Monday, April 24, 2017

Does Concussion Increase Your Risk For ACL Injury - Part I

Back in 2012 and 2013, I was blessed to be a part of a research team that was performing movement assessments on female soccer players.  This study was designed to assess female soccer players for movement patterns which put them at risk for injury and also negatively impacted their athletic performance.  Initially we were performing these assessments on Division I soccer players.  Quickly we realized limiting ourselves to just Division I female athletes would limit the numbers of athletes in our study and limit the power of our data.  As such, we began to expand this study to include athletes from 11 years old to Division I athletes.

All of the athletes involved in this study fell under our IRB (Institutional Review Board) application and were all involved in organized soccer clubs (developmental leagues) and/or school sanctioned soccer.  During this study, we were collecting (in addition to other information) demographic data, orthopedic history and movement information from a standardized movement assessment.  As we started to assess these athletes, we quickly started to see three common trends, especially in our younger athletes.

  1. Younger athletes who had a history of concussion reported an increase number of non-contact lower kinetic chain injuries (ankle sprain/strains, knee injuries, etc.).  
  2. Athletes who had a history of concussion also performed very poorly on their single limb tests.
  3.  Athletes with a history of concussion also had increased number of losses of balance during the course of our assessment.
This made us hypothesize that athletes who have a history of concussion:
  1. Have an increase risk for LKC non-contact injuries.
  2. Have an increase risk for ACL injuries.
  3. Have a decrease in athletic performance.
As an examiner, this was clearly the case and these would be some strong assumptions based on what we are seeing, the science behind the rational and based on what we see clinically.  But as a scientist, sometimes we need a paper to show us that it may hurt when you pound your thumb with a hammer.  In other words, we need several research papers looking specifically at all the possible variables before we can come to this conclusion.  

What do you think?  Does previous concussion have an impact on athletic performance and injury risk.  Over the course of the next couple of weeks, we will start to dissect that question and look at the impact that concussion has on athletic performance. #ResearchThatWorks #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 developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >3000 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. 

Monday, April 17, 2017

Exercises to Eliminate Pathokinematics - Part XI

To close out this series, we are going to include a final series of exercises we include to push efficiency throughout the system with focus on the lower kinetic chain.

Core - as mentioned throughout the history of this blog, we have provided numerous research articles highlighting the importance of the core for both mitigating risk of injury and improvement of athletic performance.  Included here are two key core exercises we use that we find have the largest impact on lower kinetic chain movement.

Plank Crawl - this video demonstrates the plank crawl which is done with the CLX band and the stability trainer.  This not only brings in a tremendous amount of core but also activates the Gmed in the transition phases of this exercise.


Side Plank with CLX Gmed Activation - this exercises is extremely difficult and is great at activating the core as well as the GMed.  This is a more advanced exercise and is done with the CLX. 

 

In addition to increasing activation of the core, we also want to increase activation of the Gmed.  The following exercises are a progression series that can be done to increase activation of the Gmed with the use of the CLX.

Gmed Series Level III

GMed Series Level IV



Dr. Nessler is a practicing physical therapist with over 17 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 and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

Monday, April 10, 2017

Exercises to Eliminate Pathokinematics: Part X

Last week, we continued our discussion on the single limb training.  Although there are a plethora of exercises that could be used, we are just outlining a couple that we find beneficial.  This series, when emphasized during the eccentric phases of the exercise not only aid in improving single limb performance but also aid in building eccentric strength of the hamstrings which is critical to reduce part to reducing hamstring strains/sprains.

Modified Single Leg Dead Lift:

Level I:  Standing on the right foot, with a slight bend in the right knee, flex at the hips while reaching towards the arch of the right foot with your left hand and the outside of the right foot with your right hand.  Once you have obtained the end of your available range, without flexing in the lumbar spine or increasing the flexion in the knee, return to the starting position.  Perform 3 sets of 10-20 reps focusing on 3-4 seconds to lower to the end range and 1-2 seconds for returning to the upright starting position.  Repeat on the left.



Level II:  While holding a dumbbell in each hand and standing on the right foot, with a slight bend in the right knee, flex at the hips while reaching towards the ball of the foot.  Once you have obtained the end of your available range return to the starting position.  Perform 3 sets of 10-20 reps focusing on 3-4 seconds to lower to the end range and 1-2 seconds for returning to the upright starting position .  Repeat on the left.


NOTES: Start with a weight which you can perform this exercise without loss of balance, “cork screwing” at the hip or loss of neutral pelvic positioning.  Once you are able to perform with #25 dumbbells, for 20 reps, progress to Level III.

Level III:  While holding a #45 weight bar in your hands and standing on the right foot, with a slight bend in the right knee, flex at the hips reaching toward the ground in front of your supporting leg.  Once you have obtained the end of your available range, return to the starting position.  Perform 3 sets of 10-20 reps focusing on 3-4 seconds to lower to the end range and 1-2 seconds for returning to the upright starting position.  Repeat on the left.  Progress in weight.





 Level IV:  While standing on the right foot on a foam pad, hold a straight bar in your hands.  With a slight bend in the right knee, flex at the hips while reaching towards the ground in front of the right foot.  Once you have obtained the end of your available range without flexing in the lumbar spine, return to the starting position.  Perform 3 sets of 10-20 reps focusing on 3-4 seconds to lower to the end range and 1-2 seconds for returning to the upright starting position.   Repeat on the left.  Progress in weight



KEYS TO SUCCESS:  Key points with this progression is to keep the non-stance hip in a neutral position (no hip extension or flexion) and the lumbar spine in a neutral position (maintain throughout without allowing spinal flexion or extension).  It is important to maintain “proper positioning” of the hip and knee as well (no adduction at the hip or internal rotation).  Preventing these will strengthen good movement patterns and prevent reinforcement of bad habits.  Only reach as far as you can while maintaining proper positioning at the hip and spine in the neutral position.   In addition, focusing on the eccentric phases allows you to push eccentric strength of the hamstrings.

Dr. Nessler is a practicing physical therapist with over 17 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 and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 




Monday, April 3, 2017

Exercises to Eliminate Pathokinematics: Part IX

Last week we discussed some specific techniques that can be used to drive single limb performance.  As reported in the literature, we know that single limb performance or stability in single limb is the best indicator of both injury risk and performance.  Knowing this we will continue on with this series looking at some additional single limb exercises we have found effective.

Single Leg with Dynamic Lower Extremity Movement:

 Level I:  Standing on the right leg with knee at ~20 degrees flexion, reach forward with the left leg while maintaining stability of the right knee in the flexed position.  Return to the starting position and immediately reach in the posterior direction.  With all directions only reach as far as you are able to while maintaining stability of the knee.  Perform 3 sets of 10-15 reps in each direction without touching the left foot down.  Repeat on the left.  Progress only when there is sustainable stability with both limbs and symmetry in distance reached.


Diagram 1: Indicates the directions reaching when standing on one foot.  The weight bearing foot is placed directly in the middle of the diagram.


Level II:  Standing on the right leg with knee at ~20 degrees flexion, reach forward with the left leg while maintaining stability of the right knee in the flexed position.  Come back to the starting position and immediately reach the left foot out in the lateral direction.  Return to the starting position and immediately reach in the posterior direction.  With all directions only reach as far as you are able to while maintaining stability of the knee and without touching the left foot down.  Perform 3 sets of 8-10 reps in each direction.  Repeat on the left.  Progress only when there is sustainable stability with both limbs and symmetry in distance reached.



Diagram 2: Indicates the directions reaching when standing on the right foot and reaching with the left foot.  The weight-bearing foot is placed directly in the middle of the diagram.

Level III:  Standing on the right leg with knee at ~20 degrees flexion, reach in the lateral direction with the left leg while maintaining stability of the right knee in the flexed position.  Come back to the starting position and immediately reach the left foot out in the posterior lateral direction.  After returning to the starting position, immediately reach the left foot out in the posterior direction.  Return to the starting position and immediately reach in the posterior medial direction.  With all directions only reach as far as you are able to while maintaining stability of the knee and without touch the left foot to the floor.  Perform 3 sets of 8-10 reps in each direction.  Repeat on the left.  Progress only when there is sustainable stability with both limbs and symmetry in distance reached.




Diagram 3:  Indicates the directions for reaching when standing on the right foot.  The weight-bearing foot is placed directly in the middle of the diagram.

Level IV:  During the course of this exercise, you are only going to be moving in the posterior medial direction, however, you will be alternating from right to left.  Standing on the right leg with knee at ~20 degrees flexion, reach in the posterior medial direction.  While returning to the starting position, hop to the left foot while reaching in the posterior medial direction with the right foot.  Alternate back and forth between the right and left while maintaining stability at the hip and knee.  With all the motions only reach as far as you are able to while maintaining stability of the knee.  Perform 3 sets of 8-20 reps in each direction.  Repeat on the left.  Progress only when there is sustainable stability with both limbs and symmetry in distance reached.


Diagram 4: Indicates the direction of reach when standing on the left foot.  The weight-bearing foot is placed directly in the middle of the diagram.

Level V:  During the course of this exercise, you will stand in front of a block wall/plyo wall/ or rebounder while holding a ball in your hands.  You will perform the above exercise again, but when performing the exercise and once you have reached the maximal distance you can reach while maintaining stability of the knee, you will simultaneously throw the ball so that it rebounds back at you. Catch it and immediately hop to the other leg and move into the posterior medial direction with the opposite leg.  With all directions only reach as far as you are able to while maintaining stability of the knee.  Perform 3 sets of 8-20 reps in each direction.  Progress only when there is sustainable stability with both limbs and symmetry in distance reached.



Diagram 5:  Indicates the directions reaching when standing on the right foot.  The weight-bearing foot is placed directly in the middle of the diagram.


Dr. Nessler is a practicing physical therapist with over 17 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 and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 
 

Monday, March 27, 2017

Exercises to Eliminate Pathokinematics: Part IIX

Last week we discussed the lumbar hip disassociation exercises that are used as a part of the ACL Play It Safe Program.  These particular exercises are ones we implement with the CLX Spiral Technique.  This technique pushes single limb performance and drives increased EMG activity of the gluteus medius.  This week we are going to discuss additional techniques that can aid in pushing single limb performance in addition to hip strength, endurance and proprioception.

Single Leg Proprioceptive Neuromuscular Facilitation (PNF) with Hip Flexion: 

Level I:  Standing on your right foot, reach across mid-line with the left hand while flexing and slightly rotating at the hips allowing you to reach toward the right knee.  Only reach as far as you are able to maintain stability of the knee.  It is important to make sure you are not rotating in the spine but that the motion is coming from the hip.  Return to the starting position.  Perform 3 sets of 10-20 reps.  Repeat on the left.


Level II:  Standing on your right foot, reach across mid-line with the left hand while flexing and slightly rotating at the hips allowing you to reach for the right little toe.  Only reach as far as you are able to while maintaining stability of the knee and without rotating in the spine.  Raise by extending and rotating at the hips and raising the left hand thumb up over your left shoulder.  Follow the motion of the left hand with your eyes throughout the exercise.  Perform 3 sets of 10-20 reps.  Repeat on the left.

  




Level III:    With a small medicine ball (1-2#) in your left hand and while standing on your right foot, reach across mid-line with the left hand while flexing and rotating at the hips allowing you to reach for the right little toe. Only reach as far as you are able to while maintaining stability of the knee and without rotating in the spine. Raise by extending and rotating at the hips and raising the left hand thumb up over your left shoulder.  Make sure to follow the motion of the ball in your hand with your eyes throughout the exercise.  Perform 3 sets of 10-20 reps.  Repeat on the left.






NOTES:  If unable to perform without maintaining knee position or without rotating in the lumbar spine, then modify the range of motion.  The most difficult portion of the exercise is at the end of the range of motion at the reach and when the hand is moving over the head.  If needed, progress the reach first then add in the hand over head.

KEYS TO SUCCESS:  Only reach as far as you can (both toward the foot and with hand overhead) while maintaining proper positioning.  If having difficulty maintaining proper position at the knee and core, then start with lighter ball or decrease the height of the throw.

The athlete's ability to create stability in single limb performance during dynamic explosive movements is critical to mitigating risk and improving performance.  The two exercises here are meant to aid in developing that stability and should be performed at the beginning of an exercise session.

Single Leg Hop - athlete is asked jump in a maximal vertical fashion.  This can be initiated in front of a mirror to provide visual feedback or another device (Motion Guidance) to provide additional feedback.  The key to this exercise is maintaining frontal plane stability during acceleration (take off) and deacceleration (landing).



Single Leg Hop Toss - this can be done with a toss or kicking a ball.  The key is to maintain frontal plane stability of the lower kinetic chain throughout the exercise.




Dr. Nessler is a practicing physical therapist with over 17 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 and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

Monday, March 20, 2017

Exercises To Eliminate Pathokinematics - Part VII

Last week we discussed the Lumbar Hip Disassociation Exercise sequence.  This is a great starting point to start providing athletes with the ability to discern the difference between hip motion, lumbar motion and femoral motion.  In addition to this series and with the advent of the #Theraband #CLX, we are now able to apply this same training methodology with the CLX.  This creates an even more challenging sequences in SL Stance.  With the incorporation of the CLX, this allows us to create resistance in internal rotation and valgus stresses which further increases EMG activity in the gluteus medius in the stance leg. 

These same exercises are a key component of the ACL Play It Safe Program.  One key component of doing these exercises is the "CLX Spiral Technique" that is done with the CLX band. 



In this technique, open the last loop of the CLX band and place this around the upper thigh of the athlete so that the next loop is located between the legs.  Take the CLX and wrap it from inside to outside (wrap from posterior thigh to lateral thigh to inner).  Complete two complete spirals so that one is located at mid-thigh and the second is just below the knee.  Place the contralateral foot in the CLX loops near the end so there is enough tension that the stance leg is being pulled into a valgus and internally rotated position.  The key wit these exercises is to maintain neutral position of the stance limb and resist the CLX pulling into internal rotation and valgus.

CLX Lumbar Disassociation - Level I - The following video provides instruction in the Level I CLX exercise.



CLX Lumbar Disassociation - Level II - The following video provides instruction in the Level II CLX exercise.



Dr. Nessler is a practicing physical therapist with over 17 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 and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

Monday, March 13, 2017

Exercises To Eliminate Pathokinematics - Part VI

Last week we talked about the King of all Exercises, the squat.  In the last couple of blogs, we have discussed a couple of ways to address the "lateral shift" with both the Squat Neuromuscular Retraining technique as well as with the squatting series.  It is imperative that the lateral shift is corrected in full body weight movements prior to the initiation of weighted movements. 

Just as equally important is the ability to teach the athlete the ability to discern the difference between lumbar motion and hip motion.  That is the reason for the Lumbar Hip Disassociation Exercise Series we will now investigate.

Lumbar Hip Disassociation Exercise Series: 

The next exercise series to use with the athlete to ensure that the rest of the progression is done correctly is the Lumbar Hip Disassociation Exercise Series. These exercises are used for retraining the athlete’s proprioception, strength and range of motion involving the hip and spine.  Teaching proper technique with this is essential to development of kinesthetic sense and in particular, differentiation between movement in the spine and movement in the hip.  The difference between movement at the hip and at the spine is notoriously difficult to train. 

Specifically, these exercises are designed to teach the athlete the difference between hip flexion and rotation and spinal flexion and rotation.  They are essential to master as they aid athletes’ ability to not only properly isolate the hip musculature which will allow for isolated strengthening but will also allow him or her the ability to activate these muscles during athletic participation.  These exercises are performed with a mirror and the subject is INITIALLY given lots of verbal and tactile or manual cueing at the hips to prevent spinal motion, and teach the athlete the difference between movement at the hip and movement at the spine.  Incorporation of additional visual cueing, like the Motion Guidance System or other similar device can aid in training this in the clinic and during their home exercise program. 

Keep in mind when doing these exercises:  If done in the recommended sequence, by the time that the athlete gets to latter exercises, the legs and hips are going to be tired.  This sequence is designed in this way deliberately.  The gluteus medius typically fails as a result of fatigue, so we want to challenge it as much as we can.  In addition, the gluteus medius also functions primarily in an eccentric fashion, so making sure we are pushing the eccentric phases of the exercise are critical to maximize carry over to sport.  It is VITAL that the athlete have success at these exercises before progressing.  So, if you see that they are failing due to fatigue, stop there.  You can attempt to perform with some slight modifications, but if unable to do that way correctly either, the routine should be concluded at this point.  The intent of this sequence is to teach the athlete the difference between lumbar motion, femoral motion and hip motion.  This sequence will take 15-20 minutes, and progresses in the following manner:

v  Prep Exercise: 

Level I:  First while standing in front of a mirror, in a stride stance with the back foot on your toes and front foot flat, and hands on hips, gently rotate the back stride leg into femoral internal and external rotation while maintaining lumbar neutral, hip in neutral position and “healthy knee alignment”.   Perform 3 sets of 10-20 reps on each leg.












Level II:   Now repeat this exercise while standing only on one leg with the hands on the hips.  Again, gently rotate into the back stride leg femoral internal and external rotation while maintaining lumbar neutral, neutral hips and “healthy knee alignment”.  Perform 3 sets of 10-20 reps on each leg.  











Level III: While standing on one leg with hands on hips in front of a mirror, have the athlete flex forward at this hips doing the “bird in the water glass” maneuver.  Only have them flex forward at the hips as far as they can WITHOUT allowing spinal flexion while maintaining lumbar neutral and “healthy knee alignment”.  The contralateral limb is maintained in hip neutral to slight hip extension.  Return to the starting position and immediately resume hip flexion.  Perform 3 sets of 20 reps on each leg. 











Level IV: While standing on one leg with hands on hips, rotate the stance hip into hip internal and external rotation while simultaneously maintaining hip flexion, as in the “bird in the water glass” maneuver.  Ensure during the course of the exercise that the athlete is maintaining the lumbar spine in a neutral position – e.g., only have them flex forward at the hips as far as they can WITHOUT allowing spinal flexion and while maintaining “healthy knee alignment”.  Return to the starting position and immediately resume hip flexion.  Perform 20 reps on each leg.  Perform 3 sets of 10-20 reps.











KEYS TO SUCCESS:   Only reach as far as possible without loss of a neutral spinal position or loss of control at the knee.  Only progress to those ranges of motion in which these alignments can be maintained.  This is an extremely difficult exercise and need to educate athletes to this fact prior to initiation.  Without this previous instruction, this can lead to frustration and mental fatigue.


Dr. Nessler is a practicing physical therapist with over 17 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 and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.