RTPlay Following ACLR - How Do We Know When Is The Right Time? - Part X

Over the course of the last 2 months, we have been discussing RTPlay.  We have reviewed a lot of literature related to this topic and last week, started to get into some real substance behind it all.  What do we do with this information.  In other words, how does this information guide our training that we do with our athletes.

Before we get into specifics, let's start this conversation by acknowledging that there are 1000s of combinations of movements that can occur with each of the tests that we do and can be a plethora of causes for those movements.  With over 12,000 assessments performed, we do see some typical patterns and where we can have the most impact.  So, we are going to focus on the most common movements we see and how we can address from a training perspective.  We will break these down in the order they are performed in the Athletic Movement Index (AMI).

Plank - during this test we look for the ability to maintain stability within 8 degrees of flexion and extension and rotation for a set period of time.  But we must look at the whole system and not just isolated portions.  There are additional movements outside of the "core stability" portion that we can look at that gives us some guidance on what is going on.

Non-traditional movements assessed:

• Scapular winging - can be indicative of serratus anterior (SA) weakness.  Since this muscle primarily functions in an eccentric fashion, this can guide us to do some targeted eccentric training to the SA through it's functional range of motion (85 to 120 degrees of flexion).

• Lack dorsiflexion - most people will position their feet in neutral ankle position to slight dorsiflexion.  Symmetry in the ankle position is normal.  Asymmetry is not.  If you see one ankle in a dorsiflexed position and the other is in a plantar flexed position, this can lead you to look at the range of motion of the ankle or further assess for pain.

• Hip internal rotation - this is most often seen at the heel when it rotates out.  This is how hip internal rotation is represented.  Although does not occur very often, it does occur in cases of extreme hip weakness and guide us for some focused training on the gluteus medius and maximus.

Traditional movements assessed:

• Hip hiking - if there is immediate movement into a hip flexed position, this might guide to assessment of hip flexor tightness or guide to TA/lower abdominal training.  Hips up in the air is a common compensation for weakness of the transverse abdominus (TA).  This movement can guide us in to some targeted training to the TA.  This should focus on RNMR as well as isolated exercises to.  

• Increased lordosis  - if there is an immediate drop, this can guide to more isolated training to the posterior chain or erector spinae.  Increase in lordosis during this test can indicate weakness of the erector spinae.  This movement can guide us to do some targeted training to the extensors.  This should focus on RNMR as well as isolated exercises to.  

• Lumbar rotation - this is also a common motion we see and can be a combination of weakness of the quadratus lumborum and internal obliques.  This movement can guide us to some targeted training there and should also include RNMR as well as isolated exercises to.

• Drop over time - If there is a significant drop over time, this might guide more endurance training. 

      

      Squat - the squat is an essential movement and improved efficiency of this movement has a direct impact on both risk and performance.  During this movement we are assessing the amount of lumbar flexion and extension during the motion as well as the degree of lateral shift that occurs.  

• Lumbar flexion – this can occur as a result of limited range of motion (ROM) of the hips, knees or ankles.  Make sure to assess the lower kinetic chain components to ensure not limited ROM.  If none, address with squat retraining.  Excessive lumbar flexion adds to increase in quad/hamstring ratios and alters loading patterns throughout the entire kinetic chain. 

• Lateral shift – this can occur from limited ROM on the contralateral (opposite side they shift to) ankle, knee or hip resulting in a shift away from the limited side.  Make sure to assess the lower kinetic chain components to ensure not limited ROM.  If no ROM restrictions are present, this can be addressed with squat neuromuscular retraining and visual motor retraining.  

      

      Side Plank - during this test we look for the ability to maintain stability within 8 degrees of lateral sidebending and rotation for a set period of time.  As with the plank, we must look at the whole system and not just isolated portions.  There are additional movements outside of the "core stability" portion that we can look at that gives us some guidance on what is going on. 

Non-traditional movements assessed:

• Shoulder rotation - when we see the non-weightbearing shoulder roll forward, this can be indicative of serratus anterior (SA) weakness on the contralateral shoulder.  The SA must stabilize the scapula on the weightbearing arm and weakness can result in winging.  In this position this is seen as the contralateral shoulder rolls forward.  

• Tibial Drop - most people will position their feet in neutral ankle position and one on top of the other.  If there is weakness in the weightbearing ankle, then the foot will supinate and the tibia will drop to the floor.  The can indicate weakness of the anterior tibialis and peroneals.  

Traditional movements assessed:

• Hip hiking or hip drop - the highest EMG activity in this movement is the gluteus medius so this is a great exercise to assess strength and endurance of.  Imagine if you will, the person in a standing position performing a hip hike or hip drop.  In the standing position, we would call the hip hike a retrotrendelenburg and a hip drop a trendelenburg.  Both of these are indications of gluteus medius weakness.  Addressing this both from a strength, endurance and rapid neuromuscular response perspective is critical for stability.

• Hip Rotation - rotation of the hip can give us some guidance on where we need to target our correctives.  An anterior rotation can be indicative of a quadratus lumborum weakness and posterior rotation a weakness of the internal obliques.  So dependent on the direction of the roation, this can guide us on some targeted interventions.  

• Drop over time - If there is a significant drop over time, this might guide more endurance training. 

As you can see, specific isolated movements within each of the tested positions can guide us on much more targeted interventions.  This was only three of the 7 movements and next week we will go through the remaining 4.  We will spend more time on this as we believe, this is where the rubber meets the road.   If you enjoy this blog, please share with your colleague and follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention.  #ViPerformAMI #ACLPlayItSafe

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 and ACL injury prevention.  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 has also been training and a competitive athlete in Brazilian Jiu Jitsu for 5 years.