Sports Therapy
Dr. Trent Nessler

Physio Sports Blog

What moves you to stay in the game? Dr. Trent Nessler, National Director of Physio Sports Medicine, shares his calling and passion for injury prevention and performance enhancement using the most current research and technologies available. As a passionate educator, he is driven to share with all the latest peer reviewed journals in sports medicine and orthopedics and what that means to how we train and treat our athletes.

Exercises To Eliminate Pathokinematics - Part VII

Last week we discussed the Lumbar Hip Disassociation Exercise sequence.  This is a great starting point to start providing athletes with the ability to discern the difference between hip motion, lumbar motion and femoral motion.  In addition to this series and with the advent of the #Theraband #CLX, we are now able to apply this same training methodology with the CLX.  This creates an even more challenging sequences in SL Stance.  With the incorporation of the CLX, this allows us to create resistance in internal rotation and valgus stresses which further increases EMG activity in the gluteus medius in the stance leg. 

These same exercises are a key component of the ACL Play It Safe Program.  One key component of doing these exercises is the "CLX Spiral Technique" that is done with the CLX band. 



In this technique, open the last loop of the CLX band and place this around the upper thigh of the athlete so that the next loop is located between the legs.  Take the CLX and wrap it from inside to outside (wrap from posterior thigh to lateral thigh to inner).  Complete two complete spirals so that one is located at mid-thigh and the second is just below the knee.  Place the contralateral foot in the CLX loops near the end so there is enough tension that the stance leg is being pulled into a valgus and internally rotated position.  The key wit these exercises is to maintain neutral position of the stance limb and resist the CLX pulling into internal rotation and valgus.

CLX Lumbar Disassociation - Level I - The following video provides instruction in the Level I CLX exercise.



CLX Lumbar Disassociation - Level II - The following video provides instruction in the Level II CLX exercise.



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 and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

Exercises To Eliminate Pathokinematics - Part VI

Last week we talked about the King of all Exercises, the squat.  In the last couple of blogs, we have discussed a couple of ways to address the "lateral shift" with both the Squat Neuromuscular Retraining technique as well as with the squatting series.  It is imperative that the lateral shift is corrected in full body weight movements prior to the initiation of weighted movements. 

Just as equally important is the ability to teach the athlete the ability to discern the difference between lumbar motion and hip motion.  That is the reason for the Lumbar Hip Disassociation Exercise Series we will now investigate.

Lumbar Hip Disassociation Exercise Series: 

The next exercise series to use with the athlete to ensure that the rest of the progression is done correctly is the Lumbar Hip Disassociation Exercise Series. These exercises are used for retraining the athlete’s proprioception, strength and range of motion involving the hip and spine.  Teaching proper technique with this is essential to development of kinesthetic sense and in particular, differentiation between movement in the spine and movement in the hip.  The difference between movement at the hip and at the spine is notoriously difficult to train. 

Specifically, these exercises are designed to teach the athlete the difference between hip flexion and rotation and spinal flexion and rotation.  They are essential to master as they aid athletes’ ability to not only properly isolate the hip musculature which will allow for isolated strengthening but will also allow him or her the ability to activate these muscles during athletic participation.  These exercises are performed with a mirror and the subject is INITIALLY given lots of verbal and tactile or manual cueing at the hips to prevent spinal motion, and teach the athlete the difference between movement at the hip and movement at the spine.  Incorporation of additional visual cueing, like the Motion Guidance System or other similar device can aid in training this in the clinic and during their home exercise program. 

Keep in mind when doing these exercises:  If done in the recommended sequence, by the time that the athlete gets to latter exercises, the legs and hips are going to be tired.  This sequence is designed in this way deliberately.  The gluteus medius typically fails as a result of fatigue, so we want to challenge it as much as we can.  In addition, the gluteus medius also functions primarily in an eccentric fashion, so making sure we are pushing the eccentric phases of the exercise are critical to maximize carry over to sport.  It is VITAL that the athlete have success at these exercises before progressing.  So, if you see that they are failing due to fatigue, stop there.  You can attempt to perform with some slight modifications, but if unable to do that way correctly either, the routine should be concluded at this point.  The intent of this sequence is to teach the athlete the difference between lumbar motion, femoral motion and hip motion.  This sequence will take 15-20 minutes, and progresses in the following manner:

v  Prep Exercise: 

Level I:  First while standing in front of a mirror, in a stride stance with the back foot on your toes and front foot flat, and hands on hips, gently rotate the back stride leg into femoral internal and external rotation while maintaining lumbar neutral, hip in neutral position and “healthy knee alignment”.   Perform 3 sets of 10-20 reps on each leg.












Level II:   Now repeat this exercise while standing only on one leg with the hands on the hips.  Again, gently rotate into the back stride leg femoral internal and external rotation while maintaining lumbar neutral, neutral hips and “healthy knee alignment”.  Perform 3 sets of 10-20 reps on each leg.  











Level III: While standing on one leg with hands on hips in front of a mirror, have the athlete flex forward at this hips doing the “bird in the water glass” maneuver.  Only have them flex forward at the hips as far as they can WITHOUT allowing spinal flexion while maintaining lumbar neutral and “healthy knee alignment”.  The contralateral limb is maintained in hip neutral to slight hip extension.  Return to the starting position and immediately resume hip flexion.  Perform 3 sets of 20 reps on each leg. 











Level IV: While standing on one leg with hands on hips, rotate the stance hip into hip internal and external rotation while simultaneously maintaining hip flexion, as in the “bird in the water glass” maneuver.  Ensure during the course of the exercise that the athlete is maintaining the lumbar spine in a neutral position – e.g., only have them flex forward at the hips as far as they can WITHOUT allowing spinal flexion and while maintaining “healthy knee alignment”.  Return to the starting position and immediately resume hip flexion.  Perform 20 reps on each leg.  Perform 3 sets of 10-20 reps.











KEYS TO SUCCESS:   Only reach as far as possible without loss of a neutral spinal position or loss of control at the knee.  Only progress to those ranges of motion in which these alignments can be maintained.  This is an extremely difficult exercise and need to educate athletes to this fact prior to initiation.  Without this previous instruction, this can lead to frustration and mental fatigue.


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 and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

Exercises to Eliminate Pathokinematics - Part V

Last week we discussed the SNMR exercise.  Perfecting this exercise is key prior to progression to the following sequence.  Making sure the athlete can perform a full squatting motion with body weight without a lateral shift is critical prior to having them perform a squat under load.  If the previous is not perfected, then you simply reinforce poor movement under loading conditions.   

Correcting of the pictured positioning here (lateral shift) is a must prior to initiation of the next level of squatting motions.

Rapid Squats:
Level I:  With the feet shoulder width apart, feet pointing straight ahead, squat down to the partial squat position (45 degrees), keeping heels in contact with the floor and knees behind the toes.  Once you obtain this position, in a controlled rapid fashion, raise to the starting position.  Perform 3 sets of 20 reps.  Rest for 10-20 seconds in the squat sit position.


             





Level II:  With the feet shoulder width apart, feet pointing straight ahead, squat down to the full squat position (greater than 90 degrees), keeping heels in contact with the floor without allowing knees to progress over the toes.  Once you obtain this position, in a rapid controlled fashion, raise to the starting position.  Perform 3 sets of 20 reps.  Rest for 10-20 seconds in the squat sit position.



 Level III:  With the feet shoulder width apart, feet pointing straight ahead, squat down to the full squat position (greater than 90 degrees), keeping heels in contact with the floor without allowing knees to progress over the toes.  Once you obtain this position, in a rapid controlled fashion jump to a full extended position.  Perform 3 sets of 20 reps.  Rest for 10-20 seconds in the squat sit position.

Controlled Squats with Weight: 

Level I:  With the feet shoulder width apart, feet pointing straight ahead, and a 40# bar across your shoulders, squat down to the partial squat position (45 degrees), very slowly keeping heels in contact with the ground and knees behind the toes.  Once you obtain this position, in a controlled fashion, raise to the starting position.  Perform 3 sets of 20 reps. 

 

  




Level II:  This is the same exercise as above, with additional weight added.  With the feet shoulder width apart, feet pointing straight ahead, and a 40# bar across your shoulders, squat down to the partial squat position (45 degrees) very slowly, keeping heels in contact with the ground without allowing knees to progress over the toes.  Once you obtain this position, in a controlled fashion, raise to the starting position.  Perform 3 sets of 20 reps.  Progress from 40# to 100% of body weight.








Level III:  With the feet shoulder width apart, feet pointing straight ahead, and a 40# bar across your shoulders, squat down to the full squat position (90 degrees) very slowly, keeping heels in contact with the ground without allowing knees to progress over the toes.  Once you obtain this position, in a controlled fashion, raise to the starting position.  Perform 3 sets of 20 reps.  SUPERSET.  Progress from 40# to 100% of body weight.

 







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 and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

Exercises to Eliminate Pathokinematics - Part IV

There are few exercises that contribute more to the overall health of the human body as well as facilitate activities of daily living better than the squat.  The ability to squat properly is critical for athletes and non-athletes alike.  Because squatting is a compound exercise which involves the entire kinetic chain, a person in motion during a squat is a window into the make-up of the human body at any given point in time.  Because of its importance as a diagnostic tool, and its wide application in daily living and sports, we have designed the movement assess with the squat as the number one exercise to film and analyze.  We know that if we see deficiencies in an individual’s ability to squat, we are seeing into the body’s core composition in many ways---and can pinpoint specific strengths, weaknesses and tightness that can be directly impacted through a targeted exercise program.

We also know from the research that the inability to squat is the number one cause of falls in the elderly, which often leads to broken hips and many other co-morbidities in aging adults.  We know that the squat speaks to the strength of the core, including the lumbar spine and hips.  Improving an athlete’s ability to squat has a direct impact on his or her ability to run, jump, land and lunge safely.  We also know that improving an athlete’s squatting mechanics has a direct impact on injury rates and performance output.  Studies show that we can increase vertical jump height and running speed measured by the 10 yard split and 40 yard dash by targeting and improving the mechanics and thereby, the efficiency of an athlete’s squat is critical. 

These are but some of the reasons the squat is the first exercise we typically address.  Because the squat is the “core” of so many of the exercises in a corrective exercise program, it is important to master before progressing to other more advanced isolation exercises.  Furthermore, if time is limited, as it so often is when training is intense or the season is live, the squat progression will give the athlete the most “bang for the buck” for time spent in the gym.  More details on the squat and how to get started follow in the paragraphs below.

The second most important exercise series in the corrective program is the Lumbar Hip Disassociation Exercise Series.  Again, the ability to disassociate hip flexion from spinal flexion is “key” to many sports activities as well as other activities of daily living.  Therefore, we believe the Lumbar Hip Disassociation Exercise Series is a foundational series upon which all other exercises in a program are built, and therefore is a starting point for the progression of the a corrective exercise program.  Ultimately, these exercises will drastically improve the athlete’s movement patterns, improve overall athletic performance and reduce the likelihood of certain types of lower extremity injuries, specifically those involving the lower back, hip, knee, and foot/ankle when prescribed and conducted properly.  These two in particular set the athlete up for safe and successful entrance into the rest of the Corrective Exercise Program. 

This section will provide you with instruction in these beginning stages of The Corrective Exercise Progression, beginning with a basic overview of how to get started and then going into detail on squats and the lumbar hip disassociation exercise series and more on why they are important: 

Squat Progression

                                               i.     Squat NMR

                                             ii.     Rapid Squats

                                           iii.     Controlled Squats with Weight 

Lumbar Hip Disassociation Exercise Series

                                               i.     Prep Exercise

                                             ii.     Single Leg Proprioceptive Neuromuscular Facilitation (PNF) with Hip Flexion

                                           iii.     Single Leg with Dynamic Lower Extremity Movement

                                            iv.     Modified Dead Lift


The Corrective Exercise Progression:  Each exercise in the CEP progresses from one level to the next.  However, it should be noted that throughout the progression, we will refer to the concept of “progression within a progression.”  This is simply a way to progress an exercise from one level of difficulty to the next without moving to the next prescribed level.  This is a concept that can be utilized when an athlete is not quite ready to progress to the next level but does require something more difficult than what the current level requires. This can be as simple as adding resistance, increasing the number of repetitions, decreasing rest time between sets, decreasing stability of the surface or using super sets. 

So, now you are undoubtedly wondering where to start and the answer to this question is the key to this entire program.  Starting off with a solid foundation will either make or break success in correcting pathokinematics.  The movement assessment is designed to assess individual weaknesses and tightness and everyone will not be the same.  However, a large majority of the athletes that we have tested over the years benefit from a foundation starting with several simple exercises up front.  So, remember when working through these beginning exercises the phrase:


Poor technique = poor motor planning = poor performance


With this in mind, we want to attempt to correct any poorly executed core movements from training day one.  Training day one is typically, in a rehabilitation setting, done on the same day as the initial evaluation.  In a performance setting, however, we are often more limited on time, so this may actually be on a separate day and consume the majority of the first training session.  No matter what setting, the sequence laid out here will aid in correcting core movements that show signs of weakness or tightness that could lead to pathokinematic movement patterns during the exercise progression, and during sport.

Squat Progression: 
Strength, endurance and co-contraction of the quadriceps and hamstrings are essential for maximal performance and injury prevention.  The one exercise that has been “proven” in the research to improve vertical jump and aid in creating co-contraction is the squat.  Performing full squats, would be considered more advanced exercises and therefore maintaining “healthy” knee/hip alignment is essential.  Therefore during the squat progression, it is imperative to follow the repetition to substitution concept very closely.  These exercises may also be performed as supersets.
It is absolutely vital that technique be a focus with these exercises from the beginning of the progression.  You are training for performance, muscle memory and motor planning.  Bad training technique adds to decreased performance.  With squats, common tightness in most athletes leads to the heels coming off the floor and the knees moving forward over the toes.  It is essential to keep the heels in contact with the floor throughout the exercise and the knees behind the toes at the end range of motion.  Common weaknesses in the female athlete (and males in many cases as well) also result in squatting technique which results in the athlete shifting more to one side than the other. 
Another vital concept related to the proper performance of the squatting exercise is to ensure proper kinematics and lumbopelivc control throughout the course of the exercise.  Making sure the knees do not progress over the toes will reduce any adverse shearing stresses imparted to the patellofemoral joint and hence reduce the potential for knee pain (squatter’s knee) from occurring with this exercise.   It is also essential for proper core stabilization to occur (keeping abdominals tight) throughout the course of the exercise in order to prevent excessive spinal extension or flexion.  Doing these things will reduce the extent of abnormal forces that can be imparted to the lumbar spine and thereby reduce potential for back pain sometimes associated with this more aggressive exercise.

Our research indicates that in fact 80% of athletes fail the full squat test.  This is despite the fact that many of them may be performing squats as a part of their regular exercise routine.  Failing this test is defined as ≥1” lateral shift.  A lateral shift typically results when an athlete who began squatting with poor mechanics was never corrected.  Through years of training, they have reinforced poor motor plans and abnormal proprioception into the system.  To the athlete, this feels normal, however these deficits result in significant asymmetries in load bearing of the tissues and asymmetrical strength gains as well as force production.  Therefore, if an athlete fails the Full Squat Test, they must perfect the Squat Neuromuscular Retraining (SNMR) prior to proceeding to any of the squatting motion exercises that follow here.  If an athlete does not perfect this test, then we will simply be training or reinforcing bad movement patterns or poor motor planning.  The SNMR is explained in depth below.  Again, remember: 

Poor technique = poor motor planning = poor performance

Squat NMR (Neuromuscular Retraining):
Teaching proper squatting motion is essential first step prior to progressing into the squatting routine as we said above.  It is essential to development of maximal force production while preventing injury and thus the reason the SNMR exercise is so essential.  The SNMR is an exercise used for retraining squat for the lateral shift prior to performing any squat training routine or progression.  It will be the base upon which most of our exercises will be developed. 

When correcting a lateral shift, one of the common things an athlete will state is that the "correct position" feels weird.  This sensation comes from proprioceptors throughout the lower kinetic chain giving the sensation of this changed position.  Since that is the position that was trained, then it will feel different or "weird".  This technique takes into account the fatigue literature to add in overriding this system and "re-setting the system" to the correct position.

  1. Have the subject perform 20 squats through their full range of motion.
  2. At the conclusion of the 20th squat, have them get into a squat sit position (end rom of motion of their squat) and hold that position with their hands out in front of them and palms pressed together.
  3. Prior to beginning the perturbations, move their hips into a neutral position if they are in a lateral shift.  When in the neutral position, perform light perturbations through their hips, knees, arms in rotation, and shoulders.  Do this at a rapid pace but not hard enough that they are not able to maintain proper position.  Perform this for 10 seconds. 
  4. Perform 20 more squats through their full range of motion.
  5. Repeat the perturbation protocol as above.
This exercise series is TYPICALLY performed 2-3 times before the subject is able to squat without lateral shift, without cueing.  This should be a part of any home exercise program as well, having the athlete perform 3-4 sets of 20 reps with 5-10 second holds in the squat sit position.
If they are unable to squat to increasingly lower levels without the shift, progress the time at the higher level squat without the shift with attempts made at each session to progress toward a 90 degree or greater squat without any shift off of the midline.  The SNMR will typically consume approximately 10-15 minutes of a session.

 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 and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

Exercises to Eliminate Pathokinematics - Part III

Last week we talked about warm-up in some detail and this week we are going to focus on Dynamic stretches.  For the purposes of this blog, we will be covering mostly how this can be used in the clinic or in the gym.  The ACL Play It Safe Program uses some of these same concepts but applies them with sport to ensure maximal carry over in the later stages of rehabilitation or for performance enhancement or as a part of your injury prevention protocol.  We will cover this later in this blog series but stick to the clinical application at the moment.  Most importantly is that the concepts that are taught here should be implemented no matter whether you are doing this on the field or in the clinic. 

Dynamic Stretches:  The purpose of these exercises is to work on the flexibility of the athlete’s hips and lower legs in order to allow him or her the flexibility that is needed to participate in sport and to prevent injury.  Dynamic stretches are also designed to incorporate balance, strength and muscular endurance which will carry over to sport.  It is also critical that technique is strictly enforced.  Allowing athletes to perform the dynamic stretches with poor movement patterns simply reinforces bad movement patterns.  Poor movement patterns that will be carried over to remaining exercises and during athletic performance.

Dynamic Lunge:

Start by lunging out with the right foot, keeping both feet straight ahead.  Do not allow the right knee to go over the toes.  Bring the right elbow to the arch of the right foot, and hold this position for 3 seconds.  Extend the right knee to the straight position while bringing the left heel to the floor (make sure to keep feet and your hips pointing straight ahead).  Keeping the hands on the floor (the goal is to keep the palms flat on floor), hold this position for 3 seconds.  Lunge forward with the left leg while making sure to prevent moving into valgus and repeat the sequence on the left side.  Perform 10-15 yards or 8 repetitions on each side.



NOTE:   Several key positions to be aware of.  When lunging out, the contact with floor is controlled and not slapping the foot and controlling the knee.  With bring the elbow toward the arch of the foot, the thigh is kept in close to the elbow to push hip flexion and the hips are aligned straight and not allowing to roll out.  On side, hip position is maintained straight ahead.  Stride through is critical to control the knee and not allowing to go into a dynamic valgus.

Sumo Squat: 

Starting in a full squat position, grab your toes and pull up with each hand.  While continuing to hold onto your toes, fully extend both knees as far as your flexibility will allow.  Hold this position for 3 seconds.  From your hands on your toes position, walk your hands out to a full push-up position.  From this position, walk on your toes to bring your feet up to your hands.  Hold this position for 3 seconds, return to the starting squat position.  Perform 10-15 yards or 8 repetitions.


NOTE:   As instructed in the video, it is critical to maintain good hip and trunk position and stability during the push-up.  During the toe walk, the knees are kept straight during the entire walk up.      

High Knee Toe Ups: 

Standing with feet shoulder width apart, bring the right knee up toward your chest while grabbing with both hands and pulling to the chest as far as your flexibility will allow.  Simultaneously rise up into a calf raise on your left foot.  Pause and hold briefly.  Return to the starting position.  Repeat with the opposite side.  Perform 10-15 yards or 8 repetitions.



NOTE:  Some key points on technique is to ensure that the trunk remains upright during the hip flexed position.  This results in bringing the knee to the chest and not the chest to the knee.  Also important to make sure you are bringing the knee into straight knee flexion and not in a circumducted position (circular fashion).

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 and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

Exercises to Eliminate Pathokinematics - Part II

Last week we started introducing the philosophy behind the exercises to reduce pathokinematics.  This week we will continue on this path with layout on the specifics of what will come in the coming weeks. 


The following series will provide you with instruction in:

  1. Warm Up.  In order to prevent injury, the athlete needs to first warm up the body, raising the core temperature.  Then he or she is able to do some dynamic (movement based) stretching to further loosen the muscles and prepare him or herself for more demanding work on each muscle group.  In some cases, it is also appropriate for the athlete to work on more intensive sprinting and plyometric activities to address speed and endurance. These also serve to further increase body temperature.  The Warm Up consists of:

·       Cardiovascular Warm Up.  Due to the endurance demands of sports, cardiovascular training is an essential component and should be built in to the training plan as a part of the overall performance program.  Our cardiovascular warm up routine will provide you with the most efficient warm up to allow the athlete to achieve optimal gains in the shortest period of time.

·       Dynamic Stretches.  Dynamic stretches provide athletes with a unique stretching routine that focuses on flexibility, balance, strength and endurance.  Dynamic stretches are NOT ballistic stretches.  These use contract- relax techniques which facilitate optimal gains in the shortest period of time.  These stretches include:

§ Dynamic Lunge

§ Sumo Squat

§ High Knee Toe Up

·       Sprint Training.  For those athletes needing to incorporate anaerobic speed or sprint training into their routine, this section will provide a detailed program to allow the athlete optimal gains in speed and anaerobic power, using the 40 yard dash.

·       Proprioceptive Neuromuscular Facilitation and Plyometrics:  Once we have ensured that the athlete’s core body temperature is raised and the muscles are loose, we can incorporate more intensive and targeted pre-stretch, proprioceptive neuromuscular facilitation and plyometric exercises in preparation for the Corrective Exercise Progression.  These exercises are:

      • Bilateral Hops
      • Single Leg Hops
      • Box Jumps
      • Lateral Box Jumps
      • Single Leg Lunge Hops
      • Jump Squats               
  1. The Corrective Exercise Progression (CEP). The exercises in this program will be categorized by the muscle and/or system being trained.  These exercises have been carefully chosen after a through literature review to ensure maximal outcomes.  Each exercise will have 3-7 levels of increasing difficulty within each progression in order to ensure they properly facilitate maximal gains in strength and performance.  Because of the size and scope of the CEP, will consume multiple blogs and devoted a section to each which follows:

The King and Queen of Exercise—The Squat and Lumbar Hip Disassociation

 

Squat Neuromuscular Retraining (SNMR)

Lumbar Hip Disassociation Exercise Series


Digging Deeper—Targeted Isolation Exercises


Gluteus Maximus Progression

                                               i.     Glut Max Press

                                             ii.     Leg Press

                                           iii.     Step Ups

Gluteus Medius Progression

                                               i.     Side Lying Gluteus Medius

                                             ii.     Side Step with Resistance Band

                                           iii.     Retro Monster Walk

                                            iv.     Standing Gluteus Medius

                                             v.     PNF Step Ups

Adductor Group Progression

i.      Standing Hip Adduction

ii.    Supine Adductors from Pike Position

iii.   Side Lying Adductors

Quad Progression

i.      Leg Extension

ii.    Standing Lunge—Alternating

iii.   Standing Lunge--Back

iv.   Walking Lunge

v.     Prone Place Running

Hip Flexor Group Progression

                                               i.     Single Leg Raises

                                             ii.     Head to Knee Pull-Throughs

Hamstrings Progression

                                               i.     Hamstring Pulls

                                             ii.     Modified Dead Lift

                                           iii.     Single Leg Dead Lift

Lower Leg Progression

                                               i.     Standing Calf Raises

                                             ii.     Seated Calf Raises

                                           iii.     Dorsi Flex Toe Ups

                                            iv.     Rebound Hops

Foot/Ankle Progression

                                               i.     Inversion/Eversion

                                             ii.     Standing Medicine Ball

                                           iii.     Bosu Ball Balance

Addressing “The Core” 

Abdominal Progression (Core Series)

                                               i.     Upper Abs on stability ball

                                             ii.     Obliques on stability ball

                                           iii.     Pike Position Lower Abs

                                            iv.     Side Bridge

                                             v.     Prone Bridge on Elbows

Lower Back Progression

                                               i.     6 Pack on stability ball

                                             ii.     Prone stability ball Leg Raises

                                           iii.     Good Mornings

Warm Up

Warm up exercises are an integral part of any exercise program.  With our program, we use cardiovascular exercise as an appropriate initial warm up step for athletes.  Warm up will consist of both aerobic exercises and anaerobic exercises.  The aerobic exercises will be used for general conditioning and the anaerobic for more sport specific conditioning.  The amount of aerobic and anaerobic conditioning for each individual is going to be determined by the demands of the sport.  For example, for soccer players and long distance runners, the aerobic component should be increased dramatically, while sprinters need more anaerobic conditioning.  At the end of the warm up period, we include a plyometric exercise component which further serves to warm up the muscles, joints and ligaments, as well as providing additional interval and power base training, which is proven highly beneficial in sport.


Cardiovascular Warm Up:  Cardiovascular training should include light aerobic exercise, which can consist of work on a treadmill, elliptical machine or stationary bike and should be at least 10-30 minutes in duration, depending on the aerobic demands of the sport for which the athlete is training.  This should not be a scheduled part of the program, but rather done on the athlete’s own time directly before the program begins.  This is accomplished by having them come in 10-30 minutes early to perform the cardiovascular warm up.  The exercise intensity should be gauged by the athlete’s heart rate (HR), which is determined using the Karvonen formula.



Training HR = [(HR max – HR rest) * .6 to .8] + HR rest


This formula gives you the targeted training HR in beats per minute, at 60-80 degree of the maximum target heart rate.  The final number can then be divided by 6.  This will give you the HR the athlete will measure during a 10 second count. 


Example:  If an athlete wishes to perform with a training HR of 120 to 138 beats/minute, dividing by 6 gives you 20 to 23 beats per 10 seconds.  So when exercising, the athlete takes their HR for 10 seconds to determine if they are within this range.  If the measured heart rate is too low, increase intensity (e.g., speed/pace, difficulty), or conversely, if it is too high, decrease the intensity of the exercise.

HR max =  220 – age
HR rest =  resting HR for 1 minute
.6 to .8 determines the relative intensity of the exercise and the number chosen should be based on the general conditioning level of the athlete.

Using this formula will create a much higher intensity than that at which many younger athletes are accustomed.  Therefore it is important that they are taught how to use this formula and how to take their own resting and exercising heart rates so that they can learn to monitor their own heart rate throughout the warm up.

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 and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 


Exercises to Eliminate Pathokinematics - Part I

Throughout the last several months this blog we have discussed pathokinematics and the impact they have on both performance and the potential for injury in athletes.  In one of the previous series, we provided you with several tools to assess movement and interpret the results of those assessments.  We also discussed how technologies could be leveraged to address.

 A movement assessment should be designed to assess movement patterns (pathokinematics) that are commonly associated with increased risk for athletic injury and reduced athletic performance.   The goal of the assessment should be to identify strengths, weaknesses, and tightness in the musculature and other structures of the body that cause or contribute to pathokinematic movement patterns.  Once these are identified, it is possible to “prescribe” corrective exercises that directly influence and improve those weaknesses and tight areas of the athlete’s body, making them stronger, more flexible, and more capable of transmitting power throughout the kinetic chain and lower extremity during sports activities.  It should be mentioned here that in addition to corrective exercise, there are many other techniques and manual interventions that clinicians use to correct deficits we see and identify using a movement assessment.  These are beyond the scope of this blog and will not be covered here but should be considered in a comprehensive treatment plan.

 In the series “How to Eliminate Pathokinematics” we reviewed some General Facts and Terminologyassociated with exercise and training in preparation for the information contained in this blog series.  Here we introduce the Corrective Exercise Program, or CEP.  The Corrective Exercise Program (CEP) is designed to directly and specifically address the components that contribute to pathokinematic movement patterns.  This is a movement specific program and not a sport specific program.  It is the concepts and methodology from all this body of work from which we developed the ACL Play It Safe Program.  However, each of the exercises included here will be the more clinical exercises and not the group/team interventions that are a part of the ACL Play It Safe Program.  Each of the exercises described here have levels of progression that increase the difficulty and/or endurance requirement of the exercise.  If prescribed and conducted correctly over time, these exercises will not only drastically improve the athlete’s movement patterns but will also improve overall athletic performance and reduce the likelihood of certain types of lower extremity injuries, specifically those involving the lower back, hip, knee, and foot/ankle.

In 2009 unpublished study 40 college athletes were placed on an exercise program to directly address weaknesses observed in a movement assessment.  The results of this targeted exercise program were phenomenal.  It was shown that when the athletes participated in the exercise program for 8-12 weeks, they were able to increase their vertical jump by and average of 4 inches and improved 40 yard dash time by 1.4 seconds.  In our current body of work, we are not only seeing dramatic decreases in overall lower limb injury rates but also huge health care savings for the university.  We are demonstrating an average savings of $30k to $50K per team per season in DI athletics.  In 2016, we continued this work with DI Football.  The results of this work is currently being written up for publication but preliminary analysis shows the lowest recordable injuries in 8 years and the team was nationally ranked for the first time in the colleges history.   

Using what we learned from this and many other similar studies, as well as years of experience working with athletes, we have developed a set of exercises that assist in reducing the potential injuries in the lower extremity and improve performance.  The program details follow, but it is important to remember that before beginning any exercise program, it is a good idea to have a complete physical performed on the athlete. 

This program is designed so that it can be used in many different ways and for many different sports.  For example, the CEP can be used for rehabilitation of an injured athlete when targeted exercises are chosen to address the injury or injuries.  The Physical Therapist or Athletic Trainer can “pick and choose” those exercises most appropriate to address the rehabilitation needs of the individual.  The CEP can also be effectively used to address pain issues associated with overuse, repetitive motion or pathokinematic movement patterns in athletes.  We have found that when the CEP is used to strengthen the athlete, either when used in a targeted fashion or as an overall exercise regime, pain with lower extremity activities is reduced.
applications.

Of interest to many in today’s fitness world is the use of this type of exercise program in athletic performance enhancement.  Our results show that athletes who use the Corrective Exercise Program in fact increase athletic performance, specifically in peak vertical jump height and sprinting speed as noted above.  This has also been validated in work by Myers, et al who have showed similar results.  The CEP can be used to improve technical ability specific to a given sport, strength, speed, endurance and power output.  Portions of the CEP can be used to target specific weaknesses or areas of tightness and inflexibility the athlete demonstrates in the movement assessment, or can be used in its entirety as a full and complete exercise program.

Because of the difficulty and intensity of the CEP, when adding it (or parts of it) to an already full training plan, it is easy to over-train the athlete.  Care must be utilized therefore in prescribing exercises in the CEP that involve the same body parts as those already being taxed in the regular training routine or sports activity.  They should instead be used to replace or substitute for those exercises, or enough rest should be allowed between them.

As discussed above, after a thorough assessment of the athlete, we now have an idea of where their individual weaknesses and tightness exist.  As with any exercise program, you and the athlete should be sure that they are physically capable of safely beginning or proceeding with a rigorous exercise program.  The exercises in this progression begin at a fairly difficult exercise level, requiring participants to have a basic level of fitness and flexibility.   Again, please be sure to have your patients/clients check with their physician before beginning this or any exercise program. 

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 and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

Innovations in Movement - Blending Movement Science with Technology - Part V

Over the course of the last several weeks we have been discussing how to leverage technology for the assessment of movement and treatment of movement dysfunction.  Most of the technologies we discussed can be easily implemented into treatment and are relatively inexpensive.  Those that are used for the assessment of movement dysfunction can, many times, also be an additional billable service that can be added to your athlete’s episode of care.  To conclude this series, we will be discussing the use technology for HEPs and tracking of compliance with the athlete.

One of the first we will discuss is the ACL Play It Safe Program.  In full transparency, this is one that I have been personally involved in but have no financial tie to.  This is a program I developed to address the preventable non-contact lower limb injury epidemic in sports.  Although the name suggest this is ACL specific, this program is movement specific.  This means this addresses the biomechanics and movements that are associated with non-contact lower kinetic chain injuries, one of the most recognized of which is the anterior cruciate ligament (ACL) injury.  In addition to mitigating injury risk, these same movements are also associated with a decrease in athletic performance.  So, this program is specifically designed to improve the efficiency of athletic movement which results in reducing injury risk and improvements in athletic performance (specifically vertical jump and sprint speed). 

This program was developed in conjunction with Theraband® and Cramer®.  The ACL Play It Safe program is a comprehensive program that can be implemented with an athlete as a part of their home exercise program.  This program includes:

·       Gender specific kit – There is variance in the male and female athlete based on the peer reviewed literature.  The research indicates there are variances in strength and proprioception among the male and female athletes which is accounted for in the male and female kit.

·       Standardized equipment - This standardized kit is designed for the individual athlete.  Having standardized equipment ensures that the athlete is using the same equipment each time and has the equipment available for every exercise.  This improves outcomes since the athlete will not be using different equipment each time and/or skip an exercise because the equipment is not available. 

·       Equipment included – each kit includes the following:
o   CLX – this is the latest development in resistance band technology and was developed by Theraband®.  Use of the CLX allows us to perform very creative exercises like the spiral technique.  This particular technique allows us to perform single limb training while increasing Gmed recruitment during this activity. 

Spiral Technique

o   Padded Cuffs – allows us to perform closed kinetic chain gmed and core strengthening.
o   Stability trainer – allows us to work on single limb proprioception and core stability training
o   Biofreeze – to do the aggressive nature of this program, this allows us to control muscle soreness and irritation that may develop as a normal part of an athletic season.

·       Standardized program – the ACL Play It Safe Program is a progressive program that is designed to be implemented as a part of your team’s practice or training.  This program includes two very distinct parts.
o   Pre-practice routine – Neuromuscular resetting – this is designed to prep the system for movement or participation in sport.  This only includes three movements but are full lower kinetic chain movements that add in improving lower kinetic chain mobility while at the same time initiating the proper movement patterns.  This routine takes 3-5 minutes.
o   Post-practice routine – Fatigue state training – we know that most injuries occur later in the game and that athletic performance is negatively impacted by fatigue.  What the literature tells us is that training in a fatigued state will have a better carry over and impact to the athlete’s movement in a fatigued state.  This means they move better, are at reduced risk for injury and they perform at a higher level.  This routine takes 15 minutes. 

·       ACL Play It Safe App – as a part of the ACL Play It Safe Program, we have developed the ACL Play It Safe App.  Knowing the importance of proper instruction in movement and corrective exercises, we have found that providing this in a comprehensive video was one of the most effective means of doing so.  The ACL Play It Safe App was developed in conjunction with Theraband® and Cramer® and is an easy way to provide a video for every exercise included in this program in an app.  The ACL Play It Safe app can be found on IOS or Android by searching “PhysioSports” and is free.   The ACL Play It Safe app provides:
o   Level I – IV exercises
o   Specific order in which the exercise should be performed
o   Specific technique for each exercise
o   Number of sets and reps for each exercise

*Note – it should be noted that this is a web-based app due to the number of videos included.  This means that you will need access to the internet or cell service in order to run this app.*

In addition to the ACL Play It Safe App, another technology that is being used in home exercise programs for correcting of movement dysfunction is Fusionetics.  Fusionetics was developed by Mike Clark, DPT.  For those in athletics and familiar with movement assessment, Dr. Clark has been an innovator in the area of movement assessment, corrective exercise and technology.  Fusionetics is his latest innovation and is quickly becoming a great platform for distribution of quality research based content and provides a tool by which we can track the athlete’s progress and compliance. 

Fusionetics is a web-based platform that that provides some very unique features.  Once the athlete’s movement has been assessed, the athletic trainer, physical therapist or personal trainer can then build a profile in the software for the athlete.  This allows the provider to assign or prescribe exercises and the frequency at which these are done.  The athlete is then provided with a link that allows them to set up their individual profile and to access the Fusionetics App.  When the athlete logs into their individual profile on the app, they are then provided all the exercises the provider has prescribed to them along with comprehensive videos of each exercise.  Once the athlete performs the exercises, they then log in the app that the exercises were performed and how they are progressing with the exercises, the level of difficulty and if they experienced pain with.

For the provider, once they log into their account, they can instantly see all their athletes, which ones are doing the exercises, who they are progressing and whether or not they should be progressed on
their exercises.  This is an invaluable tool, especially for those of us who need to track multiple athletes or for athletes that we are only able to see occasionally or who travel with their team.  The Fusionetics platform provides the provider with some invaluable information and a way they can continue to engage the athlete throughout their training and season. 

As we have seen, there is a rapid progression of technology in the area of sports medicine.  The technologies that have been mentioned throughout this blog series is only a small portion of the technologies that are available.  In addition to the aforementioned technologies, there are additional telemedicine technologies emerging on the market.  One such technology is Player's Health, which is a mix between an athletic training EMR and telemedicine platform.  This technology allows the provider to have a much more robust engagement with the athlete, team physician, coach and manager/athletic director.  With the integration of their app, this allows:


·       Communication of information to the athlete about their care or physician appointments
·       Team physician to quickly see where each athlete is in the health care continuum and get updates
·       The coach to see which athletes on are on the DL, where they are in the process and their anticipated RTPlay date
·       The athletic director/manager to see what athletes are injured, how long they have been on the DL and their anticipated RTPlay

With the emergence of technologies such as this, it creates a greater level of transparency of care and improved communication.  For those of us involved in treatment of the athlete, we know how challenging this can be and how vital consistent and clear communication is.  These technologies simply allow us to do what we do but even better and with improved efficiency. 
We hope you have enjoyed this blog series and thank you for sharing the passion for movement and prevention.




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. 




Innovations in Movement - Blending Movement Science with Technology - Part IV

Last week, we started to investigate technologies that we could incorporate into treatment that would aid us in leveraging the latest in movement science with latest in movement technology.  This included looking at it from four destinct perspectives.
  • 2D video
  • Biofeedback
  • Resistance bands & product innovations
  • Tracking & compliance
Last week, we looked at 2D products that could be used in treatment as well as those that could be used for biofeedback.  Today, we will start our discussion by looking at product innovations.

Product Innovations

There has been quite a bit in the advancement of products that we use to treat movement dysfunction.  There is a plethora of these items available on the market and this list is not all inclusive but only includes the ones we are the most familiar with.  It goes without saying that there may be better products out there but these are just some of the ones that we have had experience with.


  • CLX - cross linked Therabands is the newest innnovation by Theraband (Performance Health, Inc).  The product we all know so well has gotten even that much better.   With the advent of the CLX, we are now able to cross link the entire closed kinetic chain to improve recruitment of the entire lower kinetic chain during functional exercises.  One technique developed is the "Spiral Technique" which increases Gmed recruitment during single limb performance.  Although this is a great adjunct to single limb training, it is also a great tool to add to our core training to aid in recruitment of the entire lower kinetic chain and core.  For more on the spiral technique, you can access the Spiral Technique Video or for information on the core training, you can access the Core Training Video.
You can also access the Theraband website for additional videos on some creative CLX exercises.  Below is one example of an exercise using the CLX that works on recruitment of the lower kinetic chain.



  • DS2 Platform - the DS2 Platform was developed by a Roland Rameriz, PT, ATC, SCS who is a physical therapist and athletic trainer in the NFL.  Roland developed this as a closed kinetic training tool for his athletes rehabilitating from injury as well as those looking to do some closed kinetic chain functional training.  The DS2 is a great tool for progressing single limb closed kinetic chain exercises and is also a great tool for progressing of core training exercises.  There are also some great videos in which Roland demonstrates the use of the DS2 for lower body training.


In this video, Roland demonstrates the use of the DS2 with lower body training and for the use with the core.  For more videos and techniques, you can visit his website at the link above.


  • Primal 7 - was initially developed by Brian DeMarco an NFL player who suffered a devastating career ending injury.  After being unable to move independently, let alone train, Brian came up with a way to start training (squats) with the use of some straps and bands.  Low and behold, the prototype for Primal 7 was developed.  Since then, Primal 7 has developed into an affordable suspension training system that allows athletes and non-athletes to start training movement in weight bearing reduced environment.  With the bands, you can modify how much body weight the athlete must resist so that you can gradually increase resistance as movement is perfected.  
In the following video, Brian talks you through the use of the Primal 7 and how this system can be used to help your athletes move better.


  • Hyperice Vyper Roller - the Hyperice Vper Roller provides deep vibration in combination with a roller.  When dealing with myofascial restrictions throughout the lower kinetic chain or muscle soreness, we have found this to be another valuable tool to assist us in achieving our goals, improved outcomes and an additional tool that our athletes enjoy using and "feel" a physical benefit from using.
In this video, the founder and developer of the Hyperice Vyper Roller shows what makes this product unique over your traditional roller.


  • RMT Club - this is another fairly new fitness product on the market that allows us to address movement in a way which increases the core recruitment while creating high levels of activation of the lower kinetic chain.
In this video, the author demonstrates the use of the RMT club for increased core activation.



This is by no means an all inclusive list but just a list of the ones we have had the most experience with.  We hope you found this helpful and next week, we will be discussing some movement technologies we can use to improve compliance with the programs we recommend.  



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. 







Innovations in Movement - Blending Movement Science with Technology - Part III

Last week, we discussed various technologies that could be leveraged clinically to assist us in assessing human movement.  During last week's post, we looked at apps, 2D technologies and 3D technologies that could assist us in efficiently and reliably assessing human movement.  With the advent of technology, simply relying on the human eye has been shown to be less efficient, less accurate and less reliable.  As such, we can now leverage technologies to do what we use to through simple observation.  This provides us much more accurate and objective measures of progress and current status.

As we continue this series, we now want to start investigating what technological advancements has there been that can aid us in the treatment of human movement.  Keep in mind, throughout this discussion, the goal is not to simply use the snazziest advancement on the market but more importantly to incorporate technologies that can allow us to efficiently and reliably correct movement dysfunction and which can be easily implemented with the lowest cost barrier to entry.  To use technology that leverages the latest in movement science with the latest advancements in movement technology.  That said, we will approach this section from four perspectives.
  • 2D video
  • Biofeedback
  • Resistance bands & product innovations
  • Tracking & compliance
2D Video:

2D video provides us a great tool to provide visual feedback to the athlete.  When assessing high level athletes, some are very receptive to your interpretation of movement and some are not as receptive, especially if they are a high level athlete (or they perceive themselves as high level athlete).  Therefore, the ability to show the athlete how they move is instrumental part of getting the athlete's psychological buy in to what you are trying to achieve.  Video based software and apps allow us a medium which we can not just describe the movement we see, but actually show the athlete the motion.  From this visual feedback, we can then help them make corrections in, correlate that movement to injury risk and how that movement impacts athletic performance.

One of the most widely used video technologies is Dartfish.  This technology offers a lot of advantages for assessing movement and for treating movement.  In a systematic review by Agresta et al - J Orth Sport Phy Ther 2015 the authors showed that video feedback provided to runners by using real time feedback (via Dartfish) during their run was very effective tool at helping runners address their running movement dysfunctions.  Dartfish is one of the few technologies that allows you the ability to do live video feedback that can be used during live training with an athlete and is extremely helpful in helping them correct their movement dysfunction.   

In addition to 2D video software based technologies, there are also several apps that are offered out there that can be used to provide video feedback.  One major limitation of all of these is the inability to do live feed to a television or projector.  Where Dartfish allows the athlete to see this live, correct as they go and see the immediate results, most Apps do not allow.  With Apps, this information is recorded and then provided to the athlete after the fact.  Therefore the ability to correct that movement on the fly is not easily obtained.  Although providing feedback after and then having them correct still works, the training impact is more immediate with live feed.  

Some of the most common Apps are listed below and have the ability to function on IOS and Android.  

  1. Hudl - this is a 2D app that offers some versions for free and some upgraded versions offered at minimal cost.  This app allows you to capture movement and perform slow motion.  This allows you to show the athlete motions which occur at a high rate of speed at a speed which they can see.  
  2. Dartfish Express - this comes to us from Dartfish and includes some of the capabilities that
    are available in the software.  It allows some of the same functionality of the others but the quality and functionality of this app seems to have a step ahead.  It is available for minimal cost.  Videos can also be saved to Dartfish TV which you can then give access to the athlete to see and download in media books.
  3. Coaches Eye - this is another 2D app that initially started as a tool for coaches to assess players motion during athletic competition or practice.  The application to the treatment of movement is obvious and it also offers some of the same functionality of the previous two.  
Biofeedback

With advancements in technology, we now have several technologies that can be used for biofeedback.  Some of the most commonly used include:


  • DorsaVi - as mentioned in the previous blog, DorsaVi is a "true" 3D motion analysis system that uses an IMU (inertial measurement unit) to provide 3D data and feedback.  DorsaVi has a module that is available within the system that provides the subject real time feedback on motion. So the athlete will use the sensors during treatment to provide them real time data on where their body is in space and the system will use this to challenge them through a series of tests and exercises.  Although the current application is for balance and lumbar spine, I suspect that lower kinetic chain training will be available in the future.  In addition, there is the ability to attach the sensors to the athlete and have them go for a 1 hour, 2 hour or 4 hour run while collecting data or reporting the data during the live run.  This allows you to make adjustments to their running and see the direct impact on IPA (initial peak acceleration) and ground reaction forces. 




  • Tecnobody Isofree - has a system coming out on the market that uses the XBox One and time of flight technology combined with a force plate to provide feedback of joint position and weight distribution.  This is a great tool for providing proprioceptive retraining for the athlete.  With this device, the athlete stands on the device and the system tracks their body in space while taking them through a series of challenging, fun and interactive games.  Although there is nothing on the website about, based on their other systems, I suspect this will be in the $20K range.


  • Motion Guidance - this is a relatively simple and inexpensive device that was developed by two physical therapists.  This system uses a small laser strapped to the lower extremity and target.  This is a great tool for use in jump training and while performing single leg activities that will provide instantaneous feedback to the athlete if they are able to maintain stability of the knee in the frontal plane as well as pelvic stability.  These kits also come with a patient HEP pack that the athlete can take home for their home exercise program.



    This is by no means an exhaustive list but more at list of products that we have used and have some familiarity with.  Next week we will continue this discussions as we look at some product innovations which can be used in the the treatment of movement dysfunction.



    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. 



    Innovations in Movement - Blending Movement Science with Technology - Part II

    Last week, we started this series to look at how we can leverage what we know in the movement sciences with technology.  The intent of this series is to share with you the various technologies we have encountered as well as some of the benefits and challenges of these.  Considering this, during this series we are going to touch on several different aspects.

    1. Technologies to assess movement
    2. Technologies to treat movement
    3. Training technologies to train proper movement
    Last week, we looked at the use of 3D technologies to assess human movement.  This week, we will continue looking at 2D technologies and some specific technologies that are available on the market for doing this.  Before we do that, we should discuss the challenges associated with use of 2D.  These can be mitigated but we must be aware of in order to control.  Remember, we are attempting to make 3D interpretation off a 2D image.  Sometimes that 2D image may appear to show something that is truly not there in a 3D environment.  

    Some things to consider when performing movement assessments using 2D technology.


    1. Camera orientation - in order to get a true picture of frontal plane movement of lower kinetic chain, you must have the camera directly infront of the athlete perpendicular to the orientation of the athlete (depicted here).  If the camera orientation is slight off (off to the right or left of the athlete) then this will result in seeing a valgus or varus that is not really there.  If the camera is tilted down or up, then again you will see motion that may not actually be there.  As common knowledge as this sounds, I attend a lot of conferences with some very reputable companies presenting on 2D analysis showing adduction at the knee during a movement and the orientation of the camera to the athlete is way off to the side.  This can all be avoided by ensuring the camera orientation is perpendicular to the athlete.
    2. Angles - most of the 2D technologies out there offer the ability to measure angles.  When measuring human movement, the difference between 5 degrees and 15 degrees can mean the difference between an athlete at risk and one that is not at risk.  What we know is that when you measure angles on 2D, there is an inter and intrarater reliability of +/- 10 degrees.  So, did you really improve that frontal plane motion by 10 degrees or that supination by 5 degrees or did you simply put your starting point at a different spot.  If you are going to use the angle function on these technologies, you can reduce some of this error by palpating the bony landmarks on the athlete, placing markers on those anatomical references and use those when reviewing the video.
    3. Tracking - although this is a really cool capability of some of these technologies, use of tracking with a 2D technology is done via pixels and relies on color.  That being said, if you have an athlete in dark colors against a dark surface, the tracking capabilities will be very limited.  If you are going to use this capability, there must be some significant contrast in colors to have increased accuracy of the tracking.  In addition, the slower the movement is the more accurate the tracking will be.
    4. Stability - this one goes without saying and most control for this.  But attempting to assess movement using 2D video without use of a tripod is very difficult.  This is more common with the use of the smart phone or Ipad for assessing movement.  Again, if not controlled, you will see movement that may not be accurate.  
    5. Frames per second - for any 2D analysis, it is important to know what the fps your camera is.  Optimal is to have a camera with 120 fps or >.  Using cameras with 30-90 fps will result in videos that will be choppy when you are analyzing them in slow motion.  This will often lead to missing the pathological movement you are looking to assess.
    For 2D assessment, there is 2 basic types.  Desktop software and Apps.  

    Desktop software:

    Two of the most common desktop software companies are Dartfish and Kinovea.  Dartfish is a Switzerland based company that was originally used by high performance coaches in professional and Olympic athletics.  Dartfish developed "stromotion" which allowed coaches to see how athletes are moving through all the phases of athletic performance.  This allowed coaches to capture minor nuances throughout the extremely high speed motions in order to create more coachable opportunities.  For me, Dartfish was instrumental in my ability to truly assess and understand movement.  It allowed me to slow down movement to the point that I could capture pathological movement patterns form which I could train athletes to improve and use it to educate them about their movement.  
    Although we did not use this to put angles on movement, what we did find is much more accurate way of quantifying frontal plane motion with this technology.  By simply using plumb lines and specific anatomical landmarks, we found that this had a high correlation to frontal plane motion captured via Viacom system.  So we could not only objectively measure frontal plane motion but also objectively quantify improvements in that motion.  

    Kinovea is a French based company that offers a 2D video technology that looks and functions very similar to Dartfish.  Although this software is free, it should not be mistaken that there are some fundamental differences in Kinovea and Dartfish.  First off is reliability of the software itself.  There is nothing worse than capturing data on over 30 players and having the system corrupt the videos as you are doing your analysis on later (speaking from experience).  Although some of the functionality is similar, it does not offer the same level of capabilities of Dartfish.  If you are just starting out in movement assessment, this is a good and cheap alternative to start to get your feet wet.  But if you are doing a lot of movement capture, spending the money on Dartfish is money well spent.

    Apps:

    There are a lot of different apps that are offered out there for assessing human movement and too many to mention them all.  In this section, we will talk about some of the most common ones.  Most have the ability to function on IOS and Android.  

    1. Hudl - this is a 2D app that offers some versions for free and some upgraded versions offered at minimal cost.  This app allows you to capture movement, perform slow motion and draw lines on the video.
    2. Dartfish Express - this comes to us from Dartfish and includes some of the capabilities that are available in the software.  It allows some of the same functionality of the others but the quality and functionality of this app seems to have a step ahead.  It is available for minimal cost.
    3. Coaches Eye - this is another 2D app that initially started as a tool for coaches to assess players motion during athletic competition or practice.  The application to movement assessment is obvious and it also offers some of the same functionality of the previous two.  
    This is by no means an all inclusive list but just a list of the ones we have had the most experience with.  We hope you found this helpful and next week, we will be discussing some movement technologies we can use with treatment.  



    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. 





    Innovations in Movement - Blending Movement Science with Technology

    Over the course of the last several years, we have talked a lot about movement and the correlation to injury risk and athletic performance. Based on these discussions, I think most would agree that assessing movement as a part of athletics is important.  But how do we do this in a meaningful and reliable fashion.  How do we do in a way that is valid and yet efficient enough that we can use it with a team of 18 volleyball players or 110 football players?  This is where we need to look at various technologies and then blend those with what we know from the movement sciences.  We will preface this series with the fact that I am not an IT specialist nor do I pretend to know all the ins/outs of technology.  However, I have used technology for >10 years to assess and treat movement dysfunction.  So although I am not an expert in this area, I have some proficiency with the use of in athletics and had exposure to everything that we will be discussing in this series.

    Consider the above, in this series we are going to touch on several different aspects.

    1. Technologies to assess movement
    2. Technologies to treat movement
    3. Training technologies to train proper movement

    During the course of this discussion, we will talk about various technologies, benefits of using and some of the challenges we experience with.  This is by no means a comprehensive list but is solely based on our experiences only.  So, lets begin by looking at technologies to assess movement.

    Traditionally the ability to accurately assess movement was left to large expensive biomechanics labs.   Viacom systems (which is typically used in these labs) are the gold standard in movement assessment and in 3D movement capture.  However, Viacom systems are very expensive and require a lot of time to capture the data, interpret the data and to report it in a meaningful way that can be easily understood by the clinician and athlete.  In an efficient lab, it can take up to 3-4 hours for capturing the data on one player.  This does not include the additional 2-3 hours of data interpretation that must occur after for data reporting in a meaningful way to the consumer.  To be able to do that with an entire team of 18 players or 110, is just not feasible or cost effective.  All would agree this would provide extremely viable data we could use to develop more comprehensive programs, but in the end, the lack of efficiency and the cost make this an option for only a few.

    The next level of interpretation would be the use of 3D systems.  One such system out there is the Myomotion system by Noraxon USA.   This system has all the bells and whistles and is truly a portable biomechanics lab.  This system has the ability to provide 3D motion, 2D video, EMG data and force plate data all at the same time.  This system uses 10-13 sensors that are attached to the athlete which then is Bluetoothed to the laptop that is capturing all the data.  

    Benefits:

    1. Reliability - this system provides reliable and valid 3D data on the athlete in real time.  
    2. Data Analysis - there is no need for hours of data analysis to put this into a report.  All of the algorithms are run by the computer and this can be printed out instantaneously.  
    3. Portable - this system is portable so you can take this on the field, in the field house or in the athletic training room to do assessments.  
    4. Variability of movements - this system uses sensors to capture all the movements and does not rely on pre-programmed movements.  This allows the user to assess mechanics during a single leg squat and agility drills you create.
    Challenges:
    1. Expense - this system is very expensive and runs ~>$25,000+ depending on the capabilities you are looking for.
    2. Data interpretation - although you get this in a report format, there is no interpretation of the data.  Unless you have experience looking at mass biomechanical data, interpreting what the data means and what you do about it is challenging and time consuming.
    3. Sensors - the sensors are cumbersome.  Since you have so many of them, putting them on takes ~20-30 min.  In addition, if you are doing true athletic testing where the athlete sweats, they move all over.  This makes the data that is captured unreliable.
    4. Time needed to test athlete - to perform a typical athletic assessment, this will take 40-60+ minutes per athlete.  This is considering that there is no dropping of the sensor signals and sensors don't move during testing and need re-positioning. 
    Another 3D system on the market is DorsaVi USA.  This is an Australia company started by an Australian physiotherapist who saw the need for more reliable way to assess movement in patients and athletes.  DorsaVi uses an inertial measurement unit (IMU) with a magnetometer, gyrometer and accelerometer and provides lab quality data instantaneously.  These sensors capture motion, rotation and acceleration data within 3% of a Viacom system.  


    Benefits:

    1. Reliability - this system provides reliable and valid 3D data on the athlete in real time.  
    2. Data Analysis & Reporting - there is no need for hours of data analysis to put this into a report.  All of the algorithms are run by the computer and this can be printed out instantaneously in a comprehensive report.  This provides valid interpretation of the data from which the clinician can easily interpret.
    3. Portable - this system is portable so you can take this on the field, in the field house or in the athletic training room to do assessments.  
    4. Efficiency - this system uses sensors to capture all the movements utilizing a pre-programmed sequence of movements.  This allows for efficient use with teams and requires ~15 min per athlete.
    5. Cost - this system is very well priced and is comparable to the cost of most 2D systems on the market.  
    Challenges:
    1. Number of sensors - this system uses two sensors which helps in the efficiency but also limits capturing of movement associated with the pelvis during single limb movements.  Although this will be addressed with future upgrades, this a current limiting factor.
    2. Sensors - these can move and fall off during testing under athletic conditions.  DorsaVi has sleeves which help with this and aids in mitigating this challenge.
    3. Migration of accelerometer - with each rep, the accelerometer graph migrates upward.  Therefore this is reset with each rep but this adds an extra second to each rep.  Although this is one second, it is a variation from natural movement.
    4. Interference - this is really with any 3D system.  if there are strong magnetic fields close to where you are using the system (MRI), then this will create artifact and/or prevent capturing of data.
    With the advent of gaming technology, there are several companies offering Xbox One related assessment tools.  Considering number of these companies coming out, this will focus on the use of the Xbox One for assessing human movement.  The Xbox One uses time of flight technology to assess human movement.  In most simplistic terms (and keeping in mind I am not a IT person), this type of system shoots light to the object being assessed and the amount of time that it takes for the reflection to bounce back to the sensor determines the distance from the camera.  From that, a 3D image can be obtained and movement captured.  

    Benefits:

    1. Portable - this system is portable so you can take this on the field, in the field house or in the athletic training room to do assessments.  
    2. Efficiency - this system uses the camera (sensor) to capture all the movement so there is no sensor placement on the athlete at all.  Therefore this system is very efficient.
    3. Cost - this systems are very affordable (for the most part).  Although there is one system on the market for over $200,000, most are $1000 or less.  
    Challenges:
    1. Reliability - the reliability of the data that is captured is questionable.  If you have ever played a game on one of these systems, we all have experienced where you swing an arm and the system did not capture the movement.  Same thing happens when you do this with human movement.
    2. Environmentally sensitive - these sensors are sensitive to environmental conditions.  If you are testing outside and it is hot, the system can overheat and burn out a sensor.  In one example we went through three sensors doing testing outdoors.  
    3. Light sensitive - these systems are also sensitive to light.  In outdoor very bright conditions it appears to interfere with the time of flight capabilities. 
    4. Artifact - these systems appear to have a lot of artifact in them.  This can be programmed out of the system to account for large variances but when this is done, the movement associated with that individual rep is a guess or based on algorithmic averages.  Most providers of this tech will not tell you this and you won't see it, but understand that is going on behind the scenes.
    5. Interpretation - most of these systems provide you with the data and require the evaluator to interpret the data.
    Advances in 3D technology has come light years ahead in the last 4 years and we should see even more advances in the coming years.  Considering, this is a quick review of some of the current 3D technologies out there.  Next week, we will look at some of the 2D technologies out there.

    Happy New Year to all.  Honored to have the opportunity to provide this blog and hope you find that what we provide in 2017 is better than 2016.



    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. 


    Challenging the Status Quo - Part VI

    Throughout the course of this series, we have been providing some clinical commentary around 5 key areas:
    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
    To close out this series, we are going to be talking about how sometimes movement is just movement and we try to over complicate it.  I sometimes amazed how some "experts" in the area of movement come up with some amazing exercises to improve movement.  Yet, I am puzzled by these same individuals and some of the strategies they employ.  As someone who follows the literature, I am not sure how holding my tongue to the roof of my mouth while contracting my abs or holding a balloon in my mouth during abdominal exercise or how rolling around on the floor using pediatric movement patterns will help me move better during cutting or explosive activities.  I am sure there is some form of legitimacy to these exercises and correlations to upright explosive movement.  But I think we tend to over complicate things and when we do things like this, it makes it hard for the athlete to see the correlation.  From a sports psychology standpoint, that to me is just as critical.  Get the athlete's buy in.  If they don't buy in then compliance and effort drops off.  So how do we avoid that?  Don't over complicate it and make it relevant to what they do.

    This is not rocket science, this is movement.  We don't have to apply theoretical models, we can simply look at the science and apply what we know.  If we had to limit it to one or two things that we know have a direct correlation to movement and injury risk mitigation and performance enhancement, what would it be?

    Depending on who you ask, the answer will vary.  In my opinion, it would be control of frontal plane motion of the lower kinetic chain. Whether you are looking at this picture of this young high school athlete or this professional football player, we can all see how this motion will result in:

    1. Loss of kinetic energy transfer across the system - this means a decrease in power output which will impact vertical jump, sprint speed and agility.
    2. Altered length tension relationships - this means taking a muscle, group of muscles or the entire kinetic chain out of it's optimal position to generate force.  This equates to a decrease in the maximal force that muscle or group of muscles can generate which has a direct impact on athletic performance. 
    3. Altered force attenuation along the lower kinetic chain - this means a increase shear stress departed to the articular cartilage and ligaments and abnormal forces departed to the joints.  This means that tissues break down faster and are more susceptible to injury.

     As we have talked about in the previous blogs, this frontal plane motion "risk factor" can be measured by two components:

    1. The magnitude of motion that occurs.  Frontal plane motion >10 degrees is bad.  The larger the magnitude the worse it is.  
    2. The speed at which this motion occurs.  The faster this motion occurs, the more potential energy that is present and hence the greater force imparted to the structures.  
    This is simple physics.  Looking at the force that is imparted to the structures.  Greater  the magnitude over the same time = greater force.  2 equal magnitudes but one occurs faster, than that one generates more force.  In coaching terms, if 2 athletes travel the same distance and athlete 1 travels distance in half the time, he is said to have more power than athlete 2.  As we have stated in previous blogs, the easiest way to see this is with single leg activities.  Some examples and recommended guidelines include:
    1. Single Leg Squat - <10 degrees frontal plane motion and valgus @ <20 degrees per second
    2. Single Leg Hop - <10 degrees of frontal plane motion and valgus @ <100 degrees per second
    3. Single Leg Hop Plant - <10 degrees of frontal plane motion and valgus @ <135 degrees per second
    If you have limited time and resources, single leg squat is the quickest and best indicator.  We all realize there are others but if we want to address 80% of the problem, this is where you will get the biggest bang for your buck.  Considering this, do we have to get overly complex in our training?  Again, for the biggest bang for the buck, keep it simple!

    1. Use the concept of repetitions to substitution - do as many reps and sets as they can with proper form.  Once start losing ability to control frontal plane motion, then either step the exercise back to an easier form or stop.  This is the point at which they have reached either muscular, neuromuscular or proprioceptive fatigue.  Training beyond with bad movement will simply reinforce bad movement patterns.
    2. Focus on single limb performance- control frontal plane motion and the speed at which that motion occurs.  This can be accomplished with a plethora of exercises.  
    Some samples to start working on single limb performance and controlling frontal plane motion:


    Warm up:
    Dynamic Lunge:  Key in this exercise is to make sure they are able to get through the motion while controlling the frontal plane motion of the knee.  This is especially important on the step through phase of this exercise.



    High Knee Toe Up: Key in this exercise is to bring the leg up into straight flexion and to control the frontal plane motion of the stance leg during.


    Strengthening:
    Standing Gluteus Medius - this is an endurance exercise for the G.Med but has a single limb performance component.  Make sure to control the frontal plane motion of the knee during the performance of this exercise.


    Single leg lumbar hip disassociation - this exercises utilizes the CLX to pull the knee into a valgus and internally rotated position thus requiring greater activation to prevent this motion.  Keep a close eye on the stance limb position during.


    Single leg squat - there is no video with this one but the contralateral leg is held in a slight extended position and the athlete squats to 30-45 degrees while maintaining frontal plane control at the knee.

    These are some simple exercises we can implement that have a direct impact on the measures we know put athletes at risk.  If we carry this same methodology over to our lunges, step up, squats and other forms of training, then we should see a direct impact on frontal plane motion control.  Keeping it simple and direct to the measures we are measuring is the most direct route to mitigate risk and improve athletic performance.

    If you would like more exercises focusing in this area, you can download our free app on IOS and Android by searching "PhysioSports".  The #ACLPlayItSafe app provides four levels of progression to the ACL Play It Safe Program which can be implemented as a part of your team's performance enhancement & injury prevention protocol.

    Thank you for following our blog in 2016 and hope you will continue to find this a worthwhile read in 2017.  We will be taking the next 2 weeks off and resuming our blogs on Jan 9, 2017.  To kick off the new year, we will share some technology advancements we have seen that can be leveraged to drive better, faster outcomes with improving movement.

    From my family to yours, we wish you and yours a bless, happy and safe holiday season.

    God Bless ~ Trent Nessler, PT, MPT, DPT



    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. 


    Challenging the Status Quo - Part V

    Throughout the course of this series, we have been questioning the status quo.  This has obviously resonated with a lot of folks as we have had a 400% increase in visits to our blog.  This is great and I am humbled that people want to hear what we have to say.  At the same time, I think we all want to learn more about movement and to do that, we have to challenge the status quo and truly look to push to innovate in the area of technology and movement science.  In this series we have specifically addressed the following:
    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
    Last week we had somewhat of a controversial discussion about one of the gold standards in movement assessment, the FMS.  During this discussion we simply highlighted what some of the current research shows about the validity and reliability of this particular test.  It was intended to be a simple discussion of what current research shows us and why that might be the case.  In addition to the discussion, last week's blog leads us right into this week's discussion, which is the standard of practice or care, in my opinion, tends to be the standard of the lazy and status quo. 

    Throughout my career, I have been blessed to teach and interact with clinicians from all over the US and abroad.  I often find that there are groups that encounter who are truly inspiring to me.  Super smart, engaged and hungry for more information.  As a therapist, these types of groups (highly educated, versed in the literature, practicing on the cutting edge and highly engaged) can be intimidating.  These are the level of individuals who will challenge you, question you, back their points of view with research.  You truly must be versed in the literature.  At the same time, these are also the groups that I learn the most from and that consistently inspire me to do what I do.  This weekend, I had one such encounter with the opportunity to teach to a group in St. Louis.  Teaching to groups like this encourages me and gives me hope for our respective profession.  But frankly, that represents only 10% of our respective professions.  

    In the world of movement assessment, I feel that we tend to be the standard of lazy and status quo. Why do you say that?  If we are doing movement assessment aren't we practicing a higher standard of practice?  Aren't we doing more than 99% of the respective professions?  Are we?  Let's talk about that.  Are we using the gold standard and thinking this is the answer?  Are we using this despite the fact that the literature does not support.  More importantly, that the top risk factors for injury are not even assessed with?  Are we relying solely on 2D technology for movement assessment?  If so, are we keeping abreast of what the research shows us and updating what we do based on?  From what I see, we are not!  Honestly, it goes back to basics.

    We talked about the standard of practice so let's take a look at 2D analysis.  There has been numerous conferences I have attended where there is a presentation by someone doing movement assessment using 2D technology. This is great technology and is HUGE in helping our understanding of movement and in educating our patients about movement.  The impact to patient care has been awesome and I applaud those that are using it! However, throughout these presentations there is never any acknowledgement of the limitations this type of technology has.  I have seen clinicians show 5-10 degrees of improvement in pronation at the foot and ankle during gait based on their 2D assessment.  For the audience, we take that for granted that this is accurate.  But is it really?  When performing movement assessment with 2D technology we HAVE to know the limitations.  For example:
    1. Camera angle - a slight pitch of the camera off to the right or left can make it appear as if there is a valgus at the knee that is not there.
    2. Camera tilt - a slight tilt of the camera can make it appear there is movement at the knee, pelvis and foot that is not truly there.
    3. Angles on 2D - unless you are palpating and putting markers on the body and drawing angles from that, then your angles on 2D have an accuracy of +/- 10-15 degrees.  
    4. Tracking on 2D - this is done on pixels (color) and relies on contrast in colors.  If you don't have contrasting colors on the subject to the background, then the tracking becomes much less accurate.
    5. Measuring internal rotation - although we may to be able to visually see internal rotation on video, you can't accurately measure this on 2D video.  This is a 3 dimensional movement that can't be accurately measured on 2D.
    6. Measuring valgus from lateral view - This is a motion that occurs in the frontal plane and must be measured from an anterior or posterior view (anterior preferred).  To try to quantify this frontal plane motion from a lateral view is impossible.  
    Some of the biggest mistakes I see.

    1. No standardized placement of cameras.  If you don't control your variables then you never know if the impact you are seeing is the result of camera position or true training impact.  This should include:
      • Height of the camera is same
      • Distance from the subject is same
      • Ensure the camera is straight on with the patient
      • Ensuring the camera is plumb and level 
    2. Frames per second too slow to capture movement - this should be at 120 fps at a minimum.  90 fps will work in most cases but 120 gives a much clearer picture.
    3. Measurement of angles - measurements of angles in 2D is not accurate unless you place markers on bony landmarks.
    4. Measuring valgus or knee position from lateral view during cone hops - frontal plane motion is one of the greatest risk factors and to attempt to measure that from a lateral view is not accurate.
    If we are going to assess movement, we need to completely standardize all aspects of the movement capture. If you are using 2D, addressing the above is critical.  Most who do 2D and who read this will think they do.  But do you?  I see a lot of presentations and return to sport calls being made by 2D and when looking at the reports, you can clearly see a lot of this is not being controlled.  It is not a criticism of the individual provider but more a question on whether or not we are doing something that is in the best interest of our athlete.  Make sure what we do is accurate and the only way to do that is take the time to control the above.

    If we are making return to play decisions, from a movement perspective, there are several things that I would want to assess.
    1. What is the magnitude of frontal plane motion during single leg activities
    2. What is the speed of the frontal plane motion during single leg activities 
      • Should be <20 degrees per second in single leg squat
      • Should be <100 degrees per second in single leg hop
    3. What is the limb symmetry index during single leg activities 
    4. What is the limb symmetry during functional activities - sprinting
    Sadly you very rarely see these assessed.  Can you assess these in a efficient, reliable and affordable way?  Absolutely.  With advances in 3D technology, we now have the ability to look at movement like never before.

    We hope you enjoyed this discussion and we will close out this discussion next week.  I would like to take a moment to thank those who have been inspirational to me.  Thank you Todd Ellenbecker, Kevin Wilk, Sam Runfola, Elizabeth Darling,Thiago Lopes, Fabio Machado, Justin Sampley, Lesley Parrish, Carl DeRosa and my lovely wife and children.


    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. 



    Challenging the Status Quo - Part IV

    Over the course of the last couple of weeks, we have been providing some clinical commentary on what we have learned in 20 years of clinical practice and over 15 years in movement assessment.  Obviously, we can't encapsulate everything we have learned in a blog or two but we can provide some insights.  We have begun to discuss in detail, over the last 2 weeks, that we need to recognize where the flaws are in our current ways we assess so we can do things better.
      
    During the last 2 weeks we went into depth on some movements we can look at and what the research tells us about how we should look at them.  Assessing these movements as described in the literature should and will guide our specific interventions.  At the beginning of this section, we highlighted what we know are well documented movement risk factors.  As a point of reference, these are:
    The above referenced articles are only a few of the large number of studies showing the same thing. So although there is only one referenced here, these are some of the more current ones that have been done over the last 10 years highlighting the same risk factors.  Based on the literature, we know several things.
    1. Frontal plane motion of the knee greater than 10 degrees in motion is bad!  The larger the magnitude of this motion, the worse it is.  An athlete that has 20 degrees of frontal plane motion is at greater risk than an athlete with 10 degrees of frontal plane motion.
    2. Speed at which this motion occurs is a risk factor!  An athlete that has10 degrees of motion that occurs slowly is at less risk than an athlete that has 10 degrees that happens very fast.  Although we have not published this, some guidelines we see are: 
      •   In a single leg squat if valgus occurs at >20 degrees per second, then the athlete is at greater risk
      • In a single leg hop if valgus occurs at >100 degrees per second, then the athlete is at greater risk
    3. >20% variance in single limb symmetry is bad!  Keep in mind, an athlete can move equally bad on both legs so although, in this scenario, they are symmetrical, it is still bad.  But overall, a >20% variance is bad.  Larger the variance, the greater the risk.
    4. Asymmetry (shifting weight to one side) during the squatting motion is bad!  Whether you call it a lateral shift or lateral displacement of the pelvis during a squatting motion, this has a direct impact on force attenuation and force generation.  The larger the asymmetry is during the squat the greater the risk is.   
    5. Inability to maintain core stability within 10 degrees is bad!  This should be assessed for the ability to maintain stability in flexion/extension and rotation. 
    In addition to the above, we also know there are demographic risk factors that should be considered.  

    Considering all the above, then we should take a look at the standard of practice for movement assessment in athletics.  Remember the intent is to question the status quo so that we can do what we do better.  At the end of the day, we are not concerned about offending people, but rather prevent more injuries in our athletes!  As such, most would agree the most commonly used movement assessment today is the Functional Movement Screen or FMS.  For those of us familiar with the FMS, we recognize that the research based risk factors noted above is not assessed using the FMS.  Looking at some of the specific movements:

    • Overhead squat - assesses several factors but is not assessing lateral displacement of the pelvis or lateral shift
    • Hurdle step & In-line lunge - although they are measuring asymmetry of motion assessed with the FMS, it is not assessing magnitude or speed of frontal plane motion of the knee during SL performance or the asymmetry of this frontal plane motion.
    • Trunk stability and rotational stability test have little research support related to their correlation and core stability in sport.
    In addition to the above, some additional challenges:

    • Fatigue not assessed.  Does 3 repetitions performed with each exercise give a true picture of what the athlete looks like in sport.
    •  Demographic risk factors not considered in overall risk rating.
    • Composite score of 21 is not sensitive enough to detect minor improvements in movement.
    Considering the above, then the results of some of the current research is not a surprise.  Some of the current studies include:

    • Bardenett et al - Int J Sports Phy Ther 2015 - looked at the FMS as a predictive tool in high school athletes.  Of the 167 high school athletes that were assessed during the pre-season, the results showed the FMS was good at recognizing asymmetry in the movements tested.  But they found that the results were not a good at predicting injury.
    • Dorrel et al - J Ath Train 2015 - performed a systematic review and meta-analysis of research from 1998 to 2014.  What the results showed was that the FMS demonstrated low predictive validity for injury prediction and leading the authors to conclude that this should not be used for injury prediction.
    • Bushman et al Am J Sports Med 2016 - looked at the FMS as a predictive tool in active male soldiers.  Of the 2476 soldiers assessed, the FMS demonstrated low sensitivity and low positive predictive value.  This lead the authors to conclude this could lead to misclassification of injury risk in military personnel.  If they are assigned to hazardous duty as a result of this misclassification, it could potentially place the soldier at greater risk.
    • Frost et al J Strength Cond Res 2013 - did the FMS on healthy firefighters and scored each on the assessment.  This was followed 3 minutes later by performing the test again but just prior to testing each firefighter was instructed on what they were being scored on.  Each participant had an average of 2.6 point (12.4%) improvement in their overall score with just knowledge of how the test is scored. 
    • Wright et al Bri J Sports Med 2016 - in this clinical commentary based on the literature review showing a low sensitivity of 24% led the authors of this paper recommending that this should not be used for injury prediction or for making return to sport calls.
    Despite all the above, the FMS has been instrumental in advancing what we know about movement and screening for risk.  The FMS and the developers behind it have been instrumental in the creating this shift to look more closely at movement.  As a result, the positive impact they have had on the field and injury prevention is immeasurable.  But as a science, we must advance based on what we know.  Consider, can we do it better?

    We hope you enjoyed this week's commentary and hopefully it provoked some new thoughts.  Next week we will close this out with looking at not over complicating movement and raising the standard of practice. 



    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. 


    Please contact contactus@MyPhysio.com

    Social Media Links