Monday, June 25, 2018

Assessing Risk - Is it Possible Part VII

Throughout the course of this blog, we have touched on a lot of different topics about assessing risk in an athlete, from what we need to assess, to how we assess, to what we need to address psychologically when assessing and treating.  Lastly, we need to know how do we change what we assessed.

As easy and simplistic as that sounds, it often the most difficult aspect of what we do.  I am blessed to meet physical therapists, athletic trainers  and strength coaches from all over the US.  When I ask them, do you change movement in your athletes I get resounding yes.  But, do we really change movement in our athletes and how do we know that?  The first step to knowing is measuring correctly.  We don't know if we truly change movement unless we measure it correctly.  That is why technologies such as the ViPerform AMI are so important.  This allows a valid, reliable and sensitive measure of how an athlete moves.

In my role, I have the unique ability to travel all over the US and abroad to assess a variety of athletes for how they move.  Whether that is a part of physicals or basic training, assessing for return to play, implementation of a program or simply teaching medical teams how to implement with their team, I am afforded a wide variety of experiences.  What I see is that we often think we change movement however when truly assessed what we find is that the final outcome on movement is less than what we would desire.  Therefore accurately measuring baseline movement is the essential starting point. 

Once we do this, we can then test varying intervention strategies and see, does this change the baseline movement assessment we did.  Simple right?  As simply as it sounds, it is often where we miss the mark.  For all too often, we want to get overly complex in our strategies and miss the simplicity of simply addressing what we know.  What do we know?  Earlier in this blog series, we discussed the importance of measuring dynamic valgus.  According to Johnston et al Am J Sport Med 2018 we need to develop assessments that measure dynamic valgus and interventions which train control of dynamic valgus in single limb performance in professional athletes.  Further Owusu_Akyaw et al Am J Sport Med 2018, demonstrated there is a similar mechanism of injury in younger athletes and therefore the same applies to the younger athlete.  So, we must control dynamic valgus.  We must train that in simple tasks and build it up to more and more complex tasks once perfected in simple tasks.

In words, it sounds simple.  Lets take an example here.  Whether this athlete is a wrestler or mixed martial artist, there is an impact to both performance and risk.  Based on baseline assessment we see during his single leg activities that he has a large dynamic valgus which are occurring at high rate of speeds.  We know this will not only increase his risk for injury, but we also know this impacts his performance.  As he shoots in on his opponent the larger the valgus that occurs and the higher rate of speed will result in a loss of power that he will hit his opponent with and the speed to take down will be impacted.  Despite the fact that his team is doing a lot of training to improve his movement, this is still persistent.  Why?

When looking at his training, it is comes down to not what he is doing but how he is doing it.  This same athlete is doing a lot of core training and single limb training which should impact his movement.  It is a similar program we might deploy with him but with very different results.  What is the difference.

Let's just look at a couple of examples.  Dynamic lunges.  This is an exercise we often deploy as way of warming the athlete up for athletic participation.  In addition to being a great mobility exercise, this is also a great neuromuscular preparation exercise.  During this motion the athlete must control the knee from moving into a dynamic valgus position throughout a large range of motion and movement of the center of mass through a large displacement.  The technique for the exercise is as described here.

Performing the exercise  in this fashion and repeatedly in training sessions optimizes carry over to sport.  However, what we seeing being performed is a similar exercise but one that emphasizing dynamic valgus repeatedly with every repetition.  Although it is hard to see from this angle, what you see is the athlete's right knee moving into a dynamic valgus with every repetition.  Doing this in a semi-rested state (beginning of practice or training session) will mean that the athlete will do this when they are fresh in the round or game and even more so when they are fatigued.  This same movement will also then carry over to more complex and explosive movements like take down, exploding off the line, or sprinting down the court.

In addition to this exercise, we also see core training also being implemented with these athletes.  We know this is a critical component to improving an athletes overall movement, reducing injury risk and improving performance.  One of the exercises we commonly recommend is the sideplank exercise.  This exercise has a high EMG activity for the gluteus medius and the entire core.  Our goal with this is to be able to have the athlete maintain the proper position during the exercise which means not moving the hips up or down or rotating in the spine.  The technique for the exercise is described here.

In this exercise we start with 10 seconds and build this up to a 1 minute hold.  Maintaining this position without the hips raising up, dropping or rotating, ensures that the gluteus medius and the entire core is active throughout the exercise.  Complexity can be added to this exercise with the addition of the Theraband CLX band which brings in the entire core in a cross sectional fashion.    However, what we see when observing our athlete doing this exercises is different than what is described in the video.  What we see here is the athlete attempting to perform the same exercise but doing so with raising his hip up.  What happens is the gluteus medius on the down side is now placed in a shortened position which results in a significant reduction in EMG activity from one of the major muscles we are attempting to target and train.  More importantly, this same training technique then carries over into single limb performance.  What we then see is that the training impact is that the athlete has either a dynamic valgus in single limb activities or they have a loss of pelvic control during single limb activities.  Either way, the net result is a negative impact on performance and injury risk.

The intention here is not to say that these exercises are the end all be all (however we have shown this series of exercises to dramatically reduce injury rates in DI Sports - see FOX STORY).  Instead, we all know there are a 1000 ways to train movement.  However in our desire to strive for the most creative ways to address, we lose the simplicity of what we need to do.  Train single limb, train to control valgus and speed of valgus and train with proper form.  Once able to do with simple tasks, move to more complex.  Period.  If we simply do that without all the complexity of super sophisticated exercises we might see better results when comparing to our baseline assessments.

We hope you have enjoyed this series and looking forward to sharing with you our continued passion in our next series.  Please make sure to check out our new website at where our goal is to help you help others.  #ViPerformAMI

Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent is also a competitive athlete in Brazilian Jiu Jitsu. 

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