Last week we were discussing
the latest research related to injury risk and impact of psychology with return
to sport. Specifically, we were
discussing Ardern et al
paper from 2013 where the authors looked at the psychological factors
influencing return to sport. We
concluded that discussion talking about how the therapist, athletic trainer or
performance coach influences the sport locus of control.
Another factor touched on in this
article was fear. So, another key take
away is the rehab provider’s ability to build the patient’s confidence during
the course of rehabilitation. Most fear
full body weight support on the involved limb and single limb landing and
cutting on the involved side. There are
a lot of ways to minimize this fear, one of which is getting them to do single
leg activities early (within protocol and MD clearance) and often. Building the confidence in the limb as soon
as possible so that they can see putting weight on the leg will not result in
re-injury. Make them work it. Making an athlete work hard and pushing them
physically will build mental toughness and confidence. All too often, we are afraid to push
patients. If done within the parameters
of the healing process and within protocol, it can and will result in huge
physiological and psychological improvements.
But it must be based on sound principles. We must also be willing to take them to the
next step! Physical therapist are
notorious for stopping rehab within the clinic walls. For athletes, if they are ever to return to the
field and to the same level of performance, we must be willing to progress them
to that step. That means taking them on
the field and have a sound and systemic approach to more aggressive agility
work. Pushing with in the physiological
parameters of healing to push the psychological parameters of the athlete.
Sounds basic right? Unfortunately it is not. Let’s look at the following scenario. The following picture demonstrates an athlete
who was being evaluated for returned to sport.
The athlete was psychologically ready to return but further investigation
of his program showed he was not doing a lot of aggressive single limb exercises nor progressed to any type of agility work. When assessing his single limb performance,
there was a clear variance in symmetry between the right side and the left side
on multiple single limb closed kinetic chain tests. So, although this athlete was psychologically
prepared now, would he be when he returned to the field? Knowing the level of play this athlete was at
and how so many of these athletes are intimately aware of their bodies, one
might conclude that when he started some aggressive sprinting and agility work,
he would sense this mass variation.
Would this not play into his psychology during play and impact his
performance?
Consider for a moment an
RGIII or GSP. Phenomenal athletes and
very physical specimens in their respective sport. Even though they were “ready” to return to
sport, you could see notable asymmetries in single limb performance in both and
as a casual observer, you could see hesitation with movement to the involved
side. Most would say, in both cases,
that these athletes also had some deep (maybe subconscious) fear of moving to
that side and it dramatically impacted their performance.
So, let’s go back to what we
said at the beginning of this series. We have to get better at preventing
injuries. Despite the last 15 years of
biomechanical research related to non-contact injuries and risk factors, we
simply are not that much better at preventing them. In 2014, Dodwell et al showed,
despite all we have learned, there has been a dramatic increase in pediatric
ACL injuries over the last 20 years.
Similar results were demonstrated by Mall et al in 2014 when
looking across multiple age groups. So
is it that we are simply getting better at diagnosing these problems or is it
that there is truly an increase. We don’t
know the answer to that question but based on what we do know, we can make some
assumptions. In 2015, Jaynathi et al showed
that early specialization significantly increased the risk for serious overuse
injuries in youth athletics. Considering
the plethora of research available, today, we still assess and treat the way we
did 10+ years ago. In some instances, we
may assess movement but we do it in such a rudimentary way that it does not
assess for the what the research suggest are risk factors. Based on the most current research, it might
suggest that we consider the following when assessing risk:
- Age/Gender
- Sport/Single sport or multiple
- Previous knee/ACL injury
- History of concussion
- BMI
- Movement
- Gmed/Gmax strength relative to % body weight
- Limb symmetry
- Impact of fatigue
This is obviously not an all
inclusive list but is a list that is based on the most current research. All of these factors we can test and
ironically, if movement/symmetry is improved, there is also a huge impact to athletic performance. Some coaches will
say that they get this and know this intuitively. They are the exception. To truly and profoundly impact injury rates,
we have to come up with a better, more reliable, more sensitive and efficient
way that this can be done for the masses.
After doing this for over 17
years, there is a couple of things that are apparent to me. One is that everyone moves different but
there is always an opportunity to optimize that for performance improvement and
reduced injury risk. Second is that I
learn something new everyday. If you are
closed minded and believe you have it figured out, you will NEVER know more
than what you know today! I simply am
not that smart and every athlete I see and every coach, athletic trainer and
physical therapist I meet teaches me something new. 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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