Monday, August 13, 2018

Preventing Runner's Knee

In the U.S. there are more than 40M runners and it is a sport that continues to see tremendous growth.  Besides the recreational, fitness and competitive aspects, it is also a part of almost every major sport.  As such, this also becomes a medium or training method often employed in preparation for an athlete's main sport participation or pre-season training.  As such, keeping the athlete injury free during running is important for not only their psychological well being but also their physical well being.  According to McKean et al Clin J Sport Med 2006, 46% of runners report some running related injury in the last year.  With such a high percentage reporting a running related injury, what we can do to prevent?  First, we must look at the scope of the problem.

Did you know:

  • More than 75 percent of runners experience at least one overuse injury during training (Egermann et al. Int J Sport Med 2003).  T
  • The majority of running injuries, more than 90 percent, occur in the lower kinetic chain (Cipriani et al J Ortho Sport Phy Ther 1998)
  • In runners, the knee is the most injured body part (Van Gent et al Br J Sports Med 2007). 
  • 49% of runners report an injury in just the last year of training (Hauret et al Am J Sports Med 2016) 
  • The risk for these injuries increases as runners increase their training mileage (Burns et al. J Orth Sport Phy Ther 2003). 
  • The majority of all running injuries are non-contact in orientation (no traumatic impact, fall or collision) and are considered preventable (Hauret et al Am J Sport Med 2016).
We know from the research that non-contact injuries can result from predictable movement patterns or altered biomechanics.  Altered biomechanics (valgus collapse) have been shown to cause knee injuries (Hewett et al Am J Sport Med 2017) that are often associated with running. These same movement patterns are associated with all non-contact lower limb injuries often seen in runners, including trochanteric bursitis, patellofemoral pain, iliotibial band friction syndrome (ITBFS) and plantar fasciitis.  In addition, the same movements associated with risk are the same movement patterns that add to decreases in speed and running economy (Myers et al J Strength Cond Res 2005). Studies have shown a correlation between these altered biomechanics and impacts on running gait and injury risk. Asymmetrical hip strength has been shown to add to decreased hip extension at toe-off, increased adduction (knocking knees) and pronation at midstance as well as increased risk for ITBFS (Noehren et al J Ortho Sport Phy 2014).

With knee injuries injuries being so common among runners, this has led to a catch all diagnosis category called "Runner's Knee".  So what is runner's knee and what can we do to prevent it.  Recently I was asked to contribute to a running article on runners knee.  As such, this spawned me to take a deeper dive in this series to really look at this in depth and see what we can do from a prevention standpoint.

What are some ways regular runners can prevent runners knee?

No matter how you define runners knee (patellar tendonitis, IT band friction syndrome, patellafemoral pain syndrome, etc), what the research shows us is that >80% of these are non-contact in orientation.  As such, there is usually a root cause or something else that is leading to the “runner’s knee”.  Therefore to address what we can do to prevent, we first have to look at some common “root” causes of runner’s knee.  Keeping in mind this is not an exhaustive list, it includes only some of the most common “root” causes.

  • Shoes – poor shoes or being fit with the wrong shoe can significantly alter force attenuation (how force is absorbed by your body) during running.  Absorbing shock (or force) is vital to preventing shin splints, lower extremity injuries and runner’s knee. Several problems with shoes can add to your problem.  Some common issues include; damp shoes, worn out shoes, wrong kind of shoe.
    • Damp Shoes - One thing that can add to a decrease in shock absorption is damp shoes.  With increase in dampness of the shoe comes less shock absorption which can add to increase stress to the foot/ankle and knee.  We often suggest having two pairs of running shoes so that you can dry one out while alternating to another pair of shoes.  So, let them dry out!
    • Worn out shoes - Another problem we see with shoes is runners will use the same pair for a year or two.  With time and increase in mileage, the shoes begin to wear down and they lose some of their elastic properties which results in less shock absorption.  This means that more of the ground reaction force at heal strike and midstance is absorbed at the foot and ankle and then at the knee.  Running shoe manufactures vary on their recommendations but most will tell you that you should replace your running shoes anywhere from every 300 to 500 miles.  The more miles you put on the shoe, the less elastic recoil the shoe has which can add to increase in potential for overuse injury.  So, replace worn out shoes!
    • Wrong Shoe - Finally, another issue that we see with shoes is being fit with the wrong
      shoe.  We will often see athletes that are told they pronate or supinate and then are put in a shoe to control for that.  All too often, we will see runner put in a shoe that is supposed to control that when in fact the pronation or supination that occurs does not in fact necessitate a shoe to control.  So, you have a runner who has been running comfortably with over pronation, but not pathological pronation, and you suddenly change that.  But, you are not only changing that at the foot but the entire lower kinetic chain mechanics are then changed.  What we typically do when we assist a runner in choosing a shoe, we typically do a running assessment.  Using a 3D wearable sensor (DorsaVi), we can have the athlete run in three different types of shoes.  This system will provide us with biomechanical data for right and left IPA (initial peak acceleration – how well you control the foot into the ground), right and left ground reaction force at midstance and stance time on the right and left.  This allows us to directly see how well they are controlling the forces through the lower limb and which shoe provides them with the optimal performance and force attenuation.  So, make sure you are picking the right shoe!  It is the first contact point in the kinetic chain.

We hope you enjoyed this discussion and as we continue next week we will start to look at faulty running mechanics and how this can add to runners knee.  If you would like to find out more about how to get a 3D running assessment near you, contact us @ acl@selectmedical.com.  Stay tuned and please share with others you think might be interested.  #ViPerformAMI #DorsaVi #RunSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent is also a competitive athlete in Brazilian Jiu Jitsu. 

Monday, August 6, 2018

Psychological Measures for Return to Play Following ACLR - Part VI

Over the last couple of weeks we have been discussing kinesiophobia (fear of movement) and how if high levels of this are present on return to play that athletes are at greater risk for reinjury.  We also discussed some movement patterns that we see in our athletes that is also highly associated with kinesiophobia.  Specifically those with a lateral shift and increased frontal plane motion and speed of motion during single limb testing tend to have higher levels of kinesiophobia.  During the last 2 weeks, we discussed some training techniques we can employ that will help to reduce these abnormal movement patterns and aid in reducing kinesiophobia.

Although the majority of our discussion has been around the Tampa Scale for Kinesiophobia as a way of measuring fear with return to play, there is another measure out there called the ACL-RSI.  Webster et al Am J Sport Med 18 did a study to look at generating and validating a short version of the original ACL-RSI scale.  The original ACL-RSI (pictured below) was developed in 2008 and is a 12 item scale that measures 3 types of response believed to be associated with risk of injury: emotions, confidence in performance and risk appraisal. 




















The short version is a 6 item version that also measures these same three types of responses (it is available as an app).  In this study the authors administered both versions of the ACL-RSI to 535 athletes who had undergone ACLR at 6 months post op.  The predictive validity for return to play at 12 months following ACLR was determined and compared.  The results showed that the short version had a fair to good predictive ability for 12 month return to sport outcomes.  This is great for those of us in a busy athletic or clinical setting as this will help cut down on some time. 

So when it comes to emotions, confidence in performance and risk appraisal what really matters?  That is what Webster et al Am J Sport Med 2018, sought to identify.  In this study, the authors looked at factors that contribute to an athlete's psychological readiness to return to sport following ACLR.

Methods:
635 athletes (389 male, 246 female) who underwent an ACLR and were cleared to return to play filled out the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) questionnaire. In this study the authors captured demographic information (age, sex), sporting outcomes (preinjury frequency of participation), surgical timing (injury to surgery interval), clinical factors (ligament laxity), functional measures (single limb hop symmetry) and symptoms of pain and function (measured via IKDC).  Statistical models were applied to determine association with the above measures and the athletes psychological readiness for return to play.

Results:
After univariate analysis for the entire group, the following factors were found to have a positive impact on psychological readiness.

  • Male sex
  • Younger age
  • Shorter injury to surgery interval
  • Higher frequency of sport participation 
  • Greater limb symmetry 
  • Higher subjective knee scores
Further analysis of the data revealed that subjective knee scores and age accounted for 37% of the variance in psychological readiness.  

Conclusion/Discussion:  

Self reported symptoms and function was one of the largest influences on psychological readiness.  Knowing this, this should guide us a lot on how we approach the ACLR athlete.  If you look in depth at the IKDC, what you see is where we need to apply some focus. 

  • Pain and swelling - the first 6 questions of the IKDC is focused on pain and swelling.  Although inflammation and pain control are a normal part of what we do, we need to be very aggressive in this and managing this early in the rehab process.  The longer this goes on the more of a psychological impact it will have and the more likely we are to see this reflected on the IKDC.
  • Confidence in limb - the next 4 questions are related to functional ability in functional activities.  Controlling pain early in the rehab process and combining with early initiation of functional activity (gait without a limp, ascending/descending stairs, squatting motion through functional range of motion with symmetry) progressed to functional single limb activities (single leg hop, lateral hops, diagonal hops) will help improve confidence.
In addition to the above, all to often in PT, we are afraid to push the athlete.  Current standard of care is there is a big gap between PT and performance.  Clinically, we need to close the gap.  As long as we keep within the parameters of physiological healing process, within the physician's protocol and mindful of the athlete's technique and biomechanics, we could AND SHOULD push the athlete to the next level.  Doing so will help them build confidence, will help them see their capability with functional activities and improve chances for a safe and full return to performance.  


We hope you enjoyed this series.  Next week we will start a series on addressing runners knee in runners.  Stay tuned and please share with others you think might be interested.  #ViPerformAMI #ACLPlayItSafe



Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent is also a competitive athlete in Brazilian Jiu Jitsu. 

Monday, July 30, 2018

Psychological Measures for Return to Play Following ACLR - Part V

Last week we discussed the correlation of kinesiophobia (fear of movement) to shift of weight over to the non-involved limb.  Noehren et al Am J Sports Med 2018 highlighted this in a recent study that showed how athletes unload the involved limb during bilateral jumping tasks.  As stated in our previous blog, we discussed how we see a similar pattern (lateral shift) during a regular squatting motion.  This was followed by a focused discussion on how we can correct this lateral shift and in how doing this aids in reducing kinesiophobia.

Another common movement pattern we see in athletes with higher levels of kinesiophobia is a lack of stability in single limb performance.  Although we start to see this present itself in single leg squats, we it become more pronounced as we increase the physical demands with the single limb testing (as depicted here).  How we test this is with the following sequence:


  • Single leg squat - during this test, the athlete performs a single leg squat with the contralateral leg in the athletic position (slight hip extension with knee flexion).  The athlete is not allowed to touch the contralateral leg down at any time during the test.  The athlete performs 10 reps to ~30-40 degrees of knee flexion.  For each rep, frontal plane motion (varus to valgus), the speed at which valgus occurs and tibial inclination (in direct measure of dorsiflexion).
  • Single leg hop - during this test, the athlete performs a single leg hop with the contralateral leg in the athletic position (slight hip extension with knee flexion).  The athlete is not allowed to touch the contralateral leg down at any time during the test.  The athlete performs 10 explosive hops.  For each rep, frontal plane motion (varus to valgus), the speed at which valgus occurs and tibial inclination (in direct measure of dorsiflexion).
  • Single leg hop plant - during this test, the athlete performs a hop plant with the contralateral leg in the athletic position (slight hip extension with knee flexion).  The athlete hops in the following sequence, hop anterior, hop posterior, hop lateral and hop medial.  The athlete is not allowed to touch the contralateral leg down at any time during the test.  The athlete performs 2 bouts which equates to 8 reps total.  For each rep, frontal plane motion (varus to valgus), the speed at which valgus occurs and tibial inclination (in direct measure of dorsiflexion).
All of these tests are performed on the right leg first in succession then on the left leg.  Keeping in mind, this is only a portion of the test and doing in this fashion allows for a build up of fatigue in the limb.  At the same time, with multiple repetitions, the athlete stops thinking about controlling their knee motion and more about just being able to complete the task.  What we find is that this helps us get a truer picture of their natural motion versus what they think we want them to look like.  

During each test, the data is captured via a 3D wearable sensor that uses a gyrometer, magnitometer and accelrometer that captures this motion at greater then 200 frames per second.  This provides a very accurate measure of motion during increasingly difficult tasks.  

Single limb stability is challenged in the single leg squat and the single leg hop.  However, with the hop plant, the athlete has to actively move through several planes of motion.  Doing this creates a significant challenge to single limb stability.  As the athlete jumps (for example medial), their center of mass is moving medially and the athlete must land on the limb and prevent the knee from moving in that same direction.  Although this may appear excessive, this is nothing close to the demands required during athletic participation.  The video clip below shows the sequence of the single limb testing.



One trend that we tend to see with the single limb testing is that athletes who report higher levels of kinesiophobia on the TSK have greater frontal plane motion during single limb testing and higher speeds of valgus during testing.  Knowing this, it would make sense that if we improved an athletes stability in single limb performance that this would impact their fear of movement and reduce scores on their TSK.  And that is exactly what we see.  So, how do we do that.

There are a lot of ways to help create single limb stability.  What we have found is there are several links in the chain that add to increased frontal plane motion and increased speed of motion.  These are the:
  • Core
  • Hip
  • Foot/Ankle
Doing single limb training that will include proprioception, strengthening and endurance is a given, however we have found doing a progression that goes from:
  • Simple to complex
  • Stable to unstable
  • Single plane to multiple plane
  • Isolated to CKC to plyometric 
Let's give a couple of examples.  Keep in mind with ALL of these exercises, the athlete MUST not allow their knee to go into a dynamic valgus position.  If this is not controlled, you are simply training their poor movement patterns.

Single leg isometrics - this is a great starting point.  In this exercise the athlete places their leg against a stable surface (wall) and pushes into the wall.  This is typically done for 10-20 reps and done bilateral.  Although the force is generated in the leg pushing against the wall, the contralateral limb must also provide a lot of stability during the single leg stance.  It is important that the hips are pointing straight ahead.  If the athlete's hips roll out, this will significantly alter glut medius activation on the stance leg.  A progression for this exercise is having the athlete do this at multiple angles (moving leg up and down the wall).
Single leg PNF patterns.  Having the athlete stand in a single leg stance, the athlete can perform D1 and D2 PNF patterns with the contralateral upper extremity.  Start with limited range of motion of upper extremity movement and progress to larger ranges of motion.  Adding a medicine ball can also greatly challenge this stability.  

Lumbar hip disassociation - using the CLX spiral technique described in the video below, have the athlete stand one and place the contralateral foot on a paper plate or disc.  While keeping the stance leg at 20 - 30 degrees of knee flexion, with the contralateral foot on the slide, slide the plate/disc in a posterior lateral direction (45 degree angle).  When using the spiral technique, this will pull the stance leg into an adducted and internally rotate position which the athlete should resist.  A progression for this exercise is to bring the contralateral foot off the ground and move in the same direction but without touching the floor.  This can be advanced further by holding the end of the CLX that comes off the contralateral limb in your hands.  



In addition to these exercises, another technique that is extremely beneficial is doing perturbations during single limb exercises.  Perturbation is defined as the action of perturbing the state of being.  In our case, we would provide a slight force that would cause the athlete to increase muscle recuitment enough to resist the motion we are applying.  For this scenario, we would provide this perturbation at the knee and our force would be a adduction and internal rotation directed force.  The motion would NOT be hard enough to overcome the athlete's ability to sustain the desire stable position.  Rather, our technique would be lower load and rapid in application.  Doing so trains the athletes ability to rapidly respond without breaking.   

In addition to the exercises above, you can do the ACL Play It Safe program.  This program is offered free on IOS and Android.  Our studies show not only significant improvements in frontal plane motion with this program but also drastic reductions in speed of valgus.  

Next week, we will close out this discussion when we cover the work of Webster et al and use of the ACL-RSI.  We hope you have enjoyed this discussion and stay tuned as we continue the discussion.   #ViPerformAMI #ACLPlayItSafe



Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent is also a competitive athlete in Brazilian Jiu Jitsu. 

Monday, July 23, 2018

Psychological Measures for Return to Play Following ACLR - Part IV

Over the course of this blog series, we have been discussing Kinesiophobia (fear of movement) that is sometimes associated with athletes who have an ACL reconstruction.  During last week's discussion, we pointed out some objective measures we see in our athletes who demonstrate higher levels of kinesiophobia.  The two main things we see are:

  • An increase in lateral shift or shift of body weight over to the non-involved limb during squatting motions.  Noehren et al Am J Sports Med 2018 found similar findings in their study where they found athletes with higher levels of kinesiophobia unloaded the involved limb during drop jumps.   The following video describes lateral shift in more detail.

  • An increase in speed of valgus during single limb activities.  What we see in these cases is athletes who report higher levels of kinesiophobia fall into larger magnitudes of valgus at much higher rates of speed.  The video below is an illustration of an athlete who falls into a large degree of valgus at a higher rate of speed during single limb exercises.  


The question is, is it the chicken before the egg or the egg before the chicken.  In otherwords, is it the kinesiophobia that results in the lateral shift to the uninvolved side and lost of control of the limb speed and magnitude OR is it the lateral shift and high speeds that results in the kinesiophobia.  Although we don't know that answer, we do have our thoughts and theories on.  

That said, what we do know is that we can train an athlete to correct a lateral shift and we can train them to control the magnitude of motion of the knee in the frontal plane and the speed at which it occurs.  What we do know, is that when we do correct both of these things that kinesiophobia is dramatically reduced and in most cases completely eliminated.  

There are a lot of ways to correct a lateral shift, increase control of frontal plane motion and speed of motion.  The exercises described here are just a couple of examples of ones that we do.

Lateral Shift
The first step to correcting a lateral shift is first measuring the degree of lateral shift.  We do this with a 3D wearable sensor, called DorsaVi.  The video below is an example of how we do this in college athletics.  



There are other ways of doing this with 2D (video) technology.  Filming the athlete from the posterior view, drop a plumb line at midline from the cervical spine to the sacrum.  During the squatting motion, the hips should remain relatively equal distance from that plumb line.  If not, then the athlete is shifting their weight to one side which alters loading and recruitment patterns.  Measuring this gives us a baseline to start from.  In addition, this also provides us a visual cue we can use to show the athlete what a lateral shift is.  This is critical to gaining their understanding of and in helping them correct the motion.  

Once the athlete understands the lateral shift, we then can start working on correcting it.  There are couple of ways we address this.

  • Squatting on a force plate.  Now this may sound super expensive and out of reach of most clinics, however we use a new technology on the market call the Boditrak.  The video below demonstrates the Boditrak.  In this example, we would use this a biofeedback during the squatting motion.  We bluetooth this to a TV placed in front of the athlete.  This allows the athlete to see what the weight distribution is between the limbs.  If a lateral shift occurs, the athlete would see this demonstrated in the display and could easily correct this after multiple repetitions.  




  • Squatting with video.  Similar to what is described above, we can do the same thing without the force plate and while doing a live feed with a video.  In this scenario, we film the athlete from the posterior view and bluetooth this to a TV placed in front of the athlete.  This way, the athlete can perform the squatting motion all while visually correcting their lateral shift.
  • Squat Neuromuscular Re-education - this is another technique we will do to help correct a lateral shift.  This is a little more of an aggressive form of training which we will describe in more detail in our next blog.  
In our opinion, a lateral shift must be corrected.  All too often we see athletes that are returned to play or performance training who still demonstrate significant lateral shifts.  The problem with this is that the same athletes will then carry this lateral shift over when doing squats under load.  So, if they demonstrate a 2" to 3" lateral shift under body weight, they tend to demonstrate the same thing when performing squats with 200 to 300#.  Although this is bad under normal bodyweight conditions, this is really bad when done under higher loads.

Next week, we will continue this discussion on how to a how to correct a lack of stability (motion and speed of motion) in single limb activities.  We hope you have enjoyed this discussion and stay tuned as we continue the discussion.   #ViPerformAMI #ACLPlayItSafe



Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent is also a competitive athlete in Brazilian Jiu Jitsu. 

Monday, July 16, 2018

Psychological Measures for Return to Play Following ACLR - Part III

In this series we have been talking about kinesiophobia (fear of movement) and specifically how this is related to an increase in risk reinjury with athletes returning to play.  In the last blog, we provided a case study with an athlete that was being assess for return to sport specific testing. 

19 y/o female division I soccer player who is 5 months post op R ACLR.  She has been receiving "accelerated" rehab in an aggressive sport specific training center in Florida.  She is being assessed for return to sport specific training.  We are engaged by the team to do our movement assessments which is an aggressive movement assessment (ViPerform AMI) using 3D wearable sensors.  This test consist of:
  1. 1 minute Plank test
  2. Squat test
  3. 1 minute side plank right then left
  4. Single Limb tests all on right first then the left
    1. Single leg squat
    2. Single leg hop
    3. Single leg hop plant (multidirectional hop)
    4. Ankle lunge test


At the 5 month mark, most s/p ACLR should be able to perform the test.  Part of the pre-requisites for the test is that the athlete must have performed each of the movements safely in the clinic prior to testing.  When asked to do a single leg squat, you could visibly the athlete was hesitant to perform but did and safely.  When asked to perform a single leg hop, the athlete's hesitancy increased, she started sweating profusely and began to feel light headed.  This is an extreme case of kinesiophobia!  But why did she have this kind of response?  

This could have been avoided if several things had been done prior to the test.  
  1. Inform the athlete what the test will consist of prior to them arriving.  This athlete was unaware of what the test consisted of so the first time she was hearing about it was the moment she was asked to do.  
  2. Have the athlete safely demonstrate movements in a controlled environment prior to testing.  This is critical to see if the athlete is even at the point where testing is appropriate.
As simple as that sounds, neither of these were done in this case.  More importantly, the athlete had only begun to do single limb training a week prior to testing.  So, the athlete only began to do single limb testing just a week prior to testing and had never done single leg hops at all.  So, in the athlete's mind, this was not only the first time they had done this but also was similar to the mechanism by which they injured their knee initially.  No wonder she was having an extreme case of kinesiophobia.  She was set up for failure. 
Trends we have been seeing for the last several years in athletes with high levels of kinesiophobia are:
  1. The athlete tends to have a large lateral shift with bilateral squats where they are unloading the post operative side.
  2. The athlete has difficulty controlling how much their knee moves in the frontal plane during single limb testing
  3. The athlete has difficulty controlling the speed at which their knee moves in the frontal plane during single limb testing.
The first of our findings were confirmed recently in a study by Noehren et al Am J Sports Med 2018.  In this study the authors had athletes who were post op ACLR do a Tampa Scale for Kinesiophobia (TSK) and perform a drop jump from a 12 inch (30.48 cm) box onto a force plate.  What the authors found was that athletes who reported high levels of kinesiophobia on the TSK also unloaded their involved side during a drop jump test.  This is very similar to what we have been seeing with a lateral shift.  Athletes with higher levels of kinesiophobia demonstrate a shift away from the involved limb.  The problem with this is we would see this also carried over into their training.  So the athlete that demonstrates this in a body weight squat would also demonstrate this, sometimes even exaggerated, during a squatting motion under load.  So is it the kinesiophobia that leads to the shift or the shift that leads to the kinesiophobia?  Although we don't know this answer, we do know we can positively impact both.

The other two trends we tend to see, difficulty controlling amount and speed of frontal plane motion has not been proven in the research yet but is something that we see quite often.  This is also something that we are currently researching in our work in assessing athletes for return to play.  That being said, what we see is that athletes who have high levels of kinesiophobia have greater degrees os valgus during single leg squats, single leg hops and single leg hop plants.  What we also see is that these same athletes have higher speeds at which they fall into a valgus position during single limb testing.  

Taking the athlete pictured here, he reports a higher level of kinesiophobia and falls into valgus at >40  degrees per second in a single leg squat, >180 degrees per second in a single leg hop and >220 degrees per second in a single leg hop plant.  Considering these speeds should be 20 degrees sec in single leg squat, 100 degrees per second in single leg hop and 135 degrees per second in single leg hop plant, the athlete demonstrates speeds that are way out side the norms of what we typically see.  

This is great information to have but how do we change it?  Next week we will dive into how we can train an athlete to reduce a lateral shift, amount of valgus in single limb activities and speed and positively impact kinesiophobia.  We hope you have enjoyed this discussion and stay tuned as we continue the discussion.   #ViPerformAMI #ACLPlayItSafe



Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent is also a competitive athlete in Brazilian Jiu Jitsu. 


Monday, July 9, 2018

Psychological Measures for Return To Play Following ACLR - Part II

Last week we learned that kinesiophobia (fear of movement) is bad, especially if an athlete exhibits kinesiophobia when returning to sport following an ACL reconstruction.  According to the Paterno et al Sport Health 2018 athletes who score 19 or above on the Tampa Scale for Kinesiophobia, they are 13xs more likely to reinjure themselves with return to play.  For those of us that have treated ACL patients, this is nothing new but we now have better ways of assessing it.  Rather than just being something we see anecdotally in our athlete, we now have tools, like the Tampa Scale for Kinesiophobia, where we can objectively measure this.  For a copy of this form, please refer back to our previous blog on 7/2/18.

But measuring kinesiophobia is one thing, what you do with that information is something entirely different.  One thing that can lead to increased kinesiophobia is an athletes lack of sport locus of control.  Sport Locus of Control is the athlete's feeling or perception that they are in control of their destiny.  For most athletes, throughout their athletic career, they have been in charge of their athletic destiny.  How hard they trained, their personal effort they put forth, how they performed as an individual or as a part of a team was determined by them.  However, once an athlete has an injury, many times for the first time in their athletic career, their sport locus of control is passed onto someone else.  It is the orthopedic surgeon that tells them when they can take the brace off, start running or return to play that has some of this.  It is the physical therapist or athletic trainer that tells them what exercise they can and can't do, how they will progress with running or sport specific activities that has some of this.  So, for the first time, the athlete is depended on others for their sport locus of control, for their sports destiny.  For many, this can have big psychological impact.  With that loss of control over one's destiny comes fear.  Ardern et al Am J Sports Med 2103, showed that sport locus of control was one of the indicators that determined an athlete's successful return to play.  Therefore, it is up to us to make sure the first thing we do is we give that back to the athlete.

Well that sounds easy but how do we do that?  There are several ways we can approach this, one is from what we say and one from what we do. 
It starts in the very first session.  I am often quoted as saying;

"I am simply an educator and a coach.  I will educate you about your injury, what the process is, what you should expect and how we will progress you for return to play.  I will coach you along the process, telling you what to do, how to do it and push you hard.  BUT at the end of the day it is up to you to make it happen.  This is not easy.  There will be challenges which we will overcome.  You have to want it.  It will define you as an athlete.  But you can do it.  You will do it and we will do it together.  You will come out of this faster, stronger and a better and more rounded athlete.  Are you ready and willing to make that happen?"

In that short 2 1/2 minute discussion, I have passed the sport locus of control to the athlete.  Psychologically, what was also done?  Two things:
  1. I gave the athlete confidence in me as the clinician.  Gaining the athlete's confidence in you as a provider is critical to their success.
  2. I gave the athlete confidence in themselves.  Confidence that they can do this, that they are in control and will determine their own destiny.
This immediate first step is critical to setting the pace for the entire rehab process and critical to building the patient's confidence.  The next thing we need to do early in the rehab process is start to build confidence in their ability to return to play.  Part of this is the conversation we just had and the other part is actually performing activities that provide you confidence that you can go the the next level. 

As common knowledge as we might think this is, what we find is that it is not as common as we might think.  A recent case highlights this. 

19 y/o female division I soccer player who is 5 months post op R ACLR.  She has been receiving "accelerated" rehab in an aggressive sport specific training center in Florida.  She is being assessed for return to sport specific training.  We are engaged by the team to do our movement assessments which is an aggressive movement assessment (ViPerform AMI) using 3D wearable sensors.  This test consist of:

  1. 1 minute Plank test
  2. Squat test
  3. 1 minute side plank right then left
  4. Single Limb tests all on right first then the left
    1. Single leg squat
    2. Single leg hop
    3. Single leg hop plant (multidirectional hop)
    4. Ankle lunge test
At the 5 month mark, most s/p ACLR should be able to perform the test.  Part of the pre-requisites for the test is that the athlete must have performed each of the movements safely in the clinic prior to testing.  When asked to do a single leg squat, you could visibly the athlete was hesitant to perform but did and safely.  When asked to perform a single leg hop, the athlete's hesitancy increased, she started sweating profusely and began to feel light headed.  This is an extreme case of kinesiophobia!  But why did she have this kind of response?  

We are going to dive into this case in some detail next week and specifically how we can avoid it with our athletes.  We hope you have enjoyed this discussion and we will continue with this next week as we evaluate how we can impact kinesiophobia and and additional scales we can use for return to play.   #ViPerformAMI #ACLPlayItSafe



Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent is also a competitive athlete in Brazilian Jiu Jitsu. 




Monday, July 2, 2018

Psychological Measures for Return to Play Following ACLR

Over the history of this blog, we have focused a lot on movement and functional performance measures we should be doing with athletes to determine return to play.  Why is that?  Holm et al Am J Sport Med 2012 showed that 20% of athletes that return to play following ACLR re-injure within the first 2 years.  Further, Wiggins et al Am J Sport Med 2016 showed that one in four youths who tear their ACL will suffer another ACL injury at some point throughout their athletic career.  With odds like this, we have to do something to help improve the odds and more importantly protect our athletes as they prepare to return to play.

Traditionally and in a majority of athletic settings, return to play means just assessing the athlete's strength and endurance and maybe performing some movement assessments or functional assessments.  However, all too often we forget about the psychological factors that are associated with return to play.  In the last couple of years however, there has been a tremendous amount of work done in this area. 

One of the most common aspects talked about when determining return to play is kinesiophobia or fear of movement.  Amy times, as the result of the athlete's initial injury, there is a lack of confidence in the injured limb and therefore a fear of reinjuring upon return to play.  There has been several studies in the last couple of years that show that athletes that have higher levels of kinesiophobia are in fact at greater risk of injury.  In a systematic review done by Everhart et al in Knee Surg Sports Traum Artho 2015, the authors showed a high correlation to kinesiophobia and re-injury rates in ACLR patients.  In a recent study by Noehren et al Orth J Sport Med 2017 the authors looked at athletes that were returning to sport and for those that demonstrated kinesiophobia if there was any correlation to the way they moved and potential injury risk.  What the authors found was that athletes that demonstrated higher levels of kinesiophobia demonstrated lower weightbearing in the reconstructed limb. 

Although assessed differently than in this study, this is a similar pattern we see, especially when assessing an athlete's squatting motion.  What is demonstrated is a significant lateral shift to the contralateral limb (uninvolved side) and away from the involved side.  The authors of this study found similar results where the athlete was shifting their weight to the univolved side during vertical jumping and landing activities.  The authors compared these results to a measure of kinesiophobia and found a strong correlation between the two.  Meaning athletes that shifted weight away from the involved side scored high on the kinesiophobia scale.

With all the studies coming out showing similar corelations with risk and kinesiophobia, then how do we measure this in our athletes?  Is this an overally complex measure and is this something that requires a psychologist to do?  The answer to both those questions is no.  Simply, we can implement at Tampa Kinesiophobia Form as a part of our evaluation process.  For those that have not seen it, the Tampa Scale is below is scored on a 1-4 scale for each question.  A total score is calculated after inverting the individual scores on 4, 8, 12, and 16. 
Adding up all the scores and dividing by the total possible score (68) points.  Higher the percentage the higher the individual's kinesiophobia or fear of movement.   Paterno et al Sport Health 2018 showed that athletes who have a score of 19 (27.9%) or greater at the time of RTPlay are 13 times more likely to suffer a second ACL injury.  Based on the findings of Noehren et al, that makes sense.  Based on those studies, one could hypothesize that the higher the percentage of kinesiophobia then the greater the displacement would be to the contralateral or non-involved limb. 

Based on these results, it is high suggestive that this type of form be used in helping us make a return to play decision for our athlete.  We hope you have enjoyed this discussion and we will continue with this next week as we evaluate how we can impact kinesiophobia and and additional scales we can use for return to play.   #ViPerformAMI #ACLPlayItSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent is also a competitive athlete in Brazilian Jiu Jitsu.