Is the Squat a Good Exercise? LETS TALK ABOUT FUNCTION Is it - - PDF document

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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

• n 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 SUSTAIN the 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) CORE GAIT 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

• f 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 (Maffetone

Method)

 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