Share   Subscribe to RSS feed

Brian Schiff’s Blog

Injury Prevention, Sports Rehab & Performance Training Expert

Tag: ACL rehab

Whether doing prehab, rehab or training, I believe in using single leg exercises to attack asymmetries, imbalances and motor deficits I uncover in my assessments.  Learning to control one’s body in space with the effect of gravity in a weight bearing position is instrumental for sport and injury prevention.

Furthermore, facilitating ankle mobility and proper knee alignment during a loaded squat pattern is something most athletes and clientele I work with need some help with.  to that end, I utilize several different single leg reaching progressions and exercises.  One of my favorite ‘go to’ exercises is the anterior cone reach.

2-hand-ant-cone-reach

I recently featured this specific exercise in my ‘Functionally Fit’ column for PFP Magazine.  Click here to see the video demonstration.

This is a great exercise with progressions and regressions for clients of all ages and abilities.

Click here to read the entire column.

csm2015marquee_960x222

So, I just returned from the Combined Sections Meeting for the APTA that was held in Indianapolis.  There was lots of great networking and presentations to be sure.   I attended sessions on ACL rehab/prevention, femoroacetabular impingement, elbow injuries in throwers, running gait analysis, and shoulder plyometric training with the legendary George Davies.  I thought I would give you my top 10 list of helpful nuggets I picked up over the weekend in no particular order of importance.

1. Performing upper body plyometrics has no effect on untrained subjects so don’t waste time putting it into the rehab program, where as it does benefit trained overhead athletes.  The one caveat is it also increases passive horizontal external rotation so keep this in mind when working with athletes who have shoulder instability.

2. A new study  coming out in 2015 in AJSM revealed no major differences in throwing kinematics between those following UCL reconstruction (Tommy John) and age-matched controls.  This is good news for those worried about pitching mechanics after the procedure.

3.  According to Dr. Reiman at Duke, the orthopedic hip exam does a better job of telling us they do not have a labral tear than it does telling us they do have an intra-articular problem.  The tests have poor specificity.  In fact, he goes on to say that the “special tests are not that special.”  That brought a chuckle from the crowd including me.  Bottom line – we are not really able to conclusively say “yes you have a labral tear based on my exam today.

4. Reiman also feels we must consider look for mechanical symptoms during the lowering portion of the Thomas test, while considering the fact that fat pad impingement may cause anterior hip pain as opposed to joint pain.  Again, things are not always as they appear in the “FAI” crowd so we need to take a great history, look at the classic tests and also see how squatting and loading affects the hip.

5. More experienced pitchers do not drop the glove side arm, but instead tend to move their body toward the glove to conserve angular momentum and overcome small moments of inertia.  Less experienced pitchers rotate their trunk sooner in pitching cycles whereas pitchers who threw at higher levels rotated later and produced less torque at the shoulder.  Consequently, many players with higher elbow valgus torque and distraction force at the shoulder rotate too early.


Continue reading…

bxp63875-4

Every month there are new papers on ACL surgery and rehab appearing in the literature.  I do my best to stay up on them as this is one area of my practice I am extremely passionate about.  I am driven to understand as much as I can about both prevention and rehab, but find myself increasingly focused on preventing secondary ACL tears in my patients.

I feel poor movement patterns, muscle imbalances and inefficient neuromuscular control are major risk factors for athletes suffering a primary ACL tear.  We also know being female markedly increases injury risk.  Research also tells us that males are more likely to suffer a re-tear of the same side, whereas females are more likely to suffer a contralateral injury.

A study just published in the July issue of the American Journal of Sports Medicine looked at the incidence of second ACL injuries 2 years after a primary ACL reconstruction and return to sport.  In a nutshell, the findings were:

  • 24 months after ACLR and return to sport, patients are at greater risk (6x) to suffer a subsequent ACL tear compared to young athletes w/o a history of ACL injury
  • Female athletes in the ACLR group are 5x more likely to suffer a second injury
  • The contralateral limb of female athletes is at greatest risk

Click here to read the full abstract

This information is not surprising as I have seen it firsthand in 17 years as a physical therapist.  What we do not have much information about is how do the younger patients (e.g 15 and under) really recover from this injury.  When should they be cleared?  I worked with a young female soccer athlete who tore her ACL and medial meniscus at age 13.  She worked diligently with me in rehab 3x/week for about 6 months and then continued training with me at least 2x/week until she was about 1 year out from surgery.


Continue reading…

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).


Continue reading…

I had the pleasure of listening to Darin Padua, PhD, of UNC present some of his latest research on ACL injury prevention last week. He has been doing research for some time. One of his studies (JUMP ACL) in collaboration with the military and several others has looked at prospective data and injury occurrence among college age subjects.

Much of the research to date on injury prevention has been done by Timothy Hewett and his colleagues. It has concluded that drop landing with a valgus collapse (hip abduction/IR with valgus knee moment) is a risk factor for injury. Interstingly enough, despite that knowledge and the proliferation of prevention programs, Darin mentioned that overall these prevention programs have not slowed the rate of ACL tears in the last decade. Why is that?  He also relayed that much of what we know now is based on 15 total cases.

The Jump ACL Study in a nutshell lasted for 5 years at 3 different military academies:

N = 5,700 cadets with no prior ACL surgery

  • Soccer players = 1,690
  • Tested from 2005 to 2008
  • 39% female; 25% NCAA athletes
  • 14,653 person-years of follow-up

N = 113 incident ACL injuries

  • Soccer players = 29
  • Mean time from testing to injury = 3.1 yrs
  • N = 92 one ACL injury; N = 11 two ACL injuries

Some data (will be published) he discussed based on his findings revealed the following about high risk profiles for ACL injury:

  • Hip flexion > 40 degrees at landing = 1.76x increased risk
  • Hip adduction plus knee valgus = 3x increased risk
  • Hip adduction plus knee varus = 27x increased risk

He also mentioned that the high risk profile does not correspond to the ACL injury event profile of:

  • Hip abduction
  • Lateral trunk flexion
  • Knee valgus collapse
  • Small knee flexion
  • Tibial ER/IR

In the end, he suggests we need to better understand who to target (high risk profile clients) and what to modify (injury event profile) so we can better customize injury prevention programs that optimize proper movement and meet the needs of each individual athlete.  He reminded us that using the uninjured side for comparison is insufficient as faulty movement patterns already likely existed contributing to the first ACL injury.

So, assessing movement continuously and striving for excellent movement quality is a MUST if we are going to both prevent initial ACL injuries and reduce the re-tear rates for our athletes we send back to play.  He reports that those at increased risk simply have bad biomechanics.  His message provides more weight to having an advanced algorithm to identify asymmetry, poor motor control and flawed movement patterns in order to effectively prescribe interventions to address these things.

At UNC they use a PRIME assessment.  I am excited to learn more about it and have referred one of my female higher level soccer players to their lab for assessment as I look at this return to play decision with her now that she is just past 7 months post-op.   I think the hip/core obviously play an important role as I see so much deficiency in my female patients recovering from injury.

Clearly his findings with hip adduction and varus as a big risk factor seem to indicate it could be a top down kinetic chain breakdown as well upon impact based on the risk profile.  Pelvic stability or the lack thereof seems to be significant, only NOT in the same manner we thought about it before based on previous research available.  Stay tuned, as we have lots more to learn about ACL injuries and how best to tailor our prevention efforts.