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.

Does Concussion Increase Your Risk For ACL Injury - Part I

Back in 2012 and 2013, I was blessed to be a part of a research team that was performing movement assessments on female soccer players.  This study was designed to assess female soccer players for movement patterns which put them at risk for injury and also negatively impacted their athletic performance.  Initially we were performing these assessments on Division I soccer players.  Quickly we realized limiting ourselves to just Division I female athletes would limit the numbers of athletes in our study and limit the power of our data.  As such, we began to expand this study to include athletes from 11 years old to Division I athletes.

All of the athletes involved in this study fell under our IRB (Institutional Review Board) application and were all involved in organized soccer clubs (developmental leagues) and/or school sanctioned soccer.  During this study, we were collecting (in addition to other information) demographic data, orthopedic history and movement information from a standardized movement assessment.  As we started to assess these athletes, we quickly started to see three common trends, especially in our younger athletes.

  1. Younger athletes who had a history of concussion reported an increase number of non-contact lower kinetic chain injuries (ankle sprain/strains, knee injuries, etc.).  
  2. Athletes who had a history of concussion also performed very poorly on their single limb tests.
  3.  Athletes with a history of concussion also had increased number of losses of balance during the course of our assessment.
This made us hypothesize that athletes who have a history of concussion:
  1. Have an increase risk for LKC non-contact injuries.
  2. Have an increase risk for ACL injuries.
  3. Have a decrease in athletic performance.
As an examiner, this was clearly the case and these would be some strong assumptions based on what we are seeing, the science behind the rational and based on what we see clinically.  But as a scientist, sometimes we need a paper to show us that it may hurt when you pound your thumb with a hammer.  In other words, we need several research papers looking specifically at all the possible variables before we can come to this conclusion.  

What do you think?  Does previous concussion have an impact on athletic performance and injury risk.  Over the course of the next couple of weeks, we will start to dissect that question and look at the impact that concussion has on athletic performance. #ResearchThatWorks #ACLPlayItSafe



Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >3000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 


Exercises to Eliminate Pathokinematics - Part XI

To close out this series, we are going to include a final series of exercises we include to push efficiency throughout the system with focus on the lower kinetic chain.

Core - as mentioned throughout the history of this blog, we have provided numerous research articles highlighting the importance of the core for both mitigating risk of injury and improvement of athletic performance.  Included here are two key core exercises we use that we find have the largest impact on lower kinetic chain movement.

Plank Crawl - this video demonstrates the plank crawl which is done with the CLX band and the stability trainer.  This not only brings in a tremendous amount of core but also activates the Gmed in the transition phases of this exercise.


Side Plank with CLX Gmed Activation - this exercises is extremely difficult and is great at activating the core as well as the GMed.  This is a more advanced exercise and is done with the CLX. 

 

In addition to increasing activation of the core, we also want to increase activation of the Gmed.  The following exercises are a progression series that can be done to increase activation of the Gmed with the use of the CLX.

Gmed Series Level III

GMed Series Level IV



Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 


Exercises to Eliminate Pathokinematics: Part X

Last week, we continued our discussion on the single limb training.  Although there are a plethora of exercises that could be used, we are just outlining a couple that we find beneficial.  This series, when emphasized during the eccentric phases of the exercise not only aid in improving single limb performance but also aid in building eccentric strength of the hamstrings which is critical to reduce part to reducing hamstring strains/sprains.

Modified Single Leg Dead Lift:

Level I:  Standing on the right foot, with a slight bend in the right knee, flex at the hips while reaching towards the arch of the right foot with your left hand and the outside of the right foot with your right hand.  Once you have obtained the end of your available range, without flexing in the lumbar spine or increasing the flexion in the knee, return to the starting position.  Perform 3 sets of 10-20 reps focusing on 3-4 seconds to lower to the end range and 1-2 seconds for returning to the upright starting position.  Repeat on the left.



Level II:  While holding a dumbbell in each hand and standing on the right foot, with a slight bend in the right knee, flex at the hips while reaching towards the ball of the foot.  Once you have obtained the end of your available range return to the starting position.  Perform 3 sets of 10-20 reps focusing on 3-4 seconds to lower to the end range and 1-2 seconds for returning to the upright starting position .  Repeat on the left.


NOTES:Start with a weight which you can perform this exercise without loss of balance, “cork screwing” at the hip or loss of neutral pelvic positioning.  Once you are able to perform with #25 dumbbells, for 20 reps, progress to Level III.

Level III:  While holding a #45 weight bar in your hands and standing on the right foot, with a slight bend in the right knee, flex at the hips reaching toward the ground in front of your supporting leg.  Once you have obtained the end of your available range, return to the starting position.  Perform 3 sets of 10-20 reps focusing on 3-4 seconds to lower to the end range and 1-2 seconds for returning to the upright starting position.  Repeat on the left.  Progress in weight.





 Level IV:  While standing on the right foot on a foam pad, hold a straight bar in your hands.  With a slight bend in the right knee, flex at the hips while reaching towards the ground in front of the right foot.  Once you have obtained the end of your available range without flexing in the lumbar spine, return to the starting position.  Perform 3 sets of 10-20 reps focusing on 3-4 seconds to lower to the end range and 1-2 seconds for returning to the upright starting position.   Repeat on the left.  Progress in weight



KEYS TO SUCCESS:  Key points with this progression is to keep the non-stance hip in a neutral position (no hip extension or flexion) and the lumbar spine in a neutral position (maintain throughout without allowing spinal flexion or extension).  It is important to maintain “proper positioning” of the hip and knee as well (no adduction at the hip or internal rotation).  Preventing these will strengthen good movement patterns and prevent reinforcement of bad habits.  Only reach as far as you can while maintaining proper positioning at the hip and spine in the neutral position.   In addition, focusing on the eccentric phases allows you to push eccentric strength of the hamstrings.

Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 





Exercises to Eliminate Pathokinematics: Part IX

Last week we discussed some specific techniques that can be used to drive single limb performance.  As reported in the literature, we know that single limb performance or stability in single limb is the best indicator of both injury risk and performance.  Knowing this we will continue on with this series looking at some additional single limb exercises we have found effective.

Single Leg with Dynamic Lower Extremity Movement:

 Level I:  Standing on the right leg with knee at ~20 degrees flexion, reach forward with the left leg while maintaining stability of the right knee in the flexed position.  Return to the starting position and immediately reach in the posterior direction.  With all directions only reach as far as you are able to while maintaining stability of the knee.  Perform 3 sets of 10-15 reps in each direction without touching the left foot down.  Repeat on the left.  Progress only when there is sustainable stability with both limbs and symmetry in distance reached.


Diagram 1: Indicates the directions reaching when standing on one foot.  The weight bearing foot is placed directly in the middle of the diagram.


Level II:  Standing on the right leg with knee at ~20 degrees flexion, reach forward with the left leg while maintaining stability of the right knee in the flexed position.  Come back to the starting position and immediately reach the left foot out in the lateral direction.  Return to the starting position and immediately reach in the posterior direction.  With all directions only reach as far as you are able to while maintaining stability of the knee and without touching the left foot down.  Perform 3 sets of 8-10 reps in each direction.  Repeat on the left.  Progress only when there is sustainable stability with both limbs and symmetry in distance reached.



Diagram 2: Indicates the directions reaching when standing on the right foot and reaching with the left foot.  The weight-bearing foot is placed directly in the middle of the diagram.

Level III:  Standing on the right leg with knee at ~20 degrees flexion, reach in the lateral direction with the left leg while maintaining stability of the right knee in the flexed position.  Come back to the starting position and immediately reach the left foot out in the posterior lateral direction.  After returning to the starting position, immediately reach the left foot out in the posterior direction.  Return to the starting position and immediately reach in the posterior medial direction.  With all directions only reach as far as you are able to while maintaining stability of the knee and without touch the left foot to the floor.  Perform 3 sets of 8-10 reps in each direction.  Repeat on the left.  Progress only when there is sustainable stability with both limbs and symmetry in distance reached.




Diagram 3:  Indicates the directions for reaching when standing on the right foot.  The weight-bearing foot is placed directly in the middle of the diagram.

Level IV:  During the course of this exercise, you are only going to be moving in the posterior medial direction, however, you will be alternating from right to left.  Standing on the right leg with knee at ~20 degrees flexion, reach in the posterior medial direction.  While returning to the starting position, hop to the left foot while reaching in the posterior medial direction with the right foot.  Alternate back and forth between the right and left while maintaining stability at the hip and knee.  With all the motions only reach as far as you are able to while maintaining stability of the knee.  Perform 3 sets of 8-20 reps in each direction.  Repeat on the left.  Progress only when there is sustainable stability with both limbs and symmetry in distance reached.


Diagram 4: Indicates the direction of reach when standing on the left foot.  The weight-bearing foot is placed directly in the middle of the diagram.

Level V:  During the course of this exercise, you will stand in front of a block wall/plyo wall/ or rebounder while holding a ball in your hands.  You will perform the above exercise again, but when performing the exercise and once you have reached the maximal distance you can reach while maintaining stability of the knee, you will simultaneously throw the ball so that it rebounds back at you. Catch it and immediately hop to the other leg and move into the posterior medial direction with the opposite leg.  With all directions only reach as far as you are able to while maintaining stability of the knee.  Perform 3 sets of 8-20 reps in each direction.  Progress only when there is sustainable stability with both limbs and symmetry in distance reached.



Diagram 5:  Indicates the directions reaching when standing on the right foot.  The weight-bearing foot is placed directly in the middle of the diagram.


Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 
 

Exercises to Eliminate Pathokinematics: Part IIX

Last week we discussed the lumbar hip disassociation exercises that are used as a part of the ACL Play It Safe Program.  These particular exercises are ones we implement with the CLX Spiral Technique.  This technique pushes single limb performance and drives increased EMG activity of the gluteus medius.  This week we are going to discuss additional techniques that can aid in pushing single limb performance in addition to hip strength, endurance and proprioception.

Single Leg Proprioceptive Neuromuscular Facilitation (PNF) with Hip Flexion: 

Level I:  Standing on your right foot, reach across mid-line with the left hand while flexing and slightly rotating at the hips allowing you to reach toward the right knee.  Only reach as far as you are able to maintain stability of the knee.  It is important to make sure you are not rotating in the spine but that the motion is coming from the hip.  Return to the starting position.  Perform 3 sets of 10-20 reps.  Repeat on the left.


Level II:  Standing on your right foot, reach across mid-line with the left hand while flexing and slightly rotating at the hips allowing you to reach for the right little toe.  Only reach as far as you are able to while maintaining stability of the knee and without rotating in the spine.  Raise by extending and rotating at the hips and raising the left hand thumb up over your left shoulder.  Follow the motion of the left hand with your eyes throughout the exercise.  Perform 3 sets of 10-20 reps.  Repeat on the left.

  




Level III:    With a small medicine ball (1-2#) in your left hand and while standing on your right foot, reach across mid-line with the left hand while flexing and rotating at the hips allowing you to reach for the right little toe. Only reach as far as you are able to while maintaining stability of the knee and without rotating in the spine. Raise by extending and rotating at the hips and raising the left hand thumb up over your left shoulder.  Make sure to follow the motion of the ball in your hand with your eyes throughout the exercise.  Perform 3 sets of 10-20 reps.  Repeat on the left.






NOTES:  If unable to perform without maintaining knee position or without rotating in the lumbar spine, then modify the range of motion.  The most difficult portion of the exercise is at the end of the range of motion at the reach and when the hand is moving over the head.  If needed, progress the reach first then add in the hand over head.

KEYS TO SUCCESS:  Only reach as far as you can (both toward the foot and with hand overhead) while maintaining proper positioning.  If having difficulty maintaining proper position at the knee and core, then start with lighter ball or decrease the height of the throw.

The athlete's ability to create stability in single limb performance during dynamic explosive movements is critical to mitigating risk and improving performance.  The two exercises here are meant to aid in developing that stability and should be performed at the beginning of an exercise session.

Single Leg Hop - athlete is asked jump in a maximal vertical fashion.  This can be initiated in front of a mirror to provide visual feedback or another device (Motion Guidance) to provide additional feedback.  The key to this exercise is maintaining frontal plane stability during acceleration (take off) and deacceleration (landing).



Single Leg Hop Toss - this can be done with a toss or kicking a ball.  The key is to maintain frontal plane stability of the lower kinetic chain throughout the exercise.




Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

Exercises To Eliminate Pathokinematics - Part VII

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

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



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

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



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



Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

Exercises To Eliminate Pathokinematics - Part VI

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

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

Lumbar Hip Disassociation Exercise Series: 

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

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

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

v  Prep Exercise: 

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












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











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











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











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


Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

Exercises to Eliminate Pathokinematics - Part V

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

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

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


             





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



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

Controlled Squats with Weight: 

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

 

  




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








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

 







Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

Exercises to Eliminate Pathokinematics - Part IV

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

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

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

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

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

Squat Progression

                                               i.     Squat NMR

                                             ii.     Rapid Squats

                                           iii.     Controlled Squats with Weight 

Lumbar Hip Disassociation Exercise Series

                                               i.     Prep Exercise

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

                                           iii.     Single Leg with Dynamic Lower Extremity Movement

                                            iv.     Modified Dead Lift


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

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


Poor technique = poor motor planning = poor performance


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

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

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

Poor technique = poor motor planning = poor performance

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

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

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

 Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

Exercises to Eliminate Pathokinematics - Part III

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

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

Dynamic Lunge:

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



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

Sumo Squat: 

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


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

High Knee Toe Ups: 

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



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

Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

Exercises to Eliminate Pathokinematics - Part II

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


The following series will provide you with instruction in:

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

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

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

§ Dynamic Lunge

§ Sumo Squat

§ High Knee Toe Up

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

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

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

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

 

Squat Neuromuscular Retraining (SNMR)

Lumbar Hip Disassociation Exercise Series


Digging Deeper—Targeted Isolation Exercises


Gluteus Maximus Progression

                                               i.     Glut Max Press

                                             ii.     Leg Press

                                           iii.     Step Ups

Gluteus Medius Progression

                                               i.     Side Lying Gluteus Medius

                                             ii.     Side Step with Resistance Band

                                           iii.     Retro Monster Walk

                                            iv.     Standing Gluteus Medius

                                             v.     PNF Step Ups

Adductor Group Progression

i.      Standing Hip Adduction

ii.    Supine Adductors from Pike Position

iii.   Side Lying Adductors

Quad Progression

i.      Leg Extension

ii.    Standing Lunge—Alternating

iii.   Standing Lunge--Back

iv.   Walking Lunge

v.     Prone Place Running

Hip Flexor Group Progression

                                               i.     Single Leg Raises

                                             ii.     Head to Knee Pull-Throughs

Hamstrings Progression

                                               i.     Hamstring Pulls

                                             ii.     Modified Dead Lift

                                           iii.     Single Leg Dead Lift

Lower Leg Progression

                                               i.     Standing Calf Raises

                                             ii.     Seated Calf Raises

                                           iii.     Dorsi Flex Toe Ups

                                            iv.     Rebound Hops

Foot/Ankle Progression

                                               i.     Inversion/Eversion

                                             ii.     Standing Medicine Ball

                                           iii.     Bosu Ball Balance

Addressing “The Core” 

Abdominal Progression (Core Series)

                                               i.     Upper Abs on stability ball

                                             ii.     Obliques on stability ball

                                           iii.     Pike Position Lower Abs

                                            iv.     Side Bridge

                                             v.     Prone Bridge on Elbows

Lower Back Progression

                                               i.     6 Pack on stability ball

                                             ii.     Prone stability ball Leg Raises

                                           iii.     Good Mornings

Warm Up

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


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



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


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


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

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

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

Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 


Exercises to Eliminate Pathokinematics - Part I

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

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

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

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

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

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

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

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

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

Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

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

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

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

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

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

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

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

Spiral Technique

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

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

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

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

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

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

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

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


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

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




Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >3000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 




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

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

Product Innovations

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


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



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


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


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


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


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



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



Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >3000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 







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

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

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

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

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

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

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

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

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


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




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


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



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



    Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >3000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 



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