Monday, January 15, 2018

Make 2018 Be The Year Of Change - Part IV

In our last blog, we highlighted a current research project with Division I volleyball players.  As a note, as with all our research projects we have two major goals in mind:

  • Perform quality research that can aid to the body of evidence on movement assessment and injury prevention
  • Critically evaluate our processes for inefficiencies so we can constantly improve the process.  

The majority of testing we have done in mass physicals up to this point was with smaller teams (Volleyball, Basketball, Soccer).  The number of athletes was much less and this allowed us to become much more proficient with our testing and not rushed.  It allowed us to work out the kinks in the process.  We knew, in order for us to expand this to football and to an entire athletic program, we had to have this process down like a well oiled machine.  We knew a Division I football team could have up to 110 players and a Division I athletic program may have 500+ athletes.  When we first started this, we could do a volleyball team or basketball team in about 4 hours.  Now, through this process, we can efficiently process 104 athletes per day.

So, in this next project, we wanted to see if we would get similar results with Division I football players.  Why football?  According to industry data, Division I football teams spend a majority of their health care dollars on non-contact injuries to the lower kinetic chain.  Although the dollar amounts have been removed, this chart shows 28% of the dollars spent are for non-contact knee injuries and 51% of the dollars spent are injuries from the ankle to the hip.  When you include the lumbar spine in these numbers, you are looking at almost 70% of the health care spend.

Sadly the results are not much better in professional football.  According to data provided by the NFL for the 2014/2015 football season, 50.4% of the injuries to football players were in the lower limb.  If you include the lumbar spine, hip and foot/ankle, this represents >70% of the injuries in NFL players.  In addition, of the 202 ACL injuries in the NFL since the 2013 season, over 73% of those are non-contact in orientation.  Aside from the cost, in a recent study by Mai et al - Am J Sport Med 2017, the authors showed NFL Players who have an ACL injury:

  •   They have decreased performance for up to 2 years post ACLR
  • The shorten their professional career by average of 2 years
So, obviously identifying those at risk in football is critical.  So in this project, as a part of pre-season physicals we screened the football team.  


Methods:
This study included 220 male football players ranging in age from 19 years old to 22 years old from 2015 to 2017.  All the athletes were scholarshiped athletes and were sophomores to seniors in their academic career.  Each athlete went through a baseline movement assessment (ViPerform AMI) as a part of their preseason physicals which consisting of 7 core movements.  Prior to performing this test, demographic information from each athlete was obtained.  This included name, age, weight, previous orthopedic history, previous ACL history and concussion history.  The ViPerform AMI movements consisted of:

  • 1 minute plank
  • 20 squats
  • 1 minute sideplank (right then left)
  • 10 single leg squats
  • 10 single leg hops
  • 10 single leg hop plants
  • Ankle lunge test

Prior to performing each test, the athlete was fit with 3D wearable sensors (provided by DorsaVi).  For the first three tests, the sensors were placed at T10 and L5/S1.  For the single limb tests, the sensors were placed on the right and left shin.  Each athlete performed each test while data was captured from the sensors.

At the conclusion of testing all athletes, the 3D data and video was reviewed with the team athletic trainer and strength coach.  The evaluator then assigned each athlete to level I - level IV of the ACL Play It Safe Program based on a predetermined set of criteria for each level assignment.  The ACL Play It Safe Program consists of 2 distinct routines - a pre-practice routine (performed as a warmup) and a post-practice routine (fatigue state training).  The program was performed during the season with the pre-practice routine done prior to practice and the post practice routine being done at the conclusion  of practice.

The ACL Play It Safe exercises consist of:

  • Pre-Practice Routine
    • Dynamic Lunge
    • Sumo Squat
    • High Knee
  • Post-Practice Routine
    • Single Leg Hop
    • Single Leg Toss
    • Single Leg Lumbar Hip Disassociation (LHD)
    • Glut Med Series
    • Plank
    • Side Plank

The exercises were performed under the direction of the team strength coach and done three times per week.  Each athlete performed these exercises throughout the season and compliance was tracked via the strength coaches attendance log.  Injury data was tracked through the team's athletic training EMR over the 2015/16 and 2016/17 football season.

Results/Discussion:

Hypothesis I - If a Division I football team performs ACL Play It Safe Program based on individual player VIPerform AMI results, there should reduction in days on the disabled list and recordable musculoskeletal injuries for the entire team.

For the purposes of this study and with a lack of a control group, the seasons with the intervention was compared with the previous 5 years of injury data collected for the football team.  When comparing days on the disabled list there was >60% reduction in total days on the disabled list and the 2 years with intervention had the lowest recordable injuries in 5 years.

By region,  injury rates decreased by:

  • Knee 72%
  • Lumbar spine 65%
  • Lower leg 53%
  • Ankle 48.5%
  • Foot 7%
In addition to the above results, there was also a 44% reduction in concussions during this time period.  We don't know what the correlation is but it is something we are tracking and seeing more and more.  There are a couple of theories with this.
  • Teams are using the ViPerform AMI as baseline movement assessment and using this baseline data for making comparisons for return to play decisions after a lower kinetic chain injury and concussion.  Could this have some impact on reducing reinjury rates (concussion)?
  • The ACL Play It Safe Program is single limb training intensive.  Does this single limb training have an impact on agility which is allowing athletes to avoid concussive blows?
  • The ACL Play It Safe Program is fatigue state training.  Is this fatigue state training having an impact on performance and avoidance later in the game when concussions are more likely to occur?
We do not have the answer to this but we are tracking this trend and and seeing it repeated in several of our studies.  So although we don't understand the correlation, we should remain aware of the impact and use the information to our advantage.  


It should be acknowledged that we identify and recognize several flaws with this study.  One is uncontrolled variables.  As with the other study, without a "true" control group, all we could do is compare results to the previous 5 years of performance and injury data.  This introduces a lot of variables that are not controlled.  Why do we do this?  Frankly, we have no choice.  The schools we do our research with are schools that work with us because we provide a service.  It would be hard to ever tell a team that we are going to implement this program with half the team and not the other half.  If we were to do that, most schools would not allow us to do.  Therefore it is an all or none deal.

Considering this and the flaws, aside from this assessment and training, there were no other fundamental changes to the program.  The results are what the results are.  The athletes are happy, the coaches are happy and the school is happy.  At the end of the day, research flaws or not, that is what matters.  They see the results both injury wise, performance wise and cost wise.  There was significant reductions in injury rates, substantial health care cost savings and improvements in performance.  Whether there are controlled variables or not, the school and athletic department felt there was a significant return on investment.

Before we close this out, we must give a huge shout out to Lesley Parrish, DPT at Champion Sports Medicine at Troy University.  Without Lesley, neither one of these studies would have been possible.  She is the PI on both of these studies has been leading the way in injury prevention in college athletics.  Thank you Lesley.  Stay tuned next week as we start to discuss the impact of this type of program implementation with Division II soccer.  #ViPerformAMI #ACLPlayItSafe

Help us ring in 2018 right by spreading the word and helping to prevent athletic injuries.


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu. 








Monday, January 8, 2018

Make 2018 Be The Year Of Change - Part III

In our last blog, we laid the foundation or ground work of how we are conducting all our studies.  In this blog, we would like to highlight one of those for you as well as our results.  This study is done at the Division I level and involves female volleyball players.  As with most female sports that involve jumping, knee injuries are fairly common among this population.  So we wanted to see, if we implemented our assessment and intervention, would this have an impact on the team's injury rates and athletic performance.

Methods:
This study included 23 female volleyball players ranging in age from 19 years old to 22 years old.  All the athletes were scholarshiped athletes and were sophomores to seniors in their academic career.   Each athlete went through a baseline movement assessment (ViPerform AMI) at the conclusion of the season which consisting of 7 core movements.  Prior to performing this test, demographic information from each athlete was obtained.  This included name, age, weight, previous orthopedic history, previous ACL history and concussion history.  The ViPerform AMI movements consisted of:

  • 1 minute plank
  • 20 squats
  • 1 minute sideplank (right then left)
  • 10 single leg squats
  • 10 single leg hops
  • 10 single leg hop plants
  • Ankle lunge test

Prior to performing each test, the athlete was fit with 3D wearable sensors (provided by DorsaVi).  For the first three tests, the sensors were placed at T10 and L5/S1.  For the single limb tests, the sensors were placed on the right and left shin.  Each athlete performed each test while data was captured from the sensors.

At the conclusion of testing all athletes, the 3D data and video was reviewed with the team athletic trainer and strength coach.  The evaluator then assigned each athlete to level I - level IV of the ACL Play It Safe Program based on a predetermined set of criteria for each level assignment.  The ACL Play It Safe Program consists of 2 distinct routines - a pre-practice routine (performed as a warmup) and a post-practice routine (fatigue state training).  This was performed in the off season and as a part of their strength and conditioning program and carried through to their in-season competition.  The ACL Play It Safe exercises consist of:

  • Pre-Practice Routine
    • Dynamic Lunge
    • Sumo Squat
    • High Knee
  • Post-Practice Routine
    • Single Leg Hop
    • Single Leg Toss
    • Single Leg Lumbar Hip Disassociation (LHD)
    • Glut Med Series
    • Plank
    • Side Plank

Each athlete is provided instructions in the exercises, provided the ACL Play It Safe App (consisting of videos of each exercise) as well as the ACL Play It Safe Kit (consisting of TheraBand CLX, TheraBand padded cuffs, stability trainer and drawstring backpack).  The pre exercises are performed just prior to training or practice and the post exercises are performed immediately after practice or training.  The entire program takes ~20 minutes.  The exercises were performed under the direction of the team strength coach and done three times per week.  Each athlete performed these exercises throughout the season and compliance was tracked via the strength coaches attendance log.

Results/Discussion:
The team strength coach tracked 100% compliance with the programming as assigned to each athlete.

Hypothesis I - If an athlete performs the ACL Play It Safe program, they will show improved results on the ViPerform AMI test with retesting.  The range of improvement on the test ranged from 32-54 point improvement with the average improvement of 41 points.  Running a statistical analysis via an independent t-test, clinical significance is noted at P<.05.  The independent t-test was P=.001 showing a high correlation with performing the exercises to improvement on the test.  Restated, if an athlete performs the exercises they are assigned to based on their individual results on the ViPerform AMI, there is a high probability they will have >12% improvement on the overall battery of tests.

Hypothesis II - If an athlete performs the ACL Play It Safe program based on their individual movement results, this will result in a reduction on injuries and improvement in athletic performance.  All recordable injuries were documented through the team's athletic training electronic medical record.  For the purposes of this study and with a lack of a control group, this seasons data was compared with the previous 5 years of injury data collected for the volleyball team.  When comparing days on the disabled list and recorded non-contact musculoskeletal injuries, there was >70% reduction in total days on the DL and an 80% reduction in non-contact lower kinetic chain injuries.

In addition, there was a average 30# increase in clean and jerk, a 1.18 inch improvement in vertical jump from stance, and .944 increase in vertical jump from approach.  The team also recorded their best season performance in 5 years with ability to compete in the Quarterfinals of their division.

It should be acknowledged that we identify and recognize several flaws with this study.  One is uncontrolled variables.  Without a "true" control group, all we could do is compare results to the previous 5 years of performance and injury data.  This introduces a lot of variables that are not controlled.  However, aside from this assessment and training, there were no other fundamental changes to the program.  There was significant reductions in injury rates, substantial health care cost savings and improvements in performance.  Whether there are controlled variables or not, the school and athletic department felt there was a significant return on investment.

Before we close this out, we must give a huge shout out to Lesley Parrish, DPT at Champion Sports Medicine at Troy University.  Without Lesley, this study would not have been possible.  She is the PI on this study has been leading the way in injury prevention in college athletics.  Thank you Lesley.    #ViPerformAMI #ACLPlayItSafe

Help us ring in 2018 right by spreading the word and helping to prevent athletic injuries. 


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu. 

Monday, January 1, 2018

Make 2018 Be The Year of Change - Part II

Last week we started the discussion around some current research projects we have going on around the US.  In this series we are going to highlight three specific studies we have going on at the Division I level.  All of these studies are IRB approved.  Why Division I?  There are several reasons for this:
  • Access - with many of our relationships, this allows us access to this level of athlete.  With that, we can include our baseline movement testing as a part of their pre-season physicals fairly easily. 
  • Maturity - Division I athletes who are there on scholarship take their sport very seriously.  As such they are much more likely to put forth a solid effort needed during the assessment.
  • Tracking - at this level we can track injury rates through the athletic trainers EMR (electronic medical record) as well as claim submissions.  This allows us to track injuries but also track costs associated with.
  • Compliance - athletes at this level tend to be more compliant with the recommendations we give.
Secondly, we have a very standardized process we go through with all the athletes.  We first put each athlete through a standardized sequence of movements and based on the results, we then assign them to a standardized sequence of movement specific exercises.

For the movement assessment, each athlete is fit with a 3D sensors (provided by DorsaVi).  These sensors have an IMU (inertial measurement unit) inside that has an accelerometer, gyrometer and magnitometer.  This measures motion, rotation and acceleration data during any movement.  With these sensors, we are able to measure motion or stability within 1% of a Viacom system for spinal motion and knee motion.  

During the test, the athlete will perform three core tests, one bilateral test and 4 single limb tests.  During the core tests, the sensors will measure the athletes ability to maintain stability of the core within 10 degrees of flexion and extension and rotation.  During the bilateral tests, the sensor will provide the degree of lumbar flexion and lateral shift (how much the hips move during the motion).  In the single limb tests, the sensors provide us with the magnitude of frontal plane motion (varus and valgus) and the speed of frontal plane motion.  At the conclusion of the test, the system will provide with an automated report of all this data.  

As cumbersome and time consuming as this may sound, this process takes ~16 minutes per athlete.  In one of our largest data captures, we collected movement data on 400 athletes over a 4 day period and were assessing 109 athletes per day.  So, from an efficiency standpoint, this is a very efficient process.  

The movement test itself is exhausting.  It consists of 83 repetitions and 3 one minute timed tests.  It is an athletic exam and therefore we feel must be athletically demanding.  All of the single limb tests are first performed on the right side then the left side.  This allows to build up fatigue on one side through the completion of the tests followed by the contralateral side.  

Once the report is generated, we then assign each athlete to one of four levels on the ACL Play It Safe Program.  This is a program that we designed specifically to improve performance on the tests that we are testing.  We hypothesized that if we improved performance on the tests we were assessing that we would see an impact on injury rates and athletic performance.  And that is exactly what we are seeing.  

Next week we will get into some of the specific results and studies.  But I want all to realize, this is not just for Division I athletes.  This is for any and all athletes.  The ACL Play It Safe Program will not only reduce injury risk but we are showing that it also improves vertical jump and sprint speed.  Best of all, it is free.  Available to you on IOS or Android.  Download it today and start impacting your athlete's performance.  

Stay tuned next week as we start to discuss the first of the three studies.  #ViPerformAMI #ACLPlayItSafe

Help us ring in 2018 right by spreading the word and helping to prevent athletic injuries. 


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu. 


Monday, December 25, 2017

Make 2018 Be The Year of Change!

In this last series, we asked the question, is an anterior cruciate ligament injury a sports injury or a major life lesson.  Hopefully you get a sense at the conclusion of that series that is is a little of both.  Although it is not just a sports related injury, that is where we see it the most commonly.  But more importantly, it is a life lesson for the athlete, the parent, coach and for us as strength coaches, athletic trainers and physical therapists.  Does it have to be this way?  With almost 80% of ACL injuries being non-contact in orientation, do we just accept this or do we do something about it?  Knowing there are certain movement patterns that put athletes at risk for these injuries and which also negatively impact athletic performance, do we just accept it or do we do something about it?

2018 will be a pivotal year for me.  This represents the 20th year of following a calling to do something about this devastating injury.   I have learned a lot along this journey.  #1 thing I have learned is that if we wait for the pure researchers to figure out the solution for us, we will be waiting another 20 years.  I don't know about you, but I am not willing to wait that long.  For the purest wants to control all the variables, look at things in isolation and validate through multiple studies.  The reality in sports is this is controlled chaos.  In athletic settings you can not control all the variables and look at things in isolation.  Yes things need to be validated and we need to use sound scientific principles. 

The other thing that I have learned is that technology companies are tech people and not clinicians.  You might be saying...well duh.  But here is my point.  They are selling you technology.  They will tell you it does one thing or another but in reality have no clue of whether or not it truly does that clinically.  For example, there are now some wearable sensor technologies out there that are embedding sensors in clothing.  They say this accurately measures valgus.  Really?  So you telling me a fabric that moves on my body which is embedded with a sensor is going to accurately measure the movement of one bone on another?  This despite the fact that we know if you have a sensor on muscle tissue versus bone that this will introduce some error, not to mention clothes on your body.  I am not a biomechanist but common sense would tell me something is wrong with this picture.  I guess my point being is that we have to apply some science and common sense to what we elect to use.  Most importantly, we need to know what the limitations of the technology we are working with.

So I said that 2018 is a pivotal year.  Part of that is because this is the year that we are devoted to making sure this is the year that we start having a dramatic impact on non-contact athletic injuries and athletes' performance.  In 2017, we are wrapping up several large research projects highlighting what can happen if you apply the movement science and technology with a little common sense.  In this series, we are going to talk about three specific projects we have going on and which are currently being written up.  Now I realize in the research world, you are not supposed to do this.  You are not supposed to talk about results that you have until it has been reviewed and accepted into a major publication.  But frankly, I don't care because I am not in this for the research.  I am in this for one reason.  Preventing injuries in athletes!

We will discuss each one of these in detail but first, to give you an idea of the level of impact we are having.  To date, we have collected movement data on over 7,000 athletes!  This is astounding.  We have implemented our movement corrective program (ACL Play It Safe) with over 3,500 athletes across the US.  Next year, we are projecting to get movement data on an additional 10,000 athletes.  The coolest part of all of this, is with this amount of data, we will constantly be able to vet this data for trends and norms for sport, age, gender, etc.  In addition, the way we are doing this, we can scale this to have not only an impact on injury rates nationally but we can now scale this internationally. 

So stay tuned for this series and make 2018 the year that we all dramatically change the way we do things.  Make 2018 the year we step outside the box and try something different.  When done right, it works and has dramatic impacts on injury rates and performance.  #ViPerformAMI #ACLPlayItSafe

From my Family to yours, we wish you all a very Merry Christmas and many blessings in 2018.


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu. 










Monday, December 18, 2017

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

Over the course of the last couple of weeks, we have talked about psychological factors that influence rehab and return to sport.  Factors like sport locus of control, how vital that is and how we can impact this clinically in the very first visit with our athlete.  Last week we discussed fear and lack of confidence in the athlete and how this can lead to increased risk for re-injure.  We also discussed in some detail how this can be identified and addressed very early in the rehabilitation process.

This week, we will be discussing communication among providers and how imperative this is.  Ironically, this is one that is so basic and simple that we often think that is the standard of practice.  But, be assured that it is not a standard of practice.  So before we discuss too much in detail, let’s consider the following scenario.  Imagine you are the athlete in this scenario.

You are a 20 year old Division I athlete who has injured his/her ACL.  Prior to surgery your MD tells you that you should be back to play in 9 months.  During surgery, the surgeon finds that you have a meniscal tear and a chonral defect on the weight bearing portion of the medial femoral condyle.  Post surgery, the surgeon comes in and explains the surgery, tells you all the things that he did, that you will be non-weight bearing for 2-4 weeks and that you will be staring rehab tomorrow.  The next day you arrive for your first physical therapy visit and the PT sees a script for s/p ACLR without any additional information.  The therapist tells you that you will be off the crutches in a couple of days what the anticipated course of treatment will be and anticipated timeline for return to sport.

Now, in this scenario, there are some obvious and major implications from this lack of communication which can have a long term negative impact on overall outcomes if they are not addressed ASAP.  This is especially true considering the chondral defect on a weight bearing surface.  For the athlete, they are in a major conflict.  Who do they trust?   The obvious answer is there would be more confidence in the MD because he is the one that did the surgery and saw the inside of your knee.  Do you think they have confidence in the therapist?  Now that this is the initial perception of the therapist, how long do you think it will take to build that trust?

Let’s reverse this scenario.  The physical therapist has been seeing the athlete throughout the rehabilitation process and is going back to see the MD to determine return to sport.  The PT does an evaluation on the athlete and finds that range of motion and manual muscle testing scores are within functional limits.  However, when they do a movement assessment, they find that the limb symmetry index (variance in stability in single limb performance on multiple tests) is way off and that the athlete is still at a high risk.  The therapist communicates this to the athlete, sends this information to the MD and the athlete goes in for their appointment.  During the appointment the MD does not have the PT progress note and does a traditional post-operative assessment (which does not include a movement assessment).  Based on the post-operative assessment, the MD tells the athlete they are ready for return to sport.  Who do they trust?

As easy as these scenarios are to see, these happen every day.  So what can we do to prevent?  One, open up the lines of communication with the MD.  So many therapists hesitate to get on the phone or even go see an MD face to face.  In sports medicine, this is not an option but should be a standard of care.  As clinicians, we must put ourselves in the shoes of the athlete and the parent.  As a parent, what would you do differently in the communication if that was your son or daughter?  Would you change or improve your communication? If you are in sports medicine, it means that you have to do more and go several steps beyond.  Send the note with the patient and call the MD prior to the appointment.  A team huddle with the MD is an imperative part to doing what is in the best interest of the athlete and in optimizing the outcome the athlete is able to achieve.  It is also imperative for safe return to sport.

Although the two scenarios above did not talk about the communication between the physical therapist and the athletic trainer, this is also an imperative part of the team approach.  Imagine if you are the athletic trainer at Division I school and your star football player is being treated by a physical therapist who does not communicate to you on a weekly basis.  When that head football coach questions that athletic trainer about that athlete, they had better know the athlete’s status.  If they don’t, they won’t be there very long.  If you don’t communicate to the head ATC about that athlete, you won’t be seeing their athletes very long.  Why should they put themselves at risk if you can’t simply pick up a phone and communicate to them?  No matter how good we think we are, if we have a lack of communication, we can compromise the outcome and care just as much as a poor manual technique.  So although these scenarios talk specifically about PT communicating directly to the MD, in the treatment of the athlete we also need to consider the PT communicating directly to the ATC.

Finally, improved lines of communication often aids in preventing conflicting thoughts or contradicting communication from the MD to the athlete about their status and return to play.  If there is anything that will result in conflict between the PT and MD it is a PT contradicting the MD to the athlete.  This creates a huge problem not only for the MD but also the athlete.  Who are they to trust?  Even if they trust the therapist, the surgeon did their surgery.  Now what is my faith in what he/she did from a surgical perspective?  Think about when the athlete says something to the MD about this (which most often they will), what kind of situation does this put the athlete in?  Depending on the MD, the response can vary greatly.  From the MD pulling the athlete from the PT’s clinic, to berating the PT in front of the athlete to contradicting everything the PT has said.  MOST IMPORTANTLY, what does this do to the athlete’s psyche?  No matter if you are wrong or right, you have placed the athlete in a very bad situation.  So no matter who is right, not controlling that situation is wrong and will result in less than optimal outcomes. 

The simply solution is over communication.  Whether that communication is with the athletic trainer or physician, in the presence of the patient, it is imperative for them to know and feel like all their care provider team is on the same page.   It is imperative to the psychological wellbeing of your athlete that “all” the providers involved in the athlete’s care communicate.  If the MD, ATC, PT and the coach are not communicating, then the only one that suffers is the athlete.  We hope you found this series helpful and if you like what you read, the biggest compliment you can give is to share the passion.  Follow us on twitter @ACL_prevention or follow us on Facebook at Athletic Therapy Services and #MoveRight.



Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu. 

Monday, December 11, 2017

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

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

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

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

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

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

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

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

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



Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu. 



Monday, December 4, 2017

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

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

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

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

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


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

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

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

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

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

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



Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu.