Monday, March 30, 2020

Psychological Measures for Return to Sport 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, March 23, 2020

Psychological Measures for Return to Sport 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 sport.  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, March 16, 2020

Psychological Measures for Return To Sport 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 3/16/20.

Another scale often talked about to determine an athlete's fear with return to sport is the ACL-RSI.  This is also a great tool however, a recent study by O'Connor et al Am J Sport Med 2020 showed their was a trivial correlation with results on this patient reported outcome and strength, power and limb symmetry index.  Considering the strong correlation to quadriceps symmetry (Smith et al Am J Sport Med 2015) and quadriceps strength and kinesiophobia (Ho et al J Physio 2015), the O'Connor study would suggest that the ACL-RSI is not capturing this.  Since the TSK-11 does, this is another reason that this is the scale of preference for this author.

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, March 9, 2020

Psychological Measures for Return to Sport 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 sport.

Traditionally and in a majority of athletic settings, return to sport 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 sport.  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 sport is kinesiophobia or fear of movement.  Many 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 sport.  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 during functional tasks like bilateral box drops. 

Although assessed differently than what was done 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 the previous 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 correlations with risk and kinesiophobia, then how do we measure this in our athletes?  Is this very complex measure and 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. 






Higher the score 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 sport 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 sport.   #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. 




Monday, March 2, 2020

The Evolving Knowledge of Movement - Part VIIC What We Know Now

Last week, we ended our discussion talking about BFR (blood flow restriction) training and how this might be implemented into our training for helping athletes control frontal plane motion.  Today we can continue on with this concept of integration of BFR into our movement training.  Before we go any further, I want to be clear, this is NOT a comprehensive review of BFR.  If you want our comprehensive course on BFR, please follow this link to our BFR course with Northeastern Seminars.  For the purposes of this blog, this will be a very cursory review.  For more information on contraindications, protocols for implementation and clinical observations, please refer to our online course.

During our discussion last week, we talked about the impact of BFR on GH, IGF-1 and Myostatin and how this adds to muscle growth, soft tissue repair and bone healing.  In addition, we also talked about the increase or up-regulation of motor units with the application of BFR.  With the up-regulation of motor units of a muscle, what this means is that more of the whole muscle is recruited or activated with low exercise intensities.  Due to the fatigue that the BFR is creating, this "tricks" the system to recruit more of the muscle to perform the task at hand.  This is great for those of us trying to get our athletes to recruit more gluteus medius and maximus to aid in control of frontal plane motion.  Most of the studies out there using BFR, typically do a rep sequence of 30-15-15-15.  This is performing 30 reps, give 30 sec rest and perform 15 reps, 30 sec rest and so on throughout the sequence.  At the conclusion of this set, you release the cuff and allow for full reprofusion of the tissue.  Give a 3-5 minute rest and then repeat that sequence for 3-4 complete sets.

We know from the literature (Brazen et al Clin J Sport Med 2010) that when an athlete is fatigued, that their frontal plane motion increases.  It is this increase in motion that is often associated with risk for lower kinetic chain injuries.  As such, we need to train for this fatigue and create motor patterns in the primary motor cortex (higher centers of the brain) that control this excessive motion in these fatigued states.  In other words, we need the default pattern that the athlete resorts to in a fatigued state to be a movement that controls frontal plane motion.  The only way to create these default movement patterns is to train the athlete in a fatigued state.

Considering all this, the following a sequence is one that I do with a lot of my athletes.  This is obviously a later in the game sequence and is one that I would consider aggressive (expect some muscle soreness from).  What I am attempting to do is fatigue their gluts as much as I can, then require them to perform a task that will require frontal plane stability.

I have them do a sequence of side stepping with a theraband, retro monster walk, and glut bridges with 60% LOP on both legs and using a moderate resistance (green or blue band).

Side Step with Theraband: The band is at the ankles and the athlete is in a squatting position.  Both feet are pointing ahead throughout the exercise and the athlete does not raise up out of the squat position during the movement.  

The athlete steps out, as depicted here, without raising out of the squat position.  It is vital to keep the feet pointing straight ahead.  Most athletes with weakness of the gluteus medius will toe out.  It is important to prevent this from happening.  Perform 15 reps one direction and 15 reps back the opposite direction.

Retro Monster Walk: As soon as the athlete completes the side stepping, they turn around.  remaining in a squatting position and with the band around the ankles, they will step back in a posterior diagonal step.  Once stable, bring the opposite foot to the stance leg and immediately strive in a posterior diagonal direction.  

This will keep you moving backwards.  Repeat this for 15 steps backwards and turn around and repeat in the opposite direction for 15 strides.  The athlete should remain in the squatting position the whole time.

Glut bridges on the physioball: As soon as the athlete is complete with the above, they will lay on their back and put their feet up on the ball.  The feet are close together and digging the heals into the ball.  The knees and hips are at 90 degrees.  

Keeping the knees at 90 degrees, the athlete pushes their hips off the ground until the hips are at a neutral position (not hip flexion or extension).  Pause and repeat.  Perform 30 reps.

At this point, release pressure on the cuffs and allow full reprofusion for a 3 minute rest.  At the conclusion of three minutes, bring them back to 60% LOP and repeat the sequence for 3-4 sets total.

At the conclusion of the 3-4 sets, we remove the cuffs.  Immediately, I will move into working single limb stability.  This may consist of 2-3 sets of single leg hops followed immediately by 2-3 sets of single leg squats.

During single leg hops and single leg squats, it is essential to ensure that the athlete is controlling frontal plane motion.  This will be EXTREMELY difficult for them to do.  Considering, it is important to follow the repetitions to substitution mind set.  If they can't do the exercise with the proper form then we need to regress the exercise.  Don't stop.  Regressing the exercise to a simpler form still works motor patterns we want and prevents them from falling into the negative default program.


 Next week, we will continue this discussion with looking at some specific exercises that incorporate some of the concepts we discussed with BFR to continue to push controlling frontal plane motion.  Stay tuned as I am super excited to share with you.  If you enjoy this blog, please share with your colleagues, athletes and training partners and please be sure to follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention.  Train hard and stay well.  #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,  ViPerform AMI RTPlay, 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 also a Brazilian Jiu Jitsu purple belt and complete BJJ/MMA junkie. 

Monday, February 17, 2020

The Evolving Knowledge of Movement - Part VIIB What We Know Now

Over the last couple of weeks, we have discussed frontal plane motion.  Not only the impact that this motion has on injury risk but also the impact it can have on performance.  We also discussed how to visually assess this and how what we are seeing on this visual assessment can lead to some assumptions about risk. 

This week, we are going to discuss some targeted training to help improve these movements.  Prior to talking about training, I want to be clear that what is discussed here is not the end all be all.  There are multiple exercises we can do that will impact this which we can all do.  However, we have found some common patterns with what we see in the movement assessment with exercises that make specific changes to control of frontal plane motion.  Keeping in mind, the majority of these are tested during single limb motion.


Larger varus motions - although the motion that we are recording is not a "true" varus at the knee, it still creates a varus stress to the lower limb.  As depicted here, these athletes tend to have a lot of frontal and transverse plane motion at their hips.  When the center of mass is moved laterally on a planted foot, this creates this lower limb varus stress.  Considering, this is primarily (not all) driven from the inability of the core to stabilize and control the center of mass during single limb performance as well as the hip musculatures inability to stablize.  With these folks, focusing on core stability (planks and side planks) as well as frontal and rotational stability of the hips and core in single limb performance is critical. 

Larger of valgus motion - for those that fall into a large valgus in the absence of loss of pelvic control, we will typically focus in on the gluteus maximus and gluteus medius.  The gluteus medius and maximus are high endurance muscles and are active with every step that we take.  Research indicates when these muscles fatigue, that there is a corresponding increase in frontal plane motion (Weist et al Am J Sports 04).  Considering, I tend to focus a lot of pushing endurance and fatigue resistance with these muscles.  Combining motions that pull the limb into the dynamic valgus position under resistance (depicted here) can help facilitate the function of these two muscles to resist that motion and aid in increase recruitment of. 

Large valgus motions with high speeds - when there is a combination of a large increase in motion and speed, this is often associated with a weakness of the hip (gluteus medius and maximus) as well as core.  When speeds exceed 200 degrees/sec, we tend to see this as whole kinetic chain (meaning from the foot to the core).  Typically, one of the links in the kinetic chain will prevent the athlete from falling into these motions at such high rates of speed.  As weakness of the entire kinetic chain increases, so do the speeds of valgus because there is less resistance along the chain to slow it.  In these cases, I will do a lot of core, hip and ankle stability exercises in isolation and in single limb performance. 

Before we get into specific exercises, I would like to discuss how BFR (blood flow restriction) can be implemented to address a lot of these issues.  Although most think BFR is a fairly new, it has actually been around since the 60s and was used a lot in bodybuilding.  As a avid weightlifter for 40+ years, I vividly remember doing some form of this as a younger lifter using straps and bands (not recommended but what we did at the time).  BFR has had a resurgence in sports medicine with a variety of new products coming on the market and a lot of new research in the area.  Aside from the impact on growth hormone (GH), insulin-like growth factor 1 (IGF-1) and myostatin, there is also an up-regulation of motor units.  In addition, studies show you can have an impact on VO2Max and stroke volume with BFR.   

Considering these findings, there is a lot of application to control of frontal plane motion.  As such, some of the exercises we will discuss include the application of BFR.  This allows us to maximize the benefit of the exercise in a shorter training session.

Side planks with CLX - this is a great exercise which brings in the entire upper and lower kinetic chain.  In the side plank, the ankle everters must be every active to in an isometric and eccentric fashion in order to prevent the foot from falling into a inverted position.  With the combination of the CLX, this brings a cross link of lower kinetic chain to core to upper kinetic chain.  While the gluteus medius (on the down leg) must actively stabilize at the hip, the contralateral glut is working in a concentric and eccentric fashion.  At the same time, by drawing in the upper shoulder girdle movement and stability, this adds increased complexity to the core and lower kinetic chain. 



Next week, we will continue this discussion with looking at some specific exercises that incorporate some of the concepts we discussed with BFR to continue to push controlling frontal plane motion.  Stay tuned as I am super excited to share with you.  If you enjoy this blog, please share with your colleagues, athletes and training partners and please be sure to follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention.  Train hard and stay well.  #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,  ViPerform AMI RTPlay, 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 also a Brazilian Jiu Jitsu purple belt and complete BJJ/MMA junkie. 

Monday, February 10, 2020

The Evolving Knowledge of Movement - Part VIIA What We Know Now

Last week, we looked at the lack of frontal plane control and the impact on both performance and injury risk.  We also spoke about the control of frontal plane motion means controlling how much the knee moves and how fast it moves in that direction.

Unfortunately, this movement pattern is all too common in our athletes.  We may think we may only see this in the untrained or lower level high school athlete.  The reality is that we see this across the entire spectrum from high school athlete, to college, to Olympic to professional athlete.  Part of the reason we often don't see it is that we are not assessing for it or recognizing it during training.

The severity of the of the frontal plane motion (both amount and speed) can dictate how much this will impact an athlete's risk and the impact that this will have on performance.  So as the increase in magnitude or speed of valgus increases, so does the risk and the impact on performance.  The impact of frontal plane control is not only determined by how much and how fast the athlete moves into valgus but at which point during your assessment.

For example, compare the following athletes.
  • Athlete A starts to fall into valgus on rep one
  • Athlete B starts to fall into valgus on rep one at a high rate of speed
  • Athlete C starts to fall into valgus at rep 8
In this scenario they are all at risk however, I think we would all agree that athlete B is at the highest risk followed by A and then by C.  This can help us not only from an assessment perspective but can also guide the intervention or the starting point for the intervention.  In this scenario, with no further information, I am going to start Athlete B in a single leg squat in a staggered stance (provides increased base of support and stability) and work on controlling frontal plane motion throughout the range of the exercise.  Athlete A, I might start in a single leg squat with contralateral leg in the athletic position and work on them controlling frontal plane motion.  Athlete C, I might start in some hops until they can't control frontal plane motion and regress to single leg squat while controlling frontal plane motion.  

So, although it is the same motion, it is the severity of the motion (magnitude vs. speed and magnitude vs. control till some fatigue sets in) that dictates the exercise or level of exercise we would do with the athlete.  End of the day, any exercise that is performed where the athlete is "allowed" to train without controlling these motions will simply reinforce the default motor pathway that led to the faulty movement pattern in the first place.  Training in this pattern will result in this being the default they move to when demands are highest and they are fatigued.

For control of frontal plane motion, we traditionally think of this as just a gluteus medius weakness.  However, what we now know is this is a little more complex than that.  We often see those who have immediate inability to control motion and speed to have components of gluteus medius and gluteus maximus weakness and poor core control.  These individuals often have inability to sustain and controlled plank position for one minute and often perform poorly on side planks.  With side planks, these individuals are not only challenged with maintaining the position but also have an inability to control trunk rotation during.  

Obviously, there are over a 1000 ways to address frontal plane control and is something we are all capable of doing.  Biggest thing for us all to keep in mind:

  1. Training needs to include single limb training - ensuring to put the athlete in positions that allow them to successfully control frontal plane motion.  If this is a single leg squat in a stride stance or single leg squat with contralateral leg in the athletic position or single leg plyos doesn't matter.  As long as the athlete is controlling frontal plane motion.  When they can no longer control that frontal plane motion, then should move to a lower level of the exercise to allow them to keep training while controlling that motion.
  2. If there is high amounts of valgus and at high speeds, then there is the need to make sure to include core training and focusing on maintaining control at the hips.  Control of the hips means we want to prevention the athlete from falling into a trendelenburg, retro-trendelenburg or cork screw.

  3. We need to train for some level of fatigue in single limb training.  We know that fatigue impacts lower extremity mechanics and force attenuation in runners (Weist et al Am J Sport Med 04) and there is an increase in frontal plane motion with fatigue (Brazen et al Clin J Sport Med 10).  Therefore bringing fatigue into the equation is needed and to keep them training in this fatigued state with good mechanics.  This ensures that when they are fatigue in competition or practice that they are moving better and at decreased risk for injury.
  4. Train in the athletic position.  There is a trend to train folks in a pistol squat position or with the leg in the forward position (Position A).  Studies show that this is an effective position for strengthening the quads.  However, this is not the position that athletes injure themselves in competition.  The core, the limb and center of mass are positioned in a different position.  Therefore, from a specificity, it makes sense to train in more of an athletic position (Position C).  This position has a lot more core, pelvic and glut activation. 

Next week, we will continue that discussion with looking at some specific exercises that we find aid in controlling frontal plane motion.  Stay tuned as I am super excited to share with you.  If you enjoy this blog, please share with your colleagues, athletes and training partners and please be sure to follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention.  Train hard and stay well.  #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,  ViPerform AMI RTPlay, 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 also a Brazilian Jiu Jitsu purple belt and complete BJJ/MMA junkie.