Monday, September 17, 2018

How Will Your NFL Team Perform? - Know Their Injury Rates - Part I

As the 2018 football season kicks off, every football fan wants to know, how will my team do this year?  What if I told you, you may have some insight to how they are going to perform based on their percentage of knee injuries.  If you look at the number of reported knee injuries by NFL team for the 2014-2017 seasons and compare that to recorded wins for those teams, what you find is that teams with the highest % of knee injuries won 33.9% of the time vs. teams with lower knee injury rates won 52.7% of the time.  Why is that?  Lot of reasons for this but one of the primary is that players that tend to get injured more are players who play more, so your better players.  They have more athletic exposures and as such have a great risk of being injured.  So, when the better players are taken out of the game or season, this can have a huge impact on the team's seasonal performance.

One of the most devastating injuries to a professional football player is the anterior cruciate ligament (ACL) injury.  Why is that?  Because the impact this has on their professional career.  A great research article came out earlier this year that highlighted this fact.  In a study by Mai et al Am J Sports Med 2018, the authors looked at the impact that an ACL injury has on athletic performance and the length of professional career in NFL, NBA, NHL and MLB players.  Not only was NFL players performance decreased for 2 years after the ACL but their professional career was also cut short by 2 years on the average.   In a systematic review published by Mohtadi et al Am J Sports Med 2017, their study found similar results.  That although most players return to play, performance measures and stats across the board were reduced following an ACL injury.  So the obvious question becomes, how do we prevent knee injuries in athletics?  So how do you know how your team is going to do?  Look at their preseason ACL and knee injuries.  In the last 5 years alone, there has been an average of 23 ACL injuries prior to week 1 of the NFL season.  23 ACL injuries occurring in preseason camp.  This is more than 1/3 of the ACL injuries that occur during the entire season occur before an official snap has been taken in an NFL game. 

Throughout the course of this blog, we provided some thoughts and research on several factors that contribute to altered biomechanics or pathokinematics that put athletes at risk for an Anterior Cruciate Ligament (ACL) injury.  In a recent study by Johnston et al Am J Sports Med 2018, they performed video analysis of 156 ACL injuries during the 2013-2016 seasons.  What they found was 72.5% of these injuries were non-contact in orientation, meaning no contact with another player or object.  This is important because these are the ones that we could potentially impact and reduce.  Upon review of the video of each of these non-contact ACL injuries, what they found was the limb was in a dynamic valgus position. As pictured below, this can happen when an athlete plants their foot and cuts to the opposite direction.  The limb falling into this position under high loads and high speeds results in a rupture of the ACL. 


In the Johnson study, this led the authors to suggest that we need develop programs that create control of these motions under athletic loads.  We may think this is isolated for professional athletes, but in a recent study by Owusu-Akyaw et al Am J Sports Med 2018, the authors determined this is the same position the lower limb is in when non-professional high school and college athletes suffer a non-contact ACL injury.

Throughout the history of this blog, we have attempted to correlate these same pathokinematics to not only ACL risk but also to changes in athletic and team performance.  The previously mentioned studies further highlight this.  In this authors mind, there are two ways in which these injuries impact performance; directly or indirectly.

The direct impact is the impact that altered biomechanics has to force production and kinetic energy transfer.  When the limb moves, like depicted in this picture, this results in altered length tension relationships for muscles and altered loading patterns.  Simply stated, due to the altered mechanics, the muscles of the core and/or lower kinetic chain are placed in a shortened or lengthened position.  Knowing the impact that length (shortening or lengthening) has on force production, then the muscle cannot produce as much force or power as it could if it were in an ideal length tension relationship.  This results in muscles of the core and lower kinetic chain producing less force.  This means the athlete has decreased hitting force coming off the line, less explosive power to sprint for 50 yard touchdown, or decreased efficiency of movement resulting in altered agility or ability to avoid the tackle.  So these movements have a direct impact on the individual athletes performance.

The indirect impact is after the injury occurs.  The altered biomechanics resulting in a non-contact ACL injury result in an impact on future athletic performance.  However, this concept of how these injuries impact future performance has not been fully investigated.  That said, more and more studies are starting to investigate the impact on future athletic performance.

Case in point, a recent study by Read et al, Am J Sport Med2017, the authors looked at the impact of ACL injuries have on future performance in National Football League (NFL) players. For the purposes of this discussion, we are going to dive into this one in more depth.  

Methods:  38 NFL defensive players with a history of Anterior Cruciate Ligament Reconstruction
(ACLR) from 2006 to 2012 were identified.  For each injured player, a matched control player was identified.  For each player, demographic and performance data was collected.  Players that returned to play (RTPlay) after ACLR (N=23) were compared to players who did not RTPlay after ACLR. 

Results:  At least 74% (28/32) players who had an ACLR RTPlay in the NFL for at least one season game.  61% (23/32) successfully returned to play for at least half of the NFL season (min of 8 games).  In the seasons leading up to their injury, athletes who successfully returned to play started a greater percentage of their games (81%) and made more solo tackles per game (3.44 6 1.47) compared with athletes in the ACLR group who did not return to play.  Athletes in the ACLR group retired significantly earlier and more often after surgery than the matched control group.  In the season after ACLR, athletes who RTPlay started games 57% less times and had only 2.38 solo tackles per game compared to matched controls at 3.44 solo tackles per game.

Conclusion:  Athletes who successfully returned to play were above average NFL players before their injury but not after. 

Next week, we will start to dissect this a little more.  Specifically what does this mean to the team's performance as well as the athlete's overall earning potential.  If you are enjoying our blog, please share it and follow us on twitter @ACL_prevention and on Instagram at @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 and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent is also a competitive athlete in Brazilian Jiu Jitsu. 

Monday, September 10, 2018

Runner's Knee - Part V

Last week, we continued our discussion on how to prevent runner's knee with a discussion of some exercises that can be done for recovery as well as some post run training that helps reduce injuries and performance.  This week, we will wrap up our discussion starting with when should you see the MD for your knee pain?
  • When should a runner go to the doctor for their runner's knee?  In many states, you can see a physical therapist for your knee pain and have this covered by your insurance without seeing a physician.  As the musculoskeletal and movement experts, this can often expedite your return to running pain free.  However, it is important to make sure you get with a therapist who understands runners, running biomechanics and the nuances of dealing with runners.  So make sure to do your research.  
    • Some key indications that you should go see a doctor or a physical therapist:
      • Your pain is preventing you from running.
      • Your pain is limiting your activities of daily living.  In other words, you are having pain with ascending/descending stairs, walking long distances, or it is impending your ability to work or stand for prolonged periods.
      • If you feel like your pain is progressively getting worse.  How do you know if it is getting worse?  First rate your pain according to the scale below.  If getting worse, the pain increases in:
        • Intensity – how bad it hurts.  Pain started at a 3/10 and is now a 6/10
        • Frequency – how often it hurts.  Initially only hurt after runs, now hurts when you walk, during work or after sitting for long periods of time
        • Duration – how long it hurts.  Initially hurt only after a run for about 45 minutes.  Now it hurts for 2 days following a run.
      • Your pain is causing you to limp or altering your running gait.

    • Be Proactive - as we spoke about last couple of weeks with ice and increasing recovery methods, you can often prevent your pain from getting to this level.  Being proactive is KEY.
  • What are some holistic, diet, and/or lifestyle changes that runners can incorporate to prevent and treat runner's knee? Proactively runners can do a lot to prevent runners knee. 
    • First have a running assessment by a qualified athletic trainer, running coach or physical therapist.  Majority of runners, novice and expert, would benefit from a through running assessment.  Two traditional running assessments.
      • Video based – in this type of assessment the clinician will have you run on a treadmill while video tapping your running mechanics.  As mentioned previously, there are a lot of things we can assess with video that tells us a lot about areas of weakness, tightness and overall flaws in the running technique. When identified and corrected this will not only improve performance but decrease risk for running injuries. Couple of things for you to determine if this is right place to do your assessment.
        • Do they use an app or software based technology?  Software based is much more accurate technology.  Dartfish is the most frequently used and the gold standard in these assessments.  Use of apps is good but angles are not accurate and people tend to hold their phone to record (provides poor quality of video).
        • Do they have a standardized protocol? Is the camera secured to a tripod or stable surface.  Is there a sequence they go through with you, varying speeds of run, multiple directions.
        • Are you provided with a comprehensive report?  Some will just review the video with you.  Others will analyze the video and provide you with a comprehensive report.
      • 3D Running assessment.  We typically use a 3D wearable sensor technology that allows us to assess how you run on a treadmill and on the road.  With this technology, once your treadmill assessment is complete, we can then hook the sensors up to you and have you do a 10 mile run outside in your environment.  This allows us to see how you run on different surfaces and for a prolonged period of time.  This will provide us with data throughout that entire event and let us see where and when the system is breaking down.
        • Shoe assessment - in several of our facilities we use this technology as well to help runners choose the right shoe.  This allows the runner to try various pairs of shoes and collect biomechanical data to see what is the better shoe for them biomechanically.  This system will provide comprehensive data to allow you to make a more informed choice on what shoe is better for you.  Below is a snap shot of the data that is provided during the run.
    • Second, stay hydrated and eat a proper diet.  Nutrition and hydration have a direct impact on running biomechanics.  Athletes who are dehydrated and who put subpar fuel in the system break down faster.  Proper diet and hydration also aids in soft tissue repair.  This builds a chemical environment that is optimal for soft tissue repair.  Below is the hydration chart which will help determine your level of hydration based on the color of urine.  


    • Third, get enough sleep.  Most of the time runners knee is the result of the tissues being broken down faster than they can repair.  Getting enough sleep and REM sleep is vital for soft tissue repair and recovery.
    • Fourth, if you run a lot, consider finding a provider that provides recovery tools.  What are recovery tools?  Things like the Hypervolt, Normatec boots, Cryotherapy and dry needling.  All of these are research based methods shown in the research to aid recovery.  There are some out there that are not named here that have no basis in the science but being used a lot in recovery.  Stick with what works and what is supported in the research.  It will help you keep on the road, running pain free and continuing to enjoy a healthy life style.
    We hope you enjoyed this series.  We hope you learned something and more than anything, we hope this helps you keep on the road and injury free.  Stay tuned and please share with others you think might be interested.  #ViPerformAMI #ACLPlayItSafe


    Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent is also a competitive athlete in Brazilian Jiu Jitsu. 

    Monday, September 3, 2018

    Preventing Runners Knee - Part IV

    Last week, we continued our discussion on how to prevent runner's knee with a discussion of the variety of diagnosis's that fall under the category of "runner's knee".  We also spoke about the first line in defense to preventing runners knee.  This week we will start off our discussion looking at stretches that can be performed to prevent runner's knee.
    • What are some exercises and/or stretches people can do at home to treat runner's knee? 
      • Stretches/soft tissue mobilization – in general terms, we typically have all runners work on mobility of the entire lower kinetic chain.  This would include the following stretches/mobility movements which we perform with a vibrating foam roller (Hyperice).  Key is to make sure you are not just “smashing” the tissue but providing a good stretch while providing comfortable pressure.  Use of the vibrating roller facilitates greater relaxation of the muscle and more comfortable stretch through greater ranges of motion.  This aids in recovery following a hard run.  We typically have runners do this on their non-running days or to help recovery following a hard run.  Typically we will spend a good 15-20 minutes on these recovery exercises.  
        • ITBand - Start by lying on the vibrating roller in the position indicated.  Slowly roll the foam roller from the TFL (from the crest at the hip) down along the ITband to the knee.  At the same time, move the leg in an adducted position while bringing the hip toward the floor. 


        • Hip flexor/quad – Start by lying on the vibrating roller in the prone position, keeping your abs tight, roll the foam roller from the anterior hip down along the quad.  You can increase the stretch to the quad by flexing the knee during the motion.


        • Hamstring/Glut – lying in a long sit position, roll the foam roller from the glut along the entire length of the hamstring.  To facilitate hamstring stretch, keeping your knee straight, abs tight, bring your butt to the ground and slowly flex forward while keeping your chest up.   
        • Calf – Sitting in the long sit position with your knee straight, roll the foam roller from the back of the knee to the Achilles tendon.  To facilitate the stretch, as you roll down the calf, slowly dorsiflex (bring your foot up) while keeping your knee straight.


        • Soft tissue mobilization - In addition to the above, we have also found another great tool to aid in recovery that is relatively inexpensive.  The Hypervolt is a percussion gun that we use primarily for soft tissue mobilization and will even use in combination with stretches.  This tool has some solid science behind it and you are now finding this in most athletic training rooms in professional sports.  I find a lot of athletes get some great relief especially when working our muscle soreness from a previous training session.  


        • Pre-Run Routine - In addition to these stretches, we also have runners do the Run Safe pre-run routine prior to each run.  These dynamic stretches aid in creating the level of mobility needed for a run in addition to providing a warm up to the neuromuscular system for providing stability through full range of motion.
    • What are some recommendations you have for runner's if they want to prevent runner's knee, something they can do at home?  The Run Safe program is specifically designed to address the biomechanical issues that result in runner’s knee.  This free app has videos for every exercise and has both a pre-run routine as well as a post run routine.  
      • Pre-run routine - prepares the runner by taking the lower kinetic chain through full functional range of motion all while maintaining stability.  This routine takes 5 minutes to implement and serves a warm up for running.  
      • Post run routine - is done immediately after the run.  This fatigue state training has better carry over to improving a runner’s biomechanics when it matters the most, when they are tired.  These exercises focus on single limb stability, proprioception, glut strengthening and core strengthening.  
      • The Run Safe program - has 4 levels of progression so that as the athlete masters one level, they can move onto the next.  This way they can continue to progress their strengthening program, constantly driving improvement in biomechanics and athletic performance.  This program has not only been shown to reduce injuries in runners but also shown to improve sprint speed and endurance.   


    We hope you are enjoying this series.  Next week we will wrap up our discussion on runners knee.  Stay tuned and please share with others you think might be interested.  #ViPerformAMI #ACLPlayItSafe


    Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent is also a competitive athlete in Brazilian Jiu Jitsu. 

    Monday, August 27, 2018

    Preventing Runners Knee - Part III

    With an increase in popularity of running, we are seeing more and more running related injuries.  This series is devoted to helping prevent one of the most common running injuries, runner's knee.  Although this is catch all diagnosis, last week we started a discussion around some common root causes for non-contact knee injuries and specifically started to discuss stretching.  This week we will continue that discussion on factors that add to poor running mechanics.

    • Faulty running mechanics – there are “a lot” of faulty movement patterns in runners that can result in problems in runner.  This week we will conclude this portion talking about another root cause for faulty running mechanics.
      • Weakness – weakness throughout the lower kinetic chain can add to an increase risk for runners knee.  What we have found in our research is that if you address the most common weaknesses seen in the majority of runners (≥80%) that most will not only have a dramatic reduction in runners knee but will also have a reduction in all lower limb injuries.  Further, we have found that if you train a runner in a fatigued state (low volume specific training done at the conclusion of a run), we not only see them run better (with less faulty mechanics) throughout their run (fresh and when tired) but they also get an improvement in their performance.  This was the inspiration for the development of the Run Safe App.  This is a free app that has a video for every exercise for runners to do prior to their run and immediately following their run.  The program is done 2-3 times per week and progressed to the next level once performance of the previous level of exercises are done with the technique described. 
    • What exactly is runner's knee? What are some of the signs and symptoms runner's should look for?
      • Runner’s knee is basically a general term which encompasses multiple diagnoses.  Some of the most common diagnoses that fall into runners knee category.
        • Patellafemoral pain syndrome (PFPS) – the patellafemoral joint is the articulation between the femur and the patella.  In this joint, the patella rides in a groove in the femur.  In some runners, the patella will move too much in that groove which will cause pain.  Some cases, the under surface of the patella will become worn and develop a rough surface.  If this is the case, you will typically hear crepitus (grinding) under the knee cap as you move your knee from flexion to extension or when doing a squatting motion.  In most cases with PFPS, the pain will be under the knee cap, more of a deep ache and you may experience some grinding.  
        • IT Band Friction Syndrome – this occurs on the lateral aspect (outside) of the knee and is where the ITBand attaches.  If this is tight it will rub on the lateral aspect of the knee as the knee moves from a flexed to extended position.  This will cause point tenderness on the outside of the knee and some cases where the bursa becomes inflamed you may see localized swelling.  In addition, if there is weakness in the hips and the femur moves into a internally rotated position at midstance, this can also place wear on the insertion of the IT band causing pain and irritation. 
        • Patellar tendonitis – this occurs on the front of the knee on the patellar tendon.  When this tendon becomes inflamed (known as tendonitis) it will become painful on the anterior aspect of the knee during squatting motions, ascending/descending stairs and prolonged sitting. In some cases, this pain may start at the beginning of the run but start to resolve as the run progresses or as you get warmed up.  This typically will come back a little worse after the run and after you have cooled down. 
        • Meniscal pain – the meniscus are the shock absorbing structures of the knee.  Minor tears or wear and tear can cause pain.  This will be more of a deep pain in the knee and you may or may not be able to palpate (touch) it.  If you can touch it, it can be on the inside (medial meniscus), outside (lateral meniscus) or posterior medial corner (back inside of the knee).  This type of pain can limit your running and can feel very sharp.  This will also bother you at the joint line after prolonged sitting.  This is sometimes referred to as movie goers knee because people usually notice this after sitting for a long time in a movie.
        • Fibular head instability – this is less common but seen in some cases.  This is felt on the outside of the knee and is commonly misdiagnosed as ITBand friction syndrome.  The fibular head is held in place by the annular ligament.  If this ligament is torn, then the fibular head will move back and forth during running causing the bursa in this area to become inflamed.  The common peroneal nerve also sits right there so runners with this injury may also report an intermittent "zinging" sensation. A simple stability test confirm or rule this out and it can be treated with a athletic training taping technique which provides stabilization to the joint.  
        • Runners knee does not typically include:
          • Bone bruises
          • Ligamentous tears (ACL, PCL, LCL, MCL)
          • Meniscal tears

    • What are some exercises and/or stretches people can do at home to treat runner's knee? 
      • First and foremost – ice.  Swelling and pain inhibit strength.  There is a neurophysiological and psychological impact that pain has on strength.  Therefore, the longer the pain and swelling persist, the more it will impact strength.  Two different types of icing we recommend based on the diagnosis.
        • Patellar tendonitis, ITBand friction syndrome, fibular head instability – ice massage.  Take a paper or Styrofoam cup and fill with water.  Freeze.  Peel the paper away leaving enough that you have enough paper to hold onto the ice cube but exposed area that you can rub on the painful area.  Rub the ice cube on the painful area of 5 mins.  This will create a layer of water between the skin and ice.  This conducts the cold much better but can only be used for tissues that are close to the surface of the skin (like above).  Do this 3-5 times per day until the pain goes away.  Ice until you get back to your normal running routine without pain.
        • PFPS and meniscal pain – use an ice bag for 15 min.  The ice needs to be cold enough to make you numb in 5 minutes but not so cold that it burns your skin.  Ice for 15 min 3-5 times per day until the pain goes away.  Ice until you get back to your normal running routine without pain.

    We hope you are enjoying this series.  Next week we will start looking at additional stretches we can do to avoid runner's knee.  Stay tuned and please share with others you think might be interested.  #ViPerformAMI #ACLPlayItSafe


    Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent is also a competitive athlete in Brazilian Jiu Jitsu. 

    Monday, August 20, 2018

    Preventing Runners Knee - Part II

    With an increase in popularity of running, we are seeing more and more running related injuries.  This series is devoted to helping prevent one of the most common running injuries, runner's knee.  Although this is catch all diagnosis, last week we started a discussion around some common root causes for non-contact knee injuries in runners and how to prevent.  This week we will continue that discussion starting with how poor running mechanics can add to increase risk for injury.
    • Faulty running mechanics – there are “a lot” of faulty movement patterns in runners that can result in problems in runner (arm swing, trunk rotation, etc).  Here we will cover some of the most common ones we see that add to increase risk for runners knee.
        • Foot slap at heal strike.  In this scenario you will hear the foot slap the ground or treadmill.  Typically you get a thump, THUMP when comparing the sound of one foot contacting versus the other.  When this occurs, there is less shock absorption through the foot and ankle and this can lead to shin splints or anterior knee pain (runners knee).   A common root cause for this foot slap is weakness of the anterior tibialis or specifically, eccentric weakness of the anterior tibialis.  As a runner, you will start to feel fatigue in the anterior shin as you run.  As you continue the run, this becomes more intense and this is where you will start to hear the foot contacting harder than the opposite side.  Strengthening the anterior tibialis muscle in an eccentric fashion can help to alleviate or eliminate this.  With your toes hanging off the edge of a step, raise them all the way up (dorsiflex), pause, then slowly lower them to the starting position on a 3-6 count.  
        • Over pronation from heal strike to midstance.  In a closed kinetic chain, like running, when the foot over pronates at midstance, this results in the femur moving into adducted and internally rotated position.  This significantly alters knee mechanics and increases stress to the soft tissue and bony structures of the foot and ankle and the knee.  Although most will try to control this with a shoe, we find better success with a well fit athletic orthotic.  A DPM or PT can do a running assessment to identify and fit with a proper orthotic.  In addition, adding strengthening to the intrinsics of the foot will help.  Couple of ways to do this: place a towel on a smooth surface (tile or wood floor) with a small weight on one end of a towel (#2).  Placing your bare foot on the other end of the towel, scrunch the towel up with your toes attempting to pull the weight toward you.  Another way is while standing bare foot on one leg with knee slightly bent and holding a light medicine ball in your hands (#3-#5), extend your arms out in front of you and toss the ball hand to hand.
        • Knee adduction and internal rotation.  This will most commonly start at heal strike and become more pronounced at midstance.  In the absence of “over” pronation of the foot, this is most commonly the result of gluteus medius weakness.  Keeping in mind, in a closed kinetic chain, if the femur moves into an adducted and internally rotated position to a large degree, the foot will follow by moving into pronation.  So, the question becomes, is this a foot/ankle issue or is this a hip issue.  This is again where a through running and movement assessment can help to target where the root cause is coming from. Strengthening the gluteus medius will help a lot in preventing this.  The following are two great exercises for gluteus medius strengthening. 
    Lumbar Hip Dissassociation 

    Side Plank with CLX
        • Hip Trendelenburg.  This occurs at midstance where the hip drops on the opposite side (depicted here).  This is the result of weakness of the gluteus medius on the stance leg.  The GMed has to contract to stabilize the pelvis during single limb stance (midstance in gait).  Weakness of this muscle results in the pelvis dropping on the opposite side and can put excessive stress through the hip joint (causing hip pain and impingement) and knee.  This altered movement will result in altered force absorption throughout the entire lower limb. Again, strengthening the gluteus medius is key to addressing this.  In addition to the above exercises, you can also add the following exercise.   
    Side Stepping with Theraband  

      • Limited flexibility/Mobility – Limited flexibility and mobility is another issue that adds to increase risk for runner's knee.  Since running is typically a single plane sport (not a lot of lateral or diagonal movement) this can add to tightnesses that can lead to increased risk for runners knee.  Some of the most common tightness’s associated with runners knee:
        • Calves – tightness in the calves will limit the amount of dorsiflexion at the ankle.  With limited dorsiflexion will result in a runner who circumducts their leg during swing through.  This puts increased stress on the knee and foot and ankle.
        • Quadriceps – tightness of the quads can lead to altered force absorption and lead to patellar tendonitis and patellafemoral syndrome. 
        • Hip flexors – tightness of the hip flexors will limit how much hip extension a runner gets at toe off.  This can lead to an altered stride length and rotation of the hips at toe off.  Although this is a common cause for low back pain in runners, it can also result in runners knee.
        • IT Band – although most say they will stretch their IT band, what you are actually doing is stretching your tensor facia lata (TFL).  The TFL attaches to the IT band.  If tight, this pulls on the IT band which puts friction on the lateral side of the knee when moving from a flexed position to a full extended position. 
    For all these tightness’s we recommend stretching prior to your run and including stretching as a normal part of your routine.  Below are a couple we recommend for runners to do prior to their run.

    Dynamic Lunge

    Sumo Squat


    We have found that combining stretches with high frequency vibration and/or percussion not only feels great to the runner but is also very effective.  There are several devices out there for that but one we use is the Hyperice Vyper (vibrating foam roller) and the Hypervolt (percussion gun). 

    We hope you enjoyed this discussion.  Next week we will continue this discussion with talking about certain weaknesses that can add to runner's knee.  If you would like to find out more about how to get a 3D running assessment near you, contact us @ acl@selectmedical.com.  Stay tuned and please share with others you think might be interested.  #ViPerformAMI #DorsaVi #RunSafe


    Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent is also a competitive athlete in Brazilian Jiu Jitsu. 

    Monday, August 13, 2018

    Preventing Runner's Knee

    In the U.S. there are more than 40M runners and it is a sport that continues to see tremendous growth.  Besides the recreational, fitness and competitive aspects, it is also a part of almost every major sport.  As such, this also becomes a medium or training method often employed in preparation for an athlete's main sport participation or pre-season training.  As such, keeping the athlete injury free during running is important for not only their psychological well being but also their physical well being.  According to McKean et al Clin J Sport Med 2006, 46% of runners report some running related injury in the last year.  With such a high percentage reporting a running related injury, what we can do to prevent?  First, we must look at the scope of the problem.

    Did you know:

    • More than 75 percent of runners experience at least one overuse injury during training (Egermann et al. Int J Sport Med 2003).  T
    • The majority of running injuries, more than 90 percent, occur in the lower kinetic chain (Cipriani et al J Ortho Sport Phy Ther 1998)
    • In runners, the knee is the most injured body part (Van Gent et al Br J Sports Med 2007). 
    • 49% of runners report an injury in just the last year of training (Hauret et al Am J Sports Med 2016) 
    • The risk for these injuries increases as runners increase their training mileage (Burns et al. J Orth Sport Phy Ther 2003). 
    • The majority of all running injuries are non-contact in orientation (no traumatic impact, fall or collision) and are considered preventable (Hauret et al Am J Sport Med 2016).
    We know from the research that non-contact injuries can result from predictable movement patterns or altered biomechanics.  Altered biomechanics (valgus collapse) have been shown to cause knee injuries (Hewett et al Am J Sport Med 2017) that are often associated with running. These same movement patterns are associated with all non-contact lower limb injuries often seen in runners, including trochanteric bursitis, patellofemoral pain, iliotibial band friction syndrome (ITBFS) and plantar fasciitis.  In addition, the same movements associated with risk are the same movement patterns that add to decreases in speed and running economy (Myers et al J Strength Cond Res 2005). Studies have shown a correlation between these altered biomechanics and impacts on running gait and injury risk. Asymmetrical hip strength has been shown to add to decreased hip extension at toe-off, increased adduction (knocking knees) and pronation at midstance as well as increased risk for ITBFS (Noehren et al J Ortho Sport Phy 2014).

    With knee injuries injuries being so common among runners, this has led to a catch all diagnosis category called "Runner's Knee".  So what is runner's knee and what can we do to prevent it.  Recently I was asked to contribute to a running article on runners knee.  As such, this spawned me to take a deeper dive in this series to really look at this in depth and see what we can do from a prevention standpoint.

    What are some ways regular runners can prevent runners knee?

    No matter how you define runners knee (patellar tendonitis, IT band friction syndrome, patellafemoral pain syndrome, etc), what the research shows us is that >80% of these are non-contact in orientation.  As such, there is usually a root cause or something else that is leading to the “runner’s knee”.  Therefore to address what we can do to prevent, we first have to look at some common “root” causes of runner’s knee.  Keeping in mind this is not an exhaustive list, it includes only some of the most common “root” causes.

    • Shoes – poor shoes or being fit with the wrong shoe can significantly alter force attenuation (how force is absorbed by your body) during running.  Absorbing shock (or force) is vital to preventing shin splints, lower extremity injuries and runner’s knee. Several problems with shoes can add to your problem.  Some common issues include; damp shoes, worn out shoes, wrong kind of shoe.
      • Damp Shoes - One thing that can add to a decrease in shock absorption is damp shoes.  With increase in dampness of the shoe comes less shock absorption which can add to increase stress to the foot/ankle and knee.  We often suggest having two pairs of running shoes so that you can dry one out while alternating to another pair of shoes.  So, let them dry out!
      • Worn out shoes - Another problem we see with shoes is runners will use the same pair for a year or two.  With time and increase in mileage, the shoes begin to wear down and they lose some of their elastic properties which results in less shock absorption.  This means that more of the ground reaction force at heal strike and midstance is absorbed at the foot and ankle and then at the knee.  Running shoe manufactures vary on their recommendations but most will tell you that you should replace your running shoes anywhere from every 300 to 500 miles.  The more miles you put on the shoe, the less elastic recoil the shoe has which can add to increase in potential for overuse injury.  So, replace worn out shoes!
      • Wrong Shoe - Finally, another issue that we see with shoes is being fit with the wrong
        shoe.  We will often see athletes that are told they pronate or supinate and then are put in a shoe to control for that.  All too often, we will see runner put in a shoe that is supposed to control that when in fact the pronation or supination that occurs does not in fact necessitate a shoe to control.  So, you have a runner who has been running comfortably with over pronation, but not pathological pronation, and you suddenly change that.  But, you are not only changing that at the foot but the entire lower kinetic chain mechanics are then changed.  What we typically do when we assist a runner in choosing a shoe, we typically do a running assessment.  Using a 3D wearable sensor (DorsaVi), we can have the athlete run in three different types of shoes.  This system will provide us with biomechanical data for right and left IPA (initial peak acceleration – how well you control the foot into the ground), right and left ground reaction force at midstance and stance time on the right and left.  This allows us to directly see how well they are controlling the forces through the lower limb and which shoe provides them with the optimal performance and force attenuation.  So, make sure you are picking the right shoe!  It is the first contact point in the kinetic chain.

    We hope you enjoyed this discussion and as we continue next week we will start to look at faulty running mechanics and how this can add to runners knee.  If you would like to find out more about how to get a 3D running assessment near you, contact us @ acl@selectmedical.com.  Stay tuned and please share with others you think might be interested.  #ViPerformAMI #DorsaVi #RunSafe


    Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent is also a competitive athlete in Brazilian Jiu Jitsu. 

    Monday, August 6, 2018

    Psychological Measures for Return to Play Following ACLR - Part VI

    Over the last couple of weeks we have been discussing kinesiophobia (fear of movement) and how if high levels of this are present on return to play that athletes are at greater risk for reinjury.  We also discussed some movement patterns that we see in our athletes that is also highly associated with kinesiophobia.  Specifically those with a lateral shift and increased frontal plane motion and speed of motion during single limb testing tend to have higher levels of kinesiophobia.  During the last 2 weeks, we discussed some training techniques we can employ that will help to reduce these abnormal movement patterns and aid in reducing kinesiophobia.

    Although the majority of our discussion has been around the Tampa Scale for Kinesiophobia as a way of measuring fear with return to play, there is another measure out there called the ACL-RSI.  Webster et al Am J Sport Med 18 did a study to look at generating and validating a short version of the original ACL-RSI scale.  The original ACL-RSI (pictured below) was developed in 2008 and is a 12 item scale that measures 3 types of response believed to be associated with risk of injury: emotions, confidence in performance and risk appraisal. 




















    The short version is a 6 item version that also measures these same three types of responses (it is available as an app).  In this study the authors administered both versions of the ACL-RSI to 535 athletes who had undergone ACLR at 6 months post op.  The predictive validity for return to play at 12 months following ACLR was determined and compared.  The results showed that the short version had a fair to good predictive ability for 12 month return to sport outcomes.  This is great for those of us in a busy athletic or clinical setting as this will help cut down on some time. 

    So when it comes to emotions, confidence in performance and risk appraisal what really matters?  That is what Webster et al Am J Sport Med 2018, sought to identify.  In this study, the authors looked at factors that contribute to an athlete's psychological readiness to return to sport following ACLR.

    Methods:
    635 athletes (389 male, 246 female) who underwent an ACLR and were cleared to return to play filled out the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) questionnaire. In this study the authors captured demographic information (age, sex), sporting outcomes (preinjury frequency of participation), surgical timing (injury to surgery interval), clinical factors (ligament laxity), functional measures (single limb hop symmetry) and symptoms of pain and function (measured via IKDC).  Statistical models were applied to determine association with the above measures and the athletes psychological readiness for return to play.

    Results:
    After univariate analysis for the entire group, the following factors were found to have a positive impact on psychological readiness.

    • Male sex
    • Younger age
    • Shorter injury to surgery interval
    • Higher frequency of sport participation 
    • Greater limb symmetry 
    • Higher subjective knee scores
    Further analysis of the data revealed that subjective knee scores and age accounted for 37% of the variance in psychological readiness.  

    Conclusion/Discussion:  

    Self reported symptoms and function was one of the largest influences on psychological readiness.  Knowing this, this should guide us a lot on how we approach the ACLR athlete.  If you look in depth at the IKDC, what you see is where we need to apply some focus. 

    • Pain and swelling - the first 6 questions of the IKDC is focused on pain and swelling.  Although inflammation and pain control are a normal part of what we do, we need to be very aggressive in this and managing this early in the rehab process.  The longer this goes on the more of a psychological impact it will have and the more likely we are to see this reflected on the IKDC.
    • Confidence in limb - the next 4 questions are related to functional ability in functional activities.  Controlling pain early in the rehab process and combining with early initiation of functional activity (gait without a limp, ascending/descending stairs, squatting motion through functional range of motion with symmetry) progressed to functional single limb activities (single leg hop, lateral hops, diagonal hops) will help improve confidence.
    In addition to the above, all to often in PT, we are afraid to push the athlete.  Current standard of care is there is a big gap between PT and performance.  Clinically, we need to close the gap.  As long as we keep within the parameters of physiological healing process, within the physician's protocol and mindful of the athlete's technique and biomechanics, we could AND SHOULD push the athlete to the next level.  Doing so will help them build confidence, will help them see their capability with functional activities and improve chances for a safe and full return to performance.  


    We hope you enjoyed this series.  Next week we will start a series on addressing runners knee in runners.  Stay tuned and please share with others you think might be interested.  #ViPerformAMI #ACLPlayItSafe



    Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent is also a competitive athlete in Brazilian Jiu Jitsu.