Monday, November 21, 2016

Challenging the Status Quo - A Clinical Commentary Part III

Over the course of the last couple of weeks, we have taken a slightly different direction with our blog, offering more of a clinical commentary than our typical literature review.   20 years of practice with over 15 years in movement assessment has led me to some clear conclusions which we have begun to discuss in detail.  These include:
  1. Movement is very complex and very hard for the majority of people to see and assess
  2. The standard of practice is often 5-10 years behind the literature and clinical advancements
  3. There is a strong correlation to improvements in movement efficiency and to mitigating risk of injury and improving athletic performance
  4. We need to recognize where the flaws are in the current ways we assess movement are so that we can become better at what we do
  5. Sometimes movement is just movement and we try to over complicate it
  6. The standard of practice or care, in my opinion, tends to be the standard of the lazy and status quo. 
Over the last couple of weeks, we discussed in detail #1- #3.  Hopefully this has lead to some reflection on what we do and more importantly what we can do differently.  This week, we will dive into a discussion that I am a little uncomfortable with.  Recognizing where the flaws are in the current ways we assess movement.  I am not uncomfortable because I am unfamiliar with the topic, but uncomfortable with because so many times we get tunnel vision, passionate about we do and hypersensitive if people question it.  People know what they know and get very comfortable with certain assessments.  There is also a lot of passion around what people do and rightly so.  So, this discussion is not about you as a clinician or your thought process but more about the tools which we use.
Before we start, let's start with understanding to basic facts.  #1 - Just because something assesses movement does not mean that it is assessing a movement associated with risk.  #2 - Training methods that are designed based on a movement assessment will be affective at making someone stronger no matter what.  If you take someone with a weakness, train that weakness, they will get stronger.  That is not rocket science.  That is why, when seeing results like 30% reduction in injury risk, to me, is nothing to get excited about.  Is that a result we are happy with?  Could we do better?

Keep in mind, the topic of this blog is challenging the status quo.  It is easy to be critical of anything, especially in an environment where the other side is not able to respond to said criticism.  This discussion is not to sway you one way or the other, but is more intended to get people to think outside the box.  Leverage what we know from the literature to constantly question the way we do things.  END OF THE DAY, what we are currently doing is NOT working.  Injury rates continue to rise in youth athletics all the way to professional sports.  We have to do something different.

Insanity - doing the same thing over and over and expecting a different result! 
As much as we think everyone knows about movement, I am still surprised on a weekly basis how many folks tell me it is the result of turf vs. grass, femoral notch depth, Q-angle, and hormones.  Yes, we know that these are risk factors but can we change those?  And since we can't should we just do nothing?  Absolutely not!  So, I know this has been stated over and over in our blogs, but for refresher, let's look at what movements put you at risk.  Because it is the movements we can measure and the movements we can change.  If changed, this should mitigate injury risk.  Therefore understanding this will help guide our discussion. 
Known published risk factors include:
  • Magnitude of knee frontal plane motion – Stearns et al. Am J Sport Med 2014
  • Fatigue increases knee frontal plane motion – Brazen et al. Clin J Sports Med 2010
  • Stability in SL performance best indicator of risk – Myer et al. Am J Sports Med 2012
  • Symmetry in SL performance indicator of risk – Rohman et al. Am J Sports Med 2015
One thing we typically find in our research is that cost, days on the DL and recordable injuries commonly have a substantial percentage of those numbers coming from a few players.  Stated in another way, we find a team of 28 players with high injury costs, recordable injuries and days on the DL that a large percentage of those injuries and costs are coming from 10-15% of the players.  Season over season, they tend to be some of the same players.  So how do we find who those players are?  All too often, we think we need a comprehensive movement assessment to determine risk.  Many times, for efficiency purposes in an athletic setting, we need just one or two movements we can look at that will give us a key indication of risk.  Screen out the worse players.  Those that are found to be at high risk with these movements could then have a more comprehensive assessment. 

So based on the above, can we come up with 2-3 movements which will aid us in identifying risk?  Based on the above, one movement we should look at should be the single leg squat.  But technique and how it is performed is critical.

  • How many Reps should we do?  Due to the impact of fatigue, this should be done for minimum of 10 reps.  This allows us to start to see the impact on performance
  • What should be position of contralateral leg?  Khuu et al In J Sport Phy Ther 2016 showed the difference in EMG activity with SL squat and position of the contralateral limb.  EMG activity with the contralateral leg in extension is very similar to that in sport.  From a specificity standpoint, this position is the one that mimics running position best and the position similar to how the body is positioned during non-contact ACL injuries. 
  • What are motion are we looking for?  During the course of this movement we should be assessing the magnitude of frontal plane motion.  We know that as this motion increases, then so does the risk. 
  • Does speed of motion matter?  In addition to magnitude of motion, we also know that speed at which this motion occurs is a risk factor.  For example valgus at 21 degrees/sec in a single leg squat is a risk and 100 degrees/sec in a single leg hop is a risk.  Although we can't quantify that with our eyeball, we can see if valgus is happening very fast on one side compared to the other. 
  • What about loss of balance?  Loss of balance is a huge risk factor.  The more recordable losses of balance one has during performance of a single leg squat, the more susceptible they are to injury. 
In addition to the above factors, we should also compare right side performance to left.  Rohman et al showed limb symmetry is important.  But, keep in mind, athletes can move equally bad on each leg so we need to also consider all the above.

Although a single leg squat will give us some good idea of movement, another movement that is very telling, is a hop plant test.  In our work, we use both a single leg hop and the single leg hop plant.  However, if I had to choose one over the other, I would choose the single leg hop plant.  It is much harder for an athlete to compensate with this movement. 

During the single leg hop plant, the athlete is asked to stand one leg and hop in a forward direction followed by posterior, then lateral then medial.  They are asked to reframe from touching down the contralateral limb during the course of the test.  It is imperative with this test to do under close supervision and always discontinue the test if you see the athlete is at risk or that the movement is too great. 
  • How many reps?  With this test, we typically do 2 rounds of all 4 directions.  This equates to a total of 8 reps.
  • What do I look for?  You are assessing for all the same factors as above. 
Next week, we will continue this discussion in this area but hopefully this has given us some things to think about and two practical tests we can implement in our screening.  Next week we will continue to discuss some additional movements we can screen in addition to some of the flaws with current movement assessments.

I would like to thank you for being a follower of our blog.  It is an honor that I do not take lightly and from my family to yours, we wish you a joyous and safe Thanksgiving.  I would also like to give a shout out to #TroyTrojans.  One of our #ACLPlayItSafe schools that is nationally ranked for the first time in the universities history! #GoTrojans!

Dr. Nessler is a practicing physical therapist with over 17 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 >3000 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. 

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