Monday, December 11, 2017

Anterior Cruciate Ligament Injury: Is It Just An Athletic Injury or A Major Life Lesson? – Part II

Last week we talked about psychological factors that are a significant part of rehabilitating the ACL injured athlete.  In this discussion, we talked in detail about sport locus of control, how vital that is and how we can impact this clinically in the very first visit with our athlete.  We also began the discussion about fear and confidence and how these two are categorized together.  For fear is a natural part of this injury, in particular if the injury is a non-contact injury.  For our purposes here, a non-contact ACL injury is being defined as an ACL injury that occurred without contact with another player or object.  Fear is more likely to occur in these athletes in particular because they simply ruptured their ACL because they “moved wrong”.  They are not quite sure what that movement was but they know they moved wrong and if they move wrong again, they might re-injure their ACL.

Any injured athlete will innately have a conscious or subconscious fear of re-injure.  For the ACL injured athlete, this is a legitimate fear as reinjure occurs in 20% of athletes in the first 2 years following an ACL reconstruction.  For many athletes, if this fear is not addressed, this will lead to compensatory strategies that can linger on throughout the remainder of their athletic career.  Some studies indicate that this may be a contributing factor to lateral displacement of the pelvis during the squatting motions which alters force attenuation throughout the lower kinetic chain and can lead to asymmetrical limb development in strength and power.  This not only has implications on potential risk for future injuries but also implications on future athletic performance. 

Some basic level of fear is to be expected and is healthy.  Some athletes need this to prevent them from going overboard and doing something stupid in the initial stages of the rehabilitation process.  However, fear which results in compensation and lack of progress along standardized protocol progression or anticipated timelines is not normal.  Fear which drives changing of lifestyle habits or social interactions is not normal.  Fear which limits progress is not normal.  Fear also increases risk for future injury.

There are a lot of factors that lead to reinjure but an athlete who returns to sport following an ACL injury.  However, those who have measurable fear or lack of confidence in the involved lower extremity are 4-6xs more likely to suffer an ACL reinjure.  So, fear must be overcome and there are things we can do clinically to address this ASAP.  So, how do we identify fear and how do we over come?  Some signs that an athlete is over fearful.

·        They express fear verbally or in an outcome measure (IKDC – International Knee Documentation Committee)
·        They have a lot of hesitation to move knee into terminal knee extension or becomes nauseous with moving knee into terminal knee extension
·        Athlete continues to walk with lack of terminal knee extension
·        Athlete has vagal responses in single leg full weight bearing activities (profuse sweating, nausea, drop in blood pressure, tunnel vision, dizziness, etc)
·        Athlete is visibly fearful of putting full body weight on the involved lower extremity or refuses to put full body weight on the involved lower extremity

These are just a few signs and there are many others.  That said, if we detect fear in our athlete or they voice it, we must address it.  As the provider, we cannot be afraid to talk about it with the athlete.  Let them know this is normal and why.  Let them know this is something we must overcome and how we are going to approach it.  By providing the athlete with education on fear and starting them in weight bearing activities early on will aid in building confidence and alleviate fear. 
Studies show that sooner an athlete starts full weight bearing activities and specifically single leg activities, the more confidence they get and the less fear they have.  Hence this is why we have also included confidence in this section.  Why does an athlete lack confidence in the limb?  One reason is fear and another is they have not sufficiently stressed the limb in single leg activities enough to build that confidence.  If an athlete lacks confidence, then they are also at a greater risk of reinjure.  Therefore building confidence early is vital.  Besides the encouraging them, successfully performing single leg activities is an important part of building confidence in an athlete. 

Does fear and lack of confidence really occur in the “manly” athlete?  Absolutely.  We can all think of professional athletes that we have seen that have had an ACL reconstruction that may be lacking some confidence.  We visually see this as their hesitation to move to the involved side.  Whether it is a cutting pattern to that side or throwing kicks with that particular leg, confidence is built very early in the process.  Starting an athlete on single limb activities early in the process (and as the protocol allows) improves their confidence so when it comes time to do more cutting and explosive work on that side, they can do this with a very high degree of confidence that their knee will be able to support them under that load.  Doing this and educating them about the movement patterns that are associated with non-contact ACL injuries will not only aid in building confidence, reduce fear but will also aid in the neuromuscular retraining needed to prevent these pathokinematics we see associated with these injuries.

The final aspect is communication among providers.  This is just as important to building confidence your referral sources have in you as much as with the athlete.   Next week we will dive into this in more detail, so stay tuned.  If you like what you read, the biggest compliment you can give is to share the passion.  Follow us on twitter @ACL_prevention or follow us on Facebook at Athletic Therapy Services and #MoveRight.



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, December 4, 2017

Anterior Cruciate Ligament Injury: Is It Just An Athletic Injury or A Major Life Lesson?

Over the course of the last several years, we have looked at multiple papers highlighting the long term effects an anterior cruciate ligament (ACL) injury has on our athletes.  We know there is an impact to the long term joint health and athletic performance, but we can’t ever ignore the impact on the future systemic health and psychological status of the athlete.  It always surprising how few people completely understand the totality of the “life impact” these injuries have on our athletes.  This is especially true in our younger athletes.  But, we should all realize if we address the psychological factors immediately, it will not only impact the immediate results and outcome but also the long outcome, future athletic performance and long term psychological status of the athlete.  Case in point.

Imagine for a moment that you are a star high school athlete.  Everything you do revolves around your sport and your identity as an athlete of that sport.  All your friends are athletes, your teachers see you as an athlete and you identify yourself as athlete.  Even your family and relatives see you as an athlete.  It is always a topic of school conversations, social interactions and family discussions.  So, imagine you have an ACL injury and all of the sudden, in one day, everything that you have known is suddenly and dramatically changed.  Your personal identity has changed!

It is seeing it and realizing it from this perspective that helps us understand why so many young athletes suffer depression as the result of an ACL injury.  According to 2014 statistics from the NCAA, Division I athletes who suffer an ACL injury have a reported higher rate of depression, average of 1.0 drop in GPA and have a higher rate of obesity.  Knowing this, addressing the psychological component has to be a huge and vital part of the rehabilitation process.  As a parent, it is imperative that the provider “you choose” for rehabilitation not only has experience in rehabilitation of the ACL injured athlete but also has an approach that is conducive to addressing the psychological component of this injury.  Remember it is your choice and you should choose someone that you feel will address the physical and psychological components of your child’s injury. 
Is this too touchy feely for athletics?  Some might say yes but what does the research tell us?  

According to a 2013 paper published by Ardern et al in the American Journal of Sports Medicine, several psychological factors that must be addressed in order to optimize outcomes, performance and successfully and safely return to sport are:
  •  Sport Locus of Control
  •  Fear
  •  Confidence
  •  Communication among providers


What is Sport Locus of Control?  Sport locus of control is simply, “Does the athlete feel like they have control over their own destiny”?  Think about it.  Would you want to be in control of your destiny or would you want to control your destiny.  What happens when you feel like you have no control?  It is depressing, right.  Now think about that from the athlete’s perspective.  After an ACL reconstruction, so many athletes feel like they have no control over their future destiny.  This is extremely hard for an athlete as it is their control over their destiny, their hard work, their focus and their dedication that has led to their success in their individual sport.  Now, there is a tendency to feel they have to now rely on someone else for them to be able to have a successful outcome and return to sport.  Their fate now resides in the ability of someone that they know very little about and/or may have only known for a short period of time.  So how do you address that as a clinician?

This is addressed Day 1 of the rehabilitation process.  Something as simple as the therapist’s body language and/or patient interaction can have a very positive or very negative impact.  As a therapist, make sure you are reading your athlete’s body language and status.  They are great, especially initially (when they are in beginning phases and more vulnerable) of expressing this non-verbally.  Look for it and respond appropriately to.  If done well, this will be a huge component of building a very solid report with your athlete.  So many times you can tell by how the athlete is responding to you, whether or not they are asking leading questions or whether they are withdrawn or disengaged or simply how they are posturing their body.  Those are some of the obvious signs.  Some of the not so obvious signs are how are they sleeping, are they still engaged in their social circles, are they losing or gaining weight, or have they become angry or despondent.  

One thing that should always happen on Day 1 is that the therapist must give the athlete sport locus of control.  A statement as simple as:

“I am here as your coach and your educator.  I will teach you what to do and why.  I will coach and encourage you throughout the process.  But, it is up to you to dig deep, stay focused and keep your head in the game.  This will be your toughest game yet, but you can and you will do it.  I will help you do it but you are in control.  This is not something that cannot be overcome and it is not an undouble task.  This is where champions are made and you are a champion.”

In this scenario you are explaining your role, their role, letting them know they are in control and that you believe in them.  Now this may be a little elaborate or over the top, but you get the idea.  The goal of the therapist is just as much clinical treatment as it is professional motivation.  If the athlete is given this control and truly believes they have sport locus of control, they will be much more successful.

The next two factors that impact the psychological status of the athlete are fear and confidence.  We categorize these two together as these really go hand in hand.  Next week we will dive into these two in more detail, so stay tuned.  If you like what you read, the biggest compliment you can give is to share the passion.  Follow us on twitter @ACL_prevention or follow us on Facebook at Athletic Therapy Services and #MoveRight.



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 27, 2017

How Do We Know When It Is Time To Return To Sport - Part VI - Guest Blog

Last week, Eric Dinkins, PT, MS, OCS, Cert MT, MCTA took us on a journey to help us understand the impact on neuroplasticity in ACL rehabilitation and prevention.  This week, Eric will help us understand some ways we can influence this in our training.

What is my Inferior Temporal Gyrus? 
And why haven’t I up-trained this for my ACL Clients?

What we learned last week leads us to question how are we addressing.  What are we doing for enhancing visual feedback for our ACL or currently healthy clients? How are we up-training them visually in the attempt to prevent overload in the athletic environment?  If we know they can’t feel the knee like they used to….literally…how can we impose a greater demand on vision to help adapt more than there body, but also their brain?

Here are a few tips on how you can start addressing this need with your clients:

1)    Start changing our cues and attention to an External Focus (see our blog on external focus)
2)    Ensure that we are challenging our clients in an open environment, as soon as it is safely possible, performing dual tasks frequently
3)    Consider giving you and the client immediate visual feedback during skill training early in rehabilitation with a device such as the Motion Guidance Clinician Kit
4)    Consider taking visual feedback away at times during advanced mechanoreceptor training exercises to continue to challenge the body with different inputs.  This might be particularly challenging for the client on altered surfaces or to advance already mastered skills.  But imperative to help the athlete develop 'predictive behaviors' or feedforward skills in sports rather than relying solely on feedback mechanisms.

The two videos below demonstration how we can use visual feedback with the Motion Guidance Clinician kit during squat progressions.

Lower Chain Tutorial with Motion Guidance Visual Feedback


 Lower Extremity Dynamic Progressions



Hopefully this information has stimulated your own approach to rehabilitation of this challenging population.  We need to be aware of utilizing all possible body systems to maximize the ability of our clients to be ready to return to their best potential in their athletic or work environments.

-Eric and Tal

Motion Guidance

Eric & Tal - Thank you both so much for another great blog contribution.  As a physical therapist with over 20 years of practice, I am continually amazed by what we don't know and are continuing to learn.  The science is great at guiding us on what we should do but it is up to us as clinicians and practitioners to apply this in a way that captures the essence of the science in combination with the innovation and art of what we do.


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 20, 2017

How Do We Know When It Is Time to Return to Sport - Part V - Guest Blog

As we close out this series, we are going to once again hear from Eric Dinkins, PT, MS, OCS, Cert MT, MCTA as Eric poses the question:

What is my Inferior Temporal Gyrus? 
And why haven’t I up-trained this for my ACL Clients?



ACL injury is prevalent in athletics.  Not only are there immediate injury and changes, but there is substantial evidence that there are long term changes associated with this injury including: osteoarthritis, alterations in gait, changes in body awareness and psychology, and weakness as well as increased risk of further musculoskeletal injury compared to non-injured individuals. Even more studies have reported unresolved neuroplastic changes after injury, reconstruction, and rehabilitation that may limit function and return to sports participation.  There has been a large focus in the past decade of creating preventative programs and limiting exposures to potential injuries through conditioning and body awareness.  However, decreased body awareness is inevitable with ACL injury.  Trauma to the ACL has been shown to modify how the nervous system processes the interactions between vision and sematosensation. The loss of previously recognized reflexes and gama motor neuron drive to prepare the CNS function to engage appropriately may require “up-training” of other systems, such as increased utilization of visual feedback, to maintain the required sensory input for motor control.



Recently in JOPST, Dustin Groomes, MEd, ATC, CSCS, from The Ohio State University recently discussed the importance of understanding the changes in body systems and neuroplasticity after ACL injury.  Groomes describes how training the biomechanical factors of the ACL injury may not address all the physiologic consequences. But the capacity for neuroplasticity after injury and during rehabilitation can present an opportunity to close the gap by targeting a broader spectrum of sensorimotor function during neuromuscular training.  This can be captured by the non-contact (majority) ACL injury.  Generalizing the break down of the typical action is:

  • A failure to maintain knee neuromuscular control while attending to an external focus of attention under highly complex visual stimuli, variable surfaces, movement planning, decision making, during classically an open environment. 


During this changing environment, the sensory systems 3 main afferent pathways of vestibular, visual, and somatosensory provide complex integrated information.  This is rapidly acquired and processed to produce efferent neuromuscular control to maintain adequate stability and control.  The interaction between vision and somatosensation is particularly critical for motor control during environmental interaction. This interaction is compromised even after ACL reconstruction. The ACL receives nerve fibers from the posterior articular branches of the tibial nerve. These fibers penetrate the posterior joint capsule and run along with the synovial and periligamentous vessels surrounding the ligament to reach as far anterior to the infrapatellar fat pad. Disruptions in this input yield immediate changes in neuroplasticity and can lead to mechanical changes and compensations that may not be properly or fully rehabilitated during typical training focused solely on biomechanical changes and strength gains.

The loss of ability to relay on the bodies typical reflex afferent inputs may require “up-training” of supplementary mechanisms such as increased utilization of visual feedback to train and maintain required sensory inputs for motor control. 

Groomes further states that individuals in his fMRI studies demonstrated increased activity in the posterior inferior temporal gyrus.  This area has been linked to many cerebral functions, but may primarily be involved with visual processing of movement.  This area must work together with the hippocampus, in order to create an array of understanding of the physical world. The information received in this area is sent to the Primary Visual Cortex (V 1) for processing determining the outputs from the Motor Cortex (M 1). The increased activity in this area post ACL injury may suggest that there is an increased utilization of visual processing and motor planning for movement simultaneous with depression of the somatosensory function of the ACL previously discussed.
        

  
Simply put, the body is nothing except adaptable.  Even in ways that we don’t even understand, yet.  But it seems that if we injure our ACL, the brain automatically changes its preference to more visual based inputs to assist in making decisions for motor control.  What about those who aren’t injured yet?  On the flip side of that coin, Swanik reported, in 2007, initial findings of decreased visual reaction times and processing speeds as predictive of ACL injury. Perhaps we need more visual based processing and challenges during our preventative strategies as well?

Next week, we will begin to discuss how this can be influenced with training.  

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, 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.