Monday, August 22, 2016

Improving Movement When It Matters - Part IV

Over the course of the last couple of weeks, we have been looking at the impact of single limb performance and the importance this has to overall carry over to sport and overall injury risk reduction.  For many of us, it is also intuitive the impact that fatigue has on overall risk.  We know from antidotal data, for example, that injuries tend to occur in our players later in the game or day when the athlete is fatigued and not able to respond as quickly.  Despite this fact, very few appear to consider this or apply this when developing both assessments and intervention.

Since the late 80s, there has been over 2000 papers published in the literature outlining the impact that fatigue has on the movement.  As late as 1986, Skinner et al in  J Ortho Research showed that fatigue had an impact on joint position sense of the knee.  In 1999, Rozzi et al J Athl Training showed the effect of muscular fatigue on neuromuscular characteristics in the male and female athlete.  In 2012, Cortes et al J Athl Train showed that a short term fatigue protocol had not only an impact on frontal plane motion but also peak adduction moments expressed at the knee.  Considering, this, we want to take a look at a couple of key studies.

In 2005, Chappell et al Am J Sport Med looked at pathokinematics in a rested state and in a fatigued state on a jump stop in 20 recreational athletes.  First, each athlete performed a jump stop jumping forward, vertical and backward while measuring knee joint angles and ground reaction forces.  This was followed by each athlete then performing a fatigue protocol which consisted of 5 vertical jumps, a 30 yard sprint, 5 more vertical jumps and another 30 yard sprint.  Athletes were then measured again for the same three jump stop testing conditions.  What the authors found was that in a fatigued state, the athletes demonstrated an increase in proximal vertical shear, increase valgus and a decrease in knee flexion (resulting in increased ground reaction forces).  The take home from this is that when our athletes are fatigued, these same stresses will increase at the same time when the athlete is also not attenuating force across the system in an optimal way.  Both of these conditions not only add to an increase in risk for injury but also impact athletic performance. 

Kernozek et al in Am J Sport Med further demonstrated this fact in 2008, showing the impact that fatigue had on increased shear at the knee and decrease in force attenuation.  The fact that there is both an increase in shear and forces distributed to the knee should give us pause!  It should make us wonder if we are not including fatigue as a part of our movement assessment, are we truly getting the full picture of what the athlete looks like or what their risk is.  How can we possibly, if we are not assessing it?

According to  the previously cited studies, we are getting an idea of the impact that fatigue has on knee risk.  But, is this isolated to just the knee?  If we look at the Weist et al study of 2004 in the Am J Sport Med, we see that fatigue impacts more than just the knee.  In this study, the authors looked at the impact fatigue has on the plantar pressure patterns in the foot. The authors evaluated EMG activity of 14 muscles pre and post fatigue in addition to evaluating plantar pressures during a run in 30 experienced runners.  Each runner was put through a maximal exhaustive run and fatigue was measured via blood lactate.  What the authors found was that there was an increase in MT pressures with fatigue.  The authors further concluded that the muscles that had the most significant change in MVC were the G.med, G.max and Med/lateral gastroc, in that order.  The take home from this is that fatigue of the hip musculature results in increased MT plantar pressures.  So, this should make us all question:

  1. If our movement assessment does not take the athlete into some level of fatigue, are we truly getting an true representation of what they look like in a fatigued state?
  2. If our training does not push fatigued state training, is the carry over to sport and fatigued states the best that it could be?
Next week, we will continue this discussion as we look at adding fatigue testing to our movement assessments.

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, 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, August 15, 2016

Improving Movement When It Matters - Part IIIE


Last week we continued our discussion about the importance of single limb training and how frontal plane motion of the knee in the absence of excessive pronation and excessive pelvic motion may be more associated with weakness in the hip complex.  This week, we will conclude this discussion on single limb training by looking at the hip. 

Keeping in mind, the intent of this entire discussion is criterion based progression.  The criteria for progressing single limb training from one level to another is the fact that the athlete is able to perform the previous level while demonstrating good technique and control at the foot/ankle, knee and hip.  So specifically, what are we looking for at the hip?

Hip
As previously mentioned, sometimes due to our hyper focus on the knee, we forget about the hip/core and to closely asses what motion is occurring at the hip.  Is it the pathological motion at the hip that is driving the frontal plane motion at the knee? 

In single limb training, there are three predictable patterns that athletes fall into. 

Trendelenburg:


This is one of the most common and is easiest to identify by what happens on the contralateral side to the stance limb.  In this case, the athlete is standing on his left leg and his gluteus medius on the left side and the core musculature on his right side (obliques, quadratus laborum, multifidus)  is weak.  The result is that the pelvis drops on the non-stance leg side.  This will often lead to a significant shift of center of mass which leads to a loss of balance.  This is easily observed by the athlete needing to touch the non-stance leg to the floor in order to maintain balance. 


Retro-trendelenburg:

This is one of the most commonly missed compensations that occurs with a weakness in the core and pelvis.  In this position, the gluteus medius is placed in a shortened position which has a significant impact on gluteus medius  and core (obliques, quadratus laborum, multifidus) EMG activity.  Try this!  Stand up.  Place your fingers lightly on your right gluteus medius.  Stand on your right leg and put your left leg back in an athletic position.  Feel the muscle contraction and fasciculations occurring in your right gluteus medius.  Now, move over in the position represented in the accompanying picture.  What happens to what you feel on your glut?  You should feel a significant reduction in muscle contraction or almost completely inactive.  By putting your gluteus medius and core in this shortened position, you significantly reduce the muscles' contractual ability. 

This is really important to identify.  If this is not identified, then the likelihood that this will be missed in single leg training is increased.  If that is the case, then training that is being performed to improve gluteus medius and core strength will be much less effective and the athlete will be progressed to a level that they are not ready or capable of performing properly.  This also means the athlete could potentially be progressed to return to sport with this residual weakness which will put them at risk of re-injury with return to sport.

Cork Screw:

This motion is a combination of both a trendelenburg and rotation at the hip.  This represents more advanced weakness of the gluteus medius and core (obliques, quadratus laborum, multifidus).  During this movement, the associated muscle weakness is significant enough that the muscles are failing through a larger range of the motion that they are biomechanically designed to resist. 

These individuals are at a much higher risk for severe pathology at the hip (hip labral tears) as well as non-contact athletic low back injuries.  In addition to the impact to additional injury potential, this motion also has a significant impact on athletic performance.  The magnitude of kinetic energy loss and loss force production is most evident in the lose of vertical jump and sprint speed.  These athletes will also have a much higher risk for loss of balance.  In jumping sports (basketball and volleyball) this then puts them at greater risk for non-contact ankle injuries.

Two simple exercises that can drive improvement in the hip/core strength is the side plank and plank.

Side Plank



EMG studies of the side plank show significant EMG activity in both the gluteus medius in addition to the obliques and quadratus laborum.  The side plank is performed incorrectly 80% of the time by athletes.  Most of them demonstrate a retro trendelenburg during the movement, rotation of the hips or do not have their hips in line with their feet and shoulders.  Ensuring proper technique with this exercise is critical to maximize the training effect. 

Plank


EMG studies of the plank show significant EMG activity of the multifidus and rectus abdominus when performed correctly.  Again, the plank is performed incorrectly 80% of the time by athletes.  Most of them demonstrate a flexed hip position or increased spinal extension or rotation of the hips.  Ensuring proper technique with this exercise is critical to maximize the training effect. 

Next week we will start our discussion on fatigue state training. 


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, 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, August 8, 2016

Improving Movement When It Matters - Part IIID

Last week we continued our discussion about the importance of single limb training and how ankle range of motion and control can impact that.  As we continue that discussion and move up the chain, we now start to look at the knee. 
 
 
 
Knee
When performing movement assessment, we often get hyper focused on frontal plane motion only at the knee.  As described in the above example, this can often lead to missing the "root cause" of the dysfunction and less effective treatment strategies.  If we treated the two examples above exactly the same, then we might have a less effective treatment and potentially not address the true "root cause".


If we look at this example more closely, what we see is that the knee begins to cross midline prior to:

  • Movement of the foot into a pronated position - root cause being more at the foot and ankle
  • Movement of the pelvis into a trendelenburg or corkscrewing position - root cause being more at the core
When we are seeing this motion being driven from the hip complex (frontal plane motion of the knee in the absence of excessive pelvic motion or pelvic motion) this can indicate is weakness in the gluteal region, specifically the gluteus medius and maximus.   This is where exercise targeted to this region can be very effective. 

Glut Med Series:




Use of this exercise allows us to target to the glut medius specifically.  As indicated in the video, position of the feet is critical for those with weak gluts will toe out during this exercise which will limit the strengthening that occurs at the hip.

Single Leg Lumbar Hip Disassociation:


Due to the fact that we don't know if this is associated with weakness/endurance issues in the muscles of the hip or proprioceptive issues in the hip, using this exercise targets both strength/endurance as well as proprioception.  When done properly with proper hip positioning, we find this results in significant increase in EMG activity of the gluteus medius.

Next week, we will conclude this discussion on single limb training with our examination of what is going on at the hip.

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, 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, August 1, 2016

Improving Movement When It Matters - Part IIIC

Last week we talked about the importance of single limb training and how, by using a criterion based approach, we not only impact kinesiophobia and strength, but also drive improvements in movement that have much higher carry over to sport.  Before we move off the subject of Single limb training, there are several things we need to talk about.

In a criterion based approach, in order progress from one level to the next, we must be able to perform the prior level with good technique.  What exactly does that mean?  This means one must be able to perform the exercise while demonstrating good control at the:
  • Foot and ankle
  • Knee
  • Hip

Foot/Ankle Range of Motion
Starting at the ground and moving up, let's first look at the foot and ankle.  First in order to have good control of the foot/ankle, you must first have adequate range of motion at the ankle.  When looking at the literature, there is not a lot of literature letting us know how much motion at the ankle does an athlete need to do a single leg squat or single leg hop.  So in one of our recent studies, we looked at ankle dorsiflexion in over 700 injured and non-injured athletes.  Looking at the non-injured athletes (N=300), we found the mean ankle range motion to be following:


The mean range of motion for dorsiflexion for single leg squat was 33 degrees and those that had scored lower (higher risk and/or injured) had a mean range of motion for dorsiflexion <20 degrees. 


For a single leg hop, the mean range of motion for dorsiflexion was 30 degrees and those that had scored lower (higher risk and/or injured) had a mean range of motion for dorsiflexion <15 degrees.  What we can take away from this is that we should shoot for 30 degrees or > dorsiflexion range of motion for someone to perform a single leg squat correctly with good form.  So from a criterion based perspective, 30 degrees or > dorsiflexion could then be a criteria we consider prior to starting of single leg squatting activities in order for someone to do it right with proper technique.

When dorsiflexion range of motion is an issue, aside from the traditional exercises we do, there are also some dynamic stretches we can do that will aid in driving improvement in dorsiflexion range of motion in full weight bearing, in a closed kinetic chain and during motion. 

Dynamic Sumo:


In this dynamic stretch, you will see throughout several portions of this exercise we are pushing DF range of motion that is much greater than 30 degrees of dorsiflexion throughout various ranges of motion of the proximal links. 

Dynamic Lunge:



In this dynamic stretch, we continue to push dorsiflexion ranges of motion exceeding 30 degrees throughout various portions of the movement.  If you have an athlete with limited DF, this will typically result in predictable movements that are easily observed. 

Foot/Ankle Stability
In addition to range of motion at the ankle, having the neuromuscular control at the foot and ankle is critical injury prevention and whole kinetic chain stability.  Yet, this is often a movement that is missed in most movement assessments. 

 
As you can see from this picture, when just looking at the knee, this looks like a valgus or frontal plane motion at the knee.  Yet in one picture, we see the hip fall first and in the second picture, we see the foot fall first.  Why does that matter?  Same athlete yet the training will be considerably different on the right side versus the left side.  On the athlete's left side, we can see we need to do more ankle, intrinsic and foot/ankle proprioception versus the hip strengthening and proprioception on the athlete's right side. 
 
Next week we will continue this discussion and talk about the impact at the knee and hip.
 
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, 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. 

Thursday, July 28, 2016

Improving Movement When It Matters - Part IIIB

Last week, we discussed why we should consider doing single limb training as a normal part of our performance training but also as a part of our return to sport.  Laying out exactly how one should progress through single limb training is very dependent on the what type of procedure has been done and the physician's protocol.  The information provided here should never be considered in place of advice or recommendations provided by your health care professional.

In health care, there are typically two schools of thought related to progressing an athlete along a continuum.  One which is much more of a medial model/physician based approach is a time based approach.  The athlete will progress to running or plyometrics once the tissues are healed to the point that they can withstand the associated stresses and loads with those activities.  However, many times the tissues may be ready but the neuromuscular and muscular system may not be ready for those kinds of activities. 

The other approach is more of the athletic training/physical therapy based approach which is the criterion or movement based approach.  Once the tissues are healed and ready to withstand the associated stresses, the athlete is not progressed until they are biomechanically sound with the previous lower level or complexity of movements.  The following discussion follows along both of those continuums and however we will only discuss the movement criteria needed for progression. 

In the realm of single limb training, following a criterion based or movement criterion based approach is critical to ensure we are not re-training poor movement patterns but training proper movement patterns.  Although someone's tissues may be healed to the point that they can attempt certain movements does not mean that they are necessarily ready to start said movements.  By following this approach, we are also putting positioning the athlete for a safer return to sport. 

Following is a simple progression for low levels of single limb training to more aggressive levels of single limb training along with some criteria that we can use to make sure one is progressing safely from one level to the next.  This is by no means a comprehensive progression but can provide some ideas on how to progress.

Level I - Partial weight bearing (PWB)  - weight shifts to single leg stance & single leg press
  • Once cleared to start PWB we will typically start weight shifts.
  • Once cleared to start WBAT, we will start full weight shifts to single leg stance
    • Criteria to progress - perform single leg stance without trendelenburg or retrotrendelenburg and without movement of the knee in the frontal plane.
  • Once cleared to WBAT, start single leg press at 20% body weight and progressing up from there
    • Criteria to progress - perform full body weight leg press without movement of the knee in the frontal plane.
Level II - Full weight bearing (FWB)
  • Once cleared to FWB start body weight squats through partial to full ROM.
    • Criteria to progress - perform full ROM body weight squat without lateral shift (shift away from the affected limb) and without movement of the knee in the frontal plane.
  • Standing Gmed (use affected leg as the stance leg) with theraband.
    • Criteria to progress - perform 20+ reps with green theraband without trendlenburg or retrotrendelenburg at the hip and without movement of the knee in the frontal plane.
  • Standing Gmed Isometrics (used affected leg as stance leg) against a wall.  Alternate angles 30 - 45- 90 - 110.
    • Criteria to progress - perform 20+ reps at varying angles without trendelenburg and without movement of the knee in the frontal plane.
Level III - Prior to running
  • Single leg squats - progressing partial squats to 45 degree squats.
    • Criteria to progress - symmetrical knee flexion during squats, no trendelenburg/retrotrendelenburg and without movement of the knee in the frontal plane.
  • Dynamic Lunge - progressing from dynamic lunge stretch to full lunge exercise.
    • Criteria to progress - symmetrical motion bilateral, no movement of the knee in the frontal plane with step through and good hip extension bilateral

  • Side stepping with Theraband
    • Criteria to progress - perform 20+ reps with keeping feet pointed straight


  • Single leg lumbar hip disassociation with Theraband
    • Criteria to progress - perform 20+ reps without trendelenburg, retrotrendelenburg and without movement of the knee in the frontal plane.

  • Single leg hop
    • Criteria to progress - perform 10-15 reps without trendelenburg, retrotrendelenburg and without movement of the knee in the frontal plane.

This is just one example of a progression and some of the criteria used to determine what should be accomplished prior to progressing to the next level.  There is a plethora of exercises that could be used in place of these but the concepts should be the same.  You train the movement you want.  Train trendelenburg or movement of the knee in the frontal plane during single limb exercises this is what you will get when the athlete returns to sport.

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, 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, July 25, 2016

Improving Movement When It Matters - Part IIIB

Last week, we discussed why we should consider doing single limb training as a normal part of our performance training but also as a part of our return to sport.  Laying out exactly how one should progress through single limb training is very dependent on the what type of procedure has been done and the physician's protocol.  The information provided here should never be considered in place of advice or recommendations provided by your health care professional.

In health care, there are typically two schools of thought related to progressing an athlete along a continuum.  One which is much more of a medial model/physician based approach is a time based approach.  The athlete will progress to running or plyometrics once the tissues are healed to the point that they can withstand the associated stresses and loads with those activities.  However, many times the tissues may be ready but the neuromuscular and muscular system may not be ready for those kinds of activities. 

The other approach is more of the athletic training/physical therapy based approach which is the criterion or movement based approach.  Once the tissues are healed and ready to withstand the associated stresses, the athlete is not progressed until they are biomechanically sound with the previous lower level or complexity of movements.  The following discussion follows along both of those continuums and however we will only discuss the movement criteria needed for progression. 

In the realm of single limb training, following a criterion based or movement criterion based approach is critical to ensure we are not re-training poor movement patterns but training proper movement patterns.  Although someone's tissues may be healed to the point that they can attempt certain movements does not mean that they are necessarily ready to start said movements.  By following this approach, we are also putting positioning the athlete for a safer return to sport. 

Following is a simple progression for low levels of single limb training to more aggressive levels of single limb training along with some criteria that we can use to make sure one is progressing safely from one level to the next.  This is by no means a comprehensive progression but can provide some ideas on how to progress.

Level I - Partial weight bearing (PWB)  - weight shifts to single leg stance & single leg press
  • Once cleared to start PWB we will typically start weight shifts.
  • Once cleared to start WBAT, we will start full weight shifts to single leg stance
    • Criteria to progress - perform single leg stance without trendelenburg or retrotrendelenburg and without movement of the knee in the frontal plane.
  • Once cleared to WBAT, start single leg press at 20% body weight and progressing up from there
    • Criteria to progress - perform full body weight leg press without movement of the knee in the frontal plane.
Level II - Full weight bearing (FWB)
  • Once cleared to FWB start body weight squats through partial to full ROM.
    • Criteria to progress - perform full ROM body weight squat without lateral shift (shift away from the affected limb) and without movement of the knee in the frontal plane.
  • Standing Gmed (use affected leg as the stance leg) with theraband.
    • Criteria to progress - perform 20+ reps with green theraband without trendlenburg or retrotrendelenburg at the hip and without movement of the knee in the frontal plane.
  • Standing Gmed Isometrics (used affected leg as stance leg) against a wall.  Alternate angles 30 - 45- 90 - 110.
    • Criteria to progress - perform 20+ reps at varying angles without trendelenburg and without movement of the knee in the frontal plane.
Level III - Prior to running
  • Single leg squats - progressing partial squats to 45 degree squats.
    • Criteria to progress - symmetrical knee flexion during squats, no trendelenburg/retrotrendelenburg and without movement of the knee in the frontal plane.
  • Dynamic Lunge - progressing from dynamic lunge stretch to full lunge exercise.
    • Criteria to progress - symmetrical motion bilateral, no movement of the knee in the frontal plane with step through and good hip extension bilateral

  • Side stepping with Theraband
    • Criteria to progress - perform 20+ reps with keeping feet pointed straight


  • Single leg lumbar hip disassociation with Theraband
    • Criteria to progress - perform 20+ reps without trendelenburg, retrotrendelenburg and without movement of the knee in the frontal plane.

  • Single leg hop
    • Criteria to progress - perform 10-15 reps without trendelenburg, retrotrendelenburg and without movement of the knee in the frontal plane.

This is just one example of a progression and some of the criteria used to determine what should be accomplished prior to progressing to the next level.  There is a plethora of exercises that could be used in place of these but the concepts should be the same.  You train the movement you want.  Train trendelenburg or movement of the knee in the frontal plane during single limb exercises this is what you will get when the athlete returns to sport.

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, 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. 





Improving Movement When It Matters - Part IIIB

Last week, we discussed why we should consider doing single limb training as a normal part of our performance training but also as a part of our return to sport.  Laying out exactly how one should progress through single limb training is very dependent on the what type of procedure has been done and the physician's protocol.  The information provided here should never be considered in place of advice or recommendations provided by your health care professional.

In health care, there are typically two schools of thought related to progressing an athlete along a continuum.  One which is much more of a medial model/physician based approach is a time based approach.  The athlete will progress to running or plyometrics once the tissues are healed to the point that they can withstand the associated stresses and loads with those activities.  However, many times the tissues may be ready but the neuromuscular and muscular system may not be ready for those kinds of activities. 

The other approach is more of the athletic training/physical therapy based approach which is the criterion or movement based approach.  Once the tissues are healed and ready to withstand the associated stresses, the athlete is not progressed until they are biomechanically sound with the previous lower level or complexity of movements.  The following discussion follows along both of those continuums and however we will only discuss the movement criteria needed for progression. 

In the realm of single limb training, following a criterion based or movement criterion based approach is critical to ensure we are not re-training poor movement patterns but training proper movement patterns.  Although someone's tissues may be healed to the point that they can attempt certain movements does not mean that they are necessarily ready to start said movements.  By following this approach, we are also putting positioning the athlete for a safer return to sport. 

Following is a simple progression for low levels of single limb training to more aggressive levels of single limb training along with some criteria that we can use to make sure one is progressing safely from one level to the next.  This is by no means a comprehensive progression but can provide some ideas on how to progress.

Level I - Partial weight bearing (PWB)  - weight shifts to single leg stance & single leg press
  • Once cleared to start PWB we will typically start weight shifts.
  • Once cleared to start WBAT, we will start full weight shifts to single leg stance
    • Criteria to progress - perform single leg stance without trendelenburg or retrotrendelenburg and without movement of the knee in the frontal plane.
  • Once cleared to WBAT, start single leg press at 20% body weight and progressing up from there
    • Criteria to progress - perform full body weight leg press without movement of the knee in the frontal plane.
Level II - Full weight bearing (FWB)
  • Once cleared to FWB start body weight squats through partial to full ROM.
    • Criteria to progress - perform full ROM body weight squat without lateral shift (shift away from the affected limb) and without movement of the knee in the frontal plane.
  • Standing Gmed (use affected leg as the stance leg) with theraband.
    • Criteria to progress - perform 20+ reps with green theraband without trendlenburg or retrotrendelenburg at the hip and without movement of the knee in the frontal plane.
  • Standing Gmed Isometrics (used affected leg as stance leg) against a wall.  Alternate angles 30 - 45- 90 - 110.
    • Criteria to progress - perform 20+ reps at varying angles without trendelenburg and without movement of the knee in the frontal plane.
Level III - Prior to running
  • Single leg squats - progressing partial squats to 45 degree squats.
    • Criteria to progress - symmetrical knee flexion during squats, no trendelenburg/retrotrendelenburg and without movement of the knee in the frontal plane.
  • Dynamic Lunge - progressing from dynamic lunge stretch to full lunge exercise.
    • Criteria to progress - symmetrical motion bilateral, no movement of the knee in the frontal plane with step through and good hip extension bilateral

  • Side stepping with Theraband
    • Criteria to progress - perform 20+ reps with keeping feet pointed straight


  • Single leg lumbar hip disassociation with Theraband
    • Criteria to progress - perform 20+ reps without trendelenburg, retrotrendelenburg and without movement of the knee in the frontal plane.

  • Single leg hop
    • Criteria to progress - perform 10-15 reps without trendelenburg, retrotrendelenburg and without movement of the knee in the frontal plane.

This is just one example of a progression and some of the criteria used to determine what should be accomplished prior to progressing to the next level.  There is a plethora of exercises that could be used in place of these but the concepts should be the same.  You train the movement you want.  Train trendelenburg or movement of the knee in the frontal plane during single limb exercises this is what you will get when the athlete returns to sport.

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, 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.