Application of Movement Assessment to the Ultimate Sport: MMA

In our last blog “Does Movement Assessment Really Tell You Anything?” we discussed what a good movement assessment tells you and how you can use this information to reduce injury risk and improve athletic performance.  The pictures we provide are were actual case studies and subjects from our research and really seemed to bring this subject home for a lot of readers.  Once people see the movement, it just makes sense.  This blog in particular stirred up a lot of questions about the Movement Assessment we use in particular and its application to sport.  During some our recent courses across the US and abroad, we have been repeatedly asked if the assessment has application in one of the most physically demanding sports known today, mixed martial arts.  Our immediate answer is yes, but let us explain why that is the case.

First, the Movement Assessment we created is an athletic biomechanical analysis designed to assess quality of movement with the 6 essential movements that compose the assessment.  Each of these are done in a specific sequence that allows us to go through a process of elimination to direct us to a root cause.  The movements themselves come directly from the research.  They are movements which we know, from the research, that if improved, reduce risk for injury and improve athletic performance.  The performance improvement is the result of improved force production (by improving the efficiency of the movement) and decreased risk for injury by improving force attenuation and loading tissues in the fashion in which they are meant to be loaded.  Looking at the example of the NFL player to the right, you can see that this movement will result in loading of tissues in a way that they are not meant to be loaded and which will limit his ability to generate maximal force production.  In his case, he is an extremely talented athlete, but it begs the question, how much better could he be?

The Movement Assessment itself is physically challenging and designed to guide training programs so that the movements identified on the assessment are not carried through in training.  When adding a Fatigue Component this takes the biomechanical assessment to the next level.  This assessment includes a research based fatigue protocol followed by the Movement Assessment.  This allows you to see what the athlete looks like later in the game or later rounds when performance counts the most.

In mixed martial arts, like most sports, the ability to generate force, maintain force production and quickness are keys to success as well as injury prevention.  If the above movement patterns are seen in the athlete, then this means there is a loss of the efficiency in the system.  For even the most skilled player, when these are present they could be improved if their core movements on the Movement Assessment are improved.  When looking at a few recent examples of training protocols used throughout the sport, we see some clear examples where the Movement Assessment is applicable. 

Squats are a foundational movement in sports.  Improvement in this movement results in improved force production and vertical jump.  In the example of this fighter training with squats with kettle bells, he is demonstrating a slight anterior position of the right foot and elbow positions that are equal bilateral (side to side).  The only way for this to be occurring in a closed kinetic chain is there has to be some component of trunk rotation in the lumbar spine.  This results in increased rotational stress at the L5/S1 disc as well as asymmetrical weight bearing and force production.  If this poor movement pattern is repeated over and over with every repetition and every training session, then this not only leads to less than optimal training outcome but also increased risk for injury both in performance and in training.   This is easily identifiable in in the Movement Assessment.

Single leg activities are also critical to sports and sports performance.  Recent studies in the American Journal of Sports Medicine state that single limb testing is one of the most important movements to test as it has the highest predictive value to performance in sports.  Hence, this is why 50% of the Movement Assessment is single limb in nature.  Considering the importance of single limb testing, it is also an important movement to train. In this example, we see an athlete lunging across the cage during dynamic stretching.  As he does this, you also see (in this still) his right knee adducting toward midline.  This motion, in a closed kinetic chain, results increased stress to the ACL, MCL, labrum in the hip and medial structures of the ankle.  If this poor movement pattern is repeated over and over with every repetition and every training session, then this results in an athlete that will do this and have less than optimal force when standing on one leg to kick or standing on one leg to deliver a knee to his opponent.  This same pattern trained over and over can result in adducting at the hip and possibly tearing his ACL when going for a take down on his opponent. This is easily identifiable in in the Movement Assessment.

There is not anyone out there who would argue that core strength is not essential for sport.  In mixed martial arts, it is critical.  One of the most common exercises used to train the core is the side plank.  This is a great exercise as there is a lot of EMG activity of the gluteus medius, internal obliques, quadratus laborum and transverse abdominus.  During this movement, the EMG activity of the gluteus medius is very high and this is a critical muscle in core/hip/lumbar stability.  The gluteus medius is the muscle that assists in stabilizing the pelvis during single leg activities.  Here we see an athlete demonstrating a retrotrendelenburg, where you can see an arc from his upper body to lower body.  This should be straight.  .  If this poor movement pattern is repeated over and over with every repetition and every training session, then this results in the athlete not training the muscles he is setting out to train and the impact on performance will be less than optimal. This is easily identifiable in in the Movement Assessment.

As you can see, the movement patterns identified with the Movement Assessment have a direct impact on training, performance and injury prevention. 

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

Does Movement Assessment Really Tell You Anything?

Whether you are a physical therapist, an athletic trainer or a strength and conditioning coach, movement assessment has application across all the professions and with every athlete you see.  A good movement assessment can tell you where the athletes deficits are, what injuries they are at risk for and how those deficits will impact performance. Yet, there are many in the various fields that really question whether or not this is applicable.  How does this one isolated movement correlate to risk of injury and/or athletic performance?  Some of  these questions are legitimate and well founded.  As some professional organizations have selected various movement assessments professing to assess injury risk, do they "show or identify" the movements indicated in the research to be correlated to injury?  Sadly that answer is no.  Sadly they are now seeing the repercussions of that with increased rates of ACL injuries and health care costs.  Why are they not working?  Simply if you want to reduce ACL injuries, you need an assessment that identifies the movements associated with ACL injuries. 

Often many critics of movement assessments will base their perceptions on the understanding of one of the assessments on the market and question how those movements correlate to injury risk and performance.  Although some of those questions are well founded, they do not apply to all movement assessments.  Although we feel most of the movement assessments commonly used have some application in sports, we feel some may be more suited than others.  That said, a well founded movement assessment should be based on the research and it should, can and will assist in identifying deficits in the system.  Secondly, the movement assessment has to be physically challenging enough that it puts the athlete in fatigue like conditions so you can truly assess how they move when it counts the most.  It can not be a shot gun approach that one assessment fits all athletes no matter what level of athlete you are.  Just like a good mechanic working on a Formula 1 car can identify small imperfections in a car's operation which has a great impact on performance, a good movement assessment can do the same.  Yet, the mechanic also runs the car through race like conditions to see how it functions when performing at or near peak performance.  A good movement assessment can and should do the same and be scalable to test all levels of athletes.

Over the course of the last several months, we have presented papers and research to try to clarify many of the questions related to movement assessments.  Most of them are related to movement assessment and the impact on performance and injury prevention.  As health care providers and scientists, this research is critical.  It is important that whatever we use be based on the most current research in the field.  In the area of biomechanics, the movements associated with increased risk have been well publicized and investigated.  The challenge has always been to bridge the gap between biomechanics, physical therapy and performance enhancement.  Each brings it's own area of expertise but yet few have combined that continuum to develop a comprehensive approach to movement.  For years, we have known what the movements are, but what exactly does it mean and how do you improve.  The first component is knowing how to test.


Throughout our blog we have talked about a Movement Assessment we use.  It should be clear, we are the founders of this assessment and therefore realize that there is some bias with that.  That said, the beauty of this  assessment is that it is not rocket science.  Once people see it, it just makes sense.  You don't have to make the jump from how the movement impacts injuries or performance, it is clear.  You can see it.  This test is also based on the most current literature and it does identify the movements we "know" put an athlete at risk for injury and which impact performance.   This movement assessment consists of 6 essential movements to sport and which reveal the movement patterns we know that put athletes at risk.  Once the athlete performs, you can see clearly the deviations and how these would impact performance.  Taking the following D1 soccer player to the right as an example.  We can clearly see, after completing the fatigue component where her system is breaking down and how this will contribute to loss of kinetic energy in the system and abnormal loading of the tissues.

If a movement assessment is designed right, each subsequent test performed should aid the examiner in determining where the system is falling apart which should drive the interventions.  With the advent of technology and our understanding of biomechanics, this is much easier today than it was 10 years ago.  Although there can be many contributing factors to the overall movements themselves, technology provides us the ability to determine where the kinetic chain is falling apart and from that determine the root cause of the problem.  With a well structured assessment, differentially diagnosing this can mean the difference between using an orthotic in an athlete, strengthening their hip or both an orthotic and hip strengthening.   From a performance standpoint, anyone who looks at these pictures can clearly see how this would impact an athletes ability to maximize their sprint speed and improve their vertical jump.  In the example of the young athlete in the single leg squat position, most can see how there is a loss of kinetic energy across the system which will impact her overall performance. 

If on the other hand, we look at this athlete performing a single leg hop, this becomes even more evident the impact this will have on injuries and performance.  In this example, looking at the position of the femur in relation to the tibia, we can see how this may lead to patellofemoral issues, patellar tendonitis or an ACL injury.  At the same time, looking at the entire kinetic chain, we can also see how these mechanics can lead to loss of kinetic energy at the foot/ankle, knee, hip and lumbar spine.  Loss of kinetic energy equates to decreased endurance, decreased power output and decreased strength.  Just from this one test alone, we can clearly see the impact this would or could potentially have on injury rate and performance.

So is this just female athletes and only for the less skilled?  Absolutely not.  There is major application across all sports from recreational to professional.  Perfect example is the athlete seen below.  Although this was captured in his combine tests, his movement assessment score indicated he was at low risk.  However, this may be partially due to the fact that the assessment that was used was not able to identify the movements that placed him at risk nor was it challenging enough to put him in sport like conditions.  So, whether you deal with recreational athletes or pro-athletes, males or females, movement assessment can be a critical component to your injury prevention and sports enhancement routine.

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

Where Are We Now - Part II

Last week we concluded with a study by Howell et al that looked at the impact that concussion has on gait balance deficits in youth athletics.  We concluded with the question, what does this mean?  First and foremost this demonstrates that the impact of a concussion has on a young athlete can last for several months.  We need to manage these better!  This is critical since most are returned to sport way too early and, from what this study indicates, you may be putting them at greater risk for additional injuries.  Why?  The ability of an athlete to control COM medial/lateral displacement is critical.   Not only is this an indication of control of balance, but it also has a huge impact on injury risk and performance.  We know from the research that if you have bad balance, that you are at increased risk for non-contact ankle sprains.  But looking further at injury risk, the larger the displacement that occurs medial to lateral, the greater the load is to the medial and lateral structures of the body (spine, hip, knee and ankle).  This means that tissues and joints are being loaded in a suboptimal way and often will create shearing stresses to the articular cartilage.  In this diagram, we can see how this motion would stress the SI joint in the back, the hip joint/labrum of the hip, the meniscus and ankle.  In most cases, the athlete will also be unable to control the knee which will result in valgus and internal rotation stress at the knee in combination with the lateral displacement.  It is this suboptimal loading and shearing stresses that cause tissue breakdown and injury. 

Looking at performance, think about your athlete.  If you had an athlete that was running and had an excessive amount of medial to lateral movement of their upper body during a run, would you expect them to have optimal performance?  What we do know is the larger the magnitude of medial to lateral displacement means loss of kinetic energy and decreased force production.  This medial and lateral displacement also results in decreased efficiency of movement.  This loss of maximal force production, loss of kinetic energy transfer across the system and decreased efficiency of movement will result in decreased power output and decreased endurance over time. 

Keep in mind that this study looked at athletes “walking”.  So, the question becomes does this get worse with running and what does single limb performance look like?  Well first look at running. We know for a fact that what we see in walking gait will be magnified when observed in running due to the increased force demands.  So, if you are seeing this in walking, you can be assured that this will be even worse in running gait.

But what about single limb performance.  Well, that is where we get back to the previous study I mentioned that is ongoing.  Ironically, they are seeing very similar results with the post concussed athlete.  Not only are they seeing a much higher percentage of non-contact lower kinetic chain injuries being reported post concussion, they are also seeing dramatic changes in single limb performance.  Specifically, when concussed athletes’ single limb performance is compared to controls, you see a significant difference in ability to control medial/lateral displacement of the lower limb (adduction toward midline) in athletes with a concussion history.  Knowing that single limb performance has a better predictive value for what performance will be like in sport and that single limb performance has a better predictive value for non-contact ACL injury risk, then what we are seeing is an increased risk for non-contact ACL injuries post concussion.    

Concussion and ACL risk.  Now that is new.  But only the beginning of what we can and will learn if we use technology to its fullest capability.  Because, through all the assessments in sports and military, there are some common themes.  Whether you label it COM medial to lateral displacement, lateral trunk lean or retro-trendelenbury (all which mean essentially the same), the ability to control the core is essential to prevent injuries to the upper and lower extremity.  Upper extremity?  Yes, upper extremity.

To examine this point, let’s look at a recent paper from the March 2015 issue of the American Journal of Sports Medicine by Solomito et al.  In this study, the authors looked at the impact of lateral trunk lean on ball velocity and upper extremity joint moments.   

Methods: 99 Division I and Division III pitchers underwent a pitching analysis using 3 dimensional motion analysis techniques and 12 camera vicon motion system.   Each player was assessed for contralateral trunk lean, ball velocity as well as elbow varus and glenohumeral internal rotation moments.

Results: What the study found was that the greatest magnitude of lateral trunk lean occurred around the time of the peak elbow varus moment.  The results also indicate for every 10° increase in contralateral trunk lean, there was a corresponding increase of .5 m/s in ball velocity.  The results also showed that for every 10° increase in contralateral lean, there was a corresponding elbow varus moment of 3.7 Nm and a glenohumeral internal rotation moment increase of 2.5 Nm.    

Unfortunately what some will take away from this is that to increase ball velocity, we should instruct in contralateral trunk lean.  But that could be the furthest thing from the truth.  Contralateral trunk lean is a compensatory strategy for poor mechanics and poor throwing velocity.  The lateral trunk lean is a way to compensate to increase the velocity and maximize velocity on already bad throwing mechanics.  Because one thing that is clear from this study is that pitchers who throw with contralateral trunk lean have a limited athletic career ahead of them.  With the increased varus moment at the elbow and the increased internal rotation moment, this means that, if continued, this will eventually lead to a ulnar collateral ligament tear (Tommy John), labral tear or rotator cuff tear.  If you look further in the results section of this study what you find is that the Division I pitchers had less contralateral trunk lean when compared to the Division III athletes and an overall higher pitching velocity than the Division III athletes. 

In looking at that, it makes sense that the Division I athlete would have better throwing mechanics and better velocity and hence why they are Division I athletes.  One thing that comes abundantly apparent when assessing Division I and III athletes is that you see a signficant difference in skill acquisition and athleticism between these two levels of athletes.  That considered, it makes sense they would have better throwing mechanics and increased throwing velocity.

One thing that movement analysis has taught us is that you can see this contralateral trunk lean in pitch but also in single limb performance.  So whether you call it retrotrendelenburg or contralateral trunk lean, it has an impact on upper extremity injury risk as well as lower extremity injury risk.  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

Where Are We Now?

In this blog, I will break for a moment from our standard format as I would like to start off this blog series by saying thank you to you, our followers.  Since starting this blog, we consistently see 80-100 followers a day and have seen over 32,000 followers in the last 18 months alone.  To date, we have over 13 countries represented with US, Ukraine, UK, France and Canada representing ~60% of our followers.  This blog is not something I am paid to do but it serves as a venue by which I can share with everyone what I feel is my calling in life.  A calling to do something profound to decrease preventable athletic injuries.  To provide evidence based education so that others can use what is learned to have a positive influence on injury rates in those they work with.  And to provide those with the opportunity to share the passion for prevention with their colleagues and clients. 

The last 8-10 years have provided me with a very unique perspective which has been an instrumental part in my own professional development.  During this time I have immersed myself in the research related to movement, injury prevention and performance enhancement.  I have also been blessed to integrate research foundation with the opportunity to assess the movement of 1000s of athletes, active individuals and patients using various forms of technology.   Finally and most importantly, I have been blessed to work and interact with some truly amazing people.  Physical therapists, atheltic trainers, physicians, strength coaches, coaches and athletes who have taught me some amazing things.  What I provide in these blogs is not me, per se, but rather the collective knowledge from people much smarter and versed in movement blended together and shared with all.  What all of this has done for me is profoundly changed the way I look at movement and dramatically changed my approach. 

First and foremost, it has taught me that to really understand movement and to prevent injuries, you have to commit yourself to be a student of life.  Humility!  We don’t know what we don’t know and if we pretend to know it all, you will never know more than what you know right now!  For me, I must walk into each experience knowing that I do not know it all and that I will learn something from every experience.  To do so with humiltiy opens you to learn from anyone and everyone.  You never know where your next clinical pearl may come from.  Whether it is the athlete or the strength coach, everyone contributes something.  It has also taught me that although some may be well versed in the research does not mean they know movement or how to influence.  Research is defined by specifics, controlling variables with very stringent protocols and procedures.  That is not life and that is not athletics.  Research is great but there is a great barrier dividing what is done in  research and how that may be integrated into the clinical world or athletic settings!   

Finally, it has taught me that technology is the future!  Embrace it!  Think how technology has revolutionized sports medicine.  MRIs, arthroscopes, computer guided surgery and diagnostic ultrasounds.  All of these combined the research sciences with clinical applications in a way that forever changed they way we diagnose and treat certain conditions.  Yet, despite the plethora of research and explosion of movement technologies, we are often hesitent to integrate this in assessing movement for injury risk or performance limitations.  Today, we are on the cusp of revolutionizing the way we look at, interpret and correct human movement. It is not whether this technology is replacing us or our ability no more so than an MRI or US is replacing the physician.  It is simply a tool to improve our efficiency and reliablity of what we already know and already do.  It simply allows us, through improved efficiency and reliabilty, to expand our reach and influence 100 athletes versus the 50 we previously could.

But the other thing is that technology allows us to learn things we never knew or maybe that we suspected but now, because we can capture more data and compare, we can prove and address.  Real time evidence based practice.  Why should I wait on a paper if I have the research I need at my finger tips?  More importantly than proving is that we can do something about it to positively influence the lives of those we work with.  Case in point.  There is a current study being conducted looking at movement analysis in soccer players from 11 years of age to Division I collegiate players.  The purpose of the study is to indentify movements known to increase injury risk and which also negatively impact performance.  From the results of the assessment, each player is grouped into an intervention group and trained using a program targeting the known risk factors.  At the conclusion, the athletes will be remeasured to assess the impact of the intervention on the known risk factors and performance measures (vertical jump).  That said, there are some correlations that have been made as as result of the data being collected in this study that until recently had not been seen or recognized.

Before I get into what those correlations are, let’s look at a recent study by Howell et al in the March 2015 issue of the American Journal of Sports Medicine. 

Methods:  In this study, the authors performed gait analysis on concussed adolescent and young adult athletes and compared those results to the non-concussed control groups.  The authors specifically looked at the subject’s ability to control whole-body center-of-mass (COM) medial and lateral displacement velocity and anterior velocity during gait and while simultaneously performing a cognitive task.  Each group was compared to a like group of controls.  Concussed athletes were assessed at 72 hours post concussion and at 1 week, 2 weeks, 1 month and 2 months. 

Results:  What the study found was at 72 hours hours post concussion, adolescents displayed significantly less control with COM medial/lateral displacement and young adults displayed COM significantly less anterior velocity compared to controls.  Across the two months of testing, concussed adolescent athletes demonstrated significantly greater total COM medial/lateral displacement compared to controls and concussed young adult athletes did not significantly differ. 

So what does all that mean?  Well, you’ll have to wait till next week.  But, know this, the ramifications are huge and what we can learn from this will change the way we look at ACL risk from now on.  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

We Don't Know What We Don't Know...But We Know More Than We Think! Part Deux

Last week we talked about research related to identifying all the factors that put athletes at risk for injury.  The thought being not only for use in screening but also to aid us in development of return to sport protocols. 

Research should guide us in what we do.  However, we know more than we think!  We should base what we do on solid research principles and science.  But all too often we get hooked on the fact that we need to have research or a paper to validate everything we do and every thought that we have.  Let’s take several of the previously mentioned studies as an example.  In the previously mentioned Pollard study, one of the conclusions was altered lower extremity coupling (sequence of motor unit firing and muscle recruitment) is a risk factor.  The conclusion was that we need to figure out what leads to this altered movement pattern.  As if this is something that is highly complex when it may actually be pretty simple.

For example, if I do single leg squats on my right leg for 4 months straight and not on my left leg, do you think that there might be some difference in motor unit recruitment and quadriceps strength?  Absolutely and how can there not be.  Now imagine if I did that with every single movement, every single day.  One of the most common problems following ACLR is the fact that the athlete tends to bear more weight on the non-operative leg than the operative.  This is most apparent during a squatting motion and presents itself as a lateral shift of the pelvis to one side during the squatting motion.  In 2013, Atkins et al showed that a lateral displacement of the pelvis during the squatting motion alters the force distribution (and hence strength development) through the lower kinetic chain.   This will not only alter current strength development but also future strength development.  If not corrected, this can persist well beyond the athlete’s return to sport. 

Think this is only present in young athletes or those with less skill?  Think again.  This picture shows an NBA player who demonstrates this motion while being evaluated for return to sport.  Think how this altered motion not only impacts strength, recruitment patterns but also athletic performance.  Fortunately, once identified, it is easy to correct.  Easy?  Yes, easy.  It is not rocket science, just retraining motor patterns and strengthening.  It is a lot easier than you might think but first you have to identify it and start addressing it.  But once identified, if it is not corrected and allowed to continue on into all forms of training (weighted squats for example) then this just simply re-enforces poor movement patterns and alters strength development.

Another example is single limb performance.  We know what the movements are that put people at risk.  We know that if they are present on one limb versus the other that the athlete is at risk.  First, we must assess those in a meaningful way.  Assess them in a way that can guide us to some root cause.  One test alone is not sensitive enough nor provide enough guidance on.  Fortunately, once identified, it is easy to correct.  Easy?  Yes, easy.  Simply put, if we only focus on that movement in the limited amount of time that we have with them in rehab and then what minor change is achieved is offset with poor motor patterns developed with all the other training.  Case in point, this MLS player who has been doing a lot of single limb training.  However, under the guidance of the clinical team he performs great.  But when he works outside that environment doing strength training (lunges, single leg squats, single leg hops) and agility training (cone drills, agility drills) there is no focus or cuing to his movement pattern.  As he is prepared for return to sport and performs the agility test predetermined to validate his ability to return, there is no focus on his mechanics.  The focus is only on can he do it.  If the majority of that training is done with movement like that demonstrated above and his reserve pattern when he is fatigued is to revert to this movement, do you think he is at risk?  What is the simple answer?  Get everyone on the same page. 

Ironically as much as we may think we are, you would be surprised.  I recently had the honor of speaking with a high level professional team and everyone on the performance and clinical side got it.  They knew it and talked about it.  But when put into practical application, what was observed is high risk athletes being trained through agility work with movement patterns which re-enforce movements like those above and continue to put the athlete at risk.  One might argue this might also limit their full athletic potential.

One final example is concussion.  For me, this is a case of why didn't I think of that.  I have the honor and pleasure of collaborating with some really smart people.  People who use our technology to do research and look for correlations that we never knew existed.  One of which is concussions.  We know that concussions impact balance.  In a current ongoing study, we are using the 3D-DMA® with female high school and college soccer players.  During the history of 80+ subjects, you start seeing trends.  One trend that came apparent is those with a previous history of concussions also have poor results on balance tests and tend to have more non-contact orthopedic injuries after their concussion.  But the other correlation is the impact on movement.  Those with previous history of concussion and more non-contact injuries also tend to have horrible control in single limb performance.  This just makes total sense and talk to anyone who has treated these athletes they will agree.  So although I don’t necessarily have a paper to support it, what we do know from the basic science and the research related to concussions, it does make sense that this should be considered a risk factor for non-contact injuries.       

So, although we do not know everything, we do know a lot.  It comes down to putting it into practical application.  Integrate all the factors we know put athletes at risk and drive intervention strategies with the entire team which improves those movements in every training session.  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.  #Evolve and help us spread the passion and #3DDMA.

Build Athletes to Perform…Build Athletes to Last!™

Trent Nessler, PT, MPT, DPT:  CEO/Founder ACL, LLC | Author | Innovator in Movement Science and Technology.  Dr. Nessler is a physical therapist and CEO/Founder of ACL, LLC.  He is the researcher and developer the Dynamic Movement Assessment™, Fatigue Dynamic Movement Assessment™, 3D-DMA™, author of the textbook Dynamic Movement Assessment: Enhance Performance and Prevent Injury, and associate editor for International Journal of Athletic Therapy & Training. For more information, please see our website at www.aclprogram.com

We Don't Know What We Don't Know....But We Know More Than We Think!

Several years ago, I had the opportunity to meet a gentleman who has had a tremendous influence on me, both from  a clinical aspect but also from the non-clinical aspect.  This individual is not a clinician but a very intellegent individual for whom I have a lot of respect for and who poccesses a lot of intuitive insight.  He is often famous for a phrase that he will often qoute in talks and conversation and that is:

We Don’t Know  What We Don’t Know

Victor Bergonzoli – CEO Dartfish

That qoute has not only stuck with me but has also influenced clinically and drives the way I will look at research and development of what we do.  Two recent experiences at the 2015 NFL Combine and the APTA Combined Sections meeting lead me to believe that there needs to be more innovation in the way we look at return to sport for athletes and the way we approach risk factors.  Currently, this is one of the hottest topics in sports medicine and has been a debatable discussion for over 12 years.  Yet, we still do not have much of a standardized way to make informed decisions on return to sport.  We Don’t Know What We Don’t Know….but we do know a lot that we can use.  Before we begin this discussion, we want to clarify a term we will use in this blog, total risk.  For the purposes of this discussion, we will use the term total risk to mean risk determined by a combination of demographic data, biometric data, movement data and symmetry data.

Just looking at the Febuary 2015 issue of American Journal of Sports Medicine and you will find a plethora of information on what we should be considering in determining risk factors.  Newman et al looked for factors that influence concomitant injuries that occur in those who have an anterior cruciate ligament reconstruction.  Although this was looking at those who already had an ACL injury, the purpose was to see if there are factors that contribute to the prevalence and severity of associated chondral and meniscal injuries.  The authors found that a delay in the time to surgery resulted in greater prevalence of irreparable meniscal injuries and severity of chondral injury (take note of that parents).  It also found that those who returned to play prior to surgery had increased severity of chondral and meniscal injuries.  The authors also found that obesity played a significant influence on both the prevalence and severity of concomitant injuries associated with ACL ruptures.  So in our discussion of looking at risk factors, this brings forth the need to consider BMI (body mass index) of the athlete when attempting to assess total risk.

In 2014 study by Rugg et al, we know that athletes who have had a knee injury or surgery prior to a Division I college athletic career are not only at greater risk of re-injury but that will also spend more time on the injury reserve during their college career.  Andernord et al attempted to further identify predictors of contralateral ACL reconstruction (ACLR) in a 5 year follow up in athletes who had already undergone a primary ipsilateral ACLR.  This was a massive study looking at 9061 subjects from 2005 till 2013.  The authors showed those under the age of 20 were at a much higher risk with males at a 2.4 times higher risk and females at a 2.9 times higher risk of contralateral ACLR.  This study further concluded that females undergoing a ACLR using a autograft from the contralateral limb were 3 times higher risk than those who did not.  So, in our discussion of looking at risk factors, this brings forth the need to consider both previous knee and ACL injury, age and gender of the athlete when attempting to assess total risk.

We know from the work by Quatman et al, that abnormal biomechanical movement patterns increase risk of non- contact lower limb injury.  We also know from a 2013 study by Kristinaslund et al that single limb testing gives a better indication of how the lower limb moves in sport that just bilateral testing.  Pollard et al showed that female soccer players who undergo ACLR have asymmetrical movement patterns during side-stepping cutting maneuvers which contribute to re-injury risk.  So, in our discussion of looking at risk factors, this brings forth the need to consider both abnormal biomechanical movement patterns (the specific movements) as well as do those movements present themselves during single limb testing. 

Recently we were asked to do a guest blog on the psychological aspects that must be considered.  One landmark studies in this area and which greatly influenced us was by Ardern et al in 2013.  Here the authors looked at the psychological responses that influenced return to sport.  In our blog Psychological Responses Matter  In Return To Sport After ACLR, we touched on specific strategies that we as clinicians can do to minimize these negative influences.  In a recent 2015 study by Lentz et al, they looked further at factors that influence return to sport following ACLR.  These authors found some similar findings.  Specifically that an elevated pain related fear of movement or reinjury, quadriceps weakness and lack of confidence lead to increase risk of reinjury and decreased likelihood of return to sport.  Considering these findings, reviewing the previous blog on psychological factors will provide us with tools we can use in the rehabilitation process to aid in reducing these influences.  However, in our discussion of looking at risk factors, this brings forth the need to consider pain level, quadricep strength and lack of confidence.

Considering all the above information, there are multiple factors that must be considered when determining risk of injury in athletics.  Historically, we tend to focus solely on the movement with our assessments.  When in reality, we need to consider the whole athlete.  Their previous orthopedic history, their biometrics, their movement in bilateral and single limb performance as well as their psychological status (confidence).  It would make sense the more of these factors that are considered, the more accurate our injury prediction tools will become. 

Can we change that?  What if the technology was available that included all those?  No matter how good we are at assessing, if we train without implementing the fundamentals of what we do know, then results will be the same.  Next week we will dive into what we do know.  We hope that you found this blog insightful and useful.  Stay tuned for part II of this series.  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.  #Evolve and help us spread the passion and #3DDMA.

Build Athletes to Perform…Build Athletes to Last!™

Trent Nessler, PT, MPT, DPT:  CEO/Founder ACL, LLC | Author | Innovator in Movement Science and Technology.  Dr. Nessler is a physical therapist and CEO/Founder of ACL, LLC.  He is the researcher and developer the Dynamic Movement Assessment™, Fatigue Dynamic Movement Assessment™, 3D-DMA™, author of the textbook Dynamic Movement Assessment: Enhance Performance and Prevent Injury, and associate editor for International Journal of Athletic Therapy & Training. For more information, please see our website at www.aclprogram.com

Keep Your Head In The Game - A Guest Post

Throughout the history of our blog, we have written about the psychological impact that injuries can have on an athlete.  Several recent studies have highlighted this fact.  In 2012 McCullough et al showed that one of the factors influencing an athlete’s ability to return to sport is an athlete’s confidence.  Psychologically do they have confidence in their limb, control of that limb and have ability to move to that side explosively without fear.  In 2013 Ardern et al found several psychological factors associated with return to sport including psychological readiness, fear and sport locus control.  All of these played a major factor in the ability of the athlete to return to sport safely. 

Building on that, we are honored to have Paul Cartone, LMHC as a guest blogger to further address the athlete psychology.  As a licensed counselor and sports performance coach for over 16 years, Paul has a unique perspective on developing the mind of the champion athlete.  Thank you Paul for this blog for we truly believe, we often under value the mindset of the injured athlete as well as the healthy athlete.

Keep Your Head In The Game!

Developing the mind of a champion athlete is just as important as training physically. To reach your full potential as an athlete, you have to start training your mind. Just as you develop physical skills and techniques, you must learn to develop mental skills. In the world of sports psychology, mental skills include:

• Staying relaxed under pressure
• Being in the present
• Focusing on what’s important
• Letting go of mistakes
• Letting go of bad breaks and failures
• Handling self-doubts and negative thinking
• Using visualization for upcoming event
• Self-motivation
• Ability to recognizing mental traps and avoiding them
• Developing self-confidence

These mental skills will be difficult to master if you are not “Emotionally Fit.”

Emotional fitness is defined as the state wherein the mind is capable of staying away from negative thoughts and can focus on creative and constructive tasks. Being emotionally fit is the key to success in all aspects of life especially as an athlete. Unresolved, negative emotions can weigh you down, prevent success, drain you of the energy you need to be productive daily and limit your performance.

So what does this have to do with sports performance? Everything. Ultimately, we want congruency between our logic and emotions. If there is conflict between the two, this will cause problems; if not sooner than definitely later. Our toxic emotions can take over our logic, creating self-doubt, fears and lack of confidence. We want our logic to lead the way with a clear vision and plan to achieve our goals. An “Emotionally Fit Self” supports and feeds our logic with confidence and positive feelings.

There are some athletes that use athletics as an escape from their unhealthy environment. These athletes may argue they will lose their “competitive edge” if the negative emotions or anger they harbor is resolved. They believe those negative feelings are fueling them to become a better athlete, stronger mentally, and more competitive. Quite the opposite happens. Over time, the negative emotions take over and pose problems. The negative emotions win and personal problems begin to interfere with their sports performance. Negative toxic emotions take over their logic.

A current professional golfer (name withheld) is a perfect example of this. This golfer is having a lot of problems with his game, especially his short game. He was trained at a young age to have the mental skills to be a champion and based on his incredible success was “Emotionally Fit.” Or was he? There was a reason and deep rooted cause for his infidelity and sex addiction that came out in 2010 which led to his demise.  This has caused his professional sports career to plummet.  Most recently he blames his “injuries” on his poor play but one may argue he is not “Emotionally Fit.” His logic tells him he has all the physical ability in the world, but his unresolved negative toxic emotions are wreaking havoc and taking over to the point he cannot perform like he used to.

So you may be asking yourself, “How do I become emotionally fit?” Here is a simple test to see if you are emotionally fit. Answer some of these questions:

• Can I think of the past (as far back as infancy until now) and feel ok?
• Is there a negative emotion associated with some past event that I don't want to deal with and keep burying?
• Is there something that's plaguing me and I can't identify what it is?
• Is there someone I have not forgiven in my life? 
• Do I tend to see the glass half empty instead of half full?
• Am I sad much of the time?
• Is my current stress level high?
• Am I easily agitated or angered?
• Am I lacking confidence in my personal life and in my sport?

If you answered yes to any of these questions or you felt an “emotional charge,” then you need some work to resolve and become “Emotionally Fit.” If you do, it will require some work on your part with a professional Psychotherapist or Sports Performance Coach.

I have been helping people become emotionally fit for 16 years and have developed a system that will get you where you want to be quickly. With the use of traditional methods and an alternative cutting edge techniques you will get to a place of resolution. As a result, every aspect of your life will improve. It takes a strong person to resolve and deal with their emotions. Becoming “Emotionally Fit” brings you back to why you play your sport in the first place. For the love of the game! 

For more information on what an emotional cleanse is and various techniques, check out my website and receive half off by mentioning this article.  Not matter what, if you are not “Emotionally Fit”, make sure you seek guidance from a qualified Psychotherapist or Sports Performance Coach.