Monday, June 15, 2015

To Change Movement - We Must 1st Change - Part III

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

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