Sunday, May 15, 2016

Stop injuring the athletes - ACL reconstructions

By Ian King

I was stretching beside the oval whilst debriefing my son following his high school rugby game and I looked. Three teenage boys from the opposition school were standing nearby, and two of them were in knee braces.

I have been saying for decades now that the rate of injuries to athletes is unacceptable and unnecessary. If fact those familiar with my writings would be appear of my zero tolerance attitude – we can prevent them all.

It has been tragic watching the advent then the rise of the ACL surgery since its introduction around about 1980. A positive sign is the discussions that are now occurring. In two different countries two separate article were published recently, one by a former elite US athlete who never fulfilled his career due to injury and the other by sports medicine advocates in Australia.

One of the many limiting factors in the effectiveness of any intervention that is stimulated by this growing awareness of injury incidence is what I call interpretation. Image ten coaches watching the same game where their team say lost the game. How many different interpretations will come from these ten coaches if they are independently arrived at? Could be ten. And how many of these coaches are high achieving in terms of their association with championships or whatever is the measure of success at their respective levels? At best one of them. And chances are that the coach with the most accurate interpretation.

Understanding why athletes get injured is no different – it is subject to interpretation. And listening to the interpretation provided by this sports medicine expert as to why the incidence of ACL ruptures in the young athlete is so high let me with little comfort that anything will change.

You see these experts cited the reduction in childhood play as the primary cause. I have heard the dominant interpretation amongst my North American colleagues – that the increased injury rate in young athletes is due to the lack of diversification in sports played in formative years and that the athletes are specializing too early.

Both lovely theories, and both have validity in the bigger picture of long term athlete development. But both, in my humble opinion, miss the target. And this is where you come in. You are going to either adopt one of the theories presented here (including my theory) of form your own. Whatever path you choose, I ask two things.

Firstly understand the seriousness of your interpretative decisions. You have the live, the quality of life and the livelihood (the US athlete only dropped 5 million dollars…..) of the athlete in your hands. I know you didn’t sign the Hippocratic Oath but for the sake of athletes all over the world I hope you would adopt this attitude:

First, do no harm.

Now based on a number of factors I am not optimistic that you will take the most effective path. Why am I so negative? Firstly that most of you will do what most do. And from my perspective, this conforming path gives you social comfort but leaves you under-performing on your potential, and the athletes will path the price. Secondly, most of you will lack the experience or competence to make optimal decisions. And thirdly few of you will be in a position to monitor the cause-effect relationship of training and injuries through multi-year controlled environments.

So if you are have not been too offended and are still reading, leaves me to the second request. I respect whatever path you take, and I accept that most of you will miss the target. But what you can do is every few years take stock, reflect, and change your mind. Get better at avoiding injuries in the athletes who trust you. Now this will require taking responsibility for your decisions rather than avoiding responsibility, which in sport is easy to do. It will also take humility and the willingness to let go of any dogma. So I understand this request is a large one, but I make it with optimism.

I want you to act before the duty of care concept from the legal perspective is your driving force. You are getting away with doing things today that are causes serious injury because ‘everyone’ is doing the same thing and ‘science’ has not yet ‘confirmed’ that what you are doing is causing the injuries. But one day, science will catch up and you will be held responsible for doing the things you take for granted now, like endless walking lunges, failing to stretch the athlete, and for developing the quad dominance that your current training programs are – just to name a few. One day these debilitating practices will be frowned upon. But you don’t have to wait till everyone has caught up. You can work these things out now and, for the sake of the athletes, make the changes and STOP INJURYING the athletes!

So what, in my humble opinion, has brought on the rise of incidence in ACL surgery? There are many factors, and in every case the hierarchy will be different, and this level of individual interpretation is nigh impossible in a world that struggles with accurate generalized interpretation. However, for the sake of starting your journey to serving the athletes better, I raise three of what I consider up the top end of contributing causes in most cases. I list them alphabetically to avoid any further message of which is more important or correlative.

I will also give examples in each case to demonstrate some of the influences in my conclusions.

1. The introduction of strength training and the inherent quad dominance in the program design.

Using the young athlete as a time line, based on my experience dealing with post high school elite athletes in Australia, there were few if any formal strength training programs in high schools in Australia prior to the early to mid-1990s. I suggest, and this is a hypothesis, that you could track the rise of ACL injuries in young athletes (12-24 years) along beside the rise of strength training programs in high schools and find a strong correlation.

Am I saying that strength training is bad for young athletes and should not be done? Not at all. What I am saying is that if strength training with the same imbalances as exist traditionally in adult or elite programs is applied to kids, they will suffer injuries early. And that is what is happening, I suggest.

I propose a second hypothesis – if you could track the rate at which strength training has been offered to younger and younger athletes in the high school programs, with the rise in incidence of ACL ruptures in younger and younger athletes, I suggest you would see a correlative pattern.

Now these same imbalances have been inherent in adult elite programs since I have been studying strength training for sport, since its inception around 1970 in the US.

During the 1980s I began forming a conceptual theory that I called ‘Lines of Movement’, to understand how inherent imbalances in traditional program design could quantified. I published this concept for the first time in 1998 Here is the fundamental message:
After many years I have decided that there is two family trees in lower body exercises – one where the quad dominates, and one where the hip dominates. When I say hip I mean the posterior chain muscle groups – the hip extensors; which are gluteal, hamstrings, lower back – they’re your hip extensors. And I believe this – the head of the family in the quad dominant exercises is the squat. That’s the head of the family. And there are 101 lead-up exercises to it and there’s a few on after it as well. But the core exercise for the quad dominant group is the squat. It’s the most likely used exercise in that group for the majority of people.

The hip dominant exercises – the father of the hip dominant tree is the deadlift – which when done correctly would be the most common exercise of that group. There are lead-in exercises, and there are advanced exercises from it.

So I build my family tree around the squat and I build my family tree around the deadlift. And I balance them up. In general, for every squat exercise or every quad dominant exercise I show in that week a hip dominant exercise in that week. And what do most people do in their program designs – they would do two quad dominant exercises for every hip dominant exercise. What is the most common imbalance that occurs in the lower body?

….To balance the athlete I work on a ratio of 1 to 1 of hip and quad dominant - in general. And I can assure you – most programs you’ll see are 2 to 1 – quad and hip.

That’s a concept I’m sure you’ll have never heard before because this is the first time I have spoken about it.
The following is a sample list, not in any order, of the major muscle groups of the body that I published:
A sample list of muscle groups, not in any order.(5) _______________________________________________
Hip dominant (e.g. deadlift and its variations)
Quad dominant (e.g. squats and its variations)
Vertical pulling (i.e. scapula depressors e.g. chin ups)
Vertical pushing (i.e. arm abduction e.g. shoulder press)
Horizontal pulling (i.e. scapula retractors e.g. rows)
Horizontal pushing (i.e. horizontal flexion e.g. bench press)
The subsequent dilution of the origin of this concept has gone hand in hand with its failure to impact the athlete’s outcome to the extent it could have. I can only recommend you go to the source, to my original writings, summarized in the ‘Legacy’ book or more extensively in my ‘Legacy Course’ (Level1 KSI Coaching Program). I understand that those looking for opportunities to discredit my message may call ‘marketing!’ at this point in time, however those that know me better understand it’s not about the money, it’s about the athlete. And if that’s the best way at the moment to help the athlete, and I suggest it is – so be it.

I identified the imbalances of the lower body musculature and found a way to teach the risk and solution in the 1980s and taught it in the 1990s. I have since advanced my theories but the historic content would serve you really well as a base point.

2. The failure to address length and tension of the connective tissue

As a student of training trends and optimal training it has been extremely interesting to say the least to watch the trends in this area of training during the last four decades. The rise of connective tissues is undeniable, and the effort to find solutions pitiful. I suggest that the only thing my colleagues are concerned about is whether they are being trend conforming, dressed up in the behavioral term ‘cutting edge’.

Let me put it this way – more and more and younger and younger athletes are being exposed to strength training, and experiencing tissue shortening and tension increases. And the best that is bring offered is dynamic ‘stretching’ and foam rolling?

Again let me be clear – I am not saying that either is bad or of no value. What I am saying is this.

Dynamic stretching is barely stretching and does not replace the role of static stretching. And as for the dominant discouragements to the masses of the post 2000 era – that pre-training static stretching will make you weak and or increases your injures – injuries could not get much higher and the dominant value is stretching is minimized, what is done is predominantly dynamic. It’s not working! It never did! All I have to offer is four decades of professional application with an intensity and desire for optimal outcomes that few can match. Who cares about my experience? I can assure, the thousands of athletes who I have given injury free high performance careers to have.

Now foam rollers – the only reason you have heard about this option was because small equipment distributors in the US realized the profit in re-selling a piece of foam and instructed their seminar speakers to project expert (and I suggest overnight expertise) opinions on the value of rolling, to the extent that it was placed in the sequence of training sessions as a mandatory must do – and the non-trendy static stretching was left out!

Now anyone who has truly been involved in athlete preparation has been having their athletes roll on tennis balls and similar forever. But not instead of stretching and not as a replacement for massage. Rolling is great, but if you fail to keep it in context you under-perform for the athlete.

3. Fatigue

There is a point in time for even the well-conditioned athlete that the incidence of injury, especially what some mistakenly assume to be ‘impact’ injuries, increase rapidly. Here’s a third proposal or hypothesis – if you could track the level of fatigue of the athlete with those that suffer ACL rupture I suggest you would find a strong correlation. Now this hypothesis is probably the hardest one to test, I appreciate that.

I have witnessed the highest incidence of ‘impact’ injuries including ACL in the sporting teams with the highest volume training. I could name example coaches whose careers I have been monitoring for years and in some cases decades to understand the correlation between training volume, fatigue and injury incidence.

This is a risk that all coaches face at all times, requiring them to monitor their training volumes. The interpretation is made more difficult by realities such as the fatigued athlete could injure early in the game and we could say it can’t have been fatigue because it happened early in the game. Remember the residual nature of fatigue.


There is a growing albeit belated awareness of the high incidence of injuries such as ACL injuries in athletes, and in particular the younger athlete. Whist this is nice, and supports the strong concerns I have expressed for decades, my concern is also whether it will lead to any real intervention of this trend. My concerns are based on whether the interpretation of the cause of these injuries is accurately identified and isolated.

I provide three factors that I believe are highly correlated with the risks of ACL injuries, and provide three hypoesthesia that perhaps my more learned academic colleagues may one day investigate, to aid the thinking of the masses who wait for social proof such as this:

1. That you could track the rise of ACL injuries in young athletes (12-24 years) along beside the rise of strength training programs in high schools and find a strong correlation. 2. If you could track the rate at which strength training has been offered to younger and younger athletes in the high school programs, with the rise in incidence of ACL ruptures in younger and younger athletes, I suggest you would see a correlative pattern. 3. If you could track the level of fatigue of the athlete with those that suffer ACL rupture I suggest you would find a strong correlation.

However rather than waiting for the lagging indicators of science, for the sake of the athlete I hope that at least one coach might change their mind about how they train as the result of this article. I know the power of what is offered here, I also understand the power of conformity and dogma, and the over-riding desire of the majority to be like the majority, resulting is slow change. Thousands if not millions of athletes will get injured during this slow change, as has occurred during the last few decades.

What I would like to do is this – if you are a high school coach (physical or specific sport) and what I have said has resonated with you – and if you school would like to receive a 10 part video program I created last year titled ‘The Zero Tolerance to Injuries Video Series’, provided the school is making the purchase and it will be made accessible to all in the sports department, I would live to arrange this for you at no cost. Email my office at and ask us how you can receive this.

4) King, I., 1998, Strength Specialization Series (DVD), Disc 3, approx. 1hr 06m 00sec in.
5) King, I., 2000, How to Teach Strength Training Exercises

1 comment:

  1. I work mostly with foam roller then dynamic stretching at beginning of the session, then use static stretches at the end. If a session is most about stretching, which I also run a stretching circuit, I would combine two exercises for the same muscle group such as ostrich walks with loaded full body hanging off a low box, using Dumbbells or barbell.