2-2HQR Figure 5-2-3 50ms Pre-training2 Post-training (p<0.05, Figure 5-2-2a) 50ms (Figure 5-2-2b)HQR 50ms 50ms (Figure 5-2-3) Figure 5-2-2 %MVC of the rectus femoris (RF) and the hamstrings (Ham) for the 50ms before foot contact (a), and for the 50ms after foot contact (b) Boxes denote the middle 50% of the range and the median. The whiskers show the extent of the rest of the data. * p < 0.05 from the previous test

Figure 5-2-3 Ham/Quad-ratio (HQR) before foot contact (a), and after foot contact (b) Boxes denote the middle 50% of the range and the median. The whiskers show the extent of the rest of data.

4 ACL ACL [145, 147-150] ACL (Figure 5-2-1) [156, 160, 206][122, 156] [160]ACL ACL ACL [12, 15, 16] ACL

[30, 32] ACL ACL ACL ACL ACL ACL Onate [206] ACL 50 70 [208] [178, 179, 209, 210] (Pre activation)[153, 155]

(electromechanical delay) 50ms [172] [210] [211, 212] [173, 213] ACL ACL ACL 30 ACL [28, 33, 41] [33, 214] 60 ACL [41][177] [179] ACL ACL 3 1 5

ACL

6

ACL 4 [1] 4 2 ACL ACL ACL ACL ACL ACL ACL ACL 3 ACL Bahr [215] ACL ACL ACL ACL ACL

3 1 PCT ACL ACL 2 - ACL - ACL ACL ACL 3 ACL ACL 3 ACL 4 4 ACL ACL

ACL 4 1 ACL 2 ACL ACL 5 ACL ACL 1 ACL ACL ACL 2 1 ACL 3 ACL () ACL ACL

ACL ACL ACL ACL ACL ACL ACL ACL [216, 217] ACL 3 ACL 5 ACL 4

7

ACL ACL ACL ACL ACL ACL ACL - ACL ACL ACL ACL

ACL ACL ACL

1 Injury Report Form

Exposure Sheet

2 Point Cluster Technique PCT Andriacchi [170] PCT PCT I (( p i, y ) 2 + ( p i,z ) 2 ) m i p i,x p i, y ( m i ) p i,z p i,x ( m i ) i i i I = p i,x p i, y ( m i ) (( p i,z ) 2 + ( p i,x ) 2 ) m i p i, y p i,z ( m i ) i i i p i,z p i,x ( m i ) p i, y p i,z ( m i ) (( p i,x ) 2 + ( p i, y ) 2 ) m i i i i (1) p i i m i 3 3 R R = ( E 1, E 2, E 3 ) (2) E j j E j = ( e j,x,e j, y,e j,z ) T (3) PCT (2) R (2) R Grood [98] ()( )

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