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Transcript of Is the Squat a Good Exercise? › wp-content › uploads › 2013 › 04 › Functiona… · Is the...
5/29/2019
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FUNCTIONAL KNEE REHABILITATION
CONSIDERATIONS FOR RETURN TO SPORT
Steve Kennelly, M.Ed., ATC, CSCS
Assistant Head Athletic Trainer
New York Football Giants
DISCLOSURE – STEVE KENNELLY
Relevant Financial Disclosures
Co‐Author of Plyometric Anatomy book for which I receive publisher royalties from Human Kinetics
LETS TALK ABOUT FUNCTION
Is the Squat a Good Exercise?
Is it Functional?
How About the Deadlift?
You get the idea here!
What About These Exercises?
Hold that thought for a moment
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What is Functional Training/Rehabilitation?
Good Question!
Many Opinions
After 30+ years, I haven’t quite figured this one out yet. But for me . . .
IT’S ALL FUNCTIONAL!!
Everything I do with an athlete, or have an athlete perform, is relevant to how well they FUNCTION on the field
Let’s Get Back To This
FUNCTIONAL? FUNCTIONAL?
ACL REHABILITATION REMAINS A CHALLENGE IN TERMS OF RE‐INJURY AND RETURN TO SPORT
When Are Athletes ‘Ready to Return?’
Back to Normal Symmetry? Biomechanical Variables Remain More Asymmetrical Than Normal During Jump and Change‐of‐Direction Testing 9 Months After Anterior Cruciate Ligament Reconstruction. King E, et al. Am J Sports
Med. 2019
Low rates of patients meeting return to sport criteria 9 months after ACL reconstruction. Welling et. al., Knee Surg Sports Traum, Arthoscopy 2018.
Are Young Athletes At Risk?
Young athletes after ACL reconstruction with quadriceps strength asymmetry at the time of return‐to‐sport demonstrate decreased knee function 1 year later., Ithurburn, Knee Surg Sports Traumatol Arthrosc. 2018
Young athletes after ACL reconstruction with single‐leg landing asymmetries at the time of return to sport demonstrate decreased knee function 2 years later., Ithurburn 2017. Am J Sports Med
Young Athletes With Quadriceps Femoris Strength Asymmetry at Return to Sport After ACL Reconstruction Demonstrate Asymmetric Single‐Leg Drop‐Landing Mechanics., Ithurburn MP, et al. Am J Sports Med. 2015
Young Athletes Cleared for Sports Participation After Anterior Cruciate Ligament Reconstruction: How Many Actually Meet Recommended Return‐to‐Sport Criterion Cutoffs?, Toole AR et. al., J Orthop Sports Phys Ther. 2017
Re‐Injury Risks Are Very Real
ACLR in athletes: function, return to sport rates, and re‐injury rates. Failla M, et. al., Delaware‐Oslo ACL cohort study.
Orthop J Sports Med. 2015
Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: a systematic review and metaanalysis. Wiggins AJ, et. al. Am J
Sports Med., 2016
Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. Paterno MV, et. al. Am J Sports Med. 2014
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How Many Actually Return?
Fifty‐five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and metaanalysis including aspects of physical functioning
and contextual factors. Ardern CL et al., Br J Sports Med. 2014
Return to high school‐ and college‐level football after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic
Outcomes Network (MOON) cohort study. McCullough KA, et. al., Am J
Sports Med, 2012
Return to play and future ACL injury risk after ACL reconstruction in soccer athletes from the Multicenter Orthopaedic Outcomes
Network (MOON) group. Brophy RH, et al. Am J Sports Med. 2012
Return to Play After Anterior Cruciate Ligament Reconstruction in National Football League Athletes, Shah VM, et. al. Am J Sports Med 2010
Psychological Readiness
Psychological Readiness to Return to Sport Is Associated With Second Anterior Cruciate Ligament Injuries. McPherson AL, et al. Am J Sports Med. 2019
How Is Psychological Outcome Related to Knee Function and Return to Sport Among Adolescent Athletes After Anterior Cruciate Ligament Reconstruction? Beischer S, et al. Am J Sports Med. 2019
Progression of the Psychological ACL‐RSI Score and Return to Sport After Anterior Cruciate Ligament Reconstruction: A Prospective 2‐Year Follow‐up Study From the French Prospective Anterior Cruciate Ligament Reconstruction Cohort Study (FAST). Sadeqi M, et al. Orthop J Sports Med. 2018
Self‐Reported Fear Predicts Functional Performance and Second ACL Injury After ACL Reconstruction and Return to Sport: A Pilot Study. Paterno MV, et al. Sports Health. 2018
WHERE TO WE BEGIN?
WITH THE END IN MIND!
Criteria for Return to Sport (RTS)
Battery of tests may provide a more robust assessment of the rehabilitation status than single‐test assessment
Movement Mobility
Hip Flexion, Hip IR, Ankle Dorsiflexion
Strength Isokinetics
Isometrics: Mid‐Thigh Rack Pull
Power: Rate of Force Development Vertical: Force Decks or Counter
Movement Jumps
Horizontal: Single Hop for Distance
Criteria for Return to Sport (RTS)
Biomechanical Analysis
3D Motion: Gold Standard in measuring multi‐joint, multi‐planar, high level movement and forces
2D Motion: limited, cannot measure joint forces
Cutting Kinematics
Decision and Indecision Cuts
Psychological Profile
IKDC Score
ACL‐RSI Scale
What’s Missing?
Sport
Position
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Does Fatigue Play A Role?
Optimising the Late‐Stage Rehabilitation and Return‐to‐Sport Training and Testing Process After ACL Reconstruction. Buckthorpe M. Sports Med. 2019.
Return to play following anterior cruciate ligament reconstruction: incorporating fatigue into a return to play functional battery. Part A: treadmill running. Connell R, et al. BMJ Open Sport Exerc Med. 2019
Could This Be The Key?
Energy Demands
Goal it to return the athlete to his/her sport to SUSTAINthe demands of the sport
Two Critical Factors
The rate of energy production
Power: how fast the athlete can produce energy
The duration of energy production
Endurance: how long the athlete can produce energy
WE MUST TAKE A WHOLISTIC APPROACH
Functional Reconditioning Model
*Adapted from Al Vermeil’s Hierarchy of Athletic Development
FOUNDATIONAL PATTERNS / MOVEMENT SKILL
MetLife Stadium
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MetLife Stadium Construction Foundational Movement Patterns
SQUAT (LOWER BODY PUSH)
PRIMITIVE
HINGE (LOWER BODY PULL)
COREGAIT
UPPER BODY PULL
UPPER BODY PUSH LUNGE (SINGLE LEG)
WHAT IS THE FOUNDATION OF ATHLETIC MOVEMENT?
What Is the Common Theme Here?
How About Now? Universal Athletic Position (UAP)
SQUAT and HINGE Patterns
Work to improve the pattern, then challenge it with volume, intensity, speed, etc.
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WORK CAPACITY / STRENGTH
Work Capacity (STAMINA)
Ability to maintain or increase effort over a long period of time
Stamina = Endurance + Economy Endurance = ability to complete a task over time Economy = ability to make the same task feel easier over time
Build endurance with volume Low aerobic level: 70‐75% MHR or 180‐Age (MaffetoneMethod)
Build economy with intensity Heavy resistance training, sprints, plyometrics, sport‐specific practice
Endurance vs Economy
Stephen Seiler ‘Polarized Training’ Model Analyzed the training methods of world class rowers and cross country skiers Quantifying training intensity distribution in elite endurance athletes: is there evidence for an "optimal" distribution? Seiler KS, Scand J Med Sci Sports. 2006
Training methods and intensity distribution of young world‐class rowers. Guellich A, Seiler S, Emrich E. Int J Sports Physiol Perform. 2009
80% of training occurs at low intensity
20% of training occurs at high intensity
Further research found that elite cyclists, swimmers, triathletes and runners trained the same way
‘GO TO’ Work Capacity Exercises
Walking Medicine Ball Throws
Example of Low Intensity Training ‘GO TO’ Work Capacity Exercises
High Intensity Continuous Bike
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‘GO TO’ Work Capacity Exercises
Aerobic Strength
‘GO TO’ Work Capacity Exercises
Escalated Density Training
‘GO TO’ Strength Exercises
Squat
‘GO TO’ Strength Exercises
Deadlift
‘GO TO’ Strength Exercises
Reverse Lunge
‘GO TO’ Strength Exercises
Add Tippy Twist
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EXPLOSIVE‐ELASTIC
‘GO TO’ Explosive‐Rate of Force Development Exercises
Hang Power Clean
‘GO TO’ Explosive‐Rate of Force Development Exercises
Explosive Medicine Ball Throws
‘GO TO’ Elastic‐Plyometric Exercises
Single Leg Hops
‘GO TO’ Elastic‐Plyometric Exercises
Aerobic Plyometrics
‘GO TO’ Explosive‐Elastic‐Plyometric Exercises
Explosive Repeats
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‘GO TO’ Speed Exercises
Tempo Runs
‘GO TO’ Speed Exercises
Acceleration to Lunge Stop
‘GO TO’ Agility‐Quickness Exercises
Shuffle to Cut Stop
‘GO TO’ Agility‐Quickness Exercises
Lateral Bound to Acceleration
‘GO TO’ SARC Drills
Decision or Closed Loop Skills
Athlete chooses when and direction of cut. Predetermined start and finish
Reestablishes proper mechanics
Agility drills, position specific drills
Goal is to “memorize” or “groove” the pattern
Indecision or Open Loop Skills
Time and direction are determined by an external stimulus. Athlete reacts to an external stimulus
Well documented as increased risk for ACL tears
Process the stimulus and produce movement patterns to effectively deal with the stimulus
Mirror drills, O‐Line vs. D‐Line drills, WR vs. CB drills
‘GO TO’ Sport Specific Exercises
Position Specific Drills ‐ Linebacker
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‘GO TO’ Sport Specific Exercises
Position Specific Drills – Linebacker External Stimulus Cleared for play by MD based on return to sport criteria and functional rehabilitation
Participate in Warm‐Up and Individuals portion of practice
Progress to Individuals Plus practice
Progress to Full practice
Monitor number of plays
Monitor GPS workload data
Practice every other day
Practice on consecutive days
Complete full practice for 3+ weeks before return to game
NYG Return to Sport Guidelines
Summary
Functional rehabilitation is any exercise/program that is relevant to how an athlete functions on field
Re‐injury risks are real. Return to Sport based on return criteria and sport specific demands, not time
Rehabilitation follow as pyramid scheme by establishing proper movement skill and work capacity base, and building function through strength, power, elasticity, speed, agility, quickness, reaction, and sport specific skill/stamina
Final return to sport follows a logical and safe progression to minimize risk and re‐injury
THANK‐YOU
Steve Kennelly, M.Ed., ATC, CSCS
New York Football Giants