Monday, April 16, 2018

Does Previous Knee Injury Impact Performance & What Can We Do About It? - Part II


Last week, we looked at whether or not an ACL injury impacts an athlete’s future performance.  Based on what we learned from the Read et al and Mai et al studies, we know that an ACL injury and ACLR does have an impact on future athletic performance.  So, the obvious take home is that we need to somehow try to prevent these injuries.  How do we do that?

If we take football in isolation, the obvious question becomes, how do NFL Players’ ACLs get injured?  Most would assume that in a violent collision sport like football that the injury occurs from a contact with another player.  Some in the media have suggested that as a result of the new concussion rules and players being required to hit lower, that this is resulting in an increase in ACL injuries.  This assumption is based on the assumed fact that the majority of ACL injuries in football are contact in nature. 

Based on an analysis of NFL data from 2013 to 2016, there were a total of 202 ACL injuries.  Of the 202 ACL injuries during this time, 73% (147) were non-contact in orientation.  This means that the mechanism of injury was not another player striking the knee or the player during the injury.   Further analysis reveals that 66% of ACL injuries in the NFL are isolated to 5 key positions:
  • Wide Receivers – 19.4%
  • Linebacker – 15.5%
  • Cornerback – 11.7%
  • Offensive Line – 10.7%
  • Defensive End – 8.7%
This data is based on public record and what information is available through the NFL.  But does this hold true in the research and if so, what is there a common mechanism that results in the player rupturing their ACL?

Johnson et al published a paper in the American Journal of Sports Medicine in 2018 that looked to determine just that. 

Purpose:  The purpose of this study was to describe the mechanism, playing situation, and lower extremity limb position associated with ACL injuries in NFL players through video analysis to test the hypothesis that a majority of injuries occur via a contact mechanism.

Methods:  In this study the authors performed a retrospective cohort of National Football League (NFL) players with ACL injuries from 3 consecutive seasons (2013-2016).  Of the 156 ACL injuries identified, 77 (49%) occurred during the regular season and playoffs with 79 (51%) occurring in pre-season and training camps.  Video analysis was available for 69 injuries which was reviewed to determine the mechanism of injury. 

Results: The majority of ACL injuries analyzed occured vai a noncontact mechanism (50 of the 69 or 72.5%).  The only exception to this was offensive lineman who had only 20% of their ACL injuries by noncontact mechanism.  The most common activity leading to the noncontact injury was pivoting or cutting.  The most common position of the limb during the injury was hip adduction/flexion, early knee flexion/abduction and foot abduction/external rotation.  There was no association between injury mechanism and time of play or playing surface.

Discussion:  The results of this study suggest that the majority of ACL injuries in the NFL occur from noncontact mechanism with the lower extremity exhibiting a dynamic valgus moment at the knee.  This lead the authors to suggest that to reduce these types of injuries prevention programs should assess for these movement patterns and develop intervention programs which address.

Aside from these points, there are also some additional key points that came out of this study. 

  1. Lineman are more susceptible to contact ACL injuries.  This fact has led a lot of teams at the professional and collegiate level to proactively brace players.  Conceptually this might seem like a great idea, but there is very little support that this prevents ACL injuries in contact sports.  Additionally, we need to think about what this brace does to gait (how you walk and run) and muscle EMG activity.  What we do know is that players wearing two ACL braces walks and runs with an altered gait and EMG activity of the quads and hamstrings is decreased.  So what is the answer?  We may not have the answer to that yet but we do need to think about how we address this.
  2. Over 1/2 of ACL injuries are in the preseason.  In preseason, a lot of players are coming into preseason and camp in a deconditioned state.  Knowing the majority of these injuries are non-contact in orientation, that certain biomechanics add to increased risk of these injuries and that targeted training programs have been shown to decrease risk for these injuries, it seems implementing a post season and preseason movement training program would be beneficial.  
  3. No association between injury rates and time of play.  This is basically stating that fatigue did not play a role in the non-contact ACL injuries.  There are several authors that suggest that fatigue does play a role and a whole other contingency that states fatigue does not play a role.  For those in the fatigue does not play a role camp, they site that the literature simply does not indicate this is the case. 
We are going to save this for our next discussion to look at, does fatigue play a role.  Stay tuned next week as we look at this in more depth.  Also, please make sure to check out our new website at www.iceperform.com where our goal is to help you help others.  #ViPerformAMI



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, April 9, 2018

Does Previous Knee Injury Impact Performance & What Can We Do About It?


One of the first questions an athlete, who tears their anterior cruciate ligament (ACL), will often ask their physician is if they will be able to return to play.  The answer most physicians provide is yes, 80-90% of athletes do return to play to the same level of play.  However, what coaches, strength coaches, athletic trainers and physicals therapists have often wondered is if that return to play really means the athlete is returning to their previous level of performance?  Over the course of the last decade, researchers have attempted to start answering this question. 

In 2014, Rugg et al published a study in the American Journal of Sports Medicine that looked at division I athletes who suffered an ACL injury prior to their division I career.  What this study showed was that athletes who had an ACL injury prior to their division I career were at an 8 fold increased risk of injuring their knee or ACL, would spend more time on the disabled list and would cost the university more money than a non-injured athlete.  These findings are nothing new to college athletic administrators and have often driven recruiting decisions.  Based on these findings, one may speculate that this is isolated to division I athletes.  Seeing the implications this could have in athletics, this has spawned more researchers to look into this subject more and try to provide more clarity. 

Does a previous ACL injury impact performance in the professional athlete?  This is exactly the question that authors are attempting to answer.  In 2017 Read et al published a study in the American Journal of Sports Medicine that looked at the impact of ACL injuries on defensive lineman’s performance.  What the authors of this study showed was that 61% of defensive lineman were able to return to play following an ACL reconstruction (ACLR).  This is a much lower number than what has been reported previously in both the literature as well as the orthopedic community.  This study further showed that NFL players who had an ACLR started in 24% less games (57% vs. 81%) and had 30% less solo tackles (2.38 vs. 3.44).  These results mean that the player is not only contributing less to the overall team’s performance as a result of the injury but the player’s personal income is also impacted.  Knowing that players at this level get bonuses based on performance, if their performance goes down then so does their personal compensation. 

So, is this just isolation?  Is there truly an impact to a player’s performance after an ACLR?  That leads to one of the current studies we would like to examine.  Mai et al published a paper in the American Journal Sports Medicine 2017 titled: Performance-Based Outcomes After Anterior Cruciate Ligament Reconstruction in Professional Athletes Differ Between Sport. 

Purpose: In this study the authors wanted to see if there are differences in performance-based outcomes that exist after ACLR between professional athletes of different sports.

Methods: In this study the authors looked at players from the National Football League (NFL), National Basketball Association (NBA), National Hockey League (NHL), and Major League Baseball (MLB) who had undergone a primary ACLR for an acute rupture.  Players were identified through an established protocol of injury reports and public archives. Sport-specific performance statistics were collected before and after surgery for each athlete. Return to play (RTP) was defined as a successful return to the active roster for at least 1 regular-season game after ACLR.

Results: Of 344 professional athletes who met the inclusion criteria, a total of 298 (86.6%) returned to play. Some interesting findings by sport:

  • NHL players had a significantly higher rate of RTP (95.8% vs 83.4%) and a significantly shorter recovery time than athletes in all the other sports.
  • NFL athletes experienced significantly shorter careers postoperatively than players in all the other sports and had the lowest rate of active players 2 and 3 seasons postoperatively.  NFL players also had a decrease in performance for up to 2 years postoperatively.
  • NBA players showed decreased performance at season 1 after ACLR but recovered to baseline performance during the 2nd season.

Discussion:  These findings provide some interesting points.  We know from the research and injury data that NHL players suffer less ACL injuries than NBA and NFL players.  There are several potential reasons for this including:

  • Biomechanics of movement – for the NHL player, their lower kinetic chain does not go through the similar biomechanical patterns as a running athlete.  Due to the skate and the skating motion, the forward propulsion is not the result of the bounding motion that a running athlete goes through. Therefore the ground reaction force and the adduction moments that other athletes are subjected to, the NHL player is not subjected to. 
  • Muscle physiology of movement – in NHL players, the forward propulsion that occurs requires a significant activation of the gluteus medius and gluteus maximus.  Both of these muscles are directly responsible for preventing of the adduction and internal rotation moments that occur at the knee and therefore are often not an area of great weakness in these athletes.

In addition to these findings in NHL players, some of the other results that stick out is the impact that an ACLR has to the NFL player.  Based on the results of this study, an NFL player who has an ACLR:

  • Will have their athletic performance impacted for up to 2 years after their ACLR
  • Will have their athletic career reduced by 2 years

These results can be devastating to an NFL player.  Considering that the average NFL player’s career is only 5 years, this can have a huge impact on their career earning potential.  In addition, if their bonuses from game to game and season to season depends on their performance, if their performance is decreased for 2 years post ACLR, then this also has a huge impact on their long term professional sports earnings. 

So, now that we know that most athletes’ performance is impacted by an ACL injury, how do we prevent them?  Stay tuned next week as we explore this question and more.


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, April 2, 2018

If Your Going To Do It, Do It Right - Part II

Last week, we started our discussion about focusing on technique with exercise.  We discussed how training bad technique will equate to bad performance and reduce the impact we will have on injury risk.  So, before we get into any specific movements, let' look at a study that actually shows us why we talk about some of what we do.

Reference Article: Omi et al - Am J Sport Med - 2018  

In this particular study, the authors did a 12 year prospective study looking at the impact of hip focused injury prevention program had on female basketball players. 

Methods:

This study was a prospective study conducted for 12 years on college female basketball players.  Incident rates of ACL injuries were collected in the first 4 years (observational period).  After the observation period, a hip focused ACL injury prevention program was implemented for 8 years (intervention period).    This study included a total 309 players who were 19.6 years old (+/- 1.2 years) that were tracked for 4 years and compared to 448 players who were 19.6 years old (+/- 1.1 years) that participated in the intervention period.  Athletic exposures (AEs), ACL numbers and mechanism of injury (MOI), relative risk (RR), absolute risk reduction (ARR), numbers needed to be treated (NNT) and compliance was tracked and analyzed.

Intervention:

During the course of this program, athletes performed the following exercises with various progressions within each exercise.

Athletes participating in the program were progressed or upgraded to the next level 3 times during the season.

Results:

There were 16 ACL injuries (13 non-contact) in the 4 year observation period.  There was 9 ACL injuries (8 non-contact) were recorded in the 8 year intervention period.  The overall ACL incident rate was .25/1000 AEs in the 4 year observation period and .10 /1000 AEs during the 8 year intervention period.  The non-contact ACL injury indidence was .21/1000 AEs during the 4 year observation period and .08/1000 AEs in the 8 year intervention period.  The mean compliance rate was 89%.

Conclusion/Discussion:

It is apparent from this study that a hip focused program demonstrates significant reduction in non-contact ACL injuries in women's collegiate basketball.  Although the authors describe this as a hip-focused program, a further analysis of the program  reveals a program that is focusing on the core and hips.   Prevention of the primary non-contact ACL injury is critical to an athlete's future joint health as well as their future risk.  Wiggins et al - Am J Sport Med 2016 showed that 1 in 4 young athletes who tear their ACL will retear their ACL at some point in their athletic career.  Studies are also showing (Lopes et al - Am J Sport Med 2017), programs like this have a direct impact on the biomechanical factors associated with risk.  Further, Riddler et al - AM J Sports Med 2017 showed hip strength not only puts an athlete at risk for ACL injury, but also puts them at risk for other lower kinetic chain injuries.

Although the injury prevention aspects of this are great and much needed, we need to be able to message this so that athletes, coaches and parents also see the performance aspects of this.  We know from previous Rugg studies (Rugg et al - AM J  Sport Med 2014) that if an athlete injuries their knee they are at an 8 fold increased risk of injuring their knee during college athletics.  This means they will not be able to participate in sport and will not be contributing to the team's overall performance.  If this is a high value player, this can have a large impact on the team's overall seasonal performance.  In addition, Mia et al Am J Sports Med 2017 showed that NFL football players who tear their ACL have a decrease performance for up to two years after the injury and shorten their career by an average of two years.  So, again the prevention of the primary ACL injury is critical.

Looking at some of the specific exercises, it become apparent why technique is vital.  In the 180 degree turn and jump (Diagram A), the athlete has a band around the knees so they have to actively reduce the valgus motion that often happens with this motion and which adds to increased risk.  In the lateral side step with a ball catch, they again have a band around the knees which the athlete has to actively reduce the valgus.  In either of these exercises, if the athlete were to perform these with repeating the valgus motion at the knee with each rep, then they would simply be reinforcing the bad movement patterns, bad motor patterns and the net result would be this is the movement they would go to when in sport.

Interestingly enough, when you look at a lot of hte exercises that are used in this reference study, they are very similar to those that are used in the ACL Play It Safe Program.  As such, we are seeing a direct correlation with athletes who have a low compliance with the program itself or a low compliance with the technique end up having less than optimal results.  These three exercises are critical and a great example of why it is important to have proper technique.  In exercise A (sidelying clam with a band) you see the athlete's hip pointing straight forward while externally rotating at the hip.  This is a great exercise for the gmed.  However, if the athlete rolls their hip back during this exercise (which is a minor compensation and sometimes hard to see), this will shorten the Gmed and sigificantly decrease the gmed activation (Willcox et al J Ortho Sports Phy Ther 2013).

In both the standing hip adduction and single leg balance with dribble, it is imperative that the athlete is controlling not only the magnitude of valgus that occurs at the knee but also speed at which that occurs.  According to Nordin & Frankel (Basic Biomechanics of the Musculoskeletal System: 3rd Edition) joint force is determined by both the magnitude and speed at which the motion is imparted.  As such, in training, it is important to make sure the athlete focuses on controlling both of these factors.  If not, then the pattern that is trained is what the athlete will revert to when they are in competition or in practice.

Technique is everything.  Next week, we will look at some specific movements or key movements for athletes to focus on controlling.  Help us ring in 2018 right by spreading the word and helping to prevent athletic injuries. #ViPerformAMI #ACLPlayItSafe #ResearchThatWorks


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 26, 2018

If Your Going To Do It Do It Right!

This pretty much goes without saying.  Something my father taught me as a young man.  Son, if your going to do something, make sure you do it right!  My dad had a lot more colorful words he used about doing a job 1/2 way which may not be appropriate here but the message is the same.  If you do it, do it right or don't do it at all.  No statement could be more appropriate than that when dealing with exercise.  Especially if we are training an athlete to make a change in their movement patterns.  If you are going to train someone to improve their movement, the worst thing you could do for them is train BAD movement patterns.  This simply reinforces the neuro pathways they have created that results in the pathological movements.  In other words, what you train is what you get!  


Poor Technique = poor motor planning = poor performance

As someone who has been weight training for over 40 years, I have always struggled when I see those that are performing exercises incorrectly.  When I was younger, I felt that I did not know enough so who was I to say anything.  After completing my physical therapy education, I wondered if they just did not know enough.  Now, after a few years behind my belt, a few more degrees and a lot of work and research in this area, I feel compelled to say something.  No correction, to SHOUT something.  If you are going to do it, do it correctly!

Whether I am in the gym watching people work out independently or with a personal trainer, or they are in a clinic and a patient is performing exercise under the direction of a PT or on the field and performing exercises under the direction of a strength coach or athletic trainer, the message is the same.  If your going to do it, do it right.  That goes without saying right!  Unfortunately, that is not the case and many times not the standard of practice.

As much as we would hope that this would be the case when people are doing this under the direction of educated professionals, the reality is, it is rare that there is a focus on movement quality. Take this example of an individual training their core.  Studies show that the muscle with the highest EMG activity during this exercise is the gluteus medius (gmed) on the down side.  So, what we see here is an individual that is performing this exercise believing they are training for maximum efficiency of the gmed.  Matter of fact, to make it more difficult, they are raising their arm to make it even more difficult.  The reality is, in this position, they are shortening their gmed on the down side and lengthening it on the up side.  So, instead of strengthening their gmed, they are in fact training and reinforcing the neurological pathways that results in  pathological movement patterns (in this case a retrotrendelenburg).  So, when this person is in an upright posturing, they have essentially trained themselves to compensate in single leg stance with a retrotrendelenburg.  When we test these athletes and we do not see a change in their movement patter despie training, 9 times out of 10, this is the result of poor training technique.

So, in this series, we will discuss some specific movements that we want to ensure that the athlete is doing correctly.  So, hang with us as we break down a couple of research studies and critical movements to keep an eye out for.  Help us ring in 2018 right by spreading the word and helping to prevent athletic injuries. #ViPerformAMI #ACLPlayItSafe #ResearchThatWorks


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 19, 2018

Supporting the NATA Position on ACL Prevention

Have you seen it?  The National Athletic Trainers Association published a position statement on ACL Injury Prevention.  One of the leading authorities in sports medicine and in injury prevention has come out with an official statement on preventing ACL Injures.

As stated in the NATA's position statement, lower extremity injuries account for 66% of all sports injuries with the knee being the most commonly injured joint.  ACL injures are quite common in athlete and unfortunately reconstruction and rehab do not prevent long term consequences.  Holm et al Am J Sport Med 2012 showed that 79% of those who have an ACLR end up with osteoarthritis in 12 years.  Considering this, the initial cost of an ACL injury is high but the down stream consequence is much higher than we currently know or can quantify.

Therefore, prevention of the primary ACL injury is critical.  According the the NATA position statement, a program should:

  • Have an impact on injury prevention and performance enhancement.  The program should include components of at least three categories (strength, plyometrics, agility, balance and flexibility).
  • Training intensity - the program should be performed at progressive intensity levels that are challenging and allow for excellent movement, quality and technique.
  • Training volume - the program should be performed during pre-season and while in season at least 2 to 3 times per week.
  • Programs are effective when implemented as a dynamic warmup or as a part of a comprehensive strength and conditioning 
  • Programs should target athletes who participate in high risk sports (basketball, soccer, Lacrosse) and especially females or those with a history of an ACL injury.
This is great that such a influential organization such as the NATA comes out and makes this position statement on ACL injury prevention.  We share a similar passion, preventing injuries in youth athletics.  For those that have followed this blog long enough have seen some discussion on the ACL Play It Safe Program.  Ironically, this was launched in 2016 and to date has been used with over 3000 kids across the US.  Ironically, it almost appears as if this position statement was written directly for the ACL Play It Safe Program.

For those not familiar with, the ACL Play It Safe Program is a comprehensive progressive program that is performed 2-3 days per week as a part of practice.  But let's break it down and see how this fits the NATA position statement.

  • The program is a multicomponent program including strength, flexibility, balance and plyometrics.
  • The program is progressive in nature with 4 levels of exercise to allow the athlete to progress in their movement training.  In addition, there is a video for each movement provided in a free app where technique with each is emphasized.
  • The program is performed 2-3 days per week as a part of practice and only takes 15 minutes.
  • The program is implemented as a dynamic warmup at the beginning of practice and also includes fatigue state training that is performed at the conclusion of practice.
  • This program targets all high risk sports and female athletes.
  • Our research is showing not only a reduction in all lower extremity injuries but also improvements in performance measures.
In addition to the above, the program includes standardized equipment for each athlete.  This way, we can provide resistance and the resistance that is provided is standardized and does not vary based on what is available that day to the athlete.  

The evidence is clear on what we need to do.  One of the leading authorities in the profession has come out and stated what these programs should include.  We all have access to the this program.  So, let's take action, implement and help our kids move better, perform better and last longer.

Stay tuned as next week we discuss exercise technique.  If your going to do it, do it right!  



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 12, 2018

Innovations in Sports Science - Recovery

For an athlete, recovery is just as important as the exercise portion of our intervention.  Just as there has been advances in exercise, there has also been advances in recovery tools & equipment.  The recovery tools that we will discuss today fall into three categories, mobility tools, soft tissue/myofascial release and pneumatic compression.  The specific tools we discuss are ones that we have been exposed to and use.  But this should not be considered an endorsement of these products.  If you are interested in these tools, you should investigate them independent of this discussion.  We should all understand there are a lot of other tools out there and these are simply the ones we have the most experience with.

Mobility Tools:  Foam rollers have long been a part of our tool kit when dealing with athletes.  Everyone has their own little spin on mobility exercises with them and advancements in this area often include varying degrees of stiffness, varying contours of the roller and varying surfaces (smooth, ridges, pressure balls).  However, one company has taken the foam roller to a whole new level.  Hyperice started in 2010 and primarily in the area of some new ice compression devices.  Although these are great and something we use, this is not the focus of our discussion.  In 2012, hyperice launched a product called the Vyper.  

The Vyper is a foam roll that incorporates high intensity vibration.  Some suggest that including vibration during a stretch results in tonic vibration reflex but studies are not clear on this (Cakar et al. J Phy Ther Sci 2015).  As  with any innovation, it may take a while for the science to catch up and explain why it works.  End of the day, athletes love it and from an N of 1 (trying it on myself), it does aid in my recovery.  For myself as well as the athletes that I work with (which are mostly lower extremity), they get a lot of benefit of use post exercise.  Typically, we will apply this, followed by soft tissue work then closing out with the pneumatic compression.    

For our athletes, we use this to facilitate stretches and provide some myofascial release.  Typical protocol includes performing at the end of the exercise session.  Everyone has their own philosophy on doing before or after, for me, I find the best therapeutic effect doing at the conclusion of exercise.  Typically I have the athlete roll their  IT band, hip flexors, Quads, Hamstrings and calves with the Vyper.  Each of these are done while the athlete simultaneously does a gentle stretch to the area.

Soft Tissue/Myofascial Release:  This is a big and growing area.  Some of the biggest innovations in this area in the last 5 years is IASTM (instrument assisted soft tissue mobilization).  There are a lot of different products out there and as a clinician with over 20 years of experience, I can say personally, the advent of these devices has saved my career and my hands.  Personally I think one of the most valuable tools we provide our patients is our hands and ability to use them in a therapeutic fashion.  The tools that I use the most are Hawk Grips.

There are a lot of great tools out there and a lot of great certifications, this one just happens to be my preference.  Working through an athlete's myofascial restrictions can sometimes take a lot of pressure through the clinicians hands and joints.  I would consider myself a fairly strong guy but many times what I was able to do for an athlete was more limited by my joint pain than the athlete.  With IASTM tools, this has greatly enhanced the therapeutic effect that I can provide.  Typical protocol is using the IASTM tools while providing the area with a stretch.  IT band is a perfect example where I will place them in a lengthened position and perform my IASTM.  I may even include some gentle contract relax with this.

Pneumatic Compression:  There are a lot of folks out there that have not experienced this yet. Some may know Game Ready which is a device that provides pneumatic compression along with ice.  We use these devices a lot in sports medicine and especially with our athlete that are recovering from an injury.  For the athlete who is experiencing swelling or is post op, this is the kind of device I will default to.

However, for athletes who are in the later phases of rehab or who are in the performance phases, recovery is still vital but they may not need the cryotherapy aspects of the Game Ready and may benefit from more full limb pneumatic compression.  That is where the Normatec comes into play.  The Normatec is usually placed on both limbs at the same time and for 15 to 30 minute period of time.  During this time, the athlete is usually placed in a recliner and in a relaxed position.   The Normatec goes through phases of compression starting at the foot and works its way up the extremity toward the core.  Athletes often report this as a relaxing massage type feeling.  The evidence supporting the use of this in recovery for the non-injured athlete is very compelling and growing each year.  Typically, this is how we will wrap up a session with the athlete.  So they have performed their exercise routine, done the Vyper, had some IASTM and the finish off with a round of Normatec and come cold water.

Hopefully you found this discussion useful.  If you enjoy our blog, please share with others.  We do this out of passion for what we all do and the more we can touch and influence, the more impact we can have on our respective professions.


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 5, 2018

Innovations in Sports Science - Exercise

In our last discussion we talked about innovations in telemedicine and how these technologies aid us in expediting the care of our athletes.  This results in better outcomes, decreased health care costs and decreased episode of care.  This week, we will discuss the advances in resistance band technology.  When we think of innovations, rarely do we think about bands and how advances or innovations here that can have that big of an impact.

In 2015, TheraBand company released it's newest version of the TheraBand resistance band.  The traditional band used in rehabilitation had not been changed in over a decade, so this was a big step.  With the release of the CLX (consecutive loops), this brought a whole new level of training application for training.  The CLX band pictured here has loops throughout the length of the band.  Traditionally, we would tie the band around itself to create a loop which often led to changes in resistance and band breakage.  With the CLX, we can simply use the loop to anchor this to a body part.

For the work we are doing in movement, this was a huge advantage.  One of the things we know is that in order to reduce valgus from occurring at the knee during single limb exercises, we need to aid in recruiting of the gluteus medius.  Traditionally this was done with a TheraBand placed around the knee during a single leg activity.  The clinician would then provide a adduction stress to the band (pictured here) which would increase recruitment of the gluteus medius.  This exercise does increase recruitment of the gluteus medius but research shows this is less than 50% of MVC (maximal volitional contraction) of the gluteus medius (Gmed).  Knowing that contraction of the Gmed is critical to controlling the magnitude and speed of frontal plane motion of the knee, then how can we train the level of MVC that is needed in sport?

This is where the TheraBand CLX comes into play.  One reason that the exercise mentioned above only includes <50% MVC is due to the fact that only one direction of resistance that the muscle provides is incorporated into this exercise.  If you look at the orientation of the Gmed and Gmax, the Gmed has a component of resisting adduction and internal rotation.  The Gmax also has a component of resisting internal rotation.  It is the combination of the adduction and internal rotation that is detrimental to the ACL as well as other structures of the knee.  Therefore, if we can include components of both adduction and internal rotation into the exercise, this will translate to better carry over from training to sport.  With the advent of the CLX, we are now able to pull in both components.

An example of this is the spiral technique we use with the CLX.  In the video below, we use the consecutive loops of the CLX to loop the band around the leg and attach it to the contralateral limb.  Doing this, when the contralateral limb is lifted, the band will then pull the stance leg into adduction and a component of internal rotation.  Doing so, allows us to perform multiple exercises in single leg stance while the Gmed and Gmax have to resist both the adduction and internal rotation components.  Not only does this add to a higher MVC of both muscles but also has a higher carry over to single limb activities in sport.


In addition to the ability to use the CLX for single limb training, this advancement in the TheraBand technology also allows us to use this band in such a way that we can recruit the entire lower kinetic chain.  In the example below, we are performing a side plank exercise.  This is a great closed kinetic chain exercise for the Gmed and studies show there is a high MVC of the Gmed during this exercise.  By incorporating the CLX, we are not only able to increase the MVC of the down leg but also able to pull in more core, upper body and the contralateral GMed.


Stay tuned as next week we will discuss use of some new technologies to aid our athletes in recovery.


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.