Avascular Necrosis - Loss of Blood Supply

Avascular necrosis is also called as Osteonecrosis. Avascular necrosis is a disease resulting from the temporary or permanent loss of the blood supply to the bones. Without blood, the bone tissue dies and causes the bone to collapse. If the process involves the bones near a joint, it often leads to collapse of the joint surface.

Conditions commonly associated with osteonecrosis are serious trauma which interrupts the bone's blood supply, extended and/or high doses of corticosteroid medications (such as prednisone and Solu-Medrol or methylprednisolone), and excessive alcohol consumption.

Patients may present with hip pain or (referred) knee pain. Physical examination will disclose that internal rotation of the hip - not movement of the knee - is painful.

Initially, plain X-rays are often normal. An MRI (Magnetic Resonance Imaging), CT (Computed Tomography) scan, and bone scan are all more sensitive techniques.

o Treatment starts with pain medications and limiting weight-bearing on affected areas. This type of conservative therapy may work well for patients with early osteonecrosis in small areas of bone. However, it does not work for those with hip or knee osteonecrosis who are facing progressive bone collapse.

o A procedure called core decompression may be used to remove a piece (core) of bone from the affected area in an attempt to improve blood flow.

o Bone grafting: During this procedure, your surgeon takes healthy bone from another part of your body and implants it into the area affected by a vascular necrosis.

o Joint replacement surgery replaces your joint with an artificial one.

o Bone reshaping: This procedure reshapes the bone to reduce the amount of stressed placed on the area affected by a vascular necrosis.

Avascular necrosis usually affects people between 30 and 50 years of age; about 10,000 to 20,000 people develop avascular necrosis each year.

Avoiding Total Hip or Knee Joint Replacement Surgery

Due to arthritis and other causes, many people may need total hip or knee joint replacement surgery later in life. Physical Therapists may help you delay surgery or prevent it altogether via exercise, stretching, and pain management. Pain management may also include methods like taping, electric stimulation, ultrasound, and lasers.

Physical Therapists will help you know the source of pain, by evaluating you. A good Physical Therapist will ensure that your specific needs and goals are addressed in the program of rehabilitation. You should also receive education on how to limit stress on your injured joint to minimize pain.

If a joint replacement has to happen, work with a Physical Therapist before the surgery to get stronger and to understand what will happen after the surgery.

After total joint replacement surgery, why is Physical Therapy important to your recovery?

Your joint will function better with a good exercise program. Limited range of motion and strength after surgery can lead to pain and difficulty walking. The exact procedures your doctor has performed, should dictate the progression of strengthening and flexibility exercises. In order for healing to take place, you will have specific limitations placed on bending or putting weight on your leg.

Your Physical Therapist will design a regimen to restore flexibility and strength to your trunk, hip, and leg muscles. An important role is played by neuromuscular control in coordinating your leg muscles, so that you can balance. It is helpful to improve muscle movement and co-ordination by including balance training in any rehabilitation program. Your physical therapist should also help to limit the effects of post surgical scar tissue. Thus, limiting it's effects on your ability to move your limb due to muscle imbalances.

The Importance of Functional Rehabilitation Following Knee Injury

Injuries affecting the knee joint can cause considerable disability and time off sport. They are common in all sports that require twisting movements and sudden changes in direction. It is important to understand the role of the different ligaments and menisci in the knee joint in order to understand better the mechanisms of injury which will lead to form an appropriate rehabilitation programme. The knee injury of greatest concern to the athlete is the tear of the anterior cruciate ligament (ACL). The ACL is a tough fibrous structure that attaches the shin bone (tibia) to the thigh bone (femur). This ligament helps to stabilise the knee by preventing excessive forward movement of the tibia on the femur.

Clinical Features

Most ACL tears occur when the athlete is landing from a jump or when running, suddenly side-stepping or changing direction by decelerating. Occasionally, a tear will occur as a result of another player falling across the knee. It is often surprising to patients how a relatively simple movement can result in a torn ACL. At the time of the injury, the athlete may report hearing a "pop" and that it feels like the knee was being stretched apart. Most complete tears of the ACL are extremely painful, especially in the first few minutes after injury. Athletes are initially unable to continue their activity. Tear of the ACL is usually accompanied by the development of a haemarthrosis. This may be visible as a large tense swelling of the knee joint within a few hours of the injury. Examination of the knee is also very typical. There is often a loss of full extension of the knee and an inability of the athlete to weight-bear on the injured leg. Manual testing may reveal excessive forward movement of the tibia on the femur. Once the athlete is diagnosed with an ACL injury, they may undergo surgery to reconstruct the torn ligament, or rehabilitate the knee without surgery.

Functional Rehabilitation After ACL Reconstruction

Management principles have changed dramatically in recent years, resulting in greatly accelerated rehabilitation after ACL reconstruction. The traditional principle of complete immobilisation has been replaced with protected immobilization with a resultant dramatic decrease in stiffness and increase in range of motion of the knee joint. This has allowed earlier commencement of a strengthening programme and a rapid progression to functional exercises. Hence, the average time for rehabilitation after ACL reconstruction to return to sport has been reduced from 12 months to six to nine months.

Rehabilitation must commence from the time of injury, not from the time of surgery, which may be days or weeks later. The preoperative management aims to control swelling and restore full range of movement and adequate strength. Walking, swimming and the use of a bike is incorporated during this phase. The progression of the post-operative programme depends on the patient's determination, level of swelling and pain, and the progression of healing of the reconstructed ligament.

The second phase of the rehabilitation phase is to control swelling, regain full knee extension, improve quadriceps strength, hamstring length and increase proprioceptive input. Normal walking pattern can be achieved in this phase.

Phase 3 aims to achieve full range of movement of the knee, strength of the quadriceps and hamstring muscles, a full squat and the athlete may be able to return to straight line jogging and running. Some athletes progress rapidly in the post-operative phase, but full functional rehabilitation of the ACL may not occur until 6-12 months post-operatively. Functional testing should be used to help assess readiness to return to sport. Functional tests include agility tests, the standing vertical jump and the "Heidon" hop. The patient performs the heidon hop by jumping as far as possible using the uninjured leg, landing on the injured leg. Athletes with good function are able to land still. Those with functional disability step further or take another small hop. Another way of testing function is by incorporating sport-specific drills in the rehabilitation programme; for example, running forwards, sideways, backwards, sprinting, jumping, hopping, changing directions and then kicking.

Phase 4 of the rehabilitation programme includes high-level sport-specific strengthening as required and return to sport, progressing from restricted training to unrestricted training, and finally to match play. The therapist must be careful on the progression of the rehabilitation exercises and on the timetable for returning the athlete to their particular sport. An accelerated rehabilitation programme under a controlled environment allows the athlete to return to sport sooner without increasing the risk of complications.

ACL Surgery - How to Save Money on Your Anterior Cruciate Ligament Reconstruction

Need an ACL Reconstruction? Scared of what it might cost you? Looking for ways to save a few dollars?

If you have been diagnosed with a torn Anterior Cruciate Ligament and need to have ACL Surgery, you need to be prepared for what it will cost you. As part of your necessary preparation for an ACL Reconstruction, It is important to find out about all the costs well in advance.

Here are a number of ways that you can save money on your knee surgery and recovery journey:

1. Get Private Health Insurance - Make sure that you obtain the right level of insurance cover. You'll especially want to look for higher levels of cover from orthopaedics and physiotherapy. Check the waiting times as some health insurance plans require you to have had the insurance in place for a certain amount of time before you can make any claims. And of course, shop around for your health insurance.

2. Borrow An Exercise Bike - One of the primary muscle groups that you'll need to strengthen and exercise after an ACL Reconstruction is the quadricep muscle group. One of the most effective ways to do this is to ride an exercise bike. My Orthopaedic Surgeon told me that if I did nothing else, I should ride an exercise bike regularly. If you can borrow one instead of paying to use the one at the gym, you could save yourself a lot of money.

3. Buy a Theraband ($5 investment instead of $100's of dollars at the gym) - There are many different types of exercises to strengthen your leg muscles following ACL Surgery, but one of the cheapest ways is to buy a theraband (quite possibly from your physiotherapist) for your strengthening exercises, such as for your hamstring.

4. Explore Insurance Claim Options - You may be in a position where you are able to make a claim against the insurance policy of another party that is partly responsible for your injury. For example, if you tripped or twisted in a public place where there was a hazard that should not ordinarily be there such as a hole or broken path, you may find that the local council or owner of the property has some form of insurance policy against which you can make a claim. They may be able to pay for all of it or perhaps just a part of it.

5. Use a Referring GP that Bulk Bills - You may find that you need to see your General Practitioner (that is, your local family doctor) at various points throughout your ACL injury experience. Your visits to the GP will generally be for initial diagnosis, referrals to Orthopaedic specialists, referrals for X-rays or MRI scans, to diagnose subsequent side effects following surgery, and for prescriptions. The cost of visits to the doctor can add up if you don't use a GP that bulk bills.

6. Don't buy all the prescribed pain killers - After an ACL reconstruction, your surgeon will most likely give you three prescriptions:

1) Anti-inflammatory tablets
2) Mild Pain killers
3) Strong Pain killers

With the advancements in ACL Surgery in recent years, they have also been able to minimise the amount of pain experienced after the Anterior Cruciate Ligament Reconstruction. In most cases, you will only need the mild pain killers if any at all. You may find that you don't need any pain killers at all, however for peace of mind most patients would buy the mild pain killers just in case.

7. Do a big grocery shop BEFORE your ACL reconstruction (so that you don't spend on food orders and deliveries for the first 2 weeks) - For the first couple of weeks after your ACL Surgery, you might find it difficult to drive or walk to the shops and then to push a trolley around while you do your grocery shopping. If you do make it that far, then you have the challenge of carrying the shopping bags into your home, not to mention being against your physiotherapists advice of carrying weights. The alternative to this is paying for takeaway food or ordering deliveries. This can be an expensive alternative.

8. Use your physio's equipment (instead of the gym) - A big part of your ACL Recovery Program will involve strengthening muscles that support your knee and many people benefit from going to the gym. However, many Physiotherapists also have some gym equipment in their clinic. One way to save on expensive gym visits and memberships is to ask if your Physiotherapist would be happy for you to use the equipment at the clinic for your exercises during the first couple months. At $10-20 per gym visit, you could save yourself hundreds of dollars.

9. Pay for your surgery up front (and ask for a discount for doing so) - If you are able to pay a lump sum for your surgery up front, then you may be pleasantly surprised when you ask your orthopaedic doctor and the anaesthetist for a bit of a discount for paying up front or prior to surgery. The potential discounts can add up to a few hundred dollars.

10. Use your credit card to obtain rewards points - Now this suggestion is more about making your dollars work a bit harder for you. You will find some great benefits from getting a credit card that gives you reward points for every dollar you spend. With the thousands of dollars you spend and the number of rewards points you can accumulate, by the end of your recovery program you may be able to redeem your points for something special to treat yourself or even travel flights to take yourself on a well-earned holiday.

While the 10 ideas listed here are an excellent place to start, it is important to be fully informed of the costs that will face you as you go through the process of recovering from your ACL injury and getting back to your favourite sport. hobbies, and a normal way of life.

Alkaline Foods Provide Powerful Nutrition For Athletes - What Are They and Where Do You Get Them?

Alkaline foods may sound like something out of science fiction, but when choosing the most powerful nutrition for athletes they should be taken into consideration. If you envision a superhero with a big A on his chest for ALKALINE MAN, you are at least beginning to imagine that these all natural foods may provide a key to superior fitness.

When we refer to the alkaline forming or acid forming properties of foods, we are talking about what's left behind after your body burns them up for fuel. Depending on what you ate or drank or smoked, you end up with an alkaline or acid ash in your blood.

Anything that goes into your bloodstream affects your alkaline/acid balance, commonly referred to as your pH balance. There are several different ways to measure your pH, including urine and saliva tests, but we are talking about your blood pH when we refer to the benefits of alkaline foods.

In order to maintain proper pH balance, nutritionists suggest a balance of 80% alkaline foods and 20% acid forming foods. Most people have this 80/20 alkaline/acid ratio upside down. This can be a huge factor in fitness and should be thoroughly considered when seeking proper nutrition for athletes. When you consume too many acid-forming foods and not enough alkaline foods, you leave yourself susceptible to numerous challenges, including, but not limited to:

• Stiff joints


• Brittle bones


• Plaque buildup in arteries


• Plaque buildup on teeth


• Unhealthy gums


• Bad breath


• Lack of energy


• Poor digestion


• More, colds, allergies, and illnesses

Your body is so efficient that it will not allow your blood pH to stray far from 7.4. It will do whatever is necessary to alkalize the acid in your bloodstream, even if that means pulling calcium from your bones. The last thing anyone needs in their nutrition for athletes is something that causes a loss of calcium. Instead, the exact opposite is required, and is obtainable with the consumption of more alkaline foods.

When there is a lack of alkaline food in someone's diet to help manage that delicate blood pH balance, then the body has to pull calcium from bones in order to neutralize excess acid in the bloodstream. You can easily see how that could cause bone weakness, and again, that's the last thing you want in high quality nutrition for athletes.

Recently, I offered free nutrition coaching to some of my online health food store customers who are searching for the best nutrition for athletes. Here's how I responded to someone seeking natural remedies for arthritis symptoms:

"Thank you for your question about a healthy diet to get some relief for arthritis symptoms. Having had personal experience eliminating arthritic problems in my life let me share with you what has worked for me. Please understand I am not a medical professional and would never pretend to diagnose, treat, prevent or cure any diseases with my advice. In fact, I don't believe that natural remedies cure anything. I feel that if you give your body the right nutrients, it will take care of you beautifully for a long time.

Having said that, I will tell you what gave me some relief, but first, a little background: Most of the cartilage in my right knee was removed 28 years ago, so my right knee is basically bone on bone. Before I made dietary changes in my life a doctor told me I had the knee of a 72 year-old man, and shockingly, I was only 39 at the time. He said I would need a knee replacement in a few years. Well, it's been seven years and I just got back from a 3 hour, 20-mile mountain bike ride over grueling terrain in the Arizona desert, and my right knee feels as strong as my other knee, without any surgery or drugs. Other men my age can't understand how this is possible. I can only say the difference is that I understand the need for alkaline foods as part of a diet that provides the highest quality nutrition for athletes. All I did to make a change for the better was to eliminate many acid-forming foods from my diet and integrate more alkaline foods into my daily routine."

Once I became aware of the need for more of these all natural foods in my diet, I started to find more ways to get them. It's like what happens if you buy a blue car, suddenly you start to see blue cars everywhere. So, now that you are aware of this need for alkaline foods when searching for the highest quality nutrition for athletes, you will begin to notice them as well.

Cold Therapy for Post-Operative Rehabilitation and Pain Management

Cold therapy is a highly effective pain management and recovery accelerant for post-operative care. Cold therapy is particularly effective on post-operative knee joint rehabilitation. Best of all, it is a low-cost, high-efficiency, non-pharmaceutical rehabilitation tactic, making it an appropriate addition to just about every post-operative patient's rehabilitation strategy.

How does cool therapy work?
Cool therapy is effective in post-operative rehabilitation for a variety of reasons including:

• Decreases fluid buildup which is a significant contributor to post-operative swelling in the injured body part.


• Causes blood vessels to narrow, slowing blood flow to the injured part as well as the release of chemicals that cause pain and inflammation.


• Decreases pain by reducing the ability of the nerve endings to conduct impulses.


• Limits the muscle's ability to maintain contraction, thus reducing muscle spasm, which can be quite painful during post-operative recovery.

Both the US National Library of Medicine and National Institutes of Health recognize that cool therapy is particularly effective at alleviating pain. A German study applied continuous cold therapy with a cool therapy system in the post-operative treatment for knee ligament surgery. 80% of the knee joint patients reported no or low pain, whereas the control group noted considerable or violent pain. Likewise the study found that cool therapy lead to significantly lower swelling, which aided in quicker recovery.

For reasons such as these, cold therapy is frequently prescribed throughout the duration of post-operative rehabilitation. In many cases, cold therapy should be applied alongside compression as it can also aid in reducing swelling. In these instances it is important to select a therapy system that also provides a degree of compression. With the right cold therapy unit, cold can penetrate deep into the joint. In turn, the unit provides lasting pain relief throughout the recovery.

Why is motorized cool therapy better than traditional cold packs?
Cold packs are adequate for slight injuries, such as mildly sprains, but they are not appropriate for more significant injuries and post-operative care. An ice pack administers inconsistent temperature over a small space. Intense cold lasts for a short period of time, but the packs quickly warms against the skin, requiring multiple trips to the freezer.

A quality cold therapy system on the other hand, will deliver a motorized flow of consistent temperature through circulation pads that are specifically designed for different body parts and applications. This ensures that temperatures stay within the effective range, that the cold is applied to the correct area with the correct pressure so that it can penetrate deep into the joint, and the cold therapy session can occur for a longer period of time in accordance with the physician's prescribed treatment protocol. Depending on the type of unit you select, you should be able to administer anywhere between 6 and 11 hours of consistent cold therapy per ice change.

How to Prevent an ACL Injury

How To Prevent An ACL Injury

Athletes, both professional and amateur, are prone to numerous injuries during their careers. The body takes a beating while engaging in sports. Many of the injuries athletes sustain can be prevented, allowing the individual to avoid uncomfortable procedures and medical devices as well as keeping them 'in the game'. One of the most preventable injuries in sports today is an injury revolving around the ACL.

What is the ACL?

The ACL - anterior cruciate ligament - is a major ligament that is found in the knee. It is responsible for keeping the knee from moving too much, limiting the joint's range of motion and stabilizing leg movement. The ACL is attached to the front and top of the tibia and stretches diagonally up to attach to the back and bottom of the femur. People who complain of their knee 'giving out' or 'popping' usually have some form of ACL injury.

How does an ACL injury occur?

ACL injuries can occur during sports related activities as well as during regular day to day activities. Most of them are due to sports but the ACL can tear during a motor vehicle accident, a fall, a work related accident, rough play or during other activities that causes the knee to move in a direction it is not supposed to naturally go in. The majority of ACL injuries fall under the heading of 'non-contact' injuries. This means that the injury happens without another person being involved. For example, an athlete can turn on their foot the wrong way during a pivot or land improperly from a jump and tear the ACL. A good sign that the ACL is injured is the knee giving out from under the person when the ligament is torn.

A torn ACL that is due to non-contact usually occurs when there is a rapid deceleration of the body and the knee joint. If the body is not properly placed during a sport or physical activity, the ACL can be stressed and overloaded. When this happens, the ACL will tear. The knee is not stable and the pressure from the hips and ankles place it in a state of weakness. The muscles in the shins and thighs attempt to control the deceleration of the body and this causes the aforementioned stress and overload to the ACL.

How can you tell if you have an ACL tear?

A person can have ACL problems without a tear being present but if the ligament is not checked prolonged injury could ultimately cause a tear. A good sign that a person has an ACL injury is the popping of the knee or the knee simply giving out and causing the person to fall. ACL tears usually come with swelling and pain, but a minor injury may not be painful. Going to the doctor and having the knee tested for instability and other stressors are used to diagnose the problem. Additionally, an MRI of the knee may be ordered to verify the injury and possibly any other injuries that could be associated with an ACL tear.

What is done heal an ACL injury?

Depending on the severity of the ACL injury will determine what type of treatment may be used by the physician who diagnoses the tear in the ligament. People who suffer ACL tears that do not participate in sports or who are suffering from a partial ACL tear may be required to wear a special knee brace for a few weeks to allow the ligament to heal on its own. If the tear is severe and the person is an athlete who relies on the range of motion provided by the knee, reconstructive ACL surgery may be recommended.

It should be noted that many athletes who suffer from an ACL injury such as a tear may never regain total mobility in the ligament like they had prior to the injury. Therefore, it is better to work towards preventing ACL injuries than dealing with them after they occur.

How do you prevent an ACL injury?

It takes more than just strengthening the legs to prevent an ACL injury. Everything from weak hips to the internal rotation of the knee itself can add to an ACL injury. In order to prevent this injury, core body muscles, external hip rotators, the gluteus medius muscle, lower abs and obliques all must be stretched and strengthened in order to help prevent an ACL injury. Quadriceps and hamstrings should also be strengthened in an even ratio to help in ACL tear prevention, especially in women who are not as muscular as men. Finally, good calf and ankle muscles are also required as they help control knee deceleration and provide the body with stability.

Athletes should engage in coordination drills and training in order to learn how to properly move during sports activities. Cutting - the quick side to side movements seen in many sports - as well as landing must be done so that the center of gravity in the body is lowered and the knee flexes more. The torso should remain upright at all times if possible and where it is feasible, additional movement after the cut or land is encouraged as it helps with the deceleration process in the knee.

Finally, the proper footwear for the activity is required. Shoes are important in that they provide stability for the body. They should have a good drip on the playing surface and prevent the person from slipping.

Exercises to help prevent ACL injuries

About one month prior to any sports season starting, athletes should add stability strengthening exercises to their routine. Cross training with a stair climber or elliptical should be included in the cardiovascular routine to help the muscles warm up and stretch. Here are some strengthening exercises that can be included in the workout to help prevent painful ACL injuries. These exercises should be continued through and after the sports season.

Warm up

Because it is dangerous to stretch a cold muscle, warm ups should be done in order to prepare the body for the exercise and physical activity to follow. Warm ups should include:
o Line to line jog - slowly jog from one line or cone to another while keeping the hips, knees and ankles in a straight line. Knees should not cave in and the feet should not whip out to the sides while jogging.
o Side to side shuttle run - moving from side to side, the hips, knees and ankles remain in a straight line. The exercise should start in an athletic stance with the knees slightly bent. The participant pushes off with the back leg and sidesteps in one direction to a predetermined point and then reverses.
o Backward run - this warm up helps to prevent knee locking. The participant runs backwards from one line to another, landing on the toes lightly. The knees should remain bent at all times.

Stretches

Anyone who exercises should always stretch after warm up to limber up the muscles and ligaments in the body. Stretches allow the range of motion to be maintained and helps reduce joint stiffness, soreness after activity and injury. Never bounce or jerk the muscles during stretches. Instead, the stretch should be done to the point of tension in the muscle and held for 30 seconds. Breathing should be normal and the stretch should be muscle lengthening.
o Calf stretch - starting from a standing position, bend forward from the waist and lay the palms on the ground. The right knee should be bent slightly while the left leg remains straight with the heel of the foot on the ground. Hold for 30 seconds and then switch sides. This should be done two times for each leg.
o Quadricep stretch - this exercise is done with a partner. Lay the left hand on the partner's left shoulder and then grab the front of the right ankle with the right hand from behind. Bring the heel of the foot to the buttock with the knee pointing to the ground. The legs should remain close together and the knee should not go out to the side. Remain in an upright position and hold for 30 seconds before switching sides. This should be done two times for each leg.
o Hamstring stretch - sitting on the ground, stretch the right leg out in a straight line with the left leg bent and the left foot against the inside of the right thigh. Keeping the back straight, lean forward to touch the chest to the knee. If able, reach towards the toes and bring them back towards the head. Hold for 30 seconds and then switch sides. This should be done two times for each leg.
o Inner thigh stretch - while sitting, spread the legs apart and lower the upper body down while keeping the back straight. The muscles in the inner thigh will stretch. Sit up and reach over the right leg with the right arm while extending the left arm overhead to the right. Hold for 20 seconds and then switch sides. This should be done three times for each leg.

Strengthening

In order to build up stability in the knees and legs, strengthening exercises should follow the warm up and stretching exercises. It is important that the technique is followed closely and that the performance of the exercises is adhered to in order to get the proper results.
o Walking lunges - starting with the right leg, lunge forward keeping the front knee over the ankle. Push off with the right leg and lunge forward with the left, dropping the right knee down. The motion needs to be controlled with keep the knees from caving inwards. The toes should be visible on the leading leg. If they are not, the exercise is not being performed properly and the stance needs to be adjusted. This exercise should be done in three sets of 10 reps.
o Russian hamstring - with a partner, kneel on the ground with hands at the side while the partner holding the ankles. Lean forward from the hips with knees, hips and shoulders in a straight line and the back straight. Do not bend at the waist. The hamstrings in the thigh will be working. This exercise should be done in three sets of 10 reps.
o Single toe raise - standing with arms at sides, bend the left knee upwards and balance on one foot. Stretch the arms to the sides to help maintain balance and rise up on the toes of the right foot slowly. Hold and then lower. Repeat this exercise 30 times and then switch sides.

Plyometrics

Plyometric exercises are designed to help build up the power, speed and strength of the body. The key to performing these exercises properly is to remember to land softly when jumping. Always land with the weight on the ball of the feet and then distributing it back to the heel with the knees bent and the hips straight. It is important that the technique is followed closely and that the performance of the exercises is adhered to in order to get the proper results.
o Lateral hop over a cone - using a 6 inch high cone to the left of the body, hop sideways over the cone landing on the balls of the feet with the knees bent. Straighten the knee slowly. Hop back to the right to complete a rep. Do this exercise for 20 reps.
o Forward and backward hop over a cone - using the same 6 inch high cone, hope over the cone forwards landing on the balls of the feel with the knees bent. Straighten the knee slowly. Hop backwards over the cone to complete a rep. Do this exercise for 20 reps.
o Single leg hop over a cone - using the same technique found in the forward and backward hop over a cone, start with the right leg and complete a forward and backward hop for one rep. Do this exercise for 20 reps, switch legs and repeat.
o Single leg vertical jump with headers - stand straight with arms at side and knees slightly bent. Push off with the right foot and jump straight up, landing on the ball of the foot with the knee slightly bent. Do this exercise for 20 reps, switch legs and repeat.
o Scissors jump - using the same knee over ankle technique in the walking lunge, lunge forward with the right leg. Push off with the right foot and bring the left leg forward into a lunge position, maintain the knee and not allowing it to cave in or out. Land on the balls of the feet. Do this exercise for 20 reps.

Agilities

Agilities will help build up the range of motion in the ankle, knee and hip combination, allowing the participant to move more smoothly during exercise and physical activity. This will help stabilize the ACL and keep it flexible.
o Shuttle run forward and backward - using as many cones as desired, sprint from the starting line to the first cone and stop. Sprint to the next cone and stop. Continue this to the end and then reverse running backwards.
o Diagonal run - set the cones in a zigzag formation. Start at the line and run to the first cone to the left, pivot on the left foot, and run to the next cone on the right. Pivot off the right foot and run to the third cone. Continue to the end keeping the knee slightly bent and over the ankle. Repeat 3 times.
o Bounding run - run from one line to the other bringing the knees up high towards the chest. Land on the balls of the feet with the knees slightly bent and the hips straight.

Cool Down

The cooling down phase of any exercise routine or physical activity is important and should never be skipped. There should always be water at hand through this phase and it should take about 10 minutes. Jog slowly until the heart rate comes down and then stretch the hamstrings, calves, inner thighs, quadriceps and lower back with the exercises listed above and the following exercises.
o Alternate hip flex bridging - while lying on the ground, bend the knees and place the feet flat. Raise the buttocks off of the ground and squeeze, holding this as the right foot is lifted off the ground. Do not allow the hip to dip towards the ground. Lower the right foot and repeat the motion with the left foot. Repeat 30 times for each side.
o Abdominal crunches - while lying on the ground, bend the knees and place the feet flat. Lace the fingers behind the head with the elbows out. Breathe in and contract the abdominal muscles while exhaling. Do this 30 times. Drop the legs to the right to the ground and repeat the crunching of the muscles to work the obliques. Repeat 30 times and then switch sides.
o Knee to chest - while lying on the ground, bend the knees and place the feet flat. Bring the right knee into the chest while extending the left leg to the ground. Hug the right knee for 30 seconds, feeling the muscles of the lower back and buttocks stretching. Switch sides and then bring both knees to the chest. Repeat all three motions as a rep and do two times. If there is any pain in the lower back, discontinue the stretch.
o Figure four piriformis stretch - while lying on the ground, bend the knees and place the feet flat. Place the left ankle over the right knee. Holding this position, take hold of the right thigh and pull the right knee into the chest. Hold for 30 seconds and switch sides. This will stretch the gluteals and the sides of the thighs. Repeat the two motions as a rep and do two times. If there is any pain in the lower back, discontinue the stretch.
o Seated butterfly stretch - while sitting, bring the feet into the body so that the soles are touching. Place the elbows on the knees and slowly push the knees down to the ground. This stretches the inner thigh. Hold for 30 seconds and repeat two to three times.