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.

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. 

The Evolution in Movement Assessment - Using Wearable Sensor Technology To Reduce Athletic Injuries

HS VB Player Demonstrating Poor Movement
As a parent, there is a certain thrill of seeing our kids participate in sport.  Nothing more exciting than seeing your child be successful or victorious in competition.  Yet, 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!
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. 

Movement Efficiency in Mixed Martial Arts - Part IV

In the last several weeks we have been discussing movement assessment in the mixed martial arts athlete and how this can guide our training.  Single leg activities are also critical to sports and sports performance.  Recent studies in the American Journal of Sports Medicine state that single limb testing is one of the most important movements to test as it has the highest predictive value to performance in sports.  

Single Leg Squat – In this test, the athlete is asked to perform 10 repetitions of a body weight single leg squat on the right and on the left.  During this test, you are assessing the ability of the athlete to stabilize their knee in the front plane AND their pelvis in the transverse plane.  It is normal for an athlete to have slight movement at the knee and hip but excessive movement (greater than 10 degrees) and a large variance right to left results in an increase in injury risk and decreased athletic performance (as result of loss kinetic energy across the system).

Rational:  Single leg squat is one of the best indicators for athletic performance and injury risk in athletics.  This is true in sports which require a significant amount of single limb motion like running.  This is especially true for the MMA where a lot of the sport is kicks, knees and explosive power coming in single limb movements.  Symmetry in control of the knee in the frontal plane and control of the pelvis between the right and left lower limb is critical to optimizing performance, explosive power and keeping injury risk to a minimum. 

Training Impact:  For training purposes, the athlete is asked to perform a single leg squat using a resistance they can control throughout their range of motion while controlling motion at the hip and the knee.  The contralateral limb should be positioned in an athletic position (limb in a slight hip extension – mimicking a running position).  During the course of the exercise, the athlete should prevent the contralateral limb from touching the ground at any time.  Once proficiency is maintained at a given weight, the athlete is then progressed through progressively increased loading and eventually progressing to hopping.  Hopping should be performed in the following progression, anterior/posterior once proficient, medial and lateral once proficient all 4 directions.  If a loss of motion is considered, this could also guide some additional stability and mobility exercises that can be performed. 
 

Considering the importance of single limb testing, it is also an important movement to train and to train correctly. In this example, we see a MMA athlete lunging across the cage during dynamic stretching.  As he does this, you also see (in this still) his right knee adducting toward midline. This valgus motion is the motion that we are assessing in the previous test and a motion which we want to correct.  This motion, in a closed kinetic chain, results increased stress to the ACL, MCL, labrum in the hip and medial structures of the ankle.  If this poor movement pattern is repeated over and over with every repetition and every training session, then this results in an athlete that will do when training, when performing double leg takedowns and when fatigued in a fight.  Allowing this motion to occur in training will result in this motion occurring when this athlete shoots of a one leg or double leg take down.  This means less force (speed of take down) and increased likelihood for this motion to result in a non-contact ACL injury during.  This pattern trained over and over can result in adducting at the hip and possible injury when the athlete is fatigued and when power and stability matter the most. 

Video - in this video we demonstrate the proper form for this exercise which ensures we are training full range of motion and proper movement patterns at the same time.


In addition to this mobility exercise, adding the lumbar hip disassociation exercise will aid in the MMA athlete in improved hip mobility and provide strength and endurance to the hip and core complex.



We hope you enjoyed this series and make sure to come back for more next week.   If you enjoy our blog, please share the passion and follow us on Instagram @BJJPT_acl_guy or on Twitter at @acl_prevention.

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. 


Movement Efficiency in Mixed Martial Arts - Part III

Last week, we started our discussion about how we assess movement efficiency in the MMA athlete and how that may guide some of our training.  As we described last week, core strength is critical in mixed martial arts for both performance and injury prevention.  The side plank test is an exceptional test for assessing the strength and endurance of the core and is often an exercise that is also used as a part of our training.  This is a great exercise as there is a lot of EMG activity of the gluteus medius, internal obliques, quadratus laborum and transverse abdominus.  During this movement, the EMG activity of the gluteus medius is very high and this is a critical muscle in stabilizing the core/hip/lumbar spine.  The gluteus medius is the muscle that assists in stabilizing the pelvis during single leg activities.  Here we see an athlete demonstrating a retrotrendelenburg, where you can see an arc from his upper body to lower body.  This should be straight and when performed in this fashion this a movement pattern that adds to weakness of the gluteus medius.  If this poor movement pattern is repeated over and over with every repetition and every training session, then this results in the athlete not training the muscles he is setting out to train and the impact on performance will be less than optimal.

This week we will continue this discussion as we look at assessing power generating movements and single limb performance.  Considering this, one of the first movements we want to look at is the squatting motion.

Squat – In this test, the athlete is asked to perform 20 repetitions of a body weight squatting motion.  During this test, you are assessing the ability to perform a squatting motion without a lateral shift (if a plumb line from cervical spine to sacrum is envisioned, the hips should remain equal distance from the plumb line throughout the motion).  If there is deviation to one side or the other, this is referred to as a lateral shift.  



Video – in the following video analysis we see an Olympic athlete demonstrating a right lateral shift during the squatting motion.  This same motion is carried over to training and athletic performance.  




Rational:  The squat is a critical motion for athleticism.  Improvement in the efficiency of the squatting motion has not only been shown to be associated with a reduction in injury risk but also associated with improvement in vertical jump and sprint speed.  Reduction of a lateral shift results in symmetrical force attenuation and improved symmetrical force production.   For the MMA athlete, this means greater force which can be generated with kicks and faster and more explosive takedowns.  In addition, a lateral shift can indicate loss of motion in the ankle, knee or hip on the side they are shifting away from.  This can guide preventative techniques which aid in reducing non-contact injuries during training and fights.  In this picture, we see the athlete from the video shifting to her right side which could indicate a loss of motion in the left hip, knee or ankle.

Training Impact:  For training purposes, the athlete is asked to squat using a resistance they can control throughout their range of motion without a lateral shift.  If an athlete has a lateral shift, simply loading that and allowing them to continue with will result in greater variance in asymmetry right to left, bigger impact on athletic performance and increased injury risk.  Once proficiency is maintained at a given weight, the athlete is then progressed through progressively increased loading.  If a loss of motion is considered, this could also guide some additional mobility exercises that can be performed.  If there is a suspected true loss of motion at the ankle, you would most likely see an asymmetry in the ankle motion in the plank test discussed previously.  This will appear as an increase in plantar flexion on the suspected side during this test.  In the training example here, this MMA athlete is doing a weighted squatting motion with kettle bells.  Although this is a great exercise, the problem is that he is shifting to his left side during every rep. Allowing him to do this during his training is just adding to the problem and accentuating his asymmetry.

Next week, we will begin the discussion of single limb testing and look at ways we can assess these athletes and how this can guide our training.  If you enjoy our blog, please share the passion and follow us on Instagram @BJJPT_acl_guy or on Twitter at @acl_prevention.


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. 


Movement Efficiency in Mixed Martial Arts - Part II

Last week we started the discussion on movement efficiency in MMA and we finished with the question, So, how do we assess that?  So this week, let's begin to take a look at some of the movements that we assess in these athletes and how these equate to injury prevention and performance enhancement. 

Testing the MMA athlete

Plank - In this test, the athlete is placed in neutral spine and neutral hip position, feet all the way together and head neck in neutral position.  They are then asked to maintain this position for one minute period of time. 

Rational:  The plank is a critical position for assessing the stability of the core.  The goal of this test is for the athlete to be able to stabilize while maintaining neutral spine position and neutral hip position.  In this test, the athlete must sustain stability this position within 10⁰ of flexion and extension AND rotation.  Maintaining stability in flexion, extension and rotation is critical to provide stable base for the lower kinetic chain to pull on, to generate force from and allow efficient kinetic energy transfer across the entire kinetic chain.

Training Impact:  For training purposes, the athlete is asked to start training this basic movement correctly.  The key to training is to ensure the athlete is maintaining neutral spine and hip position throughout their training.  Once this achieved, movement and resistance can be added to this movement.  In addition, the push up portion of the dynamic sumo stretch has a big carry over to this test therefore it is critical to ensure this movement is being performed correctly.  Once this is perfected, an exercise like the plank crawl is a great addition to the MMA athlete’s core training routine. 

Plank Crawl

Next we need to look at the core's recruitment in in combination with the pelvic and hip musculature.

Side Plank – In this test, the athlete is place in the neutral spine position ensuring that the athlete is not in a retro-trendelenburg position.  The feet are placed on top of one another and the non-weight bearing arm is placed on the hip.  Head and neck are maintained in a neutral position.  They are then asked to maintain this position for one minute period of time. 

Rational:  The side plank is a critical position for assessing the stability of the core and the endurance of the gluteus medius.  The goal of this test is for the athlete to be able to stabilize while maintaining neutral spine position and neutral hip position (hips not rolling forward or back).  In this test, the athlete must sustain stability this position within 10⁰ of lateral sidebending (moving hips up or down toward the surface) AND rotation.  Maintaining stability is critical to provide stable base for the lower kinetic chain to pull on and to aid in preventing internal rotation of the lower kinetic chain in single leg stance activities.

Training Impact:  For training purposes, the athlete is asked to start training this basic movement correctly.  The key to training is to ensure the athlete is maintaining neutral spine and hip position throughout their training.  Once this achieved, movement and resistance can be added to this movement.  Once this is perfected, an exercise like the side plank with the CLX is a great addition to the MMA athlete’s core training routine. 

Side Plank with CLX


Next week, we will begin the discussion and look at ways we can assess these athletes and how this can guide our training.  If you enjoy our blog, please share the passion and follow us on Instagram @BJJPT_acl_guy or on Twitter at @acl_prevention.

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. 

Movement Efficiency in Mixed Martial Arts

Throughout the history of this blog, we have talked about how movement assessment can be used in injury prevention and aid in performance enhancement.  The association to sports like soccer, football and basketball are often easy for us to see.  However, sometimes we think there are certain sports that may be immuned to or which this does not have as much application to.  As a fan of MMA (mixed martial arts) and a student of BJJ (Brazilian Jiu Jitsu), coaches and athletes that specialize in these arts often think movement assessment has little application or that the sport is beyond it.  However, these sports more than any other are dependent on quality of motion for ultimate performance and for injury prevention.  Yet those that do use movement assessment for the sport often rely on outdated methodologies and primarily subjective measures.

Looking at the stats related to MMA and ACL (Anterior Cruciate Ligament) injuries we find some interesting key points.  Most would tend to believe that most ACL injuries in the UFC or MMA occur with contact.  A leg kick, knee bar or something of that nature.  However, the reality is that most of the ACL injuries in MMA are non-contact in orientation.  >70% of these injuries occur during a non-contact mechanism in training or during take down in a match.  One of the most common combinations of movements associated with ACL risk is valgus and internal rotation that occurs at the knee. 

As depicted here in the basketball athlete, this is sometimes easily seen in single leg stance or single limb activities.  Most often we see this in running, cutting and jumping activities.  Likely we have all seen a news reel or instant replay where a football or basketball player have a cutting movement resulting in these movement patterns and associated ACL injury.  But how does this apply to the MMA athlete and how do we identify?  Often these athletes are in such close contact with one another and the movement occur so rapidly that it is difficult to identify.  

As previously mentioned, the majority of non-contact ACL injuries in MMA occur with takedown.  As depicted in this picture, as the athlete shoots forward with his left leg, grabs his opponent and drives forward with the hips, this is when the injury occurs and usually to the stance leg (in this instance the left leg).  It is the point where you are driving the hips forward that the knee will tend to fall in toward midline.  This position not only creates a valgus stress at the knee but also results in an internal rotation moment.  The combination of these two movements creates a tremendous amount of shearing stress to the ACL and the meniscus of the knee.  Since these tissues are weakest in resisting of shearing forces, this is where a tear or rupture often occurs.  Obviously, optimizing the technique is critical to performing correctly but identifying where the weaknesses are in the system will aid in preventing these pathological movements during.

Are knee injuries and ACL injuries that common in the MMA?  This slide here represents just a few of the ACL injuries that have occurred in the UFC over the last 8 years.  Some experts associate injuries to these athletes to equate to ~$118M in lost revenue.  This loss in revenue associated with pay per view losses, sponsorships, etc. associated with each of these fights.  Considering this, >70% of non-contact injuries in these sports (MMA, BJJ, Karate) occur to the lower kinetic chain with the knee representing ~80% of those.  According to Harris et al Sport Health 2013 and Read et al Am J Sports Med 2017, professional athletes who suffered an ACL injury had a decrease across all performance measures after returning to sport following an ACL reconstruction and had a shortened athletic career as a result.  In professional sports, this meant reducing not only their professional career by 2-4 years but also the income they could get during that time (as a result of the decreased athletic performance).  When considering future performance as well as longevity of an athletic career, then obviously prevention of an ACL injury is critical.  Considering the majority of these injuries are non-contact in orientation, then this is why we focus on non-contact injuries.  In addition, non-contact injuries are also the ones that are most dramatically impacted (reduced) when properly identified and trained.  Another aspect that makes MMA so susceptible to lower limb injury is the association of concussion and lower limb injury.


This really started to come to light in 2016 when Brooks et al Am J Sport Med and Gilbert et al Sport Health both published studies showing that athletes who suffered a concussion where at greater risk of lower limb injury.  Not just a little but 1.6 to 2.9x greater risk of injury up to two years post-concussion.  This is despite the fact that cognitive testing (Impact test which is used to determine an athlete’s ability to return to sport) had returned to base line levels.  Considering that concussed athletes were found to be at greater risk of lower limb injury up to 2 years post-concussion, it makes us wonder how we could better test and train those athletes for safer return to play.  The initial studies showed similar results in Division I athletes and further studies by Pietrosimone et al Med Sci Sports Ex 2015, Cross et al Br J Sport Med 2016, Nordstrom et al Br J Sport Med 2016 showed this had similar applications in professional football, lacrosse and soccer players respectively.  Studies are showing that these athletes, despite unremarkable (meaning no signs of concussion) neurocognitive testing, when tested in single leg stance, their performance is greatly altered.  Kristinaslund et al. Am J Sport Med 2013 and Myers et al Am J Sport Med 2012 showed that single limb performance was the single best test for assessing movement associated with successful performance in sport and movement associated with risk.  Further, Howell et al Am J Sport Med 2015 may have discovered some of the underlying cause for altered single limb performance post-concussion.  In this study they found athletes who had suffered a concussion had a greater displacement of their COM  (center of mass) during single limb tasks.  As depicted here, this displacement of COM alters force distribution through the lower limb which alters force production (performance) and force attenuation (injury).  Considering, this not only guides us on how we should assess but also how we should train.

Next week, we will begin the discussion and look at ways we can assess these athletes and how this can guide our training.  If you enjoy our blog, please share the passion and follow us on Instagram @BJJPT_acl_guy or on Twitter at @acl_prevention.

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 Will Your NFL Team Perform? - Know Their Injury Rates - Part II

Last week we talked about the Read study and some of the implications that an ACL injury can have on an athletes performance after RTPlay.  This week, we are going to disect this a little more the investigate what this means to the team and to the player.

Players starting in less games.  One thing the authors spoke about was that players r
eturning to sport post ACLR started less games following RTPlay.  This can come from multiple factors including a coaching decision, a medical decision or player decision.

  • Coaching decision.  The coach may choose to not start the player due to their current performance.  They see that the player is making less tackles which means more players are getting by them which may result in more yardage per carry for the opposing team or TDs.  Net result is a decrease in the team’s performance.  The coach may also see that one of their star players is no longer one of their star players.  Coaches are there to win games and that depends on results of the individual players.  If a player’s stats drop, that means an opportunity for another player to move up.
  • Medical decision.  We know that athlete who have an ACLR are at greater risk for other lower kinetic chain injuries.  They also tend to have more knee problems and knee pain with RTplay.  This may result in the ATC or MD pulling them out of play or modifying their play based on how their knee is responding.
  • Player decision.  This is one that typically does not last long.  If the player is self-limiting their play, they may be pulled by the coach or cut from the team.  A lot of times, athletes will suffer from Kinesiophobia (fear of movement) after an ACLR.  This is where the athlete has not developed 100% confidence in their knee and its ability under the high demands of this sport, so they may self-regulate.  This is most common with those who suffer a non-contact ACL injury and typically have kinesiophobia with explosive movements and cutting movements.  Net result is a decrease in agility which may be one reason for a decrease in number of solo tackles.

Considering the above, what is the overall impact to the team and does this impact team performance.  Keeping in mind what this study showed us, one of the things we know is that the athletes that did return to play were the better defensive players prior to their injury.  That said, this study also clearly shows they did not return to the same level of play.  For defensive players, one of the game performance measures is number of solo tackles.  The number of solo tackles dropped dramatically and brought their individual ranking down from a star player to an average player.  Taking star players out of the game can and will have a dramatic impact on overall team performance in individual games as well as overall seasonal performance.

On a personal level, what is the impact to that athlete?  This is obviously the individual that is impacted the most.  NFL players know this impact and it is one reason that in 2014 and 2015, knee injuries were ranked the #1 concern among NFL football players in the NFL Players’ Association.  This is above concussion or any other injury.  Why?  Because they know how much this impacts earning potential.  This has a direct impact on the NFL player’s earning potential in 2 ways.  If their contract is up for negotiation, this is going to be based on prior year’s performance.  If they are starting in less games and making less solo tackles, then they do not have as strong negotiating power as they may have had previously.  In addition, what this study shows and what the athletes know, is that their professional football career is cut short.  Although this study shows an impact, what industry experts say is that their professional career may be reduced by 3-4 years.  On a multimillion dollar contract, that is a lot of potential income that they lose out on.

So why is this study so important?  ACL injuries are common in the NFL.  How common?    Let’s look at the numbers by season. 
  • 2016/17 – 46 ACL injuries 
  • 2015/16 – 48 ACL injuries  
  • 2014/15 – 45 ACL injuries 
  • 2013/14 – 63 ACL injuries

Over four seasons that is 202 ACL injuries.  If you look at the overall cost of those injuries, you must look at time loss, ACLR cost, rehab cost, positional replacement costs, emotional capital and impact to team performance.  Industry experts put this cost at ~1M/player.  Over 4 seasons, that is $202M in injuries.  

Sadly, over 73% of those are non-contact in orientation.  Studies suggest that you can reduce non-contact ACL injuries by as much as 80% if those athletes are properly identified and put on an appropriate program.  So over four seasons, that is a potential $118M cost savings if they had been identified and trained appropriately. 

So why is this not being done?  One is time.  How do you do that efficiently?  Here is an interesting fact.  66% of all NFL ACL injuries are associated with 5 positions. 
  • Wide receivers – 19.4% 
  • Linebackers – 15.5% 
  • Cornerbacks – 11.7% 
  • Offensive lineman – 10.7% 
  • Defensive ends – 8.7%

What does it take to make a change?  First and sadly, you need to tie it to performance.  How does this impact athletic performance, team performance and revenues.  The above study highlights the impact this will have to the individual performance of the player but also the impact this will have to the team’s overall performance.  Secondly, we need to know we can somehow efficiently identify those at risk.  With the advent of wearable sensor technology and the knowledge that 66% are associated with 5 key positions, then we now have an efficient manner to address.  Finally, having a solution.  Once those at risk have been identified, how do we change that?  There are multiple programs out there that can efficiently impact these pathokinematics and improve the movements that put athletes at risk. 


Insanity - To do the same thing over and over and expect a different outcome.  Is it time for the insanity to be over or are we going to continue what we have always done and expect a different result?  I chose the former.  


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 Will Your NFL Team Perform? - Know Their Injury Rates - Part I

Over the course of our last series “Is there a secret sauce” we provided some thoughts and research on several factors that contribute to altered biomechanics or pathokinematics that put athletes at risk for an Anterior Cruciate Ligament (ACL) injury.  Throughout the history of this blog, we have attempted to correlate these same pathokinematics to not only ACL risk but also to changes in athletic and team performance.  In this authors mind, there are two ways in which this impacts performance; directly or indirectly.

The direct impact is the impact that altered biomechanics has to force production and kinetic energy transfer.  This direct impact results in muscles of the core and lower kinetic chain producing less force.  This is the results of several factors including changes to length tension curves.  Simply stated, due to the altered mechanics, the muscles of the core and/or lower kinetic chain are placed in a shortened or lengthened position.  Knowing the impact that length (shortening or lengthening) has on force production, then the muscle cannot produce as much force or power as it could if it were in an ideal length tension relationship.

The indirect impact is after the injury occurs.  The altered biomechanics resulting in a non-contact ACL injury result in an impact on future athletic performance.  However, this concept of how these injuries impact future performance has not been fully investigated.  That said, more and more studies are starting to investigate the impact on future athletic performance.

Case in point, a recent study by Read et al, Am J Sport Med2017, the authors looked at the impact of ACL injuries have on future performance in National Football League (NFL) players. 

Methods:  38 NFL defensive players with a history of Anterior Cruciate Ligament Reconstruction
(ACLR) from 2006 to 2012 were identified.  For each injured player, a matched control player was identified.  For each player, demographic and performance data was collected.  Players that returned to play (RTPlay) after ACLR (N=23) were compared to players who did not RTPlay after ACLR. 

Results:  At least 74% (28/32) players who had an ACLR RTPlay in the NFL for at least one season game.  61% (23/32) successfully returned to play for at least half of the NFL season (min of 8 games).  In the seasons leading up to their injury, athletes who successfully returned to play started a greater percentage of their games (81%) and made more solo tackles per game (3.44 6 1.47) compared with athletes in the ACLR group who did not return to play.  Athletes in the ACLR group retired significantly earlier and more often after surgery than the matched control group.  In the season after ACLR, athletes who RTPlay started games 57% less times and had only 2.38 solo tackles per game compared to matched controls at 3.44 solo tackles per game.

Conclusion:  Athletes who successfully returned to play were above average NFL players before their injury but not after. 

Next week, we will start to dissect this a little more.  Specifically what does this mean to the team's performance as well as the athlete's overall earning potential.  If you are enjoying our blog, please share it and follow us on twitter @ACL_prevention and on Instagram at @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. 


Is There A Secret Sauce? - Part VI

Gradients of Gluteus Medius Weakness – Part III
In our last couple of blogs, we have talked about the function of the gluteus medius in both an open kinetic chain and closed kinetic chain.  We have also talked about how this muscle functions on both the femur and the hip and how weakness of this muscle will present itself at the femur versus at the hip.  Although most understand the movement that occurs at the femur, identifying weakness that is represented at the hip is just as critical as it is at the femur.  With the shear stresses that are imparted to the labrum of the hip during these motions, hip motion can have just as devastating effect on the hip as the movement can have on the ACL at the knee. 

So now that we have identified it, how do we strengthen it?  Easiest thing is to look at the function of the muscle.  Before we get into specific exercises, let’s say one obvious thing, if you are going to strengthen this muscle, do it right!  Every single day, we see physical therapists, athletic trainers and personal trainers who do these exercises wrong and just strengthen bad or compensatory movement patterns.  In these cases, it is better to not do it than to do it.  Because strengthening bad movement patterns sets them up for greater risk.  To increase recruitment or maximal volitional contraction (MVC) of the gluteus medius, we need to think of it not just as strengthening the muscle.  You have to change recruitment patterns and sequence of firing.  Yes strength is a part of that but only a part.  To change MVC during functional movement you must change motor plans in the primary motor cortex. 

In 1998, Karni et al showed that in order to change a motor plan in the primary motor cortex (PMC), it required 3,000 to 30,000 repetitions.  The authors also showed that you can employ techniques which result in quicker change and that there are also things that we do that will result in slower changes.  From this, we have developed a saying.

Poor Technique = Poor Motor Learning = Poor Performance

Learn it, live it and teach it.  Change in the PMC is critical to change how the muscle fires during movement.  Based on the science, we know for every repetition that you do incorrectly, you then must do three reps to have a positive change on the PMC.  Considering this then, you must do one rep to offset the bad movement, one rep to offset the previous bad rep and one rep to drive a positive change in the PMC.  Sounds simple enough right?  Sadly, even with highly educated individuals, we typically see athletes doing the exercise incorrectly under direct supervision.  We then wonder why their movement has not improved that even when we are focusing on the right area and muscles.  Identifying the previously mentioned movements is hard enough when doing it in an assessment let alone when we are doing exercises.   There are numerous exercises to strengthen the gluteus medius in both an open kinetic chain and closed kinetic chain.  Therefore, we will only cover two exercises in depth which work on the gluteus medius in a closed kinetic chain. 

One such exercise, we call the lumbopelvic disassociation (LPD).  You can view a video of this on our YouTube channel, by clicking here.  This exercise is intended to do several things:

·        Assist athletes in discerning lumbar motion from hip motion by improving proprioception through the hip
·        Provide a closed kinetic chain exercise to start strengthening the gluteus medius

The video is intended to give viewers some pointers.  Although the athlete may do it incorrectly, this video’s intent is to not only show the exercise but to show where people go wrong.  This said, there are some common mistakes that people make in performing this exercise and which we can look for during performance of.  Once you have viewed the video, take a look at the athlete in this photo performing the exercise, you see several key factors. 

·        Stance knee is slightly flexed – most want to hyperextend to create stability
·        Knee/ankle/foot are stable
·        Non-stance leg is extended – this places the lumbar spine in extension and aids athlete in keeping neutral spine and not going into lumbar flexion during. 
·        Chest is up – promotes thoracic extension which also promoted lumber extension
·        Hips are level

If you compare the above athlete to the athlete pictured in the next photo, you can see some slight variations that also lead to strengthening compensatory strategies.  Keep in mind, this athlete is demonstrating minor deviations and is not even close to the magnitude of deviations that you would typically see when someone does this incorrectly.  We use this example because it is even these slight changes that result in significant impacts to the MVC of the gluteus medius.  In this case what we see is:

·        Non-stance leg in extension and chest up – good
·        Neutral spine position – good
·        Retrotrendelenburg position of the right hip – indicated with the yellow circle and seen with the hips not being level and the left hip coming up (placing the right hip in a retrotrendelenburg position)
·        Externally rotated position of the right foot – indicated with the red circle

The combination of the raising of the left hip and the external rotation at the right foot makes the retrotrendelenburg much greater at the right hip.  If we allowed him to continue this with all of his training, we can anticipate that when he performs in single leg stance or single limb tests, that his natural tendency is going to go into a retrotrendelenburg on the right when performing single limb tests on the right.  The simple correction is having him bring his right foot in slightly and drop his left hip down slightly. 

What is pictured above is a retrotrendelenburg but keep in mind that this can also present itself as a trendelenburg.  Easiest way to see both of these is to simply look at the hip position.  Are the hips level during the course of this exercise?  You have to watch closely during the beginning phases of this exercise as it may present itself here as the athlete rotating their hips out.  If they do and we allow them to continue that, then we are again just reinforcing the bad movement patterns and strengthening their compensatory strategies. 

Another common exercise used to strengthen the gluteus medius in a closed kinetic chain is side-stepping with a theraband.  In this video, we again go through some specific pointers related to the technique and compensations.  Even though this is one of the most widely used exercises for gluteus medius weakness, it is also one that is often performed incorrectly a majority of time. 

Some of the most common mistakes seen during this exercise are pictured here:
·        Having the band to high – higher the band is, the easier the exercise is.  Placing the band at the ankles not only makes the exercise more difficult but also brings in higher recruitment along the lower kinetic chain.
·        Band too loose – if the band is not tight at the starting position, it will be too easy throughout the motion and only stress the muscle at its weakest point in the length tension curve.
·        Lack of core activation – keeping in mind the concept of specificity, if we train with increase in lumbar lordosis (lack core activation) throughout this exercise then this promotes lack of core activation when it matters the most.
·        Allowing compensation during performance of the exercise.  Common compensations are:
o   Externally rotating with stepping out – this allows increased recruitment of the hip flexors and reduces MVC of the gluteus medius
o   Standing when bringing feet together – this is a much easier position for the movement and maintaining this position throughout will aid in increased MVC.  

Taking these few pointers and applying to your gluteus medius strengthening will not only make a huge difference in what the athlete feels but also aid in improving their mechanics with CKC movement.  We hope that you found this blog insightful and useful.  As we stated previously, stay tuned and if you like what you see, SHARE THE PASSION!  It is the biggest compliment you can give.  Follow us on Twitter @ACL_prevention and tweet about it.  #ACLPlayItSafe and help us spread the passion.

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. 



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