I'm Dr. Karen Sutton, and I'm ready for Shark Tank. I played lacrosse at Duke University and found a huge problem with cleats when I played. So we had to have three to four different shoes in our bag all the time when we went to the field. Otherwise, we had to run laps. We had our turf shoes, we had our cleat shoes, we had our regular shoes in case we went inside. We had our running shoes in case we were punished and had to run around, you know, the golf course that we had to run around that, sometimes three miles. So we found a huge problem in lacrosse in looking at some of the cleat surface interface. So I'd like to start with that. As well as my background, to get a little bit more serious, is as an orthopedic surgeon at Hospital for Special Surgery. In sports medicine, I'm an associate professor there. The chief medical officer for World Lacrosse. I'm the head team physician for US Lacrosse, as well as team physician for US Ski and Snowboard. The significance of this study is we all know that non-contact lower extremity injury is a problem. The current epidemiology and biomechanics evidence has limited scope, predominantly in American football and soccer, and is inconclusive. Playing surface is found not to affect football knee injury rates, but synthetic surfaces affect football injury rates and not soccer. Those are in two different studies. However, when you look at some of the NFL database, they do recommend different cleats and different shoes for different surfaces. There's not a lot of evidence to back that, but you can see on their website they recommend specific shoes for different surfaces. Limited data exists for both male and female lacrosse players, and upper and lower extremity injury profiles unique. There are increasing injury rates during the second and fourth quarter of play. We published this data recently from World Lacrosse. I started an injury surveillance system for all of our World Lacrosse events, and noticed those aspects of the injury. Shoe design and the foot should be targeted. Overall natural and artificial grass injury rates are similar, but evidence suggests a combination of cleat and artificial surface. Foot type, foot function, shoe design play a role during cutting. We know that shoe surface interaction contributes to injury risk, but simplistic friction tests are not realistic. We need to consider the dynamic interaction of the shoe and the surface. Efforts to redesign the shoes are left to manufacturers and marketing, but safety should be a shoe design criterion, and the potential to change approach to shoe design is huge. One aspect in lacrosse specifically is it's really based on football cleats as well as soccer cleats. There are a few various types of cleats that are specific to lacrosse, but I think we're still novel in the development of our shoes for lacrosse. Innovation. We need data, building a normative lacrosse data set, and lacrosse has fundamentally different mechanics than other sports, and therefore we need to collect standards. A couple of the differences, it has a lot of pivoting and cutting compared to football, however compared to soccer, it doesn't need that touch of the foot when you need it with soccer. Looking at joint kinematics and EMG, and then focusing on the foot. The foot is a complicated and active structure rather than passive, therefore we must collect and examine what the shoe does. Looking at in vivo torsional and translational friction, clinical foot structure, as well as shoe motion, deformation characteristics. One example is as I was covering U.S. lacrosse a couple years ago when we were sponsored by Under Armour, we're sponsored by Nike now, but actually part of that cleat, the outer surface which has the cleats on it, actually melted on the temperature level of the cleats, and the bottom of the cleat would just come off. So again, there are significant problems with the cleats as we're designing them for lacrosse specifically. This is looking at, we started running just the initial data in our motion capture lab at HSS and looking at the turf shoe, and we'll see some data later in terms of the knee kinematics and ankle kinematics versus the cleat shoe. Here you can see the cleat shoe certainly grips more, and so the foot and ankle are a little bit more stable, however the torque on the knee is different with those. The other significance of lacrosse too is there's really not a standard in FIFA as well as some other sports. There is a standard turf that everybody uses. In lacrosse there's not specifically a standard, so you can go from grass, which is completely just a field, it could be a farm field that some of these players are playing on, and so there's divots and potholes that could be wet, it could be dry. There's surface that is that nice thicker turf that a lot of the football fields are on, and then there's still surfaces where they're playing on astroturf. Also in lacrosse there's box lacrosse and indoor lacrosse, and then sometimes they play on concrete surfaces, and sometimes they play on, again, just that old school astroturf. The approach in recruitment, we have access to New York and tri-state college teams. Our aim is to recruit 60 collegiate athletes, 30 male, 30 female, and then healthy, no prior ACL injury requiring surgery. These are some of the teams we work with, so I cover U.S. lacrosse, and then some of the coaches with U.S. lacrosse, some of the players with U.S. lacrosse cover these teams as well. We do have a relationship with HSS and Army West Point. Shoe condition, we've chosen three shoes to represent the low to high friction spectrum. Nike tends to be a very utilized shoe. You can also look at New Balance and Under Armour as well, but we wanted a difference between the Nike Huracha turf, the Finisher turf, as well as the Pro, basically increasing that grip. So you can see for shoe A that that would be typically used to play on more of an astroturf surface. Cleat B, as you're getting to a little bit better turf. Also when you look at midfielders versus attack versus defenders, the midfielders are certainly running goal to goal a lot, but the attackers and the defenders need a little bit more pivoting cutting as they're playing down a little bit in the low aspect, so sometimes I'll recommend Cleat B for some of the midfielders, even if they're playing on a larger grass turf surface versus Cleat C. Sometimes I'll recommend for the defenders and attackers who have to do a little bit more aggressive pivoting and cutting. The environment, we already have this set up. It's a 14-karama motion capture system in our gate lab, four configurable force plates, wireless EMG, three functional COD drills, so we're looking at, I'll show this in a little bit more detail, but pizza cutting, split dodge, as well as shuttle runs we're going to be doing in the lab. These are looking at some of the different formations, so A, you're looking at basically diagonal cutting, so at the different boxes, the athletes will be pivoting on those boxes, and then we have various force plates set up where they will be planting. They'll go through this a couple times until they feel comfortable really planting their foot in different surfaces. Then the second drill is looking at more of an acceleration, deceleration, as well as a split dodge, so B starts out as a split dodge where they have to accelerate to the force plate and then either pivot left or pivot right, just as their equivalent of dodging a defender. The study design, we propose an experimental repeated measures study to examine within subject effect of shoe design on cutting, looking at the female and male lacrosse athletes, and then testing turf one, turf two, and cleat, and then looking at pizza, split dodge, and shuttle. They'll go through all of these different surfaces, and then we've ordered different surfaces for these athletes to run on as well. It'll be different surfaces of AstroTurf going from short to longer length. The motion variables, this is Kristen, she's our research assistant. She played goalie in lacrosse, and then we're looking at 3D biomechanical metrics, standard knee joint variables, as well as abduction angle and abduction torque. We did talk to Tim Hewitt about just setting this up as well. He's done a lot of studies in this in terms of looking at the at-risk angles for ACL injuries, so we wanted to coordinate with him in terms of setting up the 3D biomechanical metrics. This is looking at the turf, which is the white knee. As you could see on that earlier video, in the cleat, the foot and ankle tended to stand still a little bit more and looked very stable. However, when you look at the cleat, as we looked at going through those drills, you can see the knee is in a little bit more of that abduction angle compared to when you look at the turf shoe. These are some of the data sets that Dr. Andrew ran in our lab. The 3D biomechanical metrics, looking at standard knee joint variables, shoe surface friction mechanics, the angle of attack, the shoe twist, flexion, derived variables, as well as stiffness. We'll look at foot structure as well. Clinical foot structure is a novel addition, obviously, so Kristen does a lot of research with our foot and ankle team, and so we incorporated them to look at the clinical foot structure. Sitting and standing arch height measurements with in-house tools. Clinical foot type would be determined from arch height and index, arch height flexibility. On the road, potentially, it may be worth, one, designing customized cleats for different feet, as well as potentially designing lacrosse-specific orthotics that these athletes can use. Our preliminary work, we have pilot internal seed funding from HSS. We did get the Surgeon-in-Chief grant from HSS, so they fully support this study as well, and then covers equipment and a small cohort of players. However, we would like to increase that cohort of players, as we mentioned earlier, and then the study from HSS, at this point, doesn't cover the wireless EMG, so we wanted to work with the wireless EMG and potentially get this to be a little bit more portable. What can't be portable right now are the foot plates, so that's the force plates, which is why we're doing this right now in our gait lab, but the goal later on would be to bring them to, for example, US Lacrosse and do studies down there. The study will provide important kinematic and kinetic data points to drive other investigators looking at in vivo, as I mentioned, outdoor studies and fatigue. As I mentioned earlier, so in our studies with world lacrosse, looking at injury rates at the second and fourth quarters, so men have second and fourth quarters in their games, there were definitely a higher injury rate in those quarters, so potentially fatigue may be a factor as well. In vitro robotics for enterative shoe design testing, Andrew actually started working on custom cleat design and has some specifics. He has some prototypes for his cleat design that he's using, and then in silico testing with neuromuscular skeletal models. I would like to acknowledge Kristen Caiolo, who's with our HSS foot and ankle service and then is working with us on the sports service for this study. Andrew Kaczewski, who is a PhD in our Lee and Root MD in motion analysis lab, and this is what he does on a regular basis, and then he's working with us on this study, and again, we did get the HSS Surgeon-in-Chief Research Fund for this. These are our references. These are my teams that I work with. I'm hoping to utilize this study to work with my team on the lower left. They're very high demand, and then I work with the indoor box lacrosse team as the Chief Medical Officer for World Lacrosse. I'm also involved with the U.S. ski and snowboard team. So thank you, and I'm ready for questions. However, I will say I would like to end this with an arm wrestling match, so I think it should be all done based on arm wrestling at the end. So they said they were all up for that challenge, too. All right. Thanks, Karen. So this is an interesting area, and I think an area that is evolving. I think the shoe surface interface and its impact on lower extremity injury all the way up to the ACL and perhaps even the hip is an evolving area and an area with a lot of opportunity. I think a couple of things that I have both specifically and then how to make this broadly, I think what's particularly innovative is with yours compared to some of the work that's done is maybe lacrosse to some extent, but I think less important is the sport. More important is the inclusion of males and females, which has some broad applicability. So I think those are good additions to what's going on. I would be interested in a couple of things about what you're looking at. So you have the ability to measure the friction issue between the shoe and the surface. Is that? Yes. Through the force plate, we can do that. Yes. And then through the surface. He's putting different sensors on the surface, too. Okay. Yeah. So I think that is probably one of the most important things to make sure that you get. Okay. I think... I'm just taking notes. Yeah. No. And I think there's a couple other things. Based on what you presented, this is mostly planned anticipated cutting. That's correct. And where it's particularly, I think, important is the unanticipated cutting. That, if you look at a lot of the studies, it's not the anticipated cut, it's the unanticipated cut. We've done a lot of stuff with the NFL. You know, it's punt plays where guys have to make a last minute adjustment. And I think probably that's similar. And I know Hewitt has done some of the work on this. You probably want to look at one of these where you use like a beep test or something to do an unanticipated cut rather than a planned cut. Now, your planned cut could be a way to get initial data. But I think for sure, at some point, you have to do the unanticipated cut to really kind of get at that issue, right? You know, it's one thing doing a shuttle run. It's another thing in the middle of the game having to adjust to a perturbation. So I would include that in terms of what you're thinking about. I will say with US Lacrosse, we have worked on... They are wearing wearables at times, so they are not opposed to doing wearables. And so we could do that. There's a lot of men and women lacrosse events down at headquarters. And so with the potential of having an EMG that we can bring down there, that's going to be something that we've thought of too. Well, I would emphasize the surface shoe interaction and the alignment. The EMG is probably third order. It's helpful. It's interesting. But in some ways, I think more important to look at what happens to the kinetics vis-a-vis to what's happening between the shoe and the surface, because that's where we've got to learn a lot. I mean, the EMG is useful, but don't invest all your resources in that. Make sure you have the markers, right? Yes. And then for the... We do have the markers. And then for the beep test, would you do that in the lab, you're saying? So just do that in the lab. There's ways of saying, right? So if it's green, go left. If it's red, go right. You know what I mean? It's the idea of having... We could do that with that cutting, like that end cutting. You could have something where if a beep goes off, you have to reverse your direction. You know what I mean? The idea is you have to have something where it's one thing when the athlete knows what they're doing. It's another thing when they have to adjust. I think that'd be interesting. The other thing I would think about, right? So the challenge with this is the athletes love to have great grip, right? So they want to feel very secure and stable. So I think when you look at the different shoes and the different surfaces, you probably want to have some way of rating or talking with the athletes about how they felt in the shoe, right? Because no matter what you tell them, if they feel better in a shoe, the hell with the doctor. So you might want to collect that because that would be interesting and see how their perception relates to your data and all of that. Because the athletes probably, soccer players want the shoe tight as hell, but everybody wants a shoe that grips really well with the ground, right? So I think that's an issue that goes into it. But I think there definitely is a lot of potential in this. There's a lot of interest in this area for a number of different angles. And that's what I would emphasize too. I would emphasize that this has applicability across sports. And I think that the novel aspect is more including men and women. Yeah. I mean, lacrosse is a little bit, but I think that's more third order. Right. But I think there's a lot of potential there. Yeah. I was actually talking to a couple of the MLB doctors and MLB bought over the minor league team and they changed all their surfaces in the outfield to a specific turf surface now. And now they're seeing a lot of, like they just saw a PCL injury in an athlete, like they're seeing a lot of issues with that. So they thought it was interesting because that whole surface interface hasn't really been studied. And they're obviously looking at a lot of shoulder injuries in baseball players, but now they're seeing these issues now that the turf has been changed and standardized. It is interesting. It's working perfect. Karen, this is awesome. As you know, in Charlottesville, we love lacrosse also. Yes. We have some decent teams. I was curious for- You guys beat us in the final four. Yeah, we like to win. So I was curious, at least in the lab setting, I know you talked about kind of translating this outside, but this is really specifically looking at the cleat as a variable, not really the surface as a variable, but we play a lot of our games outside as do a lot of the younger leagues. Is there a way in the lab where you could at least vary the surfaces somewhat of longer grass or shorter grass or mimic what lacrosse players see outside? If the interface is really important, I agree with that. How do you translate the information from this for lacrosse players who play on a natural grass surface? We are going to be ordering different types of turf and then grass. And then we're hoping to do this in big lumps of people. So then we are actually hoping to order just rolls of grass as well that we can put out there just because we don't have to keep it for long periods of time. So the goal would be to have just natural grass as part of what we're playing on too, but we just have to, the timing of it has to be better. So I can talk to Andrew about that and just make sure that that's completely included in the study too. The other thing to build on that you could think about, but you may have to have some equipoise with this, is adding a wet surface as well as a dry surface would be very interesting, although there's probably some risk with that. So think long and hard about that. Yes. But there is some data on that in terms of risk and how it relates to surfaces. So that would be interesting. Karen, I thought that was a great presentation. Unfortunately at Mizzou, we don't have lacrosse. So I had a couple of questions. I can demonstrate some stuff if you want. How big of a market share is lacrosse just from a sport standpoint do you anticipate in terms of the impact? So it's actually one of the fastest growing sports in the US. It's pretty much when we're recruiting for colleges, they're in Texas, Colorado, California. The newer teams now, it's pretty much all over the country. But it's one of the, if not the fastest growing sport in the United States. And then my second question was just, you have six cleats listed on those. How stable are the cleat patterns in terms of shoe design? Because I would imagine if it's one of those things that manufacturers continue to change, that the findings may have to be basically redone depending on how they evolve shoes. Those Nike cleat designs, especially the second and third, are very similar to what I played with in college as well. That second one hasn't really changed much in years. The third one has changed from originally the men were using almost those Nike Shark football cleats when I was playing. So that's evolved somewhat. But I would say the evolution of that cleat has remained fairly stable. So Karen, I thought this was a great presentation and really interesting idea. And I think including the foot shape was an innovative aspect of it. But I think one challenge I would see would be how to analyze it and how to, with 60 subjects, if you have these five to six different foot measurements along with the three different cleats, three different cutting patterns. What would your plan for including the foot measurements be? The foot measurements, I think if we saw extremes of deviation of the foot, I think what he's really looking at is pronation and supination of the foot. I think that's going to be the biggest one. So he's going to sector out just those outliers of the two and just look at confounding variables with that. If we don't have extreme outliers, obviously it's not going to make a difference. But if the athletes, especially as they get to college level, you do start to see more variability in the foot compared to the high schoolers. And so it's just going to be part of the confounding variables when we go through the study. So this was an excellent presentation and discussion. I think, unfortunately, we don't have time to go into overtime. So thank you. Great job. And we will move on to Jonathan Rebo.

cleats in lacrosse

different shoes for different surfaces

non-contact lower extremity injuries

interface between shoe and surface

effect of shoe design on cutting movements

biomechanical data in lacrosse