Transcription of Dr. Kirsten Buchanan for the show Keeping Knees Healthy #219
Lisa: Listeners of the show know that the University of New England is doing great work in the health care field and specifically in the field of physical therapy. Today, we have with us two individuals who are representing the Physical Therapy Department at the University of New England. The first is Dr. Kirsten Buchanan who is an assistant clinical professor in the Department of Physical Therapy at the University of New England, and Matt Kraft who is a third year doctor of Physical Therapy Department student at the University of New England. Thanks so much for coming in.
Kirsten: Thanks for having us.
Matt: Thank you.
Lisa: I loathe the idea that I recently heard you’ve been engaged in and that that is preventing ACL tears in young soccer players and I think specifically women but I could be wrong on this one so tell me about that if that’s so. Your ACL is your knees, it’s the anterior cruciate ligament. I have seen in my own practice increasing numbers of ACL tears. My own daughter was a soccer player and lacrosse player who had an ACL tear so it’s become a little bit of a public health issue actually.
If we want to keep young athletes fit and healthy and active, we need to keep their knees in good shape and we need to keep them uninjured. How did you Kirsten, Dr. Buchanan, how did you get interested in this?
Kirsten: Yeah. Well, I think that as you probably know girls are two to eight more times more likely to rupture their ACL. This is something that there are programs out there, preventative programs that can help to decrease the risk of this ACL and so they’re warm up programs and so that’s we decided that this would be a great community outreach program through the University of New England to try to get the research that’s out there and bring it to the community.
Lisa: Matt, what’s your relationship to this research project?
Matt: To this research project, well, I was a soccer player growing up. I’ve seen many ACL injuries. Working in some of my clinical placements through this program I’ve seen a lot of ACL repairs. It’s a preventable injury and we see way too many injuries of this kind and I think any work that we can do in the realm of prevention would be fantastic.
Lisa: Back me up a little bit because obviously, I know more about this than perhaps many people do, but I’m not sure everybody out there knows exactly what an ACL does and why it’s important in the knee and how it actually gets torn.
Kirsten: Right. There’s four major ligaments in your knee that help to stabilize your knee and your anterior cruciate ligament or the ACL is one of the cruciates, so one of the ones that crosses in your knee and it helps to ,like we said, to stabilize. It can be at a risk when people land in a more stiff way or place more pressure on that knee. The way you move can really depend on how much pressure is going to be going or force is going to be going through that ACL and we’re trying to help people move in a way that decreases the risk that it’s going to be injured.
Matt: Yeah. ACL injuries are usually a non-contact injury like a plant and pivot sort of thing. People will hear a pop and then their knee will go out. The anterior cruciate ligament is responsible for preventing forward translation of the tibia, which means like a sliding forward of the tibia on the femur, and it’s responsible for a decent percentage of that prevention. If we can strengthen the surrounding musculature and supplement that with good body mechanics hopefully, we can take a lot of that load off of the ACL.
Lisa: When I’m thinking about possibilities for ACL injuries it would be if you’re on the soccer field or lacrosse field and you stop suddenly and shift in a different direction than your body was originally going in.
Kirsten: That’s exactly right. It’s that pivot, plant and change direction that oftentimes just like Matt said, you hear a pop and before you know they’re on the ground.
Matt: It’s also very common injury in basketball as well.
Lisa: What about skiing?
Matt: Skiing, definitely. Although there are a lot more factors involved in skiing but yeah, since your foot is fixed in that boot and the rest of your body moves, yeah, the ACL is definitely at risk there.
Lisa: It’s not just the kids who are playing sports in Maine. It’s also anyone who’s out there really being active possibly on the slopes.
Kirsten: It’s true. I think that … and the group that we are really looking at and targeting are the girls because the girls are more likely … Yes, in skiing, I think it’s not necessarily just girls who might get injured because you do have, like Matt was talking about, your foot in a boot in a long lever arm of your ski that can cause a great deal of force coming up and put a lot of pressure or force on that ACL.
What we’re really looking at are the soccer athletes and the lacrosse athletes and the basketball athletes so that if we can help them move in a way that can prevent it or better alignment, that’s going to help prevent this sort of injury from happening.
Lisa: What is it about the way that girls’ bodies are formed that causes them to be more at risk?
Kirsten: It’s a great question. They’ve looked research-wise to see if is it something about a girl’s body that is, is it a hip width situation or do they tend to have flatter feet that cause this problem or is it a hormone piece of things or what is it.
There’s really no conclusive research that shows that it’s one of those things. What the research has shown is that the way they move can make a difference so there’s research that was, like I said, it was done 15 years ago that looked at if we can get girls to land from a jump in a more … absorbing more shock, being able to land without so much of a stiff knee, that is something that can … they did a prospective study and showed, they took thousands of girls in California, Southern California, and they had one group who they just did a traditional warm up. They went ahead and ran around the field and did some jumping jacks and things like that.
They took the other group and they did this injury prevention program. This PIEP program which stands for Prevent Injury Enhanced Performance. It’s a combination of strengthening, plyometric, flexibility, and it’s a 20-minute warm up type of a thing and it’s fairly basic exercises that you can do but it’s landing softly and absorbing shock and teaching them about good alignment while they’re doing that.
They found in this study that of the thousands that they studied, the ones who did the PIEP program were significantly less at risk for this ACL injury. We thought everybody should be doing this.
Lisa: Who are you working with now? I know you’re working with Yarmouth High School because my daughter’s been working with your program and where else?
Kirsten: Right now we are working with the JV Varsity from the Yarmouth team and also with the U13 girls, that travel team, the Yarmouth Colts. We figure that’s a target group. If we can really get that U13, U14 girls to start moving in a correct way, by the time they’re in high school, hopefully you don’t see anybody that has any kind of an ACL tear.
Lisa: I understand that as part of this program, you actually came in and you evaluated the biomechanics of each girl. Describe that process for me.
Matt: Well, in our motion analysis lab at UNE we had the girls do some jumping test so we’d measure with a force plate and surrounding halo cameras just basically the direction of force on the ground going through their legs and just how they moved, when they jumped, how they landed. Then we also took some measurements with some strength tests, some foot drop test just to see if they have flat feet or if they have fixed arches, that sort of thing, how far they could squat down to the ground without lifting their heels off the ground, just very basic physical therapy assessment data.
Kirsten: The hope is that from this we’ll be able … UNE has this really incredible motion analysis lab and it’s one of the only ones in the state. It’s just this really, like Matt was saying, it’s got these great cameras all around and you can get 3D motions so they put these reflective markers on them. It’s how they do animation.
The girls then they jumped off this box on the force plate like Matt was saying and we can get a snapshot of what they look like in 3D. Then we couple that with their static evaluation and from that we get a sense of like okay, what do they look like coming in. Then the hope is by adding and doing this PIEP program that maybe some of the forces that they land with or maybe some of the malalignment situation that they maybe dropped their knees into the inside or that they flexed too much at the hip or something.
Once going through the program, perhaps they’ll be able to … we’ll bring them in again at the end of the season and have them jump again. The hope is that we see some changes that there’s less force. We always tell them to land softly like a ninja and that hopefully we’re seeing softer landings and more shock absorbing and things like that.
Lisa: I know that when I see patients in my office I evaluate the entire chain so if you have somebody with some knee problems that I’m also looking at their hip and their ankle and looking at their lower back and even to some extend the upper part of their body. It seems as though that’s a real focus in physical therapy is not just to focus on the part of the body that is damaged or not working as well but to look at the entirely of the person.
Kirsten: I think that’s vital. I think you hit it right on the head. I think you have to look at the strength of the hip. The hip strength is so huge for these girls to be able to have that hip strength. When you look at some of the ACL injuries that take place, they take place more often in the third and fourth quarter of the game or the second half when fatigue is starting to kick in.
Having that strength from the hips on down and then also having stability from the feet on up is important as well, both of those. The knee is just the unfortunate joint that is stuck between the feet and the hips.
Lisa: Matt, you were a soccer player.
Matt: I was, yeah.
Lisa: And you played actually at a pretty high level in Massachusetts where you’re from.
Matt: Yeah, yeah, up through high school.
Lisa: Tell me what types of work was being done when you were a soccer player as far as biomechanics and strength flexibility, endurance. What types of work was being done to protect the knees?
Matt: To protect the knees specifically, practically nothing. It was very old school, just regular warm up, run around the fields, just drills, mostly soccer-related drills and there was a not a huge focus on proper mechanics.
Lisa: What types of injuries were you seeing?
Matt: A whole matter of types. I would mostly break bones. I broke my toe three times. Fortunately, twice it was left foot so I could still play pretty well. I did see a fair number of ACL injuries, lots of sprained ankles, some torn ligaments around the ankles and concussions too, which is a whole other discussion. I think some work is being done in that realm.
Lisa: The things that you’re seeing when you’re playing soccer versus the things that you’re seeing now as a physical therapy student, have those changed?
Matt: Not tremendously. I don’t think that a lot of preventative programs like the one that we’re implementing now are really in practice so we’re still seeing a lot of preventative injuries out there. That with proper body mechanics, proper stretching, strengthening, and just general awareness can be prevented but it’s not happening.
Lisa: Kristen, you’re a runner and you’ve worked with the Boston Marathon and you’ve worked with Beach to Beacon. Are you seeing similar types of preventable injuries in runners, maybe not as an ACL injury but maybe overuse injuries?
Kirsten: Yeah, I think that there’s, certainly in runners, there’s all kinds of flexibility programs that you can implement. Preventative medicine I think is just … it is the future of medicine. I think that and physical therapy is one of those areas that we need to look into preventative ways to do things and I think in running, there’s all kinds of things.
You look at flexibility programs. It’s very similar quite honestly to some of the ACL things. It’s about strengthening things that are weak and it’s about stretching things that are tight. When you’re younger you get away with a lot because you have a lot more flexibility and then as you get older, you start having problems where you never used to have problems before and you wonder why that is.
Yes, gait analysis is one of my backgrounds or one of the areas that I’ve looked at and people start to break down a little bit and they wonder why that is. If you can do more preventative things, whether that be strength,, whether that be flexibility, you can do something to help yourself.
Lisa: Isn’t part of what you’re talking about getting even kids or maybe adults if they haven’t already had this exposure, but getting kids used to engaging in activities that are not sports-specific but are really body-specific. Right now, I wonder if we have enough youth coaches out there who are aware of the body mechanics that you’re talking about.
Kirsten: I think Matt spoke to this a little bit before but I think that’s exactly right. I think that we have a responsibility almost to some degree to be able to provide girls with this information to be able to help them stave off these injuries because yeah, I think that once their knee is injured they’re more likely to develop osteoarthritis, they’re more likely to have a total knee at a very early age because of all of that.
If we can do things earlier preventive-wise then I think that makes a huge difference and helps them obviously down the line.
Matt: Now once somebody has an ACL injury they are at a much higher risk for injuring that same ligament and the contralateral, the other knee. That’s just what the data says.
Kirsten: Yeah. The research shows that, so if we can help them to decrease again, decrease that risk, that’s going to be huge. I think that exercises like you would talk about a little bit, exercises they can do, it’s core stuff and there are other things that you don’t have to necessarily be doing a plank. I think that getting kids to do exercises that are… Paddle boarding is a great core exercise.
Matt: Any kind of anti-rotation exercise would be fantastic.
Kirsten: Long boarding is a great core exercise. These are exercises, just getting kids out there and active and doing multiple different sports as opposed to always a specialization of just one sport is important for them and important for their health, I think.
Lisa: Matt, what is an anti-rotational exercise?
Matt: Okay, so your abdominal muscles are in three groups, you have your rectus abdominis which is the six pack, the beach muscles that everybody loves. You have your transversus which looks like a cummerbund, just keeps everything tucked away in there, keeps your guts in place. Then you have your obliques which go off at an oblique angle, which is where they get their name. They allow you to twist but really their main function is to keep your core steady while a rotation force is being put on your body.
Paddle boarding, as Kirsten said, is an anti-rotation exercise. You’re keeping your trunk stable while you’re paddling away from you off to the left or the right. That force is trying to provide a torque on your core, but your obliques are resisting that so it’s an anti-rotation exercise.
Lisa: I’m interested in general in why physical therapy seems to have gained such momentum. It used to be, I believe, that physical therapy could be an undergraduate degree. I think it still is possible to get an undergraduate degree in physical therapy but Matt, you’re getting a doctorate in physical therapy and UNE really has put a lot of emphasis on their doctoral program. Why is this?
Matt: For one thing, many states are now doing direct access to PT so you don’t need a referral from your physician anymore. You can just go directly to your physical therapist to receive treatment and in that instance it’s preferred that your provider has a doctorate degree. Yeah, there’s a lot more information coming out. PTs are doing a lot more work, doing wound care, which PT has been doing for a long time.
Just the scope of practice is broadening so much that the amount that we’re learning in school really merits this doctorate level degree.
Lisa: Kirsten, why was it important for the University of New England to begin offering this program?
Kirsten: I think it’s being able to provide the students and the population with a degree that is going to match I guess what their needs are. Just trying to stay abreast with the national trend and like Matt was saying as well, where the needs are going to be for direct
access, that’s where we need to be as well.
Lisa: Each of you has an interesting background that it wasn’t necessarily PT related. Kirsten, you graduated with a BA in German from Colby and Matt, you actually ended up having a degree in media studies or a minor in media studies and an English major. Can you explain that a little bit?
Kirsten: I think that you can, it just goes to show that you can come to physical therapy from a whole bunch of different angles. Mine happens to be a German background and I was able to take a true liberal arts education, in the way that I was able to take a couple of semesters and go to Austria and to Germany and to have this wonderful education and take other classes, while I was also actually doing premedical classes but I didn’t have to concentrate in that. I wasn’t a bio major.
For me it was a wonderful undergraduate experience. I took the year off afterwards and took a couple of prerequisites before PT school but I knew that physical therapy was always the direction that I wanted to go in. German hasn’t necessarily been handy in physical therapy. I use it perhaps occasionally but not so often. I’m not practicing physical therapy in Germany at this point anyway. I could I guess but yeah, it gave me a great broad liberal arts background which I loved.
Matt: Yeah, I think mine was a little bit more of a circuitous route. I had no idea that I was going to be getting into physical therapy when I was pursuing an English major. Medicine has been a passion of mine. I think my Latin background definitely helped me out with anatomy.
Yeah. I don’t know. I had toyed with the idea of med school and then I took some time to just travel around the country, went to Ecuador, went … came back and hiked the Appalachian trail and I think somewhere around Pennsylvania, I decided that med school wasn’t for me but found my way back to physical therapy because I’m really interested in body structure and function. I think this is a good niche for me.
Kirsten: It’s a wonderful profession. You get a chance to chat with people while you exercise with them at the same time. It’s just a great way to be.
Lisa: It also seems as if that what you are talking about, things like biomechanical analysis and gait analysis and the technology that’s now available to do these sorts of things that it used to be we would do just visually. When I see patients in the office, I analyze their gait by watching them walk down the hall and to have the availability of the next level up of tools must really be increasing the likelihood that you’ll be able to help people.
Kirsten: Yeah. I think that that’s one of the things, just being able to … like we said that the motion analysis lab has this 3D so we can do the 3D evaluation of somebody’s jumping or walking or running. In the lab one of the things I do actually is see patients for runners primarily but it’s mostly a 2D analysis but we just, by getting a camera on people and being able to slow it down, you can really start to see the biomechanics.
With, like you said, the advent of all this technology out there, you can get your iPhone on somebody and be able to slow it down well enough and really start to see these movements both in walking and running, and help them. Help them and be able to say, I can see this might be an area of weakness or this might be … do you see how you’re sort of bringing your foot out in this direction, maybe we can correct that in a certain way that will keep you from irritating your knee or whatever it might be.
All this technology is wonderful to be able to use.
Lisa: After listening to this I’m sure that people will have some interest in the work that you’re doing with ACL rupture and other sorts of injury prevention, so how can people find out about the University of New England program?
Kirsten: Certainly, if they have interest in having us help them with an ACL prevention program, not sure exactly how to get it started or what to do, emailing me is the best way to do that. That’s at [email protected]. I’m happy to help bring people in the right direction.
There’s some great things online that they can look at, programs that might be all that they need or it might be such that they want one of the students to come out and help them with a program whether that be a practice or two or a whole session like we were doing with the JV Varsity, we’re happy to do it. That’s probably the best way to get in touch.
Lisa: The University of New England website, Matt, is?
Matt: UNE.edu.
Lisa: I appreciate the work that you’re doing in this area. Obviously, it would have been great if my middle child had had access to the ACL prevention program than rehabbed herself through an ACL rupture but we keep learning as a medical profession and we keep moving on and we keep offering more to the next generation so I think it’s great that you’re doing this and I thank you for doing this for the girls in Yarmouth. Hopefully, this will continue to spread out with rippling effects throughout the state of Maine.
We’ve been speaking with Dr. Kristen Buchanan and Matt Kraft from the University of New England. Thank you so much for coming in.
Kirsten: Thanks for having us.
Matt: Thank you.