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.

Anterior Cruciate Ligament Injury: Is It Just An Athletic Injury or A Major Life Lesson? – Part II

Last week we talked about psychological factors that are a significant part of rehabilitating the ACL injured athlete.  In this discussion, we talked in detail about sport locus of control, how vital that is and how we can impact this clinically in the very first visit with our athlete.  We also began the discussion about fear and confidence and how these two are categorized together.  For fear is a natural part of this injury, in particular if the injury is a non-contact injury.  For our purposes here, a non-contact ACL injury is being defined as an ACL injury that occurred without contact with another player or object.  Fear is more likely to occur in these athletes in particular because they simply ruptured their ACL because they “moved wrong”.  They are not quite sure what that movement was but they know they moved wrong and if they move wrong again, they might re-injure their ACL.

Any injured athlete will innately have a conscious or subconscious fear of re-injure.  For the ACL injured athlete, this is a legitimate fear as reinjure occurs in 20% of athletes in the first 2 years following an ACL reconstruction.  For many athletes, if this fear is not addressed, this will lead to compensatory strategies that can linger on throughout the remainder of their athletic career.  Some studies indicate that this may be a contributing factor to lateral displacement of the pelvis during the squatting motions which alters force attenuation throughout the lower kinetic chain and can lead to asymmetrical limb development in strength and power.  This not only has implications on potential risk for future injuries but also implications on future athletic performance. 

Some basic level of fear is to be expected and is healthy.  Some athletes need this to prevent them from going overboard and doing something stupid in the initial stages of the rehabilitation process.  However, fear which results in compensation and lack of progress along standardized protocol progression or anticipated timelines is not normal.  Fear which drives changing of lifestyle habits or social interactions is not normal.  Fear which limits progress is not normal.  Fear also increases risk for future injury.

There are a lot of factors that lead to reinjure but an athlete who returns to sport following an ACL injury.  However, those who have measurable fear or lack of confidence in the involved lower extremity are 4-6xs more likely to suffer an ACL reinjure.  So, fear must be overcome and there are things we can do clinically to address this ASAP.  So, how do we identify fear and how do we over come?  Some signs that an athlete is over fearful.

·        They express fear verbally or in an outcome measure (IKDC – International Knee Documentation Committee)
·        They have a lot of hesitation to move knee into terminal knee extension or becomes nauseous with moving knee into terminal knee extension
·        Athlete continues to walk with lack of terminal knee extension
·        Athlete has vagal responses in single leg full weight bearing activities (profuse sweating, nausea, drop in blood pressure, tunnel vision, dizziness, etc)
·        Athlete is visibly fearful of putting full body weight on the involved lower extremity or refuses to put full body weight on the involved lower extremity

These are just a few signs and there are many others.  That said, if we detect fear in our athlete or they voice it, we must address it.  As the provider, we cannot be afraid to talk about it with the athlete.  Let them know this is normal and why.  Let them know this is something we must overcome and how we are going to approach it.  By providing the athlete with education on fear and starting them in weight bearing activities early on will aid in building confidence and alleviate fear. 
Studies show that sooner an athlete starts full weight bearing activities and specifically single leg activities, the more confidence they get and the less fear they have.  Hence this is why we have also included confidence in this section.  Why does an athlete lack confidence in the limb?  One reason is fear and another is they have not sufficiently stressed the limb in single leg activities enough to build that confidence.  If an athlete lacks confidence, then they are also at a greater risk of reinjure.  Therefore building confidence early is vital.  Besides the encouraging them, successfully performing single leg activities is an important part of building confidence in an athlete. 

Does fear and lack of confidence really occur in the “manly” athlete?  Absolutely.  We can all think of professional athletes that we have seen that have had an ACL reconstruction that may be lacking some confidence.  We visually see this as their hesitation to move to the involved side.  Whether it is a cutting pattern to that side or throwing kicks with that particular leg, confidence is built very early in the process.  Starting an athlete on single limb activities early in the process (and as the protocol allows) improves their confidence so when it comes time to do more cutting and explosive work on that side, they can do this with a very high degree of confidence that their knee will be able to support them under that load.  Doing this and educating them about the movement patterns that are associated with non-contact ACL injuries will not only aid in building confidence, reduce fear but will also aid in the neuromuscular retraining needed to prevent these pathokinematics we see associated with these injuries.

The final aspect is communication among providers.  This is just as important to building confidence your referral sources have in you as much as with the athlete.   Next week we will dive into this in more detail, so stay tuned.  If you like what you read, the biggest compliment you can give is to share the passion.  Follow us on twitter @ACL_prevention or follow us on Facebook at Athletic Therapy Services and #MoveRight.



Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 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.   He is also a competitive athlete in Jiu Jitsu. 




Anterior Cruciate Ligament Injury: Is It Just An Athletic Injury or A Major Life Lesson?

Over the course of the last several years, we have looked at multiple papers highlighting the long term effects an anterior cruciate ligament (ACL) injury has on our athletes.  We know there is an impact to the long term joint health and athletic performance, but we can’t ever ignore the impact on the future systemic health and psychological status of the athlete.  It always surprising how few people completely understand the totality of the “life impact” these injuries have on our athletes.  This is especially true in our younger athletes.  But, we should all realize if we address the psychological factors immediately, it will not only impact the immediate results and outcome but also the long outcome, future athletic performance and long term psychological status of the athlete.  Case in point.

Imagine for a moment that you are a star high school athlete.  Everything you do revolves around your sport and your identity as an athlete of that sport.  All your friends are athletes, your teachers see you as an athlete and you identify yourself as athlete.  Even your family and relatives see you as an athlete.  It is always a topic of school conversations, social interactions and family discussions.  So, imagine you have an ACL injury and all of the sudden, in one day, everything that you have known is suddenly and dramatically changed.  Your personal identity has changed!

It is seeing it and realizing it from this perspective that helps us understand why so many young athletes suffer depression as the result of an ACL injury.  According to 2014 statistics from the NCAA, Division I athletes who suffer an ACL injury have a reported higher rate of depression, average of 1.0 drop in GPA and have a higher rate of obesity.  Knowing this, addressing the psychological component has to be a huge and vital part of the rehabilitation process.  As a parent, it is imperative that the provider “you choose” for rehabilitation not only has experience in rehabilitation of the ACL injured athlete but also has an approach that is conducive to addressing the psychological component of this injury.  Remember it is your choice and you should choose someone that you feel will address the physical and psychological components of your child’s injury. 
Is this too touchy feely for athletics?  Some might say yes but what does the research tell us?  

According to a 2013 paper published by Ardern et alin the American Journal of Sports Medicine, several psychological factors that must be addressed in order to optimize outcomes, performance and successfully and safely return to sport are:
  •  Sport Locus of Control
  •  Fear
  •  Confidence
  •  Communication among providers


What is Sport Locus of Control?  Sport locus of control is simply, “Does the athlete feel like they have control over their own destiny”?  Think about it.  Would you want to be in control of your destiny or would you want to control your destiny.  What happens when you feel like you have no control?  It is depressing, right.  Now think about that from the athlete’s perspective.  After an ACL reconstruction, so many athletes feel like they have no control over their future destiny.  This is extremely hard for an athlete as it is their control over their destiny, their hard work, their focus and their dedication that has led to their success in their individual sport.  Now, there is a tendency to feel they have to now rely on someone else for them to be able to have a successful outcome and return to sport.  Their fate now resides in the ability of someone that they know very little about and/or may have only known for a short period of time.  So how do you address that as a clinician?

This is addressed Day 1 of the rehabilitation process.  Something as simple as the therapist’s body language and/or patient interaction can have a very positive or very negative impact.  As a therapist, make sure you are reading your athlete’s body language and status.  They are great, especially initially (when they are in beginning phases and more vulnerable) of expressing this non-verbally.  Look for it and respond appropriately to.  If done well, this will be a huge component of building a very solid report with your athlete.  So many times you can tell by how the athlete is responding to you, whether or not they are asking leading questions or whether they are withdrawn or disengaged or simply how they are posturing their body.  Those are some of the obvious signs.  Some of the not so obvious signs are how are they sleeping, are they still engaged in their social circles, are they losing or gaining weight, or have they become angry or despondent.  

One thing that should always happen on Day 1 is that the therapist must give the athlete sport locus of control.  A statement as simple as:

“I am here as your coach and your educator.  I will teach you what to do and why.  I will coach and encourage you throughout the process.  But, it is up to you to dig deep, stay focused and keep your head in the game.  This will be your toughest game yet, but you can and you will do it.  I will help you do it but you are in control.  This is not something that cannot be overcome and it is not an undouble task.  This is where champions are made and you are a champion.”

In this scenario you are explaining your role, their role, letting them know they are in control and that you believe in them.  Now this may be a little elaborate or over the top, but you get the idea.  The goal of the therapist is just as much clinical treatment as it is professional motivation.  If the athlete is given this control and truly believes they have sport locus of control, they will be much more successful.

The next two factors that impact the psychological status of the athlete are fear and confidence.  We categorize these two together as these really go hand in hand.  Next week we will dive into these two in more detail, so stay tuned.  If you like what you read, the biggest compliment you can give is to share the passion.  Follow us on twitter @ACL_prevention or follow us on Facebook at Athletic Therapy Services and #MoveRight.



Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 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.   He is also a competitive athlete in Jiu Jitsu. 




How Do We Know When It Is Time To Return To Sport - Part VI - Guest Blog

Last week, Eric Dinkins, PT, MS, OCS, Cert MT, MCTA took us on a journey to help us understand the impact on neuroplasticity in ACL rehabilitation and prevention.  This week, Eric will help us understand some ways we can influence this in our training.

What is my Inferior Temporal Gyrus? 
And why haven’t I up-trained this for my ACL Clients?

What we learned last week leads us to question how are we addressing.  What are we doing for enhancing visual feedback for our ACL or currently healthy clients? How are we up-training them visually in the attempt to prevent overload in the athletic environment?  If we know they can’t feel the knee like they used to….literally…how can we impose a greater demand on vision to help adapt more than there body, but also their brain?

Here are a few tips on how you can start addressing this need with your clients:

1)    Start changing our cues and attention to an External Focus (see our blog on external focus)
2)    Ensure that we are challenging our clients in an open environment, as soon as it is safely possible, performing dual tasks frequently
3)    Consider giving you and the client immediate visual feedback during skill training early in rehabilitation with a device such as the Motion Guidance Clinician Kit
4)    Consider taking visual feedback away at times during advanced mechanoreceptor training exercises to continue to challenge the body with different inputs.  This might be particularly challenging for the client on altered surfaces or to advance already mastered skills.  But imperative to help the athlete develop 'predictive behaviors' or feedforward skills in sports rather than relying solely on feedback mechanisms.

The two videos below demonstration how we can use visual feedback with the Motion Guidance Clinician kit during squat progressions.

Lower Chain Tutorial with Motion Guidance Visual Feedback


 Lower Extremity Dynamic Progressions



Hopefully this information has stimulated your own approach to rehabilitation of this challenging population.  We need to be aware of utilizing all possible body systems to maximize the ability of our clients to be ready to return to their best potential in their athletic or work environments.

-Eric and Tal

Motion Guidance

Eric & Tal - Thank you both so much for another great blog contribution.  As a physical therapist with over 20 years of practice, I am continually amazed by what we don't know and are continuing to learn.  The science is great at guiding us on what we should do but it is up to us as clinicians and practitioners to apply this in a way that captures the essence of the science in combination with the innovation and art of what we do.


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 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.   He is also a competitive athlete in Jiu Jitsu. 






How Do We Know When It Is Time to Return to Sport - Part V - Guest Blog

As we close out this series, we are going to once again hear from Eric Dinkins, PT, MS, OCS, Cert MT, MCTA as Eric poses the question:

What is my Inferior Temporal Gyrus? 
And why haven’t I up-trained this for my ACL Clients?



ACL injury is prevalent in athletics.  Not only are there immediate injury and changes, but there is substantial evidence that there are long term changes associated with this injury including: osteoarthritis, alterations in gait, changes in body awareness and psychology, and weakness as well as increased risk of further musculoskeletal injury compared to non-injured individuals. Even more studies have reported unresolved neuroplastic changes after injury, reconstruction, and rehabilitation that may limit function and return to sports participation.  There has been a large focus in the past decade of creating preventative programs and limiting exposures to potential injuries through conditioning and body awareness.  However, decreased body awareness is inevitable with ACL injury.  Trauma to the ACL has been shown to modify how the nervous system processes the interactions between vision and sematosensation. The loss of previously recognized reflexes and gama motor neuron drive to prepare the CNS function to engage appropriately may require “up-training” of other systems, such as increased utilization of visual feedback, to maintain the required sensory input for motor control.



Recently in JOPST, Dustin Groomes, MEd, ATC, CSCS, from The Ohio State University recently discussed the importance of understanding the changes in body systems and neuroplasticity after ACL injury.  Groomes describes how training the biomechanical factors of the ACL injury may not address all the physiologic consequences. But the capacity for neuroplasticity after injury and during rehabilitation can present an opportunity to close the gap by targeting a broader spectrum of sensorimotor function during neuromuscular training.  This can be captured by the non-contact (majority) ACL injury.  Generalizing the break down of the typical action is:

  • A failure to maintain knee neuromuscular control while attending to an external focus of attention under highly complex visual stimuli, variable surfaces, movement planning, decision making, during classically an open environment. 


During this changing environment, the sensory systems 3 main afferent pathways of vestibular, visual, and somatosensory provide complex integrated information.  This is rapidly acquired and processed to produce efferent neuromuscular control to maintain adequate stability and control.  The interaction between vision and somatosensation is particularly critical for motor control during environmental interaction.This interaction is compromised even after ACL reconstruction. The ACL receives nerve fibers from the posterior articular branches of the tibial nerve. These fibers penetrate the posterior joint capsule and run along with the synovial and periligamentous vessels surrounding the ligament to reach as far anterior to the infrapatellar fat pad. Disruptions in this input yield immediate changes in neuroplasticity and can lead to mechanical changes and compensations that may not be properly or fully rehabilitated during typical training focused solely on biomechanical changes and strength gains.

The loss of ability to relay on the bodies typical reflex afferent inputs may require “up-training” of supplementary mechanisms such as increased utilization of visual feedback to train and maintain required sensory inputs for motor control. 

Groomes further states that individuals in his fMRI studies demonstrated increased activity in the posterior inferior temporal gyrus.  This area has been linked to many cerebral functions, but may primarily be involved with visual processing of movement.  This area must work together with the hippocampus, in order to create an array of understanding of the physical world. The information received in this area is sent to the Primary Visual Cortex (V 1) for processing determining the outputs from the Motor Cortex (M 1). The increased activity in this area post ACL injury may suggest that there is an increased utilization of visual processing and motor planning for movement simultaneous with depression of the somatosensory function of the ACL previously discussed.
        

  
Simply put, the body is nothing except adaptable.  Even in ways that we don’t even understand, yet.  But it seems that if we injure our ACL, the brain automatically changes its preference to more visual based inputs to assist in making decisions for motor control.  What about those who aren’t injured yet?  On the flip side of that coin, Swanik reported, in 2007, initial findings of decreased visual reaction times and processing speeds as predictive of ACL injury. Perhaps we need more visual based processing and challenges during our preventative strategies as well?

Next week, we will begin to discuss how this can be influenced with training.  

Thank you.

Eric M. Dinkins, PT, MSPT, OCS, Cert MT, MCTA



Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 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.   He is also a competitive athlete in Jiu Jitsu. 







How Do We Know When It Is Time to Return to Sport - Part IV

HS VB Player Demonstrating Poor Movement
Over the last series, we have been talking about how do we know when it is time to return an athlete to sport.  As an industry, Sports Medicine, there is no consensus on what this should look like.  Get 10 of the top orthopedic surgeons in a room to discuss and you will have 10 very different opinions on.

As a parent and a physical therapist, this is something I am compelled to do something about.  When an injury occurs, there is a deep ache we get seeing our child suffer and wonder if there is something we could have done.  Now, there is the ability to help reduce injury risk while helping them improve athletic performance!  There is something we can do to help athletes return to play safer.  

Annually, there are over 300,000 Anterior Cruciate Ligament (ACL) injuries in youth athletics in the US (AAOSM Annual Conference 2016).  This devastating sports injury has an annual health care cost of over $5B plus long term impact to the children who suffer them.  One in four youths who tear their ACL will suffer another during their athletic career (Wiggin et al – Am J Sport Med 2016) and 20% will reinjure their ACL in 2 years (Holm et al Am J Sport Med 2012).  In addition to being at risk for re-injury, once an injury has occurred, their future performance is negatively impacted (Read et al Am J Sports Med 2017, Harris et al Sport Health 2013).

But what if you could identify those at risk?  Research indicates alterations in the way the athlete moves (biomechanics) puts them at higher risk for these injuries.  According to sports medicine experts (Wilk J Orth Sport Phy Ther 2015), we:

·       Need a better way to screen risk for ACL injuries
·       Need a better way to objectively measureprogress
·       Need a better way to objectify return to play 
Testing Division I Athletes Using ViPerform AMI
Identifying and correcting altered biomechanics has been shown to have a direct impact on ACL injuries and athletic performance.  The current standard of practice in assessing movement is a paper pencil test that relies on the visual interpretation of the assessor.  These assessments are not well supported in the literature for injury prediction or objectively measuring an athlete’s ability to return to play (Bardenett et al Int J Sport Phy Ther 2015, Bushman et al Am J Sport Med 16).  So, how do we objectively and reliably measure the altered biomechanics that put athletes at risk of injury or decreased performance?  The team at Select Medical uses the latest in wearable 3D sensor technology to identify these risk factors and have developed an exclusive program to address deficits noted.  ViPerform AMI™ is an assessment offered by Select Medical that integrates the latest movement science with 3D wearable sensor technology.

The DorsaVi ViPerform AMI™ combines movement science with accuracy of the DorsaVi system (an FDA approved) wearable sensor device.  After performing this 15 minute assessment, each player will be provided with an assessment using lab quality data which will provided a comprehensive report showing:

·       Overall movement
·       Demographic risk factors
·       Loss of balance
·       Limb symmetry index
·       Magnitude and speed of valgus in single limb performance

ViPerform AMI Report - Providing Lab Quality Data
Using this lab quality data allows the clinician to make much more informed decisions on clinical interventions and season training protocols to reduce injury risk and improve athletic performance.   
Using this information and Select Medical’s ACL Play It Safe Program, they have demonstrated >58% reduction in all lower extremity injuries and significant improvements in athletic performance in Division I athletes.  Science and technology helping to keep athletes safe, in the game and performing at a higher level!  #MoveRightPerformBetterLastLonger.  For a Select Clinic near you offer this program, visit their website at https://www.selectphysicaltherapy.com/  For more information on the ACL Play It Safe Program, download the free app on Android or IOS under "ACL Play It Safe".  




Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 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.   He is also a competitive athlete in Jiu Jitsu. 

How Do We Know When Is The Time To Return To Sport? - Part III

In last week’s blog we talked about the impact that injury has on return to sport and specifically the impact on performance.  This led to the question, how do we make return to sport calls.  Is there a way to assess both biomechanical risk factors in a closed kinetic chain and performance measures?  What does the research tell us? There are several ways this is being done today. 

One of the standards of practice is the use of the Functional Movement Screen. But is this a good predicative tool for determining return to play?   
  • 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.
  • 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.
On clear example of this is a recent paper, Dobson et al, Ortho J Sports Med 2016, that looked at injury rates, specifically ACL injuries in NFL players.  Despite implementation of the FMS, biodex testing of quad to hamstring ratios and other such tests, NFL ACL injury have risen dramatically.  Up till 2010, ACL injury rates were occurring at a rate of ~10 ACL injuries per year.  From 2010-2016 there have been a recorded 219 ACL injuries (~36/yr).  So despite having access to all the latest information, they are still not impacting them in a positive way.  What gives?  Simply stated, we are NOT looking at the right things.  When a player can score a 17 on a screen and yet his knees nearly touch on a broad jump, then we are obviously not looking in the right direction.

In 2011 Grindem et alpublished a paper looking at the single leg hop tests as a predictor of knee function.  In this study the authors compared the single leg hop test to the International Knee Documentation Committee (IKDC).  The IKDC is a self-reported outcome measure that has been shown to have a very sensitivity and specificity to actual knee function.  The authors compared the results on the single leg hop to IKDC scores for those who had ACLR.  The following diagram indicates the single leg hop tests that were performed.  This study showed that symmetry in single leg hop for distance predicted self-reported knee function on the IKDC with a high degree of sensitivity and specificity.   The single leg hop for distance is a great measure of power output in the horizontal.  This same measure of power output can also be obtained with a single leg for height.  One is great for forward propulsion (hop for distance) and one is great for vertical propulsion (hop for height).  Both of these are critical in sport but when also considering mechanics (adduction in the frontal plane) how do you quantify that with either of these tests?  Or is that even possible? With the advent of technology, it is possible, at least for the vertical single leg hop.  Taking a look at the picture here, we can easily capture not only quantify the mechanics with the single leg hop but we can also quantify her vertical displacement during the test.  Having both of these factors performed over multiple repetitions, we can then get a biomechanical assessment of risk as well as comparison of the right limb to the left limb in terms of power output.   But how do we do that objectively and with a high degree of reliability?
As we have stated in previous blogs, frontal plane motion is not the only risk factor.  Rohman et al Am J Sport Med 2015 showed that symmetry in single limb performance is a critical measure for risk.  We also know from Kristinaslund et al Am J Sports Med 2013 that one of the best indicators of risk and athletic performance is performance in single limb testing.  We can watch and record these movements with various technologies (like Dartfish) but that is often time consuming and takes a higher level or expertise to be able to do it in a fashion that is efficient and reliable.  In addition to 2D technology, we are seeing a plethora of new 3D wearable sensor technologies hit the market that are extremely reliable.  Many of these use IMU (inertial measurement units) with accelerometers, gyrometers and magnetometers to detect motion, rotation and acceleration data.  With these technologies, we can now quantify movement with lab quality results and are able to quantify both the magnitude of valgus that occurs in addition to the speed at which that motion occurs. 

As we see a further blending of these types of technologies with the movement sciences is when we will really see an impact on both lower limb injury rates and improvements in athletic performance.  Next week we will explore this a little more.  For more information on this topic and more, make sure to follow us on twitter @ACL_Prevention or on Instagram @bjjpt_acl_guy.  

Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 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.   He is also a competitive athlete in Jiu Jitsu. 

How Do We Know When Is The Time To Return To Sport? - Part II


Last week we started to look at the research for when is the right time to return to sport.  Is there a time frame or things we should be assessing that the research can provide us some guidance on.  

Currently, the majority of these decisions are based on the most current and up to date information we have available.  Or is it?  Considering that most use a Biodex to make this decision, does an open kinetic chain strength test (Biodex) really tell us anything about how stable the limb is in closed kinetic chain conditions, in running, landing or cutting situations?  Adduction in the frontal plane is a risk factor and hip strength plays a big role in.  Does this test give an indication of hip strength?  Is there a better way to assess frontal plane motion?

Considering the following scenario.  Athlete who is testing for return to play and is tested on a Biodex.  She tests to be within 90% of the non-involved limb.  But this poses several questions.  90% of what.  Is that 90% of good strength which adds to good quality movement or is that 90% of poor strength and quality of movement?  Secondly, does this open kinetic chain test truly reflect closed kinetic chain function.  I think once we see this, we can all clearly see she is at risk, but how do we quantify that?



This is a perfect example and the reason all this is so important is due to the number of athletes that return to play too early and end up being re-injured.  We know from Rugg et al, Am J Sports Med 2014 that players with a previous ACL injury are at an 8 fold increased risk of re-injury, will consume more time on the DL and cost more in health care dollars.  Return too early and you increase injury risk.  Return too early and performance is negatively impacted.  We can all think of a NFL or NBA player who has had an ACLR and once they returned to play, just did not play at the same level as previous or hesitated to move to the injured side.  We can all think of a UFC fighter that was hesitant to move to the previously injured side upon return to the ring.  That hesitation, that lack of confidence has a huge performance impact.

Over the last couple of years, several papers have attempted to look at just that.  In some of our previous blogs we cited   McCullough et al who published a MOON study in 2012 that looked at return to sport following ACL reconstruction.  What they showed was that 63% of high school players and 69% of college players were able to return to sport following ACL reconstruction.  They also showed that only 43% of those athletes were able to return to the same level of sport as prior.  In this case, return to same level of sport was defined as same level of pre-injury performance as self-reported by the athlete.  Similar studies have attempted to do this in NBA players.  Harris et al published a paper in 2013 that looked at the impact of ACLR on future performance in fifty-eight NBA players.  Performance was measured by comparing pre-injury data to post injury data in the following areas: games per season played, minutes played, points & rebounds per game and field goal percentage.  Several interesting findings came out of this study including 40% of the players who tore their ACL during a game, did so in the fourth quarter.  86% of players returned to the NBA and 12% of players returned to the FIBA or D-league.  98% of the players that returned to the NBA and 3% had revision of their ACL.  Performance upon return to sport following surgery declined significantly for all subjects.  However, this was not statistically significant when compared to controls during this same time period.  Busfield et al 2009 also investigated this in NBA players.  They looked at 27 NBA players who had ACLRs.  Of those, 22% did not return to the NBA and 78% did return to play.  Of the 78%, 15% had an increase from pre-injury performance and 44% had a significant reduction from pre-injury performance.
In both of these studies, return to play was determined by performance measures in the game (points, rebounds, free throws, etc).  All of these are good measures of performance but are indirect measures of power output, sprint speed and agility.  Is there a more direct way to measure this impact?  In a June 2014 paper for the American Journal of SportsMedicine, Aune et al looked at return to play in NFL players after a lateral meniscectomy.  In this study, return to play was defined as the ability to play in a regular season game.  Of the 77 subjects, 61% were able to return to play.  Additional findings included only 24.6% of the 77 subjects where still playing in the NFL at follow up (average 4.5 years) and speed position players (running backs, linebackers, etc) were 4.0 times less likely to return to play. 
All these studies bring out some key facts. 

  • Performance is negatively impacted by injuries and with return to sport.  This highlights the importance of directly measuring the pre/post performance variance. 
  • The fact that over 40% tore their ACL in the fourth quarter tells us that fatigue plays a significant role.  This highlights the importance of considering this in the assessment with return to play.    
  • The fact that speed position players were 4.0 times less likely to return to play may indicate the impact that injury has on power output.  Since these positions are so dependent on explosive power and agility, you would expect that if injury does have a big impact on performance that these positions would be the most significantly impacted.
The research is clearly telling us that injury does have an impact on performance.  As such, should we include this as a part of our assessment in return to sport and if we do, how do we do it?  Some will tell you the answer is clear and they are currently doing.  But do we have a standardized return to sport protocol?  No!  Whether it is an agility test, single leg hop test or figure eight, these tests are still very subjective and athletes will often figure out how to compensate to obtain desirable results.  Is there a way to assess an athlete for return to sport that also assesses biomechanical symmetry and performance symmetry?  Yes!  Make sure to check out part III next week we will discuss that in more detail.  For more information on this topic and more, make sure to follow us on twitter @ACL_Prevention or on Instagram @bjjpt_acl_guy

Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 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.   He is also a competitive athlete in Jiu Jitsu. 

How Do We Know When Is Time To Return To Sport? - Part I

Over the course of the last several years, we have posed the question, “Does Return to Sport = Return to Sport Same Level?”  This is a topic that is still not quite clear in the research and one which is becoming clearer and hotly debated.  What is reported in the literature depends on how you quantifyreturn to sport.  Are we looking at returning to play at same level of sport or is it returning to play with pre-injury level of agility, speed, power?  How do you determine pre-injury level of agility, speed and power?  This will vary greatly by sport.  However, we are starting to see researchers look more closely performance measures when looking at "return to play".  Some of the current measures being assessed include:
  • Timed 10 yard split or 40 yard dash
  • Vertical jump or single leg hop for distance
  • Timed agility drills
  • Time to  & percentage success with take down (MMA)
Depending on how you quantify your return to play criteria will often lead to varied interpretation of the results.  In research, performance measures have not been typically evaluated and as such, reporting return to play percentages have been a lot higher than what we see on the field.  The sad part is that teams, coaches and players know the reality and don't need a peer reviewed paper to tell them that these injuries are having a huge impact on performance.  Just looking at NFLs own data from 2013 to 2015 and comparing reported knee injuries to percentage of games won and the reality is clear.  Teams with the highest knee injury rates won 33.9% of the time versus teams with lower knee injury rates who won 52.7% of the time.  

In a recent study by Anand et al, Am J Sports Med 2016, we see when we start to look at some of the performance criteria, that the percentages are much lower than previously reported.  Read et al Am J Sports Med 2017 looked at NFL defensive players who underwent an ACLR and looked at their future performance once they returned to the NFL.  What the authors found was that those that did return to play, only 57% started games versus preinjury where 81% started.  These same players also had a reduction in solo tackles which dropped from 3.44 pre-injury to 2.38 post injury.  Is this impact only on football players?

Mai et al Am J Sports Med 2017 compared return to play following ACLR in:
  • NFL
  • NBA
  • NHL
  • MLB
What the authors found was that NFL players fared the worse of all the sports assessed.  NFL players had a significant impact on their career length where the average player had their career shortened by 2 years.  In addition, NFL players saw a negative impact on all performance measures for up to 2 years post ACLR.  NBA players demonstrated a decrease in athletic performance for one season after return to play but returned to pre-injury status during the second season upon return to play.  In this study, NHL players had the best results with a much higher rate of return to play and much shorter recovery time.  


So how do we currently make the call to return an athlete to sport?  Who decides when it is time to return to sport and how do we know if the athlete is ready?  Currently there is not a standardized way to make return to sport calls.  Wilk et al, J Sport Phys Ther 2014, in an editorial and literature review, asked that very question.  Can we do better?
This is something that is desperately needed and being asked for.  More often than not, making this call relies heavily on the surgeon to aid in making that decision.  Often the surgeon will base this decision on what the current research says about tissue healing and graft strength, an extensive orthopedic exam performed in his office, comparison of involved limb to non-involved limb strength on Biodex testing and often feedback from the treating physical therapist or athletic trainer.  In a literature review performed by Nessler et al Curr Review Musculoskelet Med 2017, the authors found the literature highlights several factors that should be assessed when evaluating an athlete for risk or for return to play.  This includes:

  • Stability of the limb in the frontal plane
  • Stability and impact of fatigue on single limb testing
  • Truck stability in stance and core testing
  • Limb symmetry index - comparison on R and L limb in closed kinetic chain testing
  • Lateral displacement of the pelvis during squatting motion


Stay tuned next week as we continue this discussion on when is the proper time to return to sport.  For more information on this topic and more, make sure to follow us on twitter @ACL_Prevention or on Instagram @bjjpt_acl_guy.

Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 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.   He is also a competitive athlete in Jiu Jitsu. 



Standardized Sports Testing - Have We Standardized Anything Yet? - A Guest Blog

This week's blog series comes to us by Eric Dinkins, PT, MS, OCS, Cert MT, MCTA.  Besides the plethora of designations behind his name, Eric is a fantastic physical therapist practicing out of Colorado.  Eric has a huge passion for education and is Mulligan Certified Instructor and teaches physical therapist all over the US.  I first came across Eric ~5 years ago after he had developed a technology called motion guidance.  This simple, inexpensive and very effective training device I have used in my practice and courses ever since.  I was blessed to come across Eric and learn from him.  So when it came to retraining human movement, including Eric in this series of guest blogs was a no brainer. 


Please sit back and enjoy as Eric provides us the latest. - Sincerely ~ Trent Nessler, PT, MPT, DPT

This is a 3-part blog series on the topic of Return to Play (RTP) in ACL reconstruction clients.  The goal is to provide information about the current RTP testing, potential mechanisms that are involved, and options for improving outcomes. Sports performance, in regard to prevention and return to participation, is a common part of any orthopedic practice. It deals with athletes of all levels; from the elite competitor to the weekend warrior, to the client who wants to return to tennis after a Total Knee Arthroplasty.  According to the recent recommendation published in 2016 by the British Journal of Sports Medicine, Rehabilitation after ACL injury should include a prehabilitation phase and 3 criterion-based postoperative phases: (1) impairment-based, (2) sport-specific training and (3) return to play. A battery of strength and hop tests, quality of movement and psychological tests should be used to guide progression from one rehabilitation stage to the next. Postoperative rehabilitation should continue for 9–12 months. To assess readiness to return to play and the risk for re-injury, a test battery, including strength tests, hop tests and measurement of movement quality, should be used.

Training or rehabilitation often focuses on strengthening and motor control re-education to correct faulty movement patterns, imbalances and asymmetries.  In virtually every case, functional sports testing is performed to determine if the person is ready to return to sport, and if they are at risk for re-injury. So, what happens when the tests that we use to conclusively decide if a person is ready differ so greatly in the published literature?  Why the battery of tests when we’ve been performing return to play testing for years? One answer came when Hegedus BJSM 2015 reviewed some of the most common tests used in physical performance testing and found an extremely wide variance in several aspects of the tests reviewed.  

Some of these tests included what some consider “gold standards” for return to sports play.                

Tests include: Single leg hop for distance, 6 M timed hop, cross over hop for distance, single leg squat, triple jump, and single leg vertical jump.  What Hegedus found, was that there is a variance in the procedures in which they are applied.  The warm-up and number of practice hops, number of hops recorded in the test, how the arms are used, and final scoring can be based on mean of attempts, greatest of attempts, and greatest of successful trials.  So, if we can’t rely on standardized testing that has poor reliability at the present time, the importance of movement analysis and motor control becomes magnified!

Often testing against the non-involved leg makes the assumption that the uninvolved side avoided injury because it was the stronger or more stable side…an assumption that has been proven false by far too many people who have torn ACL’s in both knees. Both sides of this story can be found in journals such as thisthis, and this.
                                                                                             

Also, joint forces and other additional elements play a role in ACL or knee injuries, therefore, focusing solely on lower limb kinematics in classifying injury risk or post-injury rehab may not encapsulate all relevant factors.  Even attempting to examine “normal” in the attempt to standardize kinetic motions for populations and translate that data into risk factors has come up short in developing a predictability rule of sorts for determining return to participation (Fox, Sports Med 2014)

This comparison suggests that at the time of testing, athletes, regardless of being cleared for return to sport, were deficient in dynamic control and therefore at risk of injury.  Furthermore, asymmetries across both groups suggest that these deficiencies likely existed before the initial ACL rupture and may have been associated with the initial injury. Routine examination or sports testing of the lower limb may not pick up on neuromotor control deficits that may be compensated for and missed during clinical evaluation but may be contributing to abnormal movement patterns increasing the re-injury risk. Clinical impairment measures do not appear to be related to measured functional ability. Performance of both functional tests, FMS, and YBT-LQ at 6 months would suggest that the typical patient in both groups would be at a greater risk of lower extremity injury (AJSM 2015).

Also, quadriceps ECC strength was more directly correlated to JPS than concentric strength in patients with PFPS. This suggests inhibition or weakness of the type II muscle fibers that are responsible for maintaining the eccentric muscle force during movement.  The link can be made between quadriceps ECC strength, proprioception and pain in this population (Knee Surg Sports 2015). But simply improving strength neither guarantees non-injury or addresses other factors that could contribute to injury occurring. Video replay and/or video analysis has shown some promise to help aide athletes to improve their joint positional sense. But, video replay lacks the immediate visual feedback that has been proven to enhance motor learning skill acquisition.

There are numerous expert clinicians in the field of sports rehabilitation capable of skillfully attempting to determine when a patient or athlete is ready to return to dynamic function, and often times the individual is able to return without future injury.  I have spoken with colleagues whose preferences range from using the ECC step down testing to return an OL in college football to play, to using a barrage of physical performance tests to acquire as much information as possible to make the determination. However, what about the clinician who is deemed with the task of determining a patient’s suitability to return to participation without the expert knowledge base?  Surely, they cannot rely on functional based sport testing for the lower extremity.  So, what resources can they rely on?  Unfortunately, the most realistic answer is devoting the time to become an educated clinician, and skilled movement analyst.  The maximum amount of information must be acquired to help determine when someone is ready to return to participation.  NOT solely relying on the hard numbers and pass criteria that are suggested in sports testing models.  Use all resources that are available to you such as sports psychology assessments, visual feedback training with the Motion Guidance system to help the patient better understand what actions may be occurring during actions in real-time feedback and help the clinician get sport specific information during those actions, and consider need for extra motor learning as well as strength and conditioning.  For example, watch this video and see how simple bilateral jump testing with visual feedback and yield valuable information about potential fatigue, form, and dynamic actions around the lower chain.




I took this information, shared it with my client, and it really hit home the training areas that she needed to focus on despite “feeling” really good at the time of testing.

It has been suggested that advancing patients through the stages of motor learning and eventually giving external cues for function will facilitate transfer of motor control to subcortical regions of the brain and free cortical resources from programming more complex actions.  Incorporating visual-motor control training into rehabilitation may decrease the reliance of visual feedback to make dynamic changes in muscle function during an open environment (JOSPT 2015).  These factors make the safe return to participation tough. A grey area instead of black and white.

The take home message? Each of these considerations must be individually applied to each individual case in order to continue to decrease the risk of injury after return to play.

Thank you.

Eric M. Dinkins, PT, MSPT, OCS, Cert MT, MCTA




Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 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.   He is also a competitive athlete in Jiu Jitsu. 


Injury, Recovery, Movement Enhancement - A Guest Blog

Enhancing recovery and improving movement efficiency is critical in the treatment and performance enhancement training of our athletes.  The balance of bringing our athletes back to the field following injury is always a delicate balance of training hard enough and yet not over training.  This is where recover is truly key.  I am truly humbled to have one of the leaders in this field Lenny Parracino, CMT, FAFS from the LA Clippers willing to give his thoughts on how he addresses and some of the tools that he uses.  
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Injury, Recovery, Movement Enhancement - A Guest Blog
By Lenny Parracino, CMT, FAFS

Injury, recovery, and movement enhancement are all common characteristics of an athlete.  It’s the balance of these three characteristics that becomes tricky.  Lets start with injury.  Injury by definition is a disruption of unity.  The reality is that all athletes during their career will experience some form/degree of injury.  Even soreness after training is technically an injury!  In fact, muscle soreness is muscle damage.  Recently, BYU research shows immune system cells help to repair muscle damage after a workout, a normal response to injury, which is great, BUT do we want our immune system always activated after working out?  What does this reaction do to our movement enhancement?  Knowing soreness is an injury and chronic soreness decreases movement performance, learning a process to optimally recover should be a critical part of everyone’s plan if long-term healthy movement is the goal!


As for the recovery, regardless of the level of injury, we need a safe/pain free environment for optimal adaptation.  All techniques can be categorized into either 1) pain control or 2) conditioning.  Pain science has taught us that the solution for pain is 1) change the sensitizing agent(s) and/or 2) build tolerance to the sensitizing agent(s) or the structural change.  Pain is a sensation of a perceived threat.  Perceived being the key word.  Pain, regardless of how one describes it can no longer be directly correlated to the degree of tissue damage. A great example is a paper cut hurts “big-time” yet a cancerous tumor may not hurt at all.  We can only imagine the cancerous tumor displaying much more tissue damage! 

The solution to enhance movement after an injury is to first decrease sensitive tissue regions followed by building up tissue tolerance.   This leads me to what I refer to as Soft Tissue Hygiene.   We are all taught how to apply a hygiene approach to our dental structures, but what about the rest of our tissues?   Teaching athletes DAILY soft tissue hygiene, utilizing tools that improve soft tissue resilience/tolerance, is key to mitigating chronic damage – just like brushing and flossing.  We don’t brush only when we think we need it, we learn to create a HABIT.  The only way to make a chronic change to your tissues is to implement a chronic habit.  Research has demonstrated tools that compress the tissues SLOWLY change the internal fluid matrix in a beneficial way[1].  When there is increased viscosity (thickness) in the internal fluid matrix it can adversely affect many mechanisms in our body.  Free nerve endings and other mechanoreceptors can be altered, leading to chronic soreness, pain and/or stiffness, and altered motor control.[2] In addition, if the tool exhibits vibration with compression (such as with the Hyperice Vyper vibrating roller or Hyperice Hypersphere vibrating ball), there is a greater benefit than just massaging over the skin or using an implement to roll up and down body parts.  Since the change occurs in the viscoelastic components of the soft tissue complex, SLOW compression/shear/vibration and heat tends to bring positive benefits in the conditioning phase.  If one is in the pain phase I would suggest ice/compression (such as Hyperice) and client/patient pain free micro-movement.

In summary, chronic soreness (injury) should be avoided at all costs if the intention is movement enhancement.  Although there are MANY factors that can contribute, far more than just mechanical, the physical aspect can be assisted by proper soft tissue hygiene.  Although research is now available on this subject, results will speak for themselves. I recommend assessing, applying, and reassessing to adjust variables for optimal adaptation.  By sharing this process I hope I have spurred thought to yours.  By using your intelligence and not memorizing protocols we shift from a master-mechanical-technician to a creative-humble-facilitator.   Lets teach people soft tissue hygiene!





[1] Roman, M., Chaudhry, H.,Bukiet, B.,Stecco, A., Findley, T.W., 2013. Mathematical analysis of the flow of hyaluronic acid around fascia during manual therapy motions. J. Am. Osteopath. Assoc. 113 (8), 600-610.
[2] Stecco C., Stern R., Porzionato A., Macchi V., Masiero S., Stecco A., De Caro R. 2011. Hyaluronan within fascia in the etiology of myofascial pain.  Surg Radiol Anat. 33(10):891-896. 



Lenny Parracino is a former author, hands on instructor, and clinician for The National Academy of Sports Medicine. Currently, he serves as a faculty member of the Gray Institute of Applied Functional Science, is the Soft Tissue Therapist for the LA Clippers, and operates a manual/movement private therapy business. Lenny has recently authored seven manual therapy manuals (Functional Soft Tissue Transformation) and the Gray Institute’s Certified Applied Functional Science (CAFS) curriculum for manual/movement practitioners of all levels.
Lenny has spent over 25 years serving the health industry as an international lecturer and a manual/movement therapist. Lenny has performed over 300 lectures/workshops and has written educational materials and consulted/lectured in the fitness/therapy industry and for various medical organizations around the world. Lenny has earned his degree in Health Science, is a Fellow of Applied Functional Science, holds a California certification/license to practice soft tissue therapy, is a Certified Functional Range Conditioning Practitioner, and holds a certification in nutritional therapy. Lenny continues his studies under the world-renowned physical therapists, Dr. Gary Gray, and Dr. David Tiberio.
Lenny has worked with professional sport teams and/or players from Phoenix Suns, LA Clippers, San Francisco Giants, Philadelphia 76ers, Philadelphia Phillies. Minnesota Twins, LA Kings, and Seattle Seahawks and Buffalo Bills. 

As a full time practitioner, Lenny integrates an eclectic approach of Manual/Movement Therapy with the intention of optimizing individual client function.

Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 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.   He is also a competitive athlete in Jiu Jitsu. 

A Dynamic Approach to ACL Rehabilitation and Prevention: Part V - A Guest Blog

Over the last couple of weeks, we have talked about Dynamic Tape and how it may be used for rehabilitation.  But how does this work in practice?  Let's look at a case study.


Trent Nessler’s Athletic Movement Index and DorsaVi vs. Keith Cronin and Dynamic Tape
I have said a lot about Dynamic Tape and how a Biomechanical Taping solution should be in every clinician’s tool belt. So, to wrap up this series I decided to take on Trent Nessler’s Athletic Movement Index for ACL assessment measured by DorsaVi.

Patient History
Throwing HIPPA out the door here. 😊
This test subject is an exceptional handsome, intelligent, and all around amazing 35-year old male who enjoys running and is beat up badly by his 6 and 3-year-old daughters every day. His relevant list of injuries from playing years of sports and now becoming his children’s human pony include: 
  • 3 concussions 
  • R/L torn hamstrings (multiple times) 
  • 13 total sprained ankles (I was never meant to play basketball) 
  • L lower leg anterior compartment syndrome  
  • L3/L4 “Dead disc” with L myotome weakness since age 17 
  • L piriformis pain (multiple times)  
  • 5-year history of tingling sore legs (disc related but not current) 
  • 3 sprained ribs  
  • Separated L Shoulder (4x) 
  • Severe strain to L coracobrachialis (did not even know this was possible) 
  • Multiple rotator cuff and elbow strains from baseball 
  • Flat spine from weakness in thoracic


At the outset, you would agree that I am walking disaster and should not be allowed to do anything moving faster than a jogging pace. Regardless, I wanted to prove I could make it through this testing while only crying and whining a moderate amount.

Round 1 – Baseline





Started off with a solid assessment that revealed I have terrible front control and difficulty with eccentrically loading, as indicated by the speed. I have no history of ACL issues but from all this you can easily conclude I fall into a “high risk” category. The varus positioning is likely compensation because of weak hip abductors and a slight general “bow” leggedness.

NOTE: What is not included is my 100% passing score for the abdominal / lower back strength testing. Take that AMI!


Round 2 – Quad Taping
Please note at this point I have gone through the entire AMI, cried in the corner, and come back to the testing. My legs are already tired but knowing that the L is a concern, I decided to go ahead with the testing. We started with the quad taping to see what affect it would have.

What we found was a little improvement with the single leg squat, more so with the single leg jump, but then the dynamic jumps showed what Dynamic Tape has been talking about for years. Dynamic Tape is a viscoelastic product, meaning the faster a body part moves, the faster and stronger it stiffens to resist motion. This fast, dynamic movement is what is most relevant with ACL rehabilitation.

You can see from this testing that frontal plane motion improved from 25 to 19 degrees with Dynamic Tape. Please note that taping the extensor mechanism deceased varus / valgus excursion. Quad control = knee control. From testing we know my low back and abdominals are working but with a history of myotome weakness on the L it is not shocking there isn’t a lot of push in it. Depth of squat decreased a little, likely because feeling the stiffening of the tape brought on a sensation earlier to control it. Rate of speed decreased a fair bit, bringing it from BAD back to ACCEPTABLE.

I went into this fatigued, meaning I should be losing control and I was GAINING IT! With my L leg now exhausted, I went ahead to prove the point even more.




Round 3 – Hip Taping
I decided to do a THIRD round of testing on the L side, now with the hip rotation taping. I did the taping over my pants so you could see where tape was going. Normally, this would be flush against the skin but ain’t no one needs to see my skinny, pale booty. 😊

Another 5-6 minutes of tears and sobbing and we had some data. My leg was completely shot at this point and going home afterwards it felt like my two-story townhome was a skyscraper of stairs.
From the original baseline, you remember that I had a very varus position. What did this show? A return to varus, which makes perfect sense! I did a hip extension / ER rotation taping that pulled me into that position. This means in open chain the hip is being pushed into external rotation, increasing the opportunity for varus on landing. So far, this makes sense. Not what I want but mechanically this is consistent with everything Dynamic Tape does.

Now look at the rate of control. How is it that after my third round of testing my rate of control is excellent? Now what I didn’t tell you was with the L plank exercises about 20 seconds in my L butt cheek was burning bad. I said I had L side myotome weakness for years so hip abductors on that side don’t have the stamina and activation they should. The hip external rotation taping gave my weak rotators and abductors a little help resulting in significant improvement in control.




DT TAKE HOME SUMMARY
I believe enough in this product to put myself through Trent’s utter soul crushing AMI DorsaVi module and through it, I hope you see what I and many clinicians around the world have been seeing for years. Using the Biomechanical Taping System of Dynamic Tape allows the clinician to:
  • Reduce Workload
  • Management Movement Patterns 
  • Improve Function

all while allowing your patient to move 100%, to restore appropriate body mechanics.

From these movement assessments, research, and reasoning I hope you will consider putting Dynamic Tape in your toolkit for ACL rehab. Waiting for an injury to occur is not a prerequisite. Dynamic Tape can manage movement patterns and improve function before an injury occurs. In concert with a quality assessment, sound reasoning, and a purposeful rehabilitation game plan, Dynamic Tape offers any clinician the opportunity to elevate rehabilitation and injury prevention to new heights.

Want to learn more about Dynamic Tape or DorsaVi? Please contact Keith J. Cronin, DPT, OCS, CSCS at keithjcroninpt@gmail.com or visit the website at www.dynamictape.com


NOTE: Big thanks to Trent Nessler for allowing me the opportunity guest write on his blog, as well as to Shawna Jamison with DorsaVi for showing helping me with testing and for holding back the sarcastic comments as I struggled to walk. 


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 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.   He is also a competitive athlete in Jiu Jitsu. 

A Dynamic Approach to ACL Rehabilitation and Prevention: Part IV - A Guest Blog

Last week, we discussed how dynamic tape could be used to control internal rotation and some specific case examples of.  This week, we will start to discuss use of taping to assist in mid-foot control and postural taping.

DYNAMIC TAPING #3: MID-FOOT PRONATION CONTROL
If you have never seen, used, or heard of Dynamic Tape I bet you have never seen a taping that looks like this?  I always loved using rigid tape to support the plantar fascia or to control over pronation. Worked pretty good but often I would get issues up the kinetic chain if I used it too long. Why? Because if I STOP motion with rigid tape or a hard orthotic, kinetic energy still needs to travel somewhere. With pronation, you utilize the mid foot to disperse forces away from the body. This taping:  
  • Slows down the navicular through rotation control 
  • Supports the plantar fascia longitudinally by creating an artificial Windlass mechanism off the great toe 
  • Squeeze up the fat pad to artificially increase the height of the arch



Watch this video on pronation control taping, click here to learn more: 


Does this mean Dynamic Tape can replace all orthotics?
No, but it may be a good start instead of using a rigid orthotic with an over pronating foot. If through reducing workload foot mechanics are re-established, then within the first couple weeks of use improvements should be noted. If not, it is likely orthotic time.

This taping is good for anyone with plantar fascia issues?
Many but not all. If a patient has a hypermobile first ray, this taping irritated the foot as it drives down the great toe in open chain. Those with a “high” arch have poor mobility so the bungee effects of Dynamic Tape are rendered minimal if the body part can’t move.

So, for an ACL rehabbing patient with over pronation, is this something I should use with everyone?
You should use this type of taping with anyone that mechanically is breaking down at the foot. Being in a brace, minimal WB, and altered gait patterns have likely weakened the foot musculature. If foot kinematics are contributing to excessive front plane motions (varus/valgus) and excessive IR at the hip because the foot cannot manage load, this is something to seriously consider for short term use.

DT TAKE HOME MESSAGE
I attend conferences and I will be honest, sometimes I tape my feet because they get exhausted from standing all day. When it comes to pronation control taping relating to the ACL, the purpose still centers around restoring normal lower quarter movement patterns. This taping, while generally not the “main driver” such as the quad or hip, needs to be considered as a viable option as the entire leg, not just the knee, has taken a beating with this surgery.

DYNAMIC TAPING #4: LOW BACK CONTROL VIA THORACIC POSTURAL TAPING
Lumbopelvic stability is pretty much essential to everything in rehab. Probably why clinicians spend so much time talking about “the core” or “the body’s center” during treatment. With Dynamic Tape, the concept of posterior kinetic chain takes on a whole new meaning with a Biomechanical Tape.

Every good ACL rehab program will have some sort of dynamic jump training involved to restore eccentric control. In the previous blogs we have examined this via the hip, quad, and foot but have you ever thought about it through the thoracic? It is not a surprise that many ACL injuries are in younger athletes, at the high school or collegiate levels. And during these years (and it seems for the rest of our lives) we can pretty much determine that handheld devices are destroying everyone’s posture.

This standing, posteriorly pelvic tilt is not the most “athletic” position. While I am making no claims that this position is constant on the field, reality is the muscles in the back are lengthened and weakened regardless. So, with Dynamic Tape, here is an opportunity to get after that problem without constantly saying “STAND UP STRAIGHT!!”

To go after apparent weakness and poor pelvic position we are going to attack this issue from the thoracic. Using the Dynamic Tape X Posutre Pal (note: this can be created with regular Dynamic Tape as well) the thoracic spine is functionally supported. If an over kyphotic position is present, so will be a deficient lordic position. Functional weakness in the thoracic is a very common issue, particulalry with somone laying around resting a knee playing video games. Thoracic strengthening exercises, using prone dumbell flexion and resistance bands in standing are essential in conjunction with correcting posture with biomehcanical tape.

DT TAKE HOME MESSAGE
Postural dysfunction in athletes, or everyone for that matter, affect everything from the mid back down. Whether it is:
·       Landing on the heels due to a posteriorly tilted pelvis
·       Difficulty maintain pelvic stability with lateral movements
·       Fatigue causing excessive rotation through the spine resulting in IR/ADD at the hips

having a practical treatment solution for the thoracic spine is a must for any clinician. With Dynamic Tape and Posture Pals that solution is only a simple step away.


Want to learn more about Dynamic Tape or the Posture Pals pre-cut system? Please contact Keith J. Cronin, DPT, OCS, CSCS at keithjcroninpt@gmail.com or visit the website at www.dynamictape.com



Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 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.   He is also a competitive athlete in Jiu Jitsu. 

A Dynamic Approach to ACL Rehabilitation and Prevention: Part III - A Guest Blog

Last week, we discussed the use of dynamic taping to assist with quad control during the ACL rehabilitation process.  This week, we will look how Dynamic Tape can assist in controling hip internal rotation.

DYNAMIC TAPING #2: HIP EXTERNAL ROTATION TAPING

There are two major strategies for balance: Ankle and Hip. For those with an ACL injury we spend a

lot of time with single and dynamic balance / jumping exercises, while watching how the foot lands. Reality is much of the control comes from the hip. Weakness at the core and hip external rotators drives an already adducted and internally rotated femur inwards. Through any screening observing the risk factors but what can you do to control it on the field?

A few clinicians in Brazil piloted a study seeing if they could change knee control with a single leg jump in volleyball players. Makes sense with a high-risk population for jumping and landing. They used this dynamic tape hip rotation technique to place the femur in a more externally rotated position. The results were amazing, but not shocking once you see this stuff in action (Bittencourt et al, Brit J Sport Med 2017).

With the hip started in full external rotation and extension, the corrective measure was designed to maximally control rotation when the hip was flexed and internally rotated.  

Watch this Spark Motion video to see all this in action.


*Note with this taping, you do not necessarily need to rotate all the way around for SI control if you don’t feel that is an issue*

“Why” This Dynamic Approach
Through proximal control of the femur, changes distally are affected. Correct the angle and direction of landing and reduction in rotation and adduction is achievable.  But a research study is not good enough for me as I wanted to see this in action. So, I met up with Doug Adams, PT and creator of Trace 3D, a motion sensing system that is essentially a “running lab in a box.” His system is validated against the best of the best so I taped him up.

First, we got a baseline for his running and then followed up with taping. After his second run of it, we looked at the data.
A 50% change in reduced IR at the hip with running, throughout the entire cycle.

Could have been a fluke, right? So that same day I did the same taping at Philadelphia Shriners Pediatric gait lab. How would Dynamic Tape fair with this system? The data was even better. We could see that with the hip external rotation approach, Dynamic Tape was able to take someone pathological with hip ER with walking and restore it to within norms.

Now look at the curve. It changed the rotation evenly throughout the entire motion both closed and open chained! And even more fun at its peak it was about a 46% change in motion, almost the exact same amount that it was just 5 hours earlier with a different person and a different system.
To go even further, we took that same person’s opposite hip and tape it from normal into a pathological hip position and as expected, took someone from normal to abnormal with the taping.




DT TAKE HOME MESSAGE
Changes in lower body mechanics take time so why not provide your athlete with a strategy that works now. For those of you worried about tape then “weakening muscles” or movement patterns rest assured, once someone can perform a battery of tests without the tape and passes, you don’t need it anymore! Therapeutic taping is not an “every day” thing, it is designed with a purpose that stems from a biomechanical need. Once the need is gone, so goes the tape.


Want to learn more about Dynamic Tape or the Trace 3D Running System? Please contact Keith J. Cronin, DPT, OCS, CSCS at keithjcroninpt@gmail.com or visit the website at www.dynamictape.com


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 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.   He is also a competitive athlete in Jiu Jitsu. 

A Dynamic Approach to ACL Rehabilitation and Prevention: Part II - A Guest Blog


DYNAMIC TAPING: #1 QUAD EXTENSOR MECHANISM
Every, and I mean EVERY, rehabilitating ACL injury has quad weakness. The swelling, soft tissue damage, and duration of inactivity is going to shrink that muscle up. When the quad does not work effectively to eccentrically control movement, combinations of adduction and IR at the hip are accentuated, putting at risk an ACL that restrains anterior translation and rotation. There are other things to consider such as:  
  • Landing technique 
  • Core activation 
  • Glute strength and stamina 
  • Force absorption (gradual / spread out vs. sharp / high peak forces) 
  • Hip external rotator activation 
  • Gastroc power / strength 
  • Foot Pronation / supination

But that quad is the big stand out every day in therapy.

First glance your response may be, “Wow, that is a lot of tape.” Yes, it is, but let’s talk about why. By having a 2” powerband (two pieces together) and a 3” on top it creates significant resistance to knee flexion, thus, turning potential energy of tape in kinetic active extension.

To see this in action, watch this video:




“Why” This Approach to Quad Control
For those who are skeptical about taping, I understand as so was I. The first time I came across Dynamic Tape it sat on my shelf for 6 months. Wasn’t till I met the creator that I realized he had truly designed a new product and approach to therapeutic taping.

Recently I started playing around with BodiTrak, a portable light-weight force and pressure mat, that is beginning its journey from golf to rehabilitation. This 11-pound stellar tech break through that operates wirelessly from your iPhone (how awesome is that!) showed some interesting information when used with Dynamic Tape. I started examining simple case examples of old ACL injuries using BodiTrak, measuring force production during a single leg jump. In the past couple months, I have done this 5x with the same success every time. The most interesting case was with a female therapist at a course I was teaching. She had a 5-year-old L ACL repair (torn twice) and a chronic history of knee pain. We had her jump up and down on the BodiTrak mat and found that her R leg produced 2.1x body weight, while the L was at 1.4x with awful motor control and high peak forces landing. 8 seconds to figure out how to jump on one leg!

I applied the power band quad taping and the next jump on the R was 2.1x BW, no changes. On the L, it was 2.1x BW!!! And this time it only took her a couple seconds to figure out how to jump. We then took the tape off and she never got above 1.7x BW but the carryover was still present.

DT TAKE HOME MESSAGE
Did the tape exert 50% more force production to make up the difference? No, but what it did to is improve eccentric control. The therapist felt more control and the appropriate motor pattern kicked in. She would absolutely need to continue to strengthen but this was a solid motivator to get her back to working harder. As a clinician, you have a new means to improve quad control while still functionally working through rehabilitation. As a bonus if your patient must wear a brace, Dynamic Tape goes right under it. 😊


Want to learn more about Dynamic Tape or BodiTrak? Please contact Keith J. Cronin, DPT, OCS, CSCS at keithjcroninpt@gmail.com or visit the website at www.dynamictape.com



Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 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.   He is also a competitive athlete in Jiu Jitsu. 

A Dynamic Approach to ACL Rehabilitation and Prevention - A Guest Blog

Throughout the history of this blog, I have attempted to share with you the latest research and how this might influence our assessment of athletes or training of athletes.  Having focused the last 20 years on ACL rehabilitation and prevention I have been blessed to come across a lot of people who share this passion (or what I call a higher calling) to help athletes stay safe and perform better.  Many of these folks have applied the latest research to their craft or technology.  I am inspired by some of the amazing products that are out there that have been created to help you and I do what we do better, to allow us to do it more efficiently and provide the athlete with a better outcome.  

Considering, I have felt like this should be shared with our viewership.  So, over the course of the next several blogs series, I have reached out to some of these folks who are on the cutting to see if they would mind contributing to our blog.  To provide our viewership a glimpse of their products, what the science is behind these products and how this can be applied to the athlete.  I have personally vetted each of these to make sure this is science based and NOT a sales pitch.  So, please sit back and enjoy as we venture into some of the latest and greatest in movement science and sports medicine. - Sincerely ~ Trent Nessler, PT, MPT, DPT
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A Dynamic Approach to ACL Rehabilitation and Prevention - A Guest Blog

Over the course of decades of clinical practice and with my adventures across the country, I get the opportunity to meet some amazing people that are doing some amazing things.  Folks who share my passion for prevention and who are on the forefront of innovation for injury prevention.  Rarely do I come across someone who shares this passion and is doing something innovative that is truly impactful on non-contact injury rates.

Keith J. Cronin, DPT, OCS, CSCS is one of those guys.  I have personally seen the impact of some tapping techniques that he is doing have a direct impact on an athlete's ability to control frontal plane motion and speed of motion at their knee (two major risk factors).  So I have asked Keith to provide a guest blog on what he is doing in order to share this with your audience.

A “Dynamic” Approach to ACL Rehabilitation and Prevention
If you are interested in ACL rehabilitation and looking for: 
  • A treatment that impacts an athlete ON and OFF the field 
  • A methodology that addresses all movement impairments the result of poor activation, weakness, or body mechanics 
  • A system that gives you, the clinician, absolute control in how much force and which direction to push or pull the body to work at its best

This blog series is for you.

Since I first saw the “ACL Play It Safe” program and kit my initial response was, “wow, this just makes sense.” ACL rehabilitation and return to sport is already confounded with many different factors, including, but not limited to: 
  • Extent of injury / movement dysfunction 
  • Quality of Rehabilitation Adherence / compliance of patient 
  • Sport played 
  • Internal healing aptitude (yes, some people are just more Wolverine than the rest of us) 
  • Anatomy 
  • Previous Injuries

If the goal is to maximally train the body using the right series of exercises to inevitably pass a battery of movement tests, what then are we most concerned about? So many things perhaps, but for this article we are going to examine improving movement using a strong recoiling viscoelastic tape is a toll that should be in everyone’s tool belt. And we aren’t talking about rigid tape or kinesiology tape, we are referring to Dynamic Tape, the “Original” Biomechanical Tape, that is changing the way clinicians think about taping.

Dynamic Tape: If Kinesiology Tape and Rigid Tape Had a Baby…….
Before we get into taping techniques, let us start with what we know.
Pretty much everyone is familiar with rigid tape. Whether its leuko (medical duct tape) or white  
athletic tape the product is simple:
  • Place the body in a neutral or corrected position 
  • Use a rigid, no elastic product to restrict movement 
  • Tape across a joint to have a mechanical effect 
  • PURPOSE – reduce stress on damaged tissues through mechanically locking up a joint

These techniques have been around for 40+ years and if you are an athletic trainer, you by trade are a master of the craft. Researchers are at least mostly in agreeance that if you prevent a joint from moving overall the kinematics of human movement will change.

In the late 1970s, a chiropractor named Dr. Kenzo Kase figured out how to push this in an entirely different direction. His approach was to use a stretch cotton product that allowed full ROM while having a neurophysiological effect on the body.

1.       Place a muscle in a lengthened position
2.       Use a stretch cotton that extends to 140 – 170% of length to pull on the skin / soft tissue
3.       Tape in different patterns to have different effects on the body
4.       PURPOSE – to create a neurophysiological interface to afferently affect the nervous system to efferent reduce pain and swelling

Millions of rolls are sold throughout the US each year from pediatrics to post-surgical to geriatrics to sports. But here is where a lot of researches and getting into some arguments. It is true that there has been research to support having a positive effect on chronic pain (more than 3 months) with the low back but when it comes to making mechanical changes, the data just isn’t there.

Ryan Kendrick, physical therapist and creator of Dynamic Tape, felt the same way. He worked with professional tennis players and was always looking for way to extend his treatments onto the court. He liked using rigid tape to make mechanical changes but it locked up motion, meaning his athletes could not move the way they wanted. Kinesiology tape allowed 100% range but did not have the ability to absorb force or alter movement patterns that would improve function. He thought to himself what if a tape could:
  • Absorb force to reduce the workload in the muscles and underlying tissue
  • Change movement patterns immediately through strong recoil 
  • Allow for 100% ROM with no rigid end to the tape  Be soft, breathe easy to prevent skin decay 
  • Stretch in 4 directions to contour to the human body exceptional well   
  • Stack “tape on top of tape” to increase force if necessary

To learn more, watch this 2-minute whiteboard video on the innovation that is Dynamic Tape

From this he created the first even Biomechanical Taping System that sports and rehab have ever seen. Since 2010, this product has made its way into 35 countries on word of mouth alone. You may have seen it and thought it was another kinesiology tape but today you will learn how this advancement in taping technology is going elevate your ability to manage ACL rehab, and everything else for that matter.  

Next week we will begin to discuss how you can use Dynamic Taping to improve quad control in your ACL patient.

About the author Keith J. Cronin DPT, OCS, CSCS

Keith J. Cronin is a physical therapist and owner of Sports and Healthcare Solutions, LLC., a consulting company that works with domestic and international companies to provide quality clinical education and sales training for rehab and athletic products. Keith graduated with his Doctorate in Physical Therapy (DPT) from Belmont University in 2008 and later earned his Orthopedic Certification Specialist (OCS). Keith currently is a reviewer for the International Journal of Sports Physical Therapy (IJSPT) on a variety of topics including throwing athletes, concussions, and ACL rehabilitation. Keith has produced several online CEU courses for PTWebcuation.com on the topics of running injuries, ACL rehabilitation, Patellofemoral Syndrome, and injuries to the Foot and Ankle. In 2012, Keith participated in a concussion education program in Newcastle, OK that resulted in the documentary “The Smartest Team: Making High School Football Safer” which had several runs on PBS worldwide.

Keith has also been published in a variety of media, publishing almost 100 articles through venues including MomsTEAM.com, Advanced Magazine, the 9s Magazine, the American Coaching Academy, and Suite101. Keith was also featured on Fox2News several times on topics of concussions and ACL injuries. In 2008, Keith was a winner of the Olin Business Cup at Washington University for his product innovation “Medibite” a jaw rehabilitation system designed to improve the outcomes for individuals suffering TMJ dysfunction. Prior to graduate school Keith was a collegiate baseball player and top-level high school cross country runner. Keith also had the opportunity to work as a personal trainer (CSCS) prior to his career in physical therapy, providing a very balanced approached to educating fitness and rehabilitation. Keith has focused his career on the evaluation, treatment, injury prevention, and sports conditioning strategies for athletes, with particular attention to youth sports.


Keith lives in the Denver, CO with his wife and two daughters, Ella and Shelby. 

Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 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.   He is also a competitive athlete in Jiu Jitsu. 

Please contact contact@novacare.com

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