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Felix Golden
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1 The Time Constrained Athlete: Developing a 15 Minute Rehabilitation Program Josh Stone, MA, ATC, NASM-CPT, CES, PES Sports Medicine Program Manager National Academy of Sports Medicine

2 Agenda 1. Introduction to the problem 2. Introduction to the human movement system 3. Human movement dysfunction 4. Introduction to NASM Corrective Exercise Continuum 5. Corrective Exercise application for time constrained athletes minute rehabilitation case studies 7. Open discussion

3 The Problem Athlete Schedule Academic Athletics Life Time Crunch Suboptimal care Athlete Mentality Desire Compliance Priorities Practitioner Availability Flexibility Creativity

4 Best Utilization of Time? Prioritization What is the single best tool for the injury Modalities Manual Therapy Prophylaxis Rehabilitation Injury dependent

5 The Keys to Optimal Care Understanding the Athletes needs Application of knowledge pertaining to human movement system Flexibility in program design Creativity in modality use

6 The Human Movement System Human Movement System Human Movement System is a very complex, well-orchestrated system of interrelated and interdependent myofascial, neuromuscular, and articular components Human Movement System Muscular System Skeletal System Nervous System Sensorimotor Integration Neuromuscular Control

7 Human Movement Impairments Human Movement Impairments Static malalignments Dynamic malalignments Foot/Ankle Knee Hip/Low Back Shoulder Altered muscle activation patterns Synergistic dominance Altered Reciprocal inhibition Relative strength and relative flexibility

8 Human Movement Dysfunction Dysfunction Altered Length-Tension Relationships (muscle tightness) Altered Force-Couple Relationships (muscle weakness) Altered Arthrokinematics Altered Sensorimotor Integration Altered Neuromuscular Efficiency Tissue Fatigue Tissue Breakdown

9 Rationale for Corrective Exercise Ankle sprains reported as most common sportsrelated injury Low back pain affects nearly 80% of all adults Seventy to 75% of ACL injuries are non-contact Most prevalent shoulder injury diagnosed is impingement syndrome.

is compromised because the components are out of alignment If

segments have to compensate in attempts to balance the weight

10 What is Poor Movement? Movement Impairment Syndromes Structural integrity of the HMS is compromised because the components are out of alignment If one segment in the HMS is out of alignment, other movement segments have to compensate in attempts to balance the weight distribution of the dysfunctional segment. arching the low back elevating the shoulders knee valgus

Altered Muscle Activation Patterns Altered Reciprocal

muscle decreasing neural drive of its functional antagonist

function for a weak or inhibited prime mover Psoas Gluteus

11 Altered Muscle Activation Patterns Altered Reciprocal Inhibition muscle inhibition caused by a tight /overactive muscle decreasing neural drive of its functional antagonist Synergistic Dominance Occurs when synergists take over function for a weak or inhibited prime mover Psoas Gluteus Maximus Hamstrings This altered muscle recruitment pattern further alters static alignment

myofascial adhesions Poor static posture Joint hypomobility is one of the most common causes

12 Static Malalignments Static malalignments may alter normal length-tension relationships. Common static malalignments include joint hypomobility (decreased range of motion) myofascial adhesions Poor static posture Joint hypomobility is one of the most common causes of pain Certain muscles become tight or hypertonic (tense) to prevent movement and prevent further injury.

13 Dynamic Malalignments Dynamic malalignment (movement impairment syndromes) static malalignments altered muscle recruitment patterns multi-segmental human movement system impairment Common movement impairment syndromes lower extremity movement impairment syndrome upper extremity movement impairment syndrome

Lower Extremity Movement Impairment Syndrome Lower Extremity Movement Impairment Syndrome Foot pronation (flat feet) Knee valgus (Knock Kneed) Increased

14 Lower Extremity Movement Impairment Syndrome Lower Extremity Movement Impairment Syndrome Foot pronation (flat feet) Knee valgus (Knock Kneed) Increased movement at the LPHC (extension and/or flexion) Typical Injury plantar fasciitis posterior tibialis tendinitis (shin splints) anterior knee pain low back pain

Upper Extremity Movement Impairment Syndrome Upper extremity movement impairment syndrome rounded shoulders forward head posture improper scapulothoracic and/or glenohumeral kinematics Common in

15 Upper Extremity Movement Impairment Syndrome Upper extremity movement impairment syndrome rounded shoulders forward head posture improper scapulothoracic and/or glenohumeral kinematics Common in individuals who: sit for extended periods of time develop pattern overload by performing repetitive motions Typical injury rotator cuff impingement shoulder instability biceps tendinitis thoracic outlet syndrome headaches

16 Kinetic Chain Checkpoints When joint motion deviates from its normal or ideal path, it is considered a compensation Presumes possible human movement system impairments or muscle imbalances.

The Overhead Squat Assessment Assesses the following: Structural alignment Dynamic flexibility Neuromuscular control ANTERIOR Position Feet

17 The Overhead Squat Assessment Assesses the following: Structural alignment Dynamic flexibility Neuromuscular control ANTERIOR Position Feet shoulder-width apart and pointed straight ahead. Arms overhead, with elbows fully extended. The upper arms should bisect the ears. LATERAL POSTERIOR

18 A Few Common Compensations Seen Overhead Squat Assessment Feet Flatten Knees Back Move Inward Excessive forward lean Feet Flatten Knees move inward Excessive Forward Lean

19 Assessment Modification Modifications to Overhead Squat: Elevating the heels Hands on the hips

The Single-leg Squat Assessment Single-leg Squat Assessment Designed to assess dynamic flexibility, core strength, balance and neuromuscular control.

20 The Single-leg Squat Assessment Single-leg Squat Assessment Designed to assess dynamic flexibility, core strength, balance and neuromuscular control. Position Place hands on the waist The feet should be pointing straight ahead The ankle, knee and the lumbo-pelvic-hip complex should be in a neutral position.

21 A Few Common Compensations Seen Single Leg Squat Assessment Knees Hips Inward movement Inward/Outward Trunk Rotation Inward Trunk Rotation Outward Trunk Rotation Knee moves inward

22 Pushing and Pulling Assessments Push-ups Assessment Standing Row Assessment

The Corrective Exercise Continuum Inhibit Lengthen Activate Integrate Inhibitory Techniques Lengthening Techniques Activation Techniques Integration Techniques

23 The Corrective Exercise Continuum Inhibit Lengthen Activate Integrate Inhibitory Techniques Lengthening Techniques Activation Techniques Integration Techniques Self-Myofascial Release Manual Therapy Static Stretching Neuromuscular Stretching Manual Therapy Isolated Strengthening Positional Isometrics Integrated Dynamic Movement

24 Case Studies Two Case Studies Tasks Background Information Goals Lifestyle Medical history Step 1. View movement assessments Step 2. Design CEx program Video footage Movement Assessments

25 Case Study 1: Rachel s Bio Bio: Age: Sophomore Sport: Cheerleader Recreation/Hobbies: Running, dancing, movies Goal: Run a marathon, improve foot/shin/knee pain Occupation: Student Athlete Medical History: Good health, no surgeries or medication

26 Case Study 1: Rachel s Overhead Squat Assessment Overhead Squat Assessment View Checkpoints Movement Observation Anterior Feet Turns out Knees Moves inward Moves outward Lateral LPHC Excessive forward lean Low back arches Low back rounds Shoulder Complex Arms fall forward Posterior Feet Flatten LPHC Asymmetrical weight shift Right -Yes Left - Yes

27 Rachel s Overhead Squat

28 Rachel s Modified Overhead Squat Assessment Modified Overhead Squat: Heels Elevated YES No Squat Improved:

29 Case Study 1: Rachel s Single-leg Squat Assessment Single-leg Squat Assessment View Checkpoints Movement Observation Right -Yes Left - Yes Anterior Knees LPHC Moves inward Hip hike Hip drop Inward rotation Outward rotation

30 Rachel s Single Leg Squat

31 Analysis of Rachel s Movement Overhead Squat Assessment Checkpoints Movement Observation Left -Yes Right - Yes Feet Turns out Knees Moves inward LPHC Low back arches Feet Flatten Notes: Her left foot flattens and turns out more than the right foot from the posterior view. She has a slight excessive forward lean and arms fall forward, however, the primary dysfunctions appear to be in the lower extremities (feet turn out/flatten, knees cave-inward, and low back arches). Modified Overhead Squat Heels Elevated Notes: Squat improved dramatically with feet and knees remaining in optimal alignment. Single-leg Squat Assessment Checkpoints Movement Observation Left -Yes Right - Yes Knees Moves inward Notes: She compensates for a lack of balance and femoral control with slight tilting of the pelvis, however, her primary compensations include her knee caving inward and feet flattening.

32 Analysis of Rachel: Program Design Overactive/Tight Lateral gastrocnemius / soleus Peroneals Biceps femoris (short head) TFL Adductor complex Vastus lateralis Hip flexors (rectus femoris, psoas) CEx Goal: Regain muscle balance of the lower extremities Reposition the shoulders back into a neutral position Relieve lower extremity pain Underactive/Weak Medial gastrocnemius Anterior & posterior tibilalis Medial hamstrings Vastus medialis oblique Gluteus medius/maximus

33 15 Minute Corrective Exercise Program Integrate Inhibit: Gastrocnemius/Soleus, Biceps Femoris (short head), TFL/IT- Band Lengthen: Time Needed Activate: Integrate: 1-2 sets reps 4/2/2 tempo 6 min 1-2 sets reps slow tempo

34 15 Minute Corrective Exercise Program Integrate Inhibit: Gastrocnemius/Soleus, Biceps Femoris (short head), TFL/IT- Band Lengthen: Gastrocnemius/Soleus, Biceps Femoris (short head), TFL/IT- Band Time Needed Activate Integrate: 1-2 sets reps 4/2/2 tempo 6 min 1-2 sets reps slow tempo

35 15 Minute Corrective Exercise Program Integrate Inhibit: Gastrocnemius/Soleus, Biceps Femoris (short head), TFL/IT- Band Lengthen: Gastrocnemius/Soleus, Biceps Femoris (short head), TFL/IT- Band Time Needed Activate: Ball Crunch (Core Stabilizers), Medial Gastrocnemius, Medial Hamstrings, Ball Bridge (gluteus maximus) Integrate: 1-2 sets reps 4/2/2 tempo 6 min 1-2 sets reps slow tempo

36 15 Minute Corrective Exercise Program Integrate Inhibit: Gastrocnemius/Soleus, Biceps Femoris (short head), TFL/IT- Band Lengthen: Gastrocnemius/Soleus, Biceps Femoris (short head), TFL/IT- Band Time Needed Activate: Ball Crunch (Core Stabilizers), Medial Gastrocnemius, Medial Hamstrings, Ball Bridge (gluteus maximus) Integrate: Ball Squat with Overhead Press 1-2 sets reps 4/2/2 tempo 6 min 1-2 sets reps slow tempo

37 Case Study 2: Jeff s Bio Bio: Age: Senior Sport: Baseball Recreation/Hobbies: Hiking, working out, fishing Goal: Improve shoulder pain Occupation: Student Athlete Medical History: Good health, no surgeries or medication

38 Case Study 2: Jeff s Overhead Squat Assessment Overhead Squat Assessment View Checkpoints Movement Observation Anterior Feet Turns out Right -Yes Left - Yes Knees Moves inward Moves outward Lateral LPHC Excessive forward lean Low back arches Low back rounds Shoulder Complex Arms fall forward Posterior Feet Flatten LPHC Asymmetrical weight shift

39 Jeff s Overhead Squat

40 Analysis of Jeff s Movement Overhead Squat Assessment Checkpoints Movement Observation Left-Yes Right Yes Shoulder Arms Fall LPHC Excessive forward lean Knee Move inward Feet Turns out Feet Flatten Notes: Primary dysfunctions appear to present themselves at each Kinetic Chain Checkpoint. A slight asymmetrical weight shift to right may be caused by additional tightness of the left calf musculature and/or right side adductors and TFL.

41 Analysis of Jeff: Program Design Overactive/Tight Latissimus Dorsi Pectoralis Major Lateral gastrocnemius / soleus Peroneals Biceps femoris (short head) Hip flexors (TFL, rectus femoris, psoas) CEx Goal: Alleviate shoulder pain Regain muscle balance in the upper and lower extremities and LPHC Improve core stabilization Prioritize issues Underactive/Weak Scapular Stabilizers Anterior/Posterior tibialis Medial gastrocnemius Medial hamstrings Gluteus medius/maximus Intrinsic core stabilizers

42 15 minute Corrective Exercise Program Integrate Inhibit: Latissimus Dorsi, Thoracic Spine, Pectoralis Major Lengthen: Time Needed Activate: Integrate: 1-2 sets reps 4/2/2 tempo 6 min 1-2 sets reps slow tempo

43 15 minute Corrective Exercise Program Integrate Inhibit: Latissimus Dorsi, Thoracic Spine, Pectoralis Major Lengthen: Latissimus Dorsi, Thoracic Spine, Pectoralis Major Time Needed Activate: Integrate: 1-2 sets reps 4/2/2 tempo 6 min 1-2 sets reps slow tempo

44 15 minute Corrective Exercise Program Integrate Inhibit: Latissimus Dorsi, Thoracic Spine, Pectoralis Major Lengthen: Latissimus Dorsi, Thoracic Spine, Pectoralis Major Time Needed Activate: Ball YTA or Positional Isometrics to Scapular Stabilizers Integrate: 1-2 sets reps 4/2/2 tempo 6 min 1-2 sets reps slow tempo

45 15 minute Corrective Exercise Program Integrate Inhibit: Latissimus Dorsi, Thoracic Spine, Pectoralis Major Lengthen: Latissimus Dorsi, Thoracic Spine, Pectoralis Major Time Needed Activate: Ball YTA or Positional Isometrics to Scapular Stabilizers Integrate: Squat to Row 1-2 sets reps 4/2/2 tempo 6 min 1-2 sets reps slow tempo

46 15 minute Corrective Exercise Program Integrate Inhibit: Latissimus Dorsi, Thoracic Spine, Pectoralis Major Lengthen: Latissimus Dorsi, Thoracic Spine, Pectoralis Major Time Needed Activate: Ball YTA or Positional Isometrics to Scapular Stabilizers Integrate: Squat to Row 1-2 sets reps 4/2/2 tempo 6 min 1-2 sets reps slow tempo

47 Thank You! Questions & Answers

Primary Movements. Which one? Rational - OHS. Assessment. Rational - OHS 1/1/2013. Two Primary Movement Assessment: Dynamic Assessment (other)

Primary Movements. Which one? Rational - OHS. Assessment. Rational - OHS 1/1/2013. Two Primary Movement Assessment: Dynamic Assessment (other) Primary Movements Practical Application for Athletic Trainers Two Primary Movement Assessment: NASM-CES Overhead Squat Single-leg Squat Dynamic Assessment (other) Single-leg Step Off Functional Movement