Over the last couple of
weeks, we have talked about the current research and how this should influence
the way we think and approach our our athletes both from a rehabilitation
standpoint and from a training perspective.
There are several thought leaders out there that will say that the push
for evidence based practice has caused us to be too data driven and not
applying enough common sense or experience to what we do with our athletes. I would agree to some degree but also
question if the way we did things in 1980s is still the way we should do things
today. So, although I agree it is bad to
rely souly on data, it is also an injustice to the athlete to not apply what we
know from the literature to what we do today.
Science does drive everything.
Applied correctly and it can and wil make a good athlete a great
athlete.
That said, there is also a
flip side to this discussion. Those who
practice that are heavily or souly evidence based practice will ask for a study
for everything you do. Do I really need
a study to show me that I should not bang my thumb with a hammer or that in
doing so will negatively impact my grip strength? No! I
know from experience that if I do, that it will hurt and greatly reduce the
strength in my grip. So, I don’t need a
study to show me that. Knowing this is
one extreme end of the spectrum, it aids in further clarifying my point. Experience is important and sometimes the
most effective things we do have not YET been validated in the research. In considering both sides of this argument,
we should consider where does innovation come from? It comes from experience. Many of the innovations in sports medicine
come from pioneers in the profession who see a problem, develop a solution or
approach and then validate this over time with anecdotal data (working with
athletes) and eventually support and validate in the research. For truly successful innovations will find
themselves in the research eventually where they will be validated and furhter
excepted as a part of evidence based practice.
However, those that rely souly on experience and who completely ignore
the research, is this truly in the best interest of the athlete?
Considering this discussion,
in 2011 Grindem et al
suggested that asymmetries in single limb performance placed athletes at a
greater risk of injury. This is a fact
that many practicing in sports medicine clinicians and coaches already
suspected and were addressing as both a part of their treatment and training. Many were already looking for ways in which
to quantify single limb assymetry and develop specific training protocols to
address the deficits which lead to single limb strength assymetry. Over time, as clincians were looking for causes
for this SL assymetry, many realized there was a connection between hip
strength and lack of stability or control of the lower limb. This
was validated in studies in 2005 looking at patellafemoral syndrome and yet
still was not a part of the standard of practice. Since this time, there have been multiple
studies further validating that improvements in hip strength symmetry aided in
reducing single limb assymetry. One such
paper was in 2014 in which Stearns
et al showed that improvements in hip strength resulted in reduction of
adduction toward midline in jumping tasks.
This reduction in hip adduction was directly correlated to reductions in the adduction
moment which reduces the risk for ACL injury.
So, if we know that SL
performance is improved with hip strengthening, what are the best exercises to
train the hip? In 2011, Boren et al
published a paper, we get some answers to this question. As discussed in previous blogs, the gluteus
medius is a critical muscle in the hip that aids in control of the pelvis and
lower limb, especially in single limb performance. Therefore, building strength and endurance of
this muscle is vital when addressing single limb assymetry. However, there are hundreds of exercises that
are used to strengthen the glutues medius and yet very little evidence showing
which ones are optimal. In this study, the
authors set out to test the MVC (maximal volitional contraction) of some of the
more commonly used gluteus medius exercises.
Methods: Twenty six healthy subjects
participated and had surface EMGs placed on both the gluteus medius and gluteus
maximus muscle bellies. MVC for the
gluteus medius and maximus was established for each subject. Each subject then performed 18 different
exercises during which the MVC of the gluteus medius and maximus was
measured.
Results: Five of the exercises
produced greater than 70% MVC of the gluteus medius muscle. These were:
- Side plank abduction with dominate leg on the bottom – 103% of MVC
- Side plank abduction with dominant leg on top – 89% MVC
- Single leg squat – 82% MVC
- Clamshell progression #4 – 77% MVC
- Front plank with hip extension – 75% MVC
Five of the exercises
produced greater than 70% MVC for the gluteus maximus muscle. These were:
Front plank with hip extension – 106% MVC
- Gluteal squeeze – 81% MVC
- Side plank abduction with dominate leg on top – 73% MVC
- Side plank abduction with dominate leg on bottom – 71% MVC
- Single leg squat – 71% MVC
Now, as an evidence based
clinician, I have a clear indication of the exercises I should be using with my
patient who has single limb assymetry.
Or do I? We will discuss that in
more detail next week. If you like what
you see, SHARE THE PASSION! It is the biggest compliment you can
give. Follow us on Twitter @ACL_prevention and tweet about it. #MovingToChangeMovement
and help us spread the passion.
Trent Nessler, PT, MPT, DPT: Physical Therapist | Author | Educator |Innovator in Movement
Science and Technology. Dr. Nessler is a physical therapist and owner
of Athletic Therapy Services. He serves as a practicing clinician
and movement change consultant for practices and organizations looking to
develop injury prevention initiatives and strategies. He has been researching and developing
movement assessments and technologies for >10 years is the author of the
textbook Dynamic Movement Assessment: Enhance Performance and Prevent Injury, and
associate editor for International Journal of Athletic Therapy &
Training. You can contact him
directly at drtrent.nessler@gmail.com
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