Monday, November 13, 2017

How Do We Know When It Is Time to Return to Sport - Part IV

HS VB Player Demonstrating Poor Movement
Over the last series, we have been talking about how do we know when it is time to return an athlete to sport.  As an industry, Sports Medicine, there is no consensus on what this should look like.  Get 10 of the top orthopedic surgeons in a room to discuss and you will have 10 very different opinions on.

As a parent and a physical therapist, this is something I am compelled to do something about.  When an injury occurs, there is a deep ache we get seeing our child suffer and wonder if there is something we could have done.  Now, there is the ability to help reduce injury risk while helping them improve athletic performance!  There is something we can do to help athletes return to play safer.  

Annually, there are over 300,000 Anterior Cruciate Ligament (ACL) injuries in youth athletics in the US (AAOSM Annual Conference 2016).  This devastating sports injury has an annual health care cost of over $5B plus long term impact to the children who suffer them.  One in four youths who tear their ACL will suffer another during their athletic career (Wiggin et al – Am J Sport Med 2016) and 20% will reinjure their ACL in 2 years (Holm et al Am J Sport Med 2012).  In addition to being at risk for re-injury, once an injury has occurred, their future performance is negatively impacted (Read et al Am J Sports Med 2017, Harris et al Sport Health 2013).

But what if you could identify those at risk?  Research indicates alterations in the way the athlete moves (biomechanics) puts them at higher risk for these injuries.  According to sports medicine experts (Wilk J Orth Sport Phy Ther 2015), we:

·       Need a better way to screen risk for ACL injuries
·       Need a better way to objectively measure progress
·       Need a better way to objectify return to play 
Testing Division I Athletes Using ViPerform AMI
Identifying and correcting altered biomechanics has been shown to have a direct impact on ACL injuries and athletic performance.  The current standard of practice in assessing movement is a paper pencil test that relies on the visual interpretation of the assessor.  These assessments are not well supported in the literature for injury prediction or objectively measuring an athlete’s ability to return to play (Bardenett et al Int J Sport Phy Ther 2015, Bushman et al Am J Sport Med 16).  So, how do we objectively and reliably measure the altered biomechanics that put athletes at risk of injury or decreased performance?  The team at Select Medical uses the latest in wearable 3D sensor technology to identify these risk factors and have developed an exclusive program to address deficits noted.  ViPerform AMI™ is an assessment offered by Select Medical that integrates the latest movement science with 3D wearable sensor technology.

The DorsaVi ViPerform AMI™ combines movement science with accuracy of the DorsaVi system (an FDA approved) wearable sensor device.  After performing this 15 minute assessment, each player will be provided with an assessment using lab quality data which will provided a comprehensive report showing:

·       Overall movement
·       Demographic risk factors
·       Loss of balance
·       Limb symmetry index
·       Magnitude and speed of valgus in single limb performance

ViPerform AMI Report - Providing Lab Quality Data
Using this lab quality data allows the clinician to make much more informed decisions on clinical interventions and season training protocols to reduce injury risk and improve athletic performance.   
Using this information and Select Medical’s ACL Play It Safe Program, they have demonstrated >58% reduction in all lower extremity injuries and significant improvements in athletic performance in Division I athletes.  Science and technology helping to keep athletes safe, in the game and performing at a higher level!  #MoveRightPerformBetterLastLonger.  For a Select Clinic near you offer this program, visit their website at https://www.selectphysicaltherapy.com/  For more information on the ACL Play It Safe Program, download the free app on Android or IOS under "ACL Play It Safe".  




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 developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu. 

Monday, November 6, 2017

How Do We Know When Is The Time To Return To Sport? - Part III

In last week’s blog we talked about the impact that injury has on return to sport and specifically the impact on performance.  This led to the question, how do we make return to sport calls.  Is there a way to assess both biomechanical risk factors in a closed kinetic chain and performance measures?  What does the research tell us? There are several ways this is being done today. 

One of the standards of practice is the use of the Functional Movement Screen. But is this a good predicative tool for determining return to play?   
  • Bardenett et al - Int J Sports Phy Ther 2015 - looked at the FMS as a predictive tool in high school athletes.  Of the 167 high school athletes that were assessed during the pre-season, the results showed the FMS was good at recognizing asymmetry in the movements tested.  But they found that the results were not a good at predicting injury.
  • Dorrel et al - J Ath Train 2015 - performed a systematic review and meta-analysis of research from 1998 to 2014.  What the results showed was that the FMS demonstrated low predictive validity for injury prediction and leading the authors to conclude that this should not be used for injury prediction.
  • Bushman et al Am J Sports Med 2016 - looked at the FMS as a predictive tool in active male soldiers.  Of the 2476 soldiers assessed, the FMS demonstrated low sensitivity and low positive predictive value.  This lead the authors to conclude this could lead to misclassification of injury risk in military personnel.  If they are assigned to hazardous duty as a result of this misclassification, it could potentially place the soldier at greater risk.
  • Wright et al Bri J Sports Med 2016 - in this clinical commentary based on the literature review showing a low sensitivity of 24% led the authors of this paper recommending that this should not be used for injury prediction or for making return to sport calls.
On clear example of this is a recent paper, Dobson et al, Ortho J Sports Med 2016, that looked at injury rates, specifically ACL injuries in NFL players.  Despite implementation of the FMS, biodex testing of quad to hamstring ratios and other such tests, NFL ACL injury have risen dramatically.  Up till 2010, ACL injury rates were occurring at a rate of ~10 ACL injuries per year.  From 2010-2016 there have been a recorded 219 ACL injuries (~36/yr).  So despite having access to all the latest information, they are still not impacting them in a positive way.  What gives?  Simply stated, we are NOT looking at the right things.  When a player can score a 17 on a screen and yet his knees nearly touch on a broad jump, then we are obviously not looking in the right direction.

In 2011 Grindem et al published a paper looking at the single leg hop tests as a predictor of knee function.  In this study the authors compared the single leg hop test to the International Knee Documentation Committee (IKDC).  The IKDC is a self-reported outcome measure that has been shown to have a very sensitivity and specificity to actual knee function.  The authors compared the results on the single leg hop to IKDC scores for those who had ACLR.  The following diagram indicates the single leg hop tests that were performed.  This study showed that symmetry in single leg hop for distance predicted self-reported knee function on the IKDC with a high degree of sensitivity and specificity.   The single leg hop for distance is a great measure of power output in the horizontal.  This same measure of power output can also be obtained with a single leg for height.  One is great for forward propulsion (hop for distance) and one is great for vertical propulsion (hop for height).  Both of these are critical in sport but when also considering mechanics (adduction in the frontal plane) how do you quantify that with either of these tests?  Or is that even possible? With the advent of technology, it is possible, at least for the vertical single leg hop.  Taking a look at the picture here, we can easily capture not only quantify the mechanics with the single leg hop but we can also quantify her vertical displacement during the test.  Having both of these factors performed over multiple repetitions, we can then get a biomechanical assessment of risk as well as comparison of the right limb to the left limb in terms of power output.   But how do we do that objectively and with a high degree of reliability?
As we have stated in previous blogs, frontal plane motion is not the only risk factor.  Rohman et al Am J Sport Med 2015 showed that symmetry in single limb performance is a critical measure for risk.  We also know from Kristinaslund et al Am J Sports Med 2013 that one of the best indicators of risk and athletic performance is performance in single limb testing.  We can watch and record these movements with various technologies (like Dartfish) but that is often time consuming and takes a higher level or expertise to be able to do it in a fashion that is efficient and reliable.  In addition to 2D technology, we are seeing a plethora of new 3D wearable sensor technologies hit the market that are extremely reliable.  Many of these use IMU (inertial measurement units) with accelerometers, gyrometers and magnetometers to detect motion, rotation and acceleration data.  With these technologies, we can now quantify movement with lab quality results and are able to quantify both the magnitude of valgus that occurs in addition to the speed at which that motion occurs. 

As we see a further blending of these types of technologies with the movement sciences is when we will really see an impact on both lower limb injury rates and improvements in athletic performance.  Next week we will explore this a little more.  For more information on this topic and more, make sure to follow us on twitter @ACL_Prevention or on Instagram @bjjpt_acl_guy.  

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 developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu. 

Monday, October 30, 2017

How Do We Know When Is The Time To Return To Sport? - Part II


Last week we started to look at the research for when is the right time to return to sport.  Is there a time frame or things we should be assessing that the research can provide us some guidance on.  

Currently, the majority of these decisions are based on the most current and up to date information we have available.  Or is it?  Considering that most use a Biodex to make this decision, does an open kinetic chain strength test (Biodex) really tell us anything about how stable the limb is in closed kinetic chain conditions, in running, landing or cutting situations?  Adduction in the frontal plane is a risk factor and hip strength plays a big role in.  Does this test give an indication of hip strength?  Is there a better way to assess frontal plane motion?

Considering the following scenario.  Athlete who is testing for return to play and is tested on a Biodex.  She tests to be within 90% of the non-involved limb.  But this poses several questions.  90% of what.  Is that 90% of good strength which adds to good quality movement or is that 90% of poor strength and quality of movement?  Secondly, does this open kinetic chain test truly reflect closed kinetic chain function.  I think once we see this, we can all clearly see she is at risk, but how do we quantify that?



This is a perfect example and the reason all this is so important is due to the number of athletes that return to play too early and end up being re-injured.  We know from Rugg et al, Am J Sports Med 2014 that players with a previous ACL injury are at an 8 fold increased risk of re-injury, will consume more time on the DL and cost more in health care dollars.  Return too early and you increase injury risk.  Return too early and performance is negatively impacted.  We can all think of a NFL or NBA player who has had an ACLR and once they returned to play, just did not play at the same level as previous or hesitated to move to the injured side.  We can all think of a UFC fighter that was hesitant to move to the previously injured side upon return to the ring.  That hesitation, that lack of confidence has a huge performance impact.

Over the last couple of years, several papers have attempted to look at just that.  In some of our previous blogs we cited   McCullough et al who published a MOON study in 2012 that looked at return to sport following ACL reconstruction.  What they showed was that 63% of high school players and 69% of college players were able to return to sport following ACL reconstruction.  They also showed that only 43% of those athletes were able to return to the same level of sport as prior.  In this case, return to same level of sport was defined as same level of pre-injury performance as self-reported by the athlete.  Similar studies have attempted to do this in NBA players.  Harris et al published a paper in 2013 that looked at the impact of ACLR on future performance in fifty-eight NBA players.  Performance was measured by comparing pre-injury data to post injury data in the following areas: games per season played, minutes played, points & rebounds per game and field goal percentage.  Several interesting findings came out of this study including 40% of the players who tore their ACL during a game, did so in the fourth quarter.  86% of players returned to the NBA and 12% of players returned to the FIBA or D-league.  98% of the players that returned to the NBA and 3% had revision of their ACL.  Performance upon return to sport following surgery declined significantly for all subjects.  However, this was not statistically significant when compared to controls during this same time period.  Busfield et al 2009 also investigated this in NBA players.  They looked at 27 NBA players who had ACLRs.  Of those, 22% did not return to the NBA and 78% did return to play.  Of the 78%, 15% had an increase from pre-injury performance and 44% had a significant reduction from pre-injury performance.
In both of these studies, return to play was determined by performance measures in the game (points, rebounds, free throws, etc).  All of these are good measures of performance but are indirect measures of power output, sprint speed and agility.  Is there a more direct way to measure this impact?  In a June 2014 paper for the American Journal of SportsMedicine, Aune et al looked at return to play in NFL players after a lateral meniscectomy.  In this study, return to play was defined as the ability to play in a regular season game.  Of the 77 subjects, 61% were able to return to play.  Additional findings included only 24.6% of the 77 subjects where still playing in the NFL at follow up (average 4.5 years) and speed position players (running backs, linebackers, etc) were 4.0 times less likely to return to play. 
All these studies bring out some key facts. 

  • Performance is negatively impacted by injuries and with return to sport.  This highlights the importance of directly measuring the pre/post performance variance. 
  • The fact that over 40% tore their ACL in the fourth quarter tells us that fatigue plays a significant role.  This highlights the importance of considering this in the assessment with return to play.    
  • The fact that speed position players were 4.0 times less likely to return to play may indicate the impact that injury has on power output.  Since these positions are so dependent on explosive power and agility, you would expect that if injury does have a big impact on performance that these positions would be the most significantly impacted.
The research is clearly telling us that injury does have an impact on performance.  As such, should we include this as a part of our assessment in return to sport and if we do, how do we do it?  Some will tell you the answer is clear and they are currently doing.  But do we have a standardized return to sport protocol?  No!  Whether it is an agility test, single leg hop test or figure eight, these tests are still very subjective and athletes will often figure out how to compensate to obtain desirable results.  Is there a way to assess an athlete for return to sport that also assesses biomechanical symmetry and performance symmetry?  Yes!  Make sure to check out part III next week we will discuss that in more detail.  For more information on this topic and more, make sure to follow us on twitter @ACL_Prevention or on Instagram @bjjpt_acl_guy

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 developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu. 

Monday, October 23, 2017

How Do We Know When Is Time To Return To Sport? - Part I

Over the course of the last several years, we have posed the question, “Does Return to Sport = Return to Sport Same Level?”  This is a topic that is still not quite clear in the research and one which is becoming clearer and hotly debated.  What is reported in the literature depends on how you quantify return to sport.  Are we looking at returning to play at same level of sport or is it returning to play with pre-injury level of agility, speed, power?  How do you determine pre-injury level of agility, speed and power?  This will vary greatly by sport.  However, we are starting to see researchers look more closely performance measures when looking at "return to play".  Some of the current measures being assessed include:
  • Timed 10 yard split or 40 yard dash
  • Vertical jump or single leg hop for distance
  • Timed agility drills
  • Time to  & percentage success with take down (MMA)
Depending on how you quantify your return to play criteria will often lead to varied interpretation of the results.  In research, performance measures have not been typically evaluated and as such, reporting return to play percentages have been a lot higher than what we see on the field.  The sad part is that teams, coaches and players know the reality and don't need a peer reviewed paper to tell them that these injuries are having a huge impact on performance.  Just looking at NFLs own data from 2013 to 2015 and comparing reported knee injuries to percentage of games won and the reality is clear.  Teams with the highest knee injury rates won 33.9% of the time versus teams with lower knee injury rates who won 52.7% of the time.  

In a recent study by Anand et al, Am J Sports Med 2016, we see when we start to look at some of the performance criteria, that the percentages are much lower than previously reported.  Read et al Am J Sports Med 2017 looked at NFL defensive players who underwent an ACLR and looked at their future performance once they returned to the NFL.  What the authors found was that those that did return to play, only 57% started games versus preinjury where 81% started.  These same players also had a reduction in solo tackles which dropped from 3.44 pre-injury to 2.38 post injury.  Is this impact only on football players?

Mai et al Am J Sports Med 2017 compared return to play following ACLR in:
  • NFL
  • NBA
  • NHL
  • MLB
What the authors found was that NFL players fared the worse of all the sports assessed.  NFL players had a significant impact on their career length where the average player had their career shortened by 2 years.  In addition, NFL players saw a negative impact on all performance measures for up to 2 years post ACLR.  NBA players demonstrated a decrease in athletic performance for one season after return to play but returned to pre-injury status during the second season upon return to play.  In this study, NHL players had the best results with a much higher rate of return to play and much shorter recovery time.  


So how do we currently make the call to return an athlete to sport?  Who decides when it is time to return to sport and how do we know if the athlete is ready?  Currently there is not a standardized way to make return to sport calls.  Wilk et al, J Sport Phys Ther 2014, in an editorial and literature review, asked that very question.  Can we do better?
This is something that is desperately needed and being asked for.  More often than not, making this call relies heavily on the surgeon to aid in making that decision.  Often the surgeon will base this decision on what the current research says about tissue healing and graft strength, an extensive orthopedic exam performed in his office, comparison of involved limb to non-involved limb strength on Biodex testing and often feedback from the treating physical therapist or athletic trainer.  In a literature review performed by Nessler et al Curr Review Musculoskelet Med 2017, the authors found the literature highlights several factors that should be assessed when evaluating an athlete for risk or for return to play.  This includes:

  • Stability of the limb in the frontal plane
  • Stability and impact of fatigue on single limb testing
  • Truck stability in stance and core testing
  • Limb symmetry index - comparison on R and L limb in closed kinetic chain testing
  • Lateral displacement of the pelvis during squatting motion


Stay tuned next week as we continue this discussion on when is the proper time to return to sport.  For more information on this topic and more, make sure to follow us on twitter @ACL_Prevention or on Instagram @bjjpt_acl_guy.

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 developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu. 


Monday, October 16, 2017

Standardized Sports Testing - Have We Standardized Anything Yet? - A Guest Blog

This week's blog series comes to us by Eric Dinkins, PT, MS, OCS, Cert MT, MCTA.  Besides the plethora of designations behind his name, Eric is a fantastic physical therapist practicing out of Colorado.  Eric has a huge passion for education and is Mulligan Certified Instructor and teaches physical therapist all over the US.  I first came across Eric ~5 years ago after he had developed a technology called motion guidance.  This simple, inexpensive and very effective training device I have used in my practice and courses ever since.  I was blessed to come across Eric and learn from him.  So when it came to retraining human movement, including Eric in this series of guest blogs was a no brainer. 


Please sit back and enjoy as Eric provides us the latest. - Sincerely ~ Trent Nessler, PT, MPT, DPT

This is a 3-part blog series on the topic of Return to Play (RTP) in ACL reconstruction clients.  The goal is to provide information about the current RTP testing, potential mechanisms that are involved, and options for improving outcomes. Sports performance, in regard to prevention and return to participation, is a common part of any orthopedic practice. It deals with athletes of all levels; from the elite competitor to the weekend warrior, to the client who wants to return to tennis after a Total Knee Arthroplasty.  According to the recent recommendation published in 2016 by the British Journal of Sports Medicine, Rehabilitation after ACL injury should include a prehabilitation phase and 3 criterion-based postoperative phases: (1) impairment-based, (2) sport-specific training and (3) return to play. A battery of strength and hop tests, quality of movement and psychological tests should be used to guide progression from one rehabilitation stage to the next. Postoperative rehabilitation should continue for 9–12 months. To assess readiness to return to play and the risk for re-injury, a test battery, including strength tests, hop tests and measurement of movement quality, should be used.

Training or rehabilitation often focuses on strengthening and motor control re-education to correct faulty movement patterns, imbalances and asymmetries.  In virtually every case, functional sports testing is performed to determine if the person is ready to return to sport, and if they are at risk for re-injury. So, what happens when the tests that we use to conclusively decide if a person is ready differ so greatly in the published literature?  Why the battery of tests when we’ve been performing return to play testing for years? One answer came when Hegedus BJSM 2015 reviewed some of the most common tests used in physical performance testing and found an extremely wide variance in several aspects of the tests reviewed.  

Some of these tests included what some consider “gold standards” for return to sports play.                

Tests include: Single leg hop for distance, 6 M timed hop, cross over hop for distance, single leg squat, triple jump, and single leg vertical jump.  What Hegedus found, was that there is a variance in the procedures in which they are applied.  The warm-up and number of practice hops, number of hops recorded in the test, how the arms are used, and final scoring can be based on mean of attempts, greatest of attempts, and greatest of successful trials.  So, if we can’t rely on standardized testing that has poor reliability at the present time, the importance of movement analysis and motor control becomes magnified!

Often testing against the non-involved leg makes the assumption that the uninvolved side avoided injury because it was the stronger or more stable side…an assumption that has been proven false by far too many people who have torn ACL’s in both knees. Both sides of this story can be found in journals such as thisthis, and this.
                                                                                             

Also, joint forces and other additional elements play a role in ACL or knee injuries, therefore, focusing solely on lower limb kinematics in classifying injury risk or post-injury rehab may not encapsulate all relevant factors.  Even attempting to examine “normal” in the attempt to standardize kinetic motions for populations and translate that data into risk factors has come up short in developing a predictability rule of sorts for determining return to participation (Fox, Sports Med 2014)

This comparison suggests that at the time of testing, athletes, regardless of being cleared for return to sport, were deficient in dynamic control and therefore at risk of injury.  Furthermore, asymmetries across both groups suggest that these deficiencies likely existed before the initial ACL rupture and may have been associated with the initial injury. Routine examination or sports testing of the lower limb may not pick up on neuromotor control deficits that may be compensated for and missed during clinical evaluation but may be contributing to abnormal movement patterns increasing the re-injury risk. Clinical impairment measures do not appear to be related to measured functional ability. Performance of both functional tests, FMS, and YBT-LQ at 6 months would suggest that the typical patient in both groups would be at a greater risk of lower extremity injury (AJSM 2015).

Also, quadriceps ECC strength was more directly correlated to JPS than concentric strength in patients with PFPS. This suggests inhibition or weakness of the type II muscle fibers that are responsible for maintaining the eccentric muscle force during movement.  The link can be made between quadriceps ECC strength, proprioception and pain in this population (Knee Surg Sports 2015). But simply improving strength neither guarantees non-injury or addresses other factors that could contribute to injury occurring. Video replay and/or video analysis has shown some promise to help aide athletes to improve their joint positional sense. But, video replay lacks the immediate visual feedback that has been proven to enhance motor learning skill acquisition.

There are numerous expert clinicians in the field of sports rehabilitation capable of skillfully attempting to determine when a patient or athlete is ready to return to dynamic function, and often times the individual is able to return without future injury.  I have spoken with colleagues whose preferences range from using the ECC step down testing to return an OL in college football to play, to using a barrage of physical performance tests to acquire as much information as possible to make the determination. However, what about the clinician who is deemed with the task of determining a patient’s suitability to return to participation without the expert knowledge base?  Surely, they cannot rely on functional based sport testing for the lower extremity.  So, what resources can they rely on?  Unfortunately, the most realistic answer is devoting the time to become an educated clinician, and skilled movement analyst.  The maximum amount of information must be acquired to help determine when someone is ready to return to participation.  NOT solely relying on the hard numbers and pass criteria that are suggested in sports testing models.  Use all resources that are available to you such as sports psychology assessments, visual feedback training with the Motion Guidance system to help the patient better understand what actions may be occurring during actions in real-time feedback and help the clinician get sport specific information during those actions, and consider need for extra motor learning as well as strength and conditioning.  For example, watch this video and see how simple bilateral jump testing with visual feedback and yield valuable information about potential fatigue, form, and dynamic actions around the lower chain.




I took this information, shared it with my client, and it really hit home the training areas that she needed to focus on despite “feeling” really good at the time of testing.

It has been suggested that advancing patients through the stages of motor learning and eventually giving external cues for function will facilitate transfer of motor control to subcortical regions of the brain and free cortical resources from programming more complex actions.  Incorporating visual-motor control training into rehabilitation may decrease the reliance of visual feedback to make dynamic changes in muscle function during an open environment (JOSPT 2015).  These factors make the safe return to participation tough. A grey area instead of black and white.

The take home message? Each of these considerations must be individually applied to each individual case in order to continue to decrease the risk of injury after return to play.

Thank you.

Eric M. Dinkins, PT, MSPT, OCS, Cert MT, MCTA




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 developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu. 

Monday, October 9, 2017

Injury, Recovery, Movement Enhancement - A Guest Blog

Enhancing recovery and improving movement efficiency is critical in the treatment and performance enhancement training of our athletes.  The balance of bringing our athletes back to the field following injury is always a delicate balance of training hard enough and yet not over training.  This is where recover is truly key.  I am truly humbled to have one of the leaders in this field Lenny Parracino, CMT, FAFS from the LA Clippers willing to give his thoughts on how he addresses and some of the tools that he uses.  
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Injury, Recovery, Movement Enhancement - A Guest Blog
By Lenny Parracino, CMT, FAFS

Injury, recovery, and movement enhancement are all common characteristics of an athlete.  It’s the balance of these three characteristics that becomes tricky.  Lets start with injury.  Injury by definition is a disruption of unity.  The reality is that all athletes during their career will experience some form/degree of injury.  Even soreness after training is technically an injury!  In fact, muscle soreness is muscle damage.  Recently, BYU research shows immune system cells help to repair muscle damage after a workout, a normal response to injury, which is great, BUT do we want our immune system always activated after working out?  What does this reaction do to our movement enhancement?  Knowing soreness is an injury and chronic soreness decreases movement performance, learning a process to optimally recover should be a critical part of everyone’s plan if long-term healthy movement is the goal!


As for the recovery, regardless of the level of injury, we need a safe/pain free environment for optimal adaptation.  All techniques can be categorized into either 1) pain control or 2) conditioning.  Pain science has taught us that the solution for pain is 1) change the sensitizing agent(s) and/or 2) build tolerance to the sensitizing agent(s) or the structural change.  Pain is a sensation of a perceived threat.  Perceived being the key word.  Pain, regardless of how one describes it can no longer be directly correlated to the degree of tissue damage. A great example is a paper cut hurts “big-time” yet a cancerous tumor may not hurt at all.  We can only imagine the cancerous tumor displaying much more tissue damage! 

The solution to enhance movement after an injury is to first decrease sensitive tissue regions followed by building up tissue tolerance.   This leads me to what I refer to as Soft Tissue Hygiene.   We are all taught how to apply a hygiene approach to our dental structures, but what about the rest of our tissues?   Teaching athletes DAILY soft tissue hygiene, utilizing tools that improve soft tissue resilience/tolerance, is key to mitigating chronic damage – just like brushing and flossing.  We don’t brush only when we think we need it, we learn to create a HABIT.  The only way to make a chronic change to your tissues is to implement a chronic habit.  Research has demonstrated tools that compress the tissues SLOWLY change the internal fluid matrix in a beneficial way[1].  When there is increased viscosity (thickness) in the internal fluid matrix it can adversely affect many mechanisms in our body.  Free nerve endings and other mechanoreceptors can be altered, leading to chronic soreness, pain and/or stiffness, and altered motor control.[2] In addition, if the tool exhibits vibration with compression (such as with the Hyperice Vyper vibrating roller or Hyperice Hypersphere vibrating ball), there is a greater benefit than just massaging over the skin or using an implement to roll up and down body parts.  Since the change occurs in the viscoelastic components of the soft tissue complex, SLOW compression/shear/vibration and heat tends to bring positive benefits in the conditioning phase.  If one is in the pain phase I would suggest ice/compression (such as Hyperice) and client/patient pain free micro-movement.

In summary, chronic soreness (injury) should be avoided at all costs if the intention is movement enhancement.  Although there are MANY factors that can contribute, far more than just mechanical, the physical aspect can be assisted by proper soft tissue hygiene.  Although research is now available on this subject, results will speak for themselves. I recommend assessing, applying, and reassessing to adjust variables for optimal adaptation.  By sharing this process I hope I have spurred thought to yours.  By using your intelligence and not memorizing protocols we shift from a master-mechanical-technician to a creative-humble-facilitator.   Lets teach people soft tissue hygiene!





[1] Roman, M., Chaudhry, H.,Bukiet, B.,Stecco, A., Findley, T.W., 2013. Mathematical analysis of the flow of hyaluronic acid around fascia during manual therapy motions. J. Am. Osteopath. Assoc. 113 (8), 600-610.
[2] Stecco C., Stern R., Porzionato A., Macchi V., Masiero S., Stecco A., De Caro R. 2011. Hyaluronan within fascia in the etiology of myofascial pain.  Surg Radiol Anat. 33(10):891-896. 



Lenny Parracino is a former author, hands on instructor, and clinician for The National Academy of Sports Medicine. Currently, he serves as a faculty member of the Gray Institute of Applied Functional Science, is the Soft Tissue Therapist for the LA Clippers, and operates a manual/movement private therapy business. Lenny has recently authored seven manual therapy manuals (Functional Soft Tissue Transformation) and the Gray Institute’s Certified Applied Functional Science (CAFS) curriculum for manual/movement practitioners of all levels.
Lenny has spent over 25 years serving the health industry as an international lecturer and a manual/movement therapist. Lenny has performed over 300 lectures/workshops and has written educational materials and consulted/lectured in the fitness/therapy industry and for various medical organizations around the world. Lenny has earned his degree in Health Science, is a Fellow of Applied Functional Science, holds a California certification/license to practice soft tissue therapy, is a Certified Functional Range Conditioning Practitioner, and holds a certification in nutritional therapy. Lenny continues his studies under the world-renowned physical therapists, Dr. Gary Gray, and Dr. David Tiberio.
Lenny has worked with professional sport teams and/or players from Phoenix Suns, LA Clippers, San Francisco Giants, Philadelphia 76ers, Philadelphia Phillies. Minnesota Twins, LA Kings, and Seattle Seahawks and Buffalo Bills. 

As a full time practitioner, Lenny integrates an eclectic approach of Manual/Movement Therapy with the intention of optimizing individual client function.

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 developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu. 

Monday, October 2, 2017

A Dynamic Approach to ACL Rehabilitation and Prevention: Part V - A Guest Blog

Over the last couple of weeks, we have talked about Dynamic Tape and how it may be used for rehabilitation.  But how does this work in practice?  Let's look at a case study.


Trent Nessler’s Athletic Movement Index and DorsaVi vs. Keith Cronin and Dynamic Tape
I have said a lot about Dynamic Tape and how a Biomechanical Taping solution should be in every clinician’s tool belt. So, to wrap up this series I decided to take on Trent Nessler’s Athletic Movement Index for ACL assessment measured by DorsaVi.

Patient History
Throwing HIPPA out the door here. 😊
This test subject is an exceptional handsome, intelligent, and all around amazing 35-year old male who enjoys running and is beat up badly by his 6 and 3-year-old daughters every day. His relevant list of injuries from playing years of sports and now becoming his children’s human pony include: 
  • 3 concussions 
  • R/L torn hamstrings (multiple times) 
  • 13 total sprained ankles (I was never meant to play basketball) 
  • L lower leg anterior compartment syndrome  
  • L3/L4 “Dead disc” with L myotome weakness since age 17 
  • L piriformis pain (multiple times)  
  • 5-year history of tingling sore legs (disc related but not current) 
  • 3 sprained ribs  
  • Separated L Shoulder (4x) 
  • Severe strain to L coracobrachialis (did not even know this was possible) 
  • Multiple rotator cuff and elbow strains from baseball 
  • Flat spine from weakness in thoracic


At the outset, you would agree that I am walking disaster and should not be allowed to do anything moving faster than a jogging pace. Regardless, I wanted to prove I could make it through this testing while only crying and whining a moderate amount.

Round 1 – Baseline





Started off with a solid assessment that revealed I have terrible front control and difficulty with eccentrically loading, as indicated by the speed. I have no history of ACL issues but from all this you can easily conclude I fall into a “high risk” category. The varus positioning is likely compensation because of weak hip abductors and a slight general “bow” leggedness.

NOTE: What is not included is my 100% passing score for the abdominal / lower back strength testing. Take that AMI!


Round 2 – Quad Taping
Please note at this point I have gone through the entire AMI, cried in the corner, and come back to the testing. My legs are already tired but knowing that the L is a concern, I decided to go ahead with the testing. We started with the quad taping to see what affect it would have.

What we found was a little improvement with the single leg squat, more so with the single leg jump, but then the dynamic jumps showed what Dynamic Tape has been talking about for years. Dynamic Tape is a viscoelastic product, meaning the faster a body part moves, the faster and stronger it stiffens to resist motion. This fast, dynamic movement is what is most relevant with ACL rehabilitation.

You can see from this testing that frontal plane motion improved from 25 to 19 degrees with Dynamic Tape. Please note that taping the extensor mechanism deceased varus / valgus excursion. Quad control = knee control. From testing we know my low back and abdominals are working but with a history of myotome weakness on the L it is not shocking there isn’t a lot of push in it. Depth of squat decreased a little, likely because feeling the stiffening of the tape brought on a sensation earlier to control it. Rate of speed decreased a fair bit, bringing it from BAD back to ACCEPTABLE.

I went into this fatigued, meaning I should be losing control and I was GAINING IT! With my L leg now exhausted, I went ahead to prove the point even more.




Round 3 – Hip Taping
I decided to do a THIRD round of testing on the L side, now with the hip rotation taping. I did the taping over my pants so you could see where tape was going. Normally, this would be flush against the skin but ain’t no one needs to see my skinny, pale booty. 😊

Another 5-6 minutes of tears and sobbing and we had some data. My leg was completely shot at this point and going home afterwards it felt like my two-story townhome was a skyscraper of stairs.
From the original baseline, you remember that I had a very varus position. What did this show? A return to varus, which makes perfect sense! I did a hip extension / ER rotation taping that pulled me into that position. This means in open chain the hip is being pushed into external rotation, increasing the opportunity for varus on landing. So far, this makes sense. Not what I want but mechanically this is consistent with everything Dynamic Tape does.

Now look at the rate of control. How is it that after my third round of testing my rate of control is excellent? Now what I didn’t tell you was with the L plank exercises about 20 seconds in my L butt cheek was burning bad. I said I had L side myotome weakness for years so hip abductors on that side don’t have the stamina and activation they should. The hip external rotation taping gave my weak rotators and abductors a little help resulting in significant improvement in control.




DT TAKE HOME SUMMARY
I believe enough in this product to put myself through Trent’s utter soul crushing AMI DorsaVi module and through it, I hope you see what I and many clinicians around the world have been seeing for years. Using the Biomechanical Taping System of Dynamic Tape allows the clinician to:
  • Reduce Workload
  • Management Movement Patterns 
  • Improve Function

all while allowing your patient to move 100%, to restore appropriate body mechanics.

From these movement assessments, research, and reasoning I hope you will consider putting Dynamic Tape in your toolkit for ACL rehab. Waiting for an injury to occur is not a prerequisite. Dynamic Tape can manage movement patterns and improve function before an injury occurs. In concert with a quality assessment, sound reasoning, and a purposeful rehabilitation game plan, Dynamic Tape offers any clinician the opportunity to elevate rehabilitation and injury prevention to new heights.

Want to learn more about Dynamic Tape or DorsaVi? Please contact Keith J. Cronin, DPT, OCS, CSCS at keithjcroninpt@gmail.com or visit the website at www.dynamictape.com


NOTE: Big thanks to Trent Nessler for allowing me the opportunity guest write on his blog, as well as to Shawna Jamison with DorsaVi for showing helping me with testing and for holding back the sarcastic comments as I struggled to walk. 


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 developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu.