Brian Schiff’s Blog
Injury Prevention, Sports Rehab & Performance Training Expert
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I came across some very good reads on Twitter last week week that I wanted to pass along. The first is a blog post by Rich Willy, a PT, professor and researcher who specializes in running and running related injuries. If you or any of your friends have suffered from nagging IT Band pain, this is a must read. In this post, he discusses proper treatment strategies:
The second pearl involves long toss and force on the elbow. Ever wonder how advising a pitcher to reduce his throwing intensity actually impacts velocity and torque on the elbow? It seems that decreasing effort level by 25% and 50% does not equate to the same reduction in actual velocity with a study using the motus sleeve. Read more below:
Baseball Pitchers’ Long Toss Perceived Effort & Actual Velocity
Finally, there has been much discussion about return to sport assessment after ACL reconstruction. Lately, many have begun to question how effective hop testing really is when it cones to determining readiness to return to sport. I use several assessments (one of which is hop testing), but I also feel psychological readiness is crucial.
This article sheds light on the connection between proper single limb landing mechanics and psychological readiness.
Association of Psychological Readiness for RTS after ACLR and Hip and Knee Landing Mechanics
Unfortunately, too many athletes who recover from ACL tears go on to suffer another injury within a short period of time. Click here to read a prior post on secondary injuries. There are differing opinions on when or if there is an exactly “right time” to clear an athlete for return to play.
We already know that athletes have persistent weakness and asymmetry at 1 year post-op and even beyond. I recently had one of my collegiate soccer players re-tear while helping out with a youth soccer camp. She had not yet done hop testing with me or been cleared for full soccer, but as she was 1 year out she did not think it would be an issue playing with 12 year-old girls. It only took 20 minutes before she suffered a non-contact re-injury and lateral meniscus tear.
Consider the following paper that reveals low rates of patients meeting return to sport (RTS) criteria at 9 months post-op:
https://www.ncbi.nlm.nih.gov/pubmed/29574548
Another paper recent published in the Journal of Sports Rehabilitation revealed marked deficits in balance and hop testing at 6 and 9 months post-op:
https://www.ncbi.nlm.nih.gov/pubmed/29466066
A recent paper in the American Journal of Sports Medicine (https://www.ncbi.nlm.nih.gov/pubmed/29659299) lists positive predictors of a return to knee-strenuous sport 1 year after ACL reconstruction were male sex, younger age, a high preinjury level of physical activity, and the absence of concomitant injuries to the medial collateral ligament and meniscus.
In 2016, research in the American Journal of Sports Medicine revealed delaying return to sport at least 9 months markedly reduced re-injury risk in those who passed RTS testing. Click below for more on that study:
https://www.ncbi.nlm.nih.gov/pubmed/27162233
So, where are we now? I employ multiple functional tests including the Y-Balance Test, FMS, single leg squatting, hand held dynamometry, hop testing, qualitative movement assessment and jump landing assessments. But, is that enough?
Poor landing mechanics are often cited as a predictor of ACL injury risk. In my 20 years as a physical therapist, I have rehabbed many athletes with this injury. I believe that injury prevention, whether to prevent a primary or secondary injury, hinges on the ability to train the body to decelerate and land appropriately. Some athletes simply move better than others. Nonetheless, teaching a soft bent knee landing while minimizing dynamic valgus is essential.
The following video from my online PFP column reveals a foundational exercise that can be used in prevention and rehab alike.
Click here if you want to read about another landing exercise that I utilize in my training and rehab programs.
I rehab far too many athletes under the age of 18 with ACL tears. In many cases, I am rehabbing some who have suffered multiple ACL ruptures before they graduate from high school. The burning question is why do so many clients suffer a graft failure or contralateral injury so so often?
Is it related to genetics? Is sports specialization to blame? Perhaps fatigue and limited recovery is a problem. I think the answer is multifactorial, but to be perfectly honest we as a profession have yet to truly arrive at a consensus as to when the “right time” to return to play is. Opinions vary widely based on the athlete, sport, native movement patterns, graft choice, additional injuries (ligament, cartilage or soft tissue) and the provider.
As a clinician dedicated to both prevention and the best rehab, I am always re-evlauating my own algorithm and rehab techniques, while looking for scientific rationale to direct my exercise selection and decision making processes. A recent paper by Webster and Feller in the November 2016 edition of AJSM looked at subsequent ACL injuries in subjects who underwent their primary ACLR under the age of 20 utilizing a hamstring autograft reconstruction procedure.
Perhaps one of the most researched topics is ACL injuries. I have been studying and working for years in my clinical practice to find the best ways to rehab athletes following injury as well as implement the most effective injury prevention strategies. Prior studies indicate prevention programs even when self directed can be successful.
However, on the whole injury rates have not declined over the past decade or so. Much attention has been given to valgus landing mechanics, poor muscle firing, stiff landings, genetic difference between males and females, ligament dominance, quad dominance, and so forth. The predominant thoughts today for prevention center around neuromuscular training and eliminating faulty movement patterns (refer to work being done by Timothy Hewett and Darin Padua).
We also know from a biomechanical standpoint that the hamstrings play an integral role in preventing excess anterior tibial translation, and as such hamstring strengthening needs to be a big part of the rehab and prevention program. I believe in hamstring training that allows for activation in non-weaightbearing and weight bearing positions. Common exercises I will use include:
- HS bridging patterns (double /single leg, marching, knee extension, stability ball)
- Nordic HS curls
- HS curls (stability ball, TRX or machine)
- Sliders – focus on slow eccentric motion moving into knee extension followed by simultaneous curls/bridge
- Single leg RDL (add dumbbells or kettle bells for more load)
Note: click on any of the thumbnail images above for a full view of the exercise. From left to right: Nordic HS curls, sliding hamstring curls and single leg RDL).
A recent blog post entry by the UNC Department of Exercise and Sport Science (@UNCEXSS) has spurred my post today. Click here to read their entry on optimizing injury prevention based on work done by Professor Troy Blackburn regarding the effect of isometric and isotonic training on hamstring stiffness and ACL loading mechanisms. The research that was done holds promise for hamstring training designed to increased musculotendinous stiffness (MTS).
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