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Brian Schiff’s Blog

Injury Prevention, Sports Rehab & Performance Training Expert

Tag: knee rehab

All effective prehab and rehab programs for recreational and competitive athletes should include single leg stability exercises.  I like to use sliding exercises as one way to improve neuromuscular control of the core, hip and knee.  Frontal plane collapse is a common issue with respect to knee dysfunction.  Using sliders/gliding discs as well as theraband is an excellent way to improve strength and kinetic chain control.  Below is an exercise i recently featured for Personal Fitness Professional:

This exercise is effective in injury prevention and rehab programs for those with ankle instability, anterior knee pain, hip weakness, poor landing mechanics and higher ACL risk if playing pivoting and cutting sports.  It will improve core stability, hip and knee strength/stability, dynamic balance, groin flexibility and trunk control.

The band serves to enhance activation of the hip external rotators and further challenge stability of the hip and knee.  The band should not pull too forcefully, but just enough to cue the desired muscle activation pattern.  A slower cadence on the eccentric portion of the exercise is preferable to maximize stability and strength gains.  Do not force through any painful ranges of motion, and remember that form and alignment are paramount so limit the reaching based on the client’s ability to maintain adequate control.

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…

Weakness in the gluteus maximus and gluteus medius is often cited in contributing to patellofemoral pain, IT band problems, hip pathology and even back pain.  Furthermore, activating the glutes and minimizing tensor fascia lata (TFL) activation is preferential to avoid synergistic dominance with abduction exercises.  This is a common finding on my clinical exams.

myers-it-band-proximal

Photo from Myers

In the February 2013 issue of the Journal of Orthopaedic and Sports Physical Therapy (JOSPT), Selkowitz et al. examined several exercises to determine which ones had the highest gluteal-to-TFL muscle activation (GTA) index. The clam exercise proved to be the best with an index value of 115.  The second highest exercise was a sidestep with elastic resistance with a value of 64.

The other three exercises to score a GTA index of 50 or higher were: Unilateral bridge (59), quadruped hip extension w/knee extended (50) and quadruped hip extension with knee flexed (50).  Below is the clam executed against a wall as described in the study referenced.

clam

Clam with resistance

Additional research done by Wilcox and Burden (published in the May issue of JOSPT) suggests that a neutral spine alignment and 60 degrees of hip flexion is the best position for gluteal activation during the clam.  This study was done without resistance but offers additional insight to positioning.  I try to mimic this hip flexion angle in the standing single and double leg versions I employ with mini-bands as part of my gluteal activation series in the clinic as well.

mini-band-er

Single Leg ER (left)

In the Selkowitz study, participants performing the sidestep were instructed to step to the left replacing 50% of the distance between the feet in the start position and follow with the right leg also stepping at this 50% increment.  This was then repeated to the right to return to the starting position for a total of 3 cycles.

This exercise has one of the lowest TFL activation and reinforces proper frontal plane mechanics and can be used with clients and athletes to reduce anterior knee pain and injury risk.  To increase resistance and/or difficulty, bands can be moved to the ankles or a band can be applied above the knees and at the ankle.  In my practice, I typically have clients sidestep for 10 yards in one direction (using the 50% rule) and then repeat moving back to the other side for 10 yards.

side-step

Sidestep

Another option is to perform the sidestep exercise with a staggered stance.  For example, lead with the right leg forward moving to the right and vice versa.  Again, small steps replacing 50% of the original stance is best to ensure quality work.

staggered-sidestep

Staggered sidestep

For additional information on execution and application for these exercises, click on the links below for the online columns I wrote for Personal Fitness Professional Magazine:

Resisted side lying clam

Sidestep with elastic resistance


I utilize bridging as an assessment and exercise tool in my training and rehab programs.  Posterior chain/hip stability is poor in many clients.  The ability to maintain a neutral spine, engage the glutes and fight rotation is NOT an easy task by any means. So, coaching and cueing proper bridging is a great way to enhance pillar strength and reduce injury risk, while facilitating better movement patterns in sport.

I wrote a recent column for PFP magazine entitled iso bridge with alternate knee extension.  Click here to read the column and the application, regression and progression of the exercise.  In addition, I have included a short video below showing double leg and single leg bridge exercises that can be used to work on the hips and core.  The second exercise is the dynamic version of the iso alternate knee extension bridge I write about. I show you some of the single leg progressions that come after mastering the iso bridge as well.

I hope this video and article is useful to you.  I also want to take this opportunity to thank you for reading my blog and wish you a very Happy New Year!

I have been attending the 26th Annual Cincinnati Sports Medicine Advances on the Shoulder and Knee conference in Hilton Head, SC.  This is my first time here and the course has not disappointed.  I have always known that Dr. Frank Noyes is a very skilled surgeon and has a great group in Cincinnati as I am originally an Ohio guy too.

So, I thought I would just share a few little nuggets that I have taken away from the first three days of the course so far.  I am not going into great depth, but suffice it to say these pearls shed some light on some controversial and difficult problems we see in sports medicine.

Shoulder Tidbits

  1. Fixing SLAP tears may not always fix shoulder pain as in many cases it may be in part due to posterior capsule tightness and anterior instability leading to internal impingement.  Additionally, many of the docs here choose not to repair type 2 tears in those over 40 tears and provide a biceps tenotomy or tenodesis to instead to deliver more predictable pain relief as opposed to a labral repair.
  2. Intraoperative pain pumps in the shoulder are causing glenohumeral joint chondrolysis in the shoulder in many cases. According to the panel of docs, this has been seen in teenagers and patients in their twenties as well.  They have often undergone other procedures from outside docs and then developed increasing pain afterward.  Many have had to even undergo a total shoulder replacement after a few years post-op.  The MDs here have suggested even post-operative Marcaine injections for pain relief in the shoulder should probably not be used.  It was very sad to see an 18 y/o shoulder x-ray they put up that looked as if the patient was 80 years old.
  3. Double row rotator cuff tendon repairs seem to outperform single row repairs with respect to tendon healing (90% for DR and 76% for SR techniques in a comprehensive review of the literature)
  4. Stretching cross body horizontal adduction may be more important for throwers and overhead athletes than the sleeper stretch - best to have a therapist stabilize the scapula and then move the shoulder across the body keeping the shoulder in neutral rotation (it will tend to externally rotate)
  5. Arthroscopic stabilization is better than open surgery for posterior shoulder instability as the posterior cuff and deltoid are not violated, ROM recovery is more predictable, patient satisfaction is higher and there is a more predictable return to sport

Knee Tidbits

  1. Increased femoral anteversion and torsion is a developmental factor that does in fact control the knee to a great extent. The tibial tubercle-sulcus angle, thigh-foot angle and foot alignment is also key according to Dr. Lonnie Paulos.  In cases of miserable patella mal-alignment, many will need de-rotation and re-alignment procedures to improve their symptoms.
  2. The consensus among the orthopods here was that using a bone-tendon-bone patella tendon autograft to reconstruct torn ACLs in the younger more active athletes (soccer players and football players) is preferable to a hamstring graft or allograft.  Allografts did not seem to be the graft of choice by any of the docs for the younger patients.  Some would use a hamstring autograft provided there was no MCL pathology.  The PTG autograft was the gold standard for years (always my favorite graft choice for high level/demand athletes) so I was pleased to see the trend for this population moving away from the ST/gracilis HS grafts.
  3. Kevin Wilk, DPT (primary PT for Dr. James Andrews), was advocating restoring full and symmetrical ROM after ACL surgery.  I tend to agree with this principle myself.  However, Dr. Noyes was not in agreement and rather cautiously noted he would be okay with about 3 degrees of hyperextension on the repaired side no matter how much hyperextension was available on the other side.  Kevin also noted that restoring full flexion was paramount to restoring running mechanics and speed in higher level athletes.
  4. The golden time to repair a MCL tear is in the first 7-10 days.  Dr. Paulos also suggested it is absolutely necessary to fix the deep layer as well as the superficial layer.  His talk emphasized how big of a mistake it is to not repair the deep layer.  He also warns that the strength of the repair is less important than restoring proper length, tension and collagen.
  5. For PCL augmented repairs, a 2 bundle repair is repaired.  Most of the docs like to use a quad tendon autograft from the contralateral thigh, but will take it from the same leg if patients insist.  The consensus seemed to be that a repair should be done if there is 10 millimeters or more of drop off.

These are just some of the highlights I wanted to pass along.  There was lots of other good stuff (much of it a nice review of anatomy, biomechanics and protocol guidelines for rehab) but I wanted to pass along some of these key items while they were fresh in my head.  I will likely be sharing more in the future, particularly with respect to patello-femoral pain and SLAP tears as these are just so controversial in terms of surgical and rehab management.