Forskning i idrætsmedicin. Korsbåndsskader i håndbold hvor galt står det til? Long term consequences

Transkript

1 Forskning i idrætsmedicin Korsbåndsskader i håndbold hvor galt står det til? Jesper Bencke, cand.scient, PhD Laboratorieleder Ganganalyse-Laboratoriet Ortopædkirurgisk Afdeling Hvidovre Hospital jesper.bencke@hvh.regionh.dk Van Mechelen et al, 1992 Tidligere elitefodboldspiller; alder 32 ÅR År 1994: Delvis ACL overrivning, menisk læsion, MCL læsion => MCL rekonstruktion => genopstarter fodbold År 1996: Arthroskopi pga. smerter og knæløshed År 1997: Arthroskopi pga. smerter og knæløshed => stopper fodbold aktivitet År 1999: Arthroskopi => ACL rekonstruktion År 2: Arthroskopi => ACL overrivning og menisk læsion År 22: Arthroskopi => ACL rekonstruktion, delvis resektion af lateral menisk, reinsertion af medial menisk 15 procent invalid CMJ (cm) Cathrine Paaske Efter Slut styrketræning efterår 1999 Slut forår 2 TD test cm 31 cm 36 cm 4 cm Nationalt ACL register (25-27) Long term consequences Ewa Roos (25) 1

2 Lind et al. 28 Korsbåndsskadens empiri Kvindelige idrætsudøvere har en 4-8 gang større sandsynlighed for at pådrage sig en ACL skade sammenlignet med deres mandlige kollegaer indenfor samme idrætsgren. (Malinzak et al. 21, Ostenberg & Roos 2, Myklebust et al. 1997) Incidens raten for ACL skade => ACL skader/1 time for kvindelige elitehåndboldspillere =>1-2 spiller/hold/spilsæson (Myklebust et al. 1998, Myklebust et al. 23) Incidens raten for ACL skade =>.12 ACL skader/1 time for kvindelige elitefodboldspillere =>1 spiller/hold/spilsæson. (Le Gall et al. 28) Korsbåndsskadens empiri Korsbåndsskadens empiri I håndbold er retningsskiftet (fodfinten) den mest risikable bevægelse i forh.t. risiko for korsbåndsskade. Strand et al, 199. Mange forskellige skadesmekanismer nogle veldefinerede og andre stadig hypotetiske. Korsbåndsskadens empiri 75 9 % af alle korsbåndsskader sker uden kontakt med modstanderen. Skal disse piger fortsætte med håndbold? Strand et al,

3 Korsbåndsskader i håndbold - biomekaniske årsager og forebyggelse Jesper Bencke, cand.scient, PhD Laboratorieleder Ganganalyse-Laboratoriet Ortopædkirurgisk Afdeling Hvidovre Hospital jesper.bencke@hvh.regionh.dk Projekt formål ACL screening Primary investigator: Mette Zebis, Jesper Bencke Vi håber, at have et redskab til mere præcis vurdering af skadesrisiko for unge håndboldpiger. Det giver potentiale til individuel forebyggelse Det giver mulighed for bedre rådgivning ved return-to-sport tidspunktet. Vi håber at vide mere om langtidskonsekvenserne af ACL-skader give bedre rådgivning. Vi håber at vide meget mere om hvilke kvaliteter en øvelse skal indeholde for at virke skadesforebyggende. Måske potentiale for individualiseret træning mhp præstationsforbedring. Forskning i idrætsmedicin Forskning i idrætsmedicin Van Mechelen et al, 1992 Van Mechelen et al, 1992 Faktorer af betydning Anatomiske og fysiologiske Biomekaniske belastninger In vitro Kadaverstudier In vivo Biomekaniske bevægelsesanalyser Neuromuskulær kontrol Anatomiske og fysiologiske Genetiske (køns)forskelle? 3

4 Kønsforskelle: Intercondylær notch Kønsforskelle: Intercondylær notch Kvinder<mænd? Kønsforskelle: Q-angle Kønsforskelle: Hormonelle faktorer Menstruationscyklus?? Foreløbige studier: P-piller nedsætter tilsyneladende risikoen Risikofaktor? Ingen koncensus Strength For girls, strength-to-weight ratio or after puberty, especially compared to boys. Bevægelser der belaster forreste korsbånd ACL Sagittal: Anteriore translationer af tibia. Transversal: Rotationer af tibia. Frontal: Valgusbevægelse Ahmad et al, 26 4

5 Biomekaniske belastninger - Sagittal plan: Anterior translation af tibia Ved 9 flekteret knæled virker m. quadriceps femoris komprimerende på knæleddet. Ved mere ekstenderet stilling optræder tillige translation af tibia. Biomekaniske belastninger Kraftige rotationer? Kraftig valgusbevægelse? Biomekaniske belastninger Kraftige rotationer Kraftig valgusbevægelse Video analyser Injuries to the anterior cruciate ligament (ACL) has previously been reported to occur early (<4 ms) in the eccentric part of a handball sidecut manoeuvre with: the knee near full extension, in outward or internal rotation, and with increased valgus movement. (Olsen et al., 24) Biomechanical movement analyses Bevægelseslaboratorium Kinematics Joint angles in 3D Kinetics Net joint moments in 3D Power Electromyography (EMG) Neuromuscular coordination Jan Chrisensen 8 infrarøde kameraer 5

6 Bevægelseslaboratorium Biomekanisk metode 2 kraftplatforme Calculation of a 3D coordinate for a marker needs a minimum of 2 cameras to see the marker Biomekanisk metode Sagittal plan Antropometri Ledvinkler Kraftdata Moment udvikling Simonsen et al, 2 Sagittal plan Frontal plan Hewett et al., 25; The American Journal of Sports Medicine, Vol.33, No 4 n=25 6

7 The handball side step cut The handball side step cut The handball side step cut Local maximum The handball side step cut The handball side step cut The handball side step cut NB! Hofteled 7

8 The handball side step cut Hip joint kinematics may influence knee joint moments Significant relation between hip joint internal rotation and knee valgus moments during sidecutting. (Bencke, Zebis et al. BJSM, 214) Biomekanisk profil External knee valgus moments Teknik 1 Teknik 2 Teknik 1 Teknik 2 External knee joint moment (Nm/kg BM) Valgus Varus Time (sec) 45 Whydo so manyacl-injuries occur during sidecutting? Neuromuskulære faktorer One-legged landing demanding high muscle strength. A frontal plane and transverseplane movement! (Differentfrom stopping or dropjump) Pause Players should learn: To land on flexedknees With hips less internally rotated With CoMmore abovethe knee External moments trying to rotate kneeor bring it in valgus straining the ACL. Higher values than other movements. The BiomechanicalGaitAnalysis Laboratory Copenhagen UniversityHospital at Hvidovre 47 8

9 Vigtige muskelgrupper Undgå strakt knæ stærk quad Modvirke valgus Mediale haser+vas.med. Modvirke udadrotation mediale haser Explosive muscle strength Rate of force development (RFD) Explosive muscle strength Neuromuskulær koordination under håndboldfodfinte Zebiset al, 211 Bencke & Zebis, JEK 211 Kønsforskelle Kønsforskelle IC Toe-off Bencke & Zebis, JEK 211 Bencke & Zebis, JEK 211 9

10 EMG ACTIVITY (% OF MAX) Neuromuskulær koordination under håndboldfodfinte X : ACL cases (n=5) NEUROMUSCULAR ACTIVITY OF ST (1 ms pre-landing) 1 % 1 % P =.2 P =.9 case O: Non-injured (n=5) EMG ACTIVITY (% OF MAX) NEUROMUSCULAR ACTIVITY OF VL (1 ms pre-landing) case Zebis et al. AJSM 29 PRE-ACTIVATION DIFFERENCE NEUROMUSCULAR ACTIVATION DIFFERENCE 8 % HIGH RISK ZONE? VL - ST CASE MEAN + SD MEAN - SD Zebis et al. AJSM 29 Why are young female players more at risk? Unfortunate technique during sidecutting, thus increasing external moments. Lower activation of hamstring muscles prior to ground contact during sidecutting Lack of adequate explosive muscle strength may also be a factor, especially in the hamstrings, and more pronounced in younger players. Optimal development of talent! Kan korsbåndsskader forebygges? Forskning i idrætsmedicin JA! Van Mechelen et al,

11 Forebyggelse af korsbåndsskader? Injury prevention JA: Caraffa 1996: Fodbold. Hewett 1999: Basketball og fodbold. Wedderkopp 1999: Håndbold. Heidt 2. Fodbold. Junge 22: Fodbold. Myklebust 23: Håndbold. Olsen 25: Håndbold. NEJ: Söderman 2: Fodbold. OLSEN et al. 25 => Exercises to prevent lower limb injuries in youth sports: cluster randomized controlled trial (BMJ 25; 33;449-;) ;) Myklebust et al. 23 => ikke-kontakt ACL skader 38% EFFEKT AF FOREBYGGELSE => Antal af akutte knæ- eller ankelskader i kamp INTERVENTIONSGRUPPE: 28 >< KONTROLGRUPPE: 57 (p<.1) Video from: ALDER: ÅR Forebyggelse af korsbåndsskader? Øge eksplosiv muskelstyrke specielt for hasemusklerne? Ændre intermuskulær koordination? 66 11

12 F z F o rc e T im e (m ilis e c o n d s) s e m i te n d b ic fe m c l rect fem v a s t m e d v a s t la t Myklebust et al., 23 Risk movement in the lab Newton uvolt uvolt uvolt uvolt uvolt Fotograf: Geert Mørch 68 Effekt af neuromuskulær træning Effekt af neuromuskulær træning Effekt på neuromuskulær aktivitet af glut.med under fodfinte: nedsat pre-aktivitet. Zebis et al, CJSM 28 Zebis et al, CJSM 28 Springstyrke før og efter skadesforebyggende neuromuskulær træning SPRINGSTYRKE Zebis et al., CJSM 28 PRE * POST Photo: Jan Christensen Forebyggelse af korsbåndsskader? Øge eksplosiv muskelstyrke specielt for hasemusklerne? Ændre intermuskulær koordination? Træningsøvelser? 12

13 Identifying Exercises with high ST activity? Specific Strength exercises 2, 1,5 ST BF Hip joint angle 12 1 EMG amplitude (V) 1,,5, -,5-1, Hip joint angle ( o ) -1,5-2, TIME (ms) Andersen et al. Phys Ther STYRKETRÆNING Specific exercise evaluation Hasetræning??? Øhhhh.jeg laver den der, hvor jeg ligger og sparker bagud. EMG ACTIVITY DIFFERENCE ST dominant * KS RD SPL LU FJU DJU PLC FJ NH BFcl dominant HEB SJ SeLC * HE SuLC EMG ACTIVITY DIFFERENCE Zebis et al. Br. J. Sports Med. 212 Nordic hamstring Leg Curl ST 8% (±2) BF 9% (±2) ST 91% (23) BF 16% (58) ST 83% (4) BF 92% (36) Zebis et al. Br. J. Sports Med. 212 Zebis et al. Br. J. Sports Med

14 ST Dominant 6 weeks of Kettlebell training Week 1: 3 x 2 min Monday - Easy swings: 5-6% of what you could do in the allotted time if you went all-out. Wednesday - Moderate swings: 7-8% of what you could do in the allotted time if you went all-out. Friday - Hard swings: as many as you can do in the allotted time. Week 2: 3 x 3 min ST 115% (55) * BF 93% (33) Monday - Easy swings: 5-6% of what you could do in the allotted time if you went all-out. Wednesday - Moderate swings: 7-8% of what you could do in the allotted time if you went all-out. Friday - Hard swings: as many as you can do in the allotted time. Week 3: 5 x 2 min Monday - Easy swings: 5-6% of what you could do in the allotted time if you went all-out. Wednesday - Moderate swings: 7-8% of what you could do in the allotted time if you went all-out. Friday - Hard swings: as many as you can do in the allotted time. Week 4: 4 x 3 min ST 73% (32) * BF 56% (2) Monday - Easy swings: 5-6% of what you could do in the allotted time if you went all-out. Wednesday - Moderate swings: 7-8% of what you could do in the allotted time if you went all-out. Friday - Hard swings: as many as you can do in the allotted time. Week 5: 3 x 4 min Monday - Easy swings: 5-6% of what you could do in the allotted time if you went all-out. Wednesday - Moderate swings: 7-8% of what you could do in the allotted time if you went all-out. Friday - Hard swings: as many as you can do in the allotted time. Week 6: 5 x 1 min + 5 x 2 min Zebis et al. Br. J. Sports Med. 212 Adjust pauses between intervals as it fits you. If you monitor your heart rate you can for example start each interval when the heart rate has dropped 25-3 heart beats from the end heart rate from last working interval. Injury prevention program Young handball players (15-17 yrs) 15 selected Exercises Balance mat Acute ankle and knee injuries 5% Wobble board Floor Instep OLSEN et al. 25 => Exercises to prevent lower limb injuries in youth sports: cluster randomized controlled trial (BMJ 25; 33;449-;) Forskning i idrætsmedicin Er der færre skader nu? Van Mechelen et al,

15 Screenings tests Drop jump Single leg hop Andre? Måler vi det vi vil? Single leg hop Sammenligner med et rask ben, som måske har tabt styrke? Man springer med tre led; hofte og ankel kan kompensere for knæled! Knæ ekstensorerer dominerende, ikke fleksorer. Optimal screeningstest fra biomekanisk evidensbaseret synspunkt Måling af eksterne valgusmomenter (og rotationsmomenter?) under individuel spillignende situationer Måling af neuromuskulæraktivitet, semitendinosuspreaktivitet, i relation til vastuslateralispreaktivitetunder individuel spil-lignende situationer. Måling af eksplosiv hasemuskelstyrke (RFD) Opsummering og perspektivering The BiomechanicalGaitAnalysis Laboratory Copenhagen UniversityHospital at Hvidovre 88 Why? High magnitude of knee injuries! Terrible physicaland social short-term consequences and long-term consequences. Why? High magnitude of knee injuries! Terrible physicaland social short-term consequences and long-term consequences Disruption of talent development fewer good players in handball. 15

16 When? At what age should players commence specific prohylactic training? Wouldspecialperiods in the seasonbemore optimal? (Do wehave the time to prioritisethiselement?) Whenin the traininglesson? In the beginning, latein the training? How much? Who? Whoshoulddo thistraining? Most important for girls but boys also get injured! Who is responsible? The players? The parents? The physiotherapist? The trainer? The club management? How? How canthisbeimplementedin the real life of handball training? How do wechoosethe exercises? How shouldthe attitude of the coach be? Of the players? Allocation of time? How couldthe national handballassociations act? Tak for opmærksomheden Jesper Bencke Tlf: The BiomechanicalGaitAnalysis Laboratory Copenhagen UniversityHospital at Hvidovre 94 FJU LU DJU FJ SPL KS NH SuLC The BiomechanicalGaitAnalysis Laboratory Copenhagen UniversityHospital at Hvidovre SJ 95 16

17 HE HEB RD SeLC The BiomechanicalGaitAnalysis Laboratory Copenhagen UniversityHospital at Hvidovre PrLC 97 17