Brian Schiff’s Blog

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.

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 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.

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.

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

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!

Below are two videos demonstrating some sliding exercises I like to use in training and rehab.  The first video reveals one of my tougher hamstring exercises I prescribe, while the second video displays some shoulder/core stability variations using sliding discs.  I have included links to the PFP columns that better explain the set-up, execution and application for each exercise.

Click here for the Functionally Fit Column on sliding hamstring curls.

Click here for the Functionally Fit column on sliding shoulder raises.

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.

Knowing just when to put an athlete back on the field after ACL reconstruction is a difficult proposition. Surgeons often look at swelling , graft stability and quad girth. In the past, we have relied on isokinetic testing and hop testing measures in the clinic as guidelines as well.

As a sports performance specialist and clinician, I am keenly interested in not only fully rehabbing this injury, but also preventing it form happening again in the future. Observing quality of movement in cutting, jumping, running and drills offers good insight in this process, but I think we need more.

The FMS and Y-Balance test are things I use in my equation as well. I often see clients ace the YBT, but struggle to obtain a passing score on the FMS based on issues in core stability and the deep squat.  Current literature reports that any score less than a 14 carries a 4-fold increase for non-contact injury risk in female collegiate athletes.  Click here to read that study.

In addition, I look at the following for return to play decision making:

• Single leg squat depth
• Single leg broad jump
• Single leg impact mechanics
• Deceleration and cutting form
• Cross-over hop test
• Single leg triple hop
• 6 M timed hop test

Below is a video of the single leg broad jumps, the triple hop, cross-over hop test and 6 M timed hop test.

What does research have to say?  I think we have a vacuum where athletes get “cleared” or released from PT and they wonder back to sport too soon.  
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