Movement Impairments Related to Overuse Injuries of the Knee

Transcription

1 Movement Impairments Related to Overuse Injuries of the Knee Most common sites of injury in runners (n=1579) Taunton et al., Br. J Sports Med, Knee (42%) 2. Foot/ankle (17%) 3. Lower leg (13%) 4. Hip/pelvis (11%) 5. Achilles/calf (7%) 6. Upper leg (5%) 7. Low back (3%) 8. Other (2%) The Knee: Caught in the Middle! Mobile adaptor between 2 long bones Influenced proximally & distally Half the Knee Joint is the Femur!! The knee is a victim of what is happening above and below. Medial knee pain (MCL) Pes Anserine Bursitis MCL Resists IR of femur on tibia Valgus moment or motion Pes anserine complex under strain with valgus moment or position

2 Pes Anserine Bursitis Lateral knee pain (LCL) Pes anserine complex eccentrically resists varus thrust at knee LCL Resists IR of femur on tibia Varus moment or motion ITB Friction Syndrome Excessive Hip Adduction & ITB Stress Increased tension with: Hip adduction * Varus moment/position Knee rotation IR of tibia (foot pronation?) IR of femur *Predictor of ITBS in a prospective study Noehren et al., Clin Biomech,2007 Pelvic Drop & Knee Varus Thrust Hip Abductor weakness in distance runners with Iliotibial Band Syndrome Fredericson et al. Clin J Sports Med, long distance runners with ITBS had diminished hip abduction strength in the affected leg compared to the unaffected leg and runners without ITBS. After 6 weeks of hip abductor strengthening, 22 of 24 of the runners were pain free and returned to running. 30

3 Posterior Knee Pain Popliteus Tendinitis Popliteus Resists IR of femur on tibia Hyperextension Patellar Tendinitis/Tendinosis Jumpers Knee Tendinosis Model Sonographic Changes Tendon Thickening Courtesy of Kornelia Kulig & Shruti Arya Mechanism of Injury: Excessive Eccentric Loading Movement Impairments that can contribute to Patella Tendinitis Injury Threshold Upright trunk Knee forward of Toes

4 Movement Impairments that can contribute to Patella Tendinitis Rehabilitation of Patellar Tendinopathy Using Hip Extensor Strengthening & Landing Strategy Modification Silva et al. JOSPT, 2015 Upright trunk Knee forward of Toes Improving use of the hip to reduce patella tendon loading Influence of Frontal and Transverse Plane Rotations on Patellar Tendon Stress & Strain Transverse Plane Rotations & Patellar Tendon Stress & Strain Peak Patellar Tendon Stress (MPa) 6 5 Peak Patellar tendon Strain (%) External rotation rotation Internal External rotation rotation Internal Tibia Femur Tibia Femur Unpublished data (submitted for publication) Frontal Plane Rotations & Patellar Rotations in Frontal Plane Tendon Stress & Strain Peak Patellar Tendon Stress (MPa) Abduction Adduction Tibia Femur Unpublished data (submitted for publication) Peak Patellar Tendon Strain (%) Abduction Adduction Tibia Femur Intra articular Pain/Meniscus Injury Poor shock absorption Varus moment or position Medial compartment loading Valgus moment or position Lateral compartment loading Excessive knee rotation Femur rotation Tibia rotation

5 Radin et al., J Orthop Res, 1991 Inadequate knee flexion Decreased shock absorption Increased rate of loading Precursor to tibio femoral OA? Medial vs. Lateral Compartment loading Tibiofemoral Rotation and Shear forces? How do ACL injuries occur? Biomechanics of Non Contact ACL Injuries 70% of injuries are noncontact Running & cutting Landing from a jump 30% are contact fouls, tackling from behind ACL injured athletes often recall unanticipated event, perturbation, or loss of concentration

6 Mechanism of Injury (Kirkendall and Garrett, 2000) Deceleration/Change in direction Knee flexion 0 30 degrees Tibial rotation and varus/valgus forces Gender Bias Incidence of ACL injury in females is 4 8 times that of males. Arendt et al., 1995 Hutchinson et al., 1995 Malone et al., 1993 High risk group: females years. Each year, one out of 100 high school female athletes and one of 10 college female athletes experiences an ACL injury Adams et al., 2002 Non contact ACL Injury: Categorical Risk Factors I. Structural Normal Function Injury threshold II. Hormonal III. Biomechanical IV. Neuromuscular Movement Impairements & ACL Injury Risk Biomechanical Risk Factors Kinematics hip and knee flexion knee valgus hip internal rotation Kinetics knee valgus moments knee extensor moments hip extensor moments Muscle activation patterns quadriceps activity gluteus max activity Pollard, et al Sigward & Powers, 2007 Pollard, et al., 2009

7 Neuromuscular Control and Valgus Loading of the Knee Predict ACL Injury Risk in Female Athletes Hewett et al. Am J Sports Med, 2005 Biomechanical Assessment: Drop Jump Prospective study of 205 female athletes Those who tore their ACL during the course of a season demonstrated knee valgus moments that were 2.5 times greater than those who did not tear their ACL Females: Knee Strategy Males: Hip Strategy Biomechanical Assessment: Side Step Cut Female Sigward & Powers, Clin Biomech, 2006 Male

8 Causes of Valgus Loading at the Knee Ground reaction force vector moves lateral shifting of COM lateral Medial movement of the knee joint center Hip adduction & internal rotation Combination of both Female Male Trunk Lean & Knee Valgus Torque average hip internal rotation angle Gluteus Maximus: Protector of the ACL ER IR ( ) males females Extensor Abductor External Rotator Pollard, Sigward & Powers, Am J Sports Med, 2006

9 Impaired Gluteus Maximus Muscle Performance & ACL Injury Sagittal Plane Gluteus Maximus Activity Frontal/Transverse Plane Hip Adduction & Int. Rotation Quadriceps Activity Knee Joint Anterior Shear Knee Valgus Angle External Knee Valgus Moment Prospective study of 501 Soccer athletes Risk of ACL injury? Those who tore their ACL during the course of a season had weaker hip abductors than those who did not tear their ACL. Behavioral Changes Following ACL Injury Prevention Training PEP Program Prevent injury and Enhance Performance 1. Agilities 2. Flexibility 3. Strengthening 4. Plyometrics 5. Technique PEP Program Series of warm up, stretching, strengthening, plyometric and sports specific agility drills. 2 3 times a week prior to soccer practice 20 minutes/session (12 week season) Results: Year 1 Mandelbaum et al. Am J Sports Med, 2005 Control: 32 ACL s in 1901 athletes Enrolled: 2 ACL s in 1041 athletes 88% reduction in ACL tears

10 Results: Year 2 Mandelbaum et al. Am J Sports Med, 2005 Pre training biomechanical analysis Control: 35 ACL s in 1913 athletes Enrolled: 4 ACL s in 844 athletes 74% reduction in ACL tears ACL injury prevention program Post training biomechanical analysis Improved Hip Kinematics Following PEP Training Decreased hip internal rotation Decreased hip adduction Knee/Hip Extensor Moment Ratio Drop Jump * Pre- training Post-training *Decreased knee extensor moment Pollard et al., Clin J Sports Med, 2006 Pollard et al. (In review) ACL Injury Prevention: Less Dependence on a Knee Strategy

11 Movement Impairments Related to Overuse Injuries of the Hip Trochanteric Bursitis & Snapping Hip Syndrome Potential Biomechanical Mechanism Repetitive IR Adduction Trochanteric Pain Gluteus Medius Injuries Excessive hip adduction Excessive hip internal rotation

12 Piriformis Syndrome Potential Biomechanical Mechanism Repetitive IR Overstretching of external rotators Adduction Treatment of an Individual with Piriformis Syndrome Focusing on Hip Muscle Strengthening & Movement Re education Tonley et al. JOSPT, 2010 Femoro Acetabular Impingement Bony Predisposition combined with faulty movement patterns Structural Predisposition (Cam impingement)

13 Structural Predisposition (Pincer impingement) Anterior Hip Pain Anterior Hip Pain Reproduced with Flexion, Adduction, Internal Rotation Identification of Abnormal Hip Motion Associated with Acetabular Labral Pathology Austin et al. JOSPT, 2009 The Presence of Intra articular Fluid Results in Gluteal Muscle Inhibition Freeman et al. Clin Biomech, 2012 Altered Pelvis Kinematics & FAI Pelvic drop Excessive anterior tilt (contributes to impingement) Limited posterior tilt (limits ability to avoid impingement)

14 Posterior Pelvic Tilt During Squatting Patients with FAI have decreased Posterior Pelvic Tilt During Squatting Bagwell et al, Clin Biomech, 2016 FAI Pathomechanics Hamstring Injuries Typically occur in terminal swing (period of maximum muscle length). Strong eccentric action to decelerate hip flexion and knee extension in terminal swing. Hamstrings work in conjunction with Gluteus Maximus to decelerate the thigh in terminal swing. Predisposing Factors Limited hamstring length Poor strength/activation of gluteus maximus Wagner, JOSPT, 2010 Hip flexor tightness Compensatory anterior pelvic tilt

15 Strengthening & Neuromuscular Re education of the Gluteus Maximus in a Triathlete with Exercise Associated Hamstring Cramping Wagner et al. JOSPT, 2010 Improving Strength and Changing Neuromuscular Recruitment Pre Intervention Post Intervention Average Hamstrings 65% Gluteus Maximus 35% Average Hamstrings 41% Gluteus Maximus 59%

16 Movement Impairments Related to Patellofemoral Joint Dysfunction The Problem of Patellofemoral Pain The Low Back Pain of the Lower Extremity 10 most common overuse injuries in runners (n=1579) Taunton et al., Br. J Sports Med, Patellofemoral pain (21%) 2. ITB friction syndrome (11%) 3. Plantar facsitis (10%) 4. Meniscal injuries (6%) 5. Shin splints (6%) 6. Patellar tendinitis (6%) 7. Achilles tendinitis(6%) 8. Gluteus Medius injuries (4%) 9. Tibia stress fractures (4%) 10. Spine injuries (3%) Movement Impairments Associated with Patellofemoral Pain Excessive hip internal rotation Excessive hip adduction Knee varus Knee Strategy Quadriceps overuse Interventional MRI system Hip Internal Rotation Contributes to Patellofemoral Joint Maltracking in Weightbearing Christopher M. Powers, PhD, PT, FACSM, FAPTA

17 Open Chain Closed Chain Powers et al., JOSPT, 2003, Souza & Powers, JOSPT, 2009 Femur Internal Rotation & MPFL Tensioning Video of CKC femoral rotation Femur Internal Rotation & PFP Femur Internal Rotation & Lateral Facet Pressure Liao et al. Med Sci Sports Exerc, 2015 Christopher M. Powers, PhD, PT, FACSM, FAPTA

18 Excessive Hip Internal and PFP Souza et al., 2009 Increased hip internal rotation in females with PFP during step down, running, drop jump Boling et al., 2009 Increased hip internal was found to be a risk factor for the development of PFP Wirtz et al, 2011 Increased hip internal rotation in females with PFP while running Noehren et al., 2011 Increased hip internal in female runners with PFP Hip Adduction Contributes to Increased Lateral Forces Acting on the Patellofemoral Joint Lower limb alignment & lateral forces on the patella Dynamic Q Angle Powers, JOSPT, 2003 Q angle: 15 Lateral vector Dynamic Q angle & PFP Dynamic Q angle & PFP Christopher M. Powers, PhD, PT, FACSM, FAPTA

19 How much of a change in the Q angle is relevant? Huberti & Hayes., JBJS, degree change in the Q angle increased peak pressures by 45%. A decrease in the Q angle decreased stress on the lateral facet and median ridge Hip Adduction and PFP Willson & Davis, 2008 Increased hip adduction with single leg squats, jump and running Noehren et al., 2011 Reported increased hip adduction in female runners with PFP Noehren et al., 2013 Females who developed PFP exhibited greater hip adductions than those who did not (prospective) Hip Kinematics are Associated with Pain and Function in Males & Females with PFP Nakagawa et al., Int J Sports Med, 2013 Peak internal rotation and hip adduction during a step down test were significant predictors of pain Peak hip adduction was a significant predictor of function Distal motions that can influence the Dynamic Q angle Powers CM. J Orthop Sports Phys Ther, 2003 Foot Pronation Tibia rotation Foot pronation contributes to tibia internal rotation Tibia internal rotation decreases the Q Angle 15 6 Christopher M. Powers, PhD, PT, FACSM, FAPTA

20 Knee Varus Medial Patellofemoral Joint Loading Varus alignment subjects the patella to medially directed forces Medial vector Modeling of Patellofemoral Stress Influence of Tibia & Femur Motions Transverse Plane Rotations & PFJ Stress Unpublished data (submitted for publication) 28 Frontal Plane Rotations & PFJ Stress Patellofemoral Stress: Influence of Femur and Tibia motions Femur internal rotation Femur adduction Tibia & Femur external rotation Unpublished data (submitted for publication) 29 Tibia & Femur abduction Christopher M. Powers, PhD, PT, FACSM, FAPTA

21 Knee Strategy Quadriceps Overuse Increases PFJ Compression Dependent on: Patellofemoral Joint Reaction Force Quadriceps force (Primary) Knee joint angle Worst Case Scenario: Femur Internal Rotation & Valgus Worst Case Scenario: Femur Internal Rotation & Valgus MPFL Tensioning Excessive Lateral Force Vector Christopher M. Powers, PhD, PT, FACSM, FAPTA

22 Historic Treatment Approach for PFP Treatment Implications Paradigm shift in the treatment of PFP Positive Clinical Outcomes Associated with Hip Strengthening for PFP Control of femoral rotation and adduction Emphasis on gluteus maximus & medius strengthening Mascal et al. JOSPT, 2003 Nakagawa et al. Clin Rehab, 2009 Fukuda et al. JOSPT, 2010 Earl & Hoch, Am J Sports Med, 2011 Khayambashi et al. JOSPT, 2012 Khayambashi et al, Arch Phys Med Rehabil, 2014 Ferber et al, J Athl Train, 2015 Hip vs. Quadriceps Strengthening for PFP Journal of Athletic Training, 2015 Archives Physical Medicine & Rehabilitation, 2014 Christopher M. Powers, PhD, PT, FACSM, FAPTA

23 Movement Impairments Related to Low Back Pain Non specific low back pain Activity related My back tightens up when I run I get low back pain when I walk distances I get back pain when I squat and/or lift Probable tissue sources Facet joints Paraspinal muscles Lumbar Facet Joints Muscular Anatomy Essential for spinal stability Distributes forces across the spinal column Load sharing Facet compression caused by Lateral flexion Rotation Support and stabilize the spinal column Deep layers anchored to the pelvis Trunk Stabilizers Trunk Stability vs. Pelvis Stability Trunk Muscles Abdominals Obliques Paraspinals

24 Pelvis Stabilizers Pelvis or Trunk Instability? Hip/Pelvis Muscles Gluteus Medius Gluteus Maximus Courtesy of John Popovich Excessive Spinal Motion as a Compensation for Hip Abductor weakness Hip Abductor Weakness & Lateral Trunk Lean Uncompensated Compensated

25 Facet Joint Compression Uncompensated Compensated Facet Joint Degeneration on Side of Compression Transient Scoliosis Porterfield, JA and DeRosa, C. Mechanical Low Back Pain Lateral Trunk Lean Lumbar Facet Joint & Intervertebral Disc Loading During Simulated Pelvic Obliquity Popovich et al., Spine, 2013 Increased facet loading during simulated pelvic obliquity in the frontal and transverse planes Intradiscal pressure highest in lateral flexion

26 Muscular Low Back Pain & Running Paraspinal Muscle Overuse Hip Abductor Weakness Paraspinal/Quadratus Lumborum Muscle Overuse Pelvic Drop and Muscular Overuse What is the True Core of the Problem? Gluteus Medius

27 Gluteus Maximus: The Tri planar Muscle Lumbopelvic Landing Kinematics & EMG in Women with Contrasting hip Strength Popovich & Kulig, Med Sci Sports Exerc, 2012 Extensor Abductor External Rotator Greater frontal and transverse plane trunk excursions in persons with hip abductor weakness Greater activation of erector spinae and external obliques in persons with hip abductor weakness Before Treatment After Treatment Excessive Pelvis Motions as a Compensation for Hip Flexor Tightness Hip Extension Terminal Stance Hip Extension Toe Off

28 Hip Flexor Tightness & Low Back Pain Excessive pelvis motions to compensate for hip flexor tightness Anterior pelvic tilt Transverse plane pelvic rotation Compensatory Anterior Pelvic Tilt

29 Intervention Strategies for the Lower Quarter Dysfunction: An Overview General Treatment Philosophy Most lower extremity movement impairments stem from poor hip strength and/or control. Improving hip utilization can lead to: Improved hip/pelvis/trunk stability Improved shock absorption Less reliance on quadriceps Treatment Goal: Permanent Change in Movement Behavior Motor Adaptation vs. Motor Learning Motor Adaptation (minutes to hours)

30 Which is the Better Hip Strategy??

31 Motor Learning (days to months) Hip Training Paradigm Activation Increase corticomotor excitability Increase representational area Strengthening Movement training Motor Learning Coordination Control Skill Muscle Performance Activation Strength Movement training Why is Strengthening Gluteus Maximus so Difficult? Exercise Mode Static Dynamic Ballistic Dilemma #1 Dilemma #2 Gluteus Maximus is a postural muscle with poor representational area in the primary motor cortex The Hip is a Redundant Muscular System: It is easy to Compensate! How do you Strengthen Gluteus Maximus if you Cannot Access it?

32 Abductors GMED, GMINI ABDuctor Extensors GMAX Hamstrings ABDuctor ADDuctor External Rotator Abductors TFL GMAX ABDuctor ABDuctor Internal Rotator External Rotator Adductor Magnus ADDuctor Extensors Hamstrings Adductor Magnus(P) ADDuctor ADDuctor Neuroplasticity Associated with Gluteus Maximus Activation Training Quantifying Corticomotor Function: Transcranial Magnetic Stimulation (TMS) Safe, noninvasive & painless way to stimulate the human motor cortex through electromagnetic induction to evaluate the evoked motor response TMS can be used to assess the integrity and responsiveness of the corticomotor pathways TMS Data Acquisition TMS can be used to Identify Areas of Representation in the Primary Motor Cortex Stimulator coil Recording EMG Electrode <40ms

33 TMS Data Acquisition for Glut Max Fisher et al., JOSPT, 2013 TMS Mapping Gluteus Maximus vs. Vastus Lateralis VL:59.3 GM:43.0 VL : 18.8 GM: 63.5 Changes in Cortical Motor Output Maps with Skill Training Day 1 Day 3 Day 5 Isolated Gluteus Maximus Contraction (Isometric) Trained Untrained Pascual Leone 1995 Why Static Holds?? Static holds facilitate the encoding phase for cognitive processes which are thought to play an important role in helping the learner create a motor memory. Fisher et al, Neuro Report, 2016 Static holds require prolonged focus and concentration, thus strengthening the corticomotor pathway.arner create a motor

34 Lower Extremity Strengthening in Weightbearing Using a Hip Bias Which is a Better Hip Strategy? How do you know? Trunk angle vs. Ankle Dorsiflexion Biscarini et al., 2011 Which is a Better Hip Strategy? Trunk: 25 Ankle: 25 Trunk: 20 Ankle: 5 Trunk: 0 Ankle: 5 Elements of a Hip Strategy Squat 45

35 Increased Hip Extensor Torque Demand with a Forward Trunk Decreased Knee Extensor Torque Demand with a Forward Trunk Trunk Position Influences Lower Extremity Demand During Lunging Farrokhi, et al., JOSPT, 2008 Forward trunk posture increased hip extensor moments and hip extensor activation What about the Hamstrings? Greater hamstring torque requires greater quadriceps torque to balance the knee Can contribute to quadriceps overuse Hamstrings function as hip adductors Can contribute to dynamic valgus

36 Improving Functional Hip Abductor Muscle Performance Requires Use of Exercises that Challenge Pelvis & Trunk Stability! Before Treatment After Treatment Single Limb Squats Step Down (Single Limb)

37 Address Both Limbs!! Pre-treatment Post-treatment Improving Use of the Hip Extensors for Active Shock Absorption Requires Use of Ballistic (ie. plyometric) Exercises BEFORE AFTER Use of a Forward Trunk Lean is Required to Decrease Quadriceps Overuse & Improve use of a Hip Strategy

38 Uphill Walking to Facilitate a Forward Trunk Lean Flat 5% incline Forward trunk lean reduces use of quadriceps & patellofemoral stress Self selected trunk (SELF) Self selected Flexed Forward flexed trunk (FLEX) Low Flex High Flex N 1200 N MPa PFJ stress Teng & Powers, JOSPT, 2014 Trunk Lean & Running Downhill Facilitating a Hip Strategy in the Runner: How? Increase hip flexion angle during weight acceptance to improve glut max activity Increase forward trunk lean (~10 degrees)

39 What about External Supports? Can Orthotics Change Hip and Knee Kinematics? Femoral Strapping to Temporarily Improve Dynamic Hip Stability (DJ Orthopaedics) Medial wedging changed frontal & transverse plane knee kinematics 1 2 Nester et al., Gait & Posture, 2003 Eng & Pierrynowski, Phys Ther, 1994 Over the counter orthotic caused a 2 decrease in hip internal rotation Jenkins et al., J Appl Biomech, 2009

40 SERF Strap & Decreased Symptoms Piriformis Syndrome (Tonley 2010) Femoro Acetabular Impingment (Austin 2009)

41 8 Step Hip Exercise Program & Progression Exercise Progression Non weightbearing Weightbearing Activation Double limb support (static) Single limb support (static) Double limb support (dynamic) Strength Single limb support (dynamic) Double limb support (ballistic) Movement Single limb support (ballistic) training Sport Specific Training (return to sport) Level 1: Non Weightbearing Why trunk stability? Difficult to achieve hip strategy without ability to maintain neutral spine Goals: Hip & Trunk Muscle Isolation Increase ability to activate Clam: Bi planar motion Fire Hydrants: Tri planar motion Christopher M. Powers, PhD, PT, FACSM, FAPTA

42 Sidelying Hip Abduction Trunk Trunk Activation EMG Biofeedback to Trunk Facilitate Activation if Necessary Progression Criteria for Level 1: Hold each exercise for 60 seconds (bilaterally) Level 2: Weightbearing (Double Limb Static) Squat with Theraband Goals: Weightbearing activation Increase ability to activate Christopher M. Powers, PhD, PT, FACSM, FAPTA

43 Surfer Squat with Theraband Squat with Trunk Activation Squat with Trunk Activation Progression Criteria for Level 2: Hold each exercise for 60 seconds Level 3: Weightbearing (Single Limb Static) Simulated Wall Push (Standing) Goals: Weightbearing activation Increase ability to activate Christopher M. Powers, PhD, PT, FACSM, FAPTA

44 Standing Fire Hydrant Kneeling Bosu: Balance for 60 seconds Clam with Trunk Activation Advanced Level 1: Hip & Trunk Activtion Hold each exercise for 60 seconds Hip Abduction with Trunk Activation Progression Criteria for Level 3: Hold each exercise for 60 seconds (bilaterally) Christopher M. Powers, PhD, PT, FACSM, FAPTA

45 Level 4: Weightbearing (Double Limb Dynamic) Resisted Squats with Theraband Goals: Improve Muscle Performance: (Strength & Power) Kettlebell Squats with Theraband Crab Walks Crab Walks with Trunk Activation Monster Walks (Forward) Christopher M. Powers, PhD, PT, FACSM, FAPTA

46 Monster Walks (Backward) Supplemental Hip Abductor Strengthening Side Step with straight leg Sidelying Hip Abduction (repetitions) Advanced Level 4: Weightbearing (Double Limb Dynamic): Forward Lunge (hip bias) Goal: Prepare limb for full weightbearing Christopher M. Powers, PhD, PT, FACSM, FAPTA

47 Single Leg Squat (bench assisted) Progression Criteria for Level 4: Consistent Performance of Program for about 4 weeks Level 5: Weightbearing (Single Limb Dynamic) Single Leg Squat Goals: Improve Muscle Performance: (Strength & Power) Romanian Deadlift (RDL) Low Cable Pulls Christopher M. Powers, PhD, PT, FACSM, FAPTA

48 Standing Fire Hydrants (dynamic) Step ups (hip bias) Step Down (hip strategy) Standing Hip Hike Progression Criteria for Level 5: Normal knee extensor strength Normal hip extensor strength Normal hip abductor strength Hip/knee extensor strength ratio=1.0 Functional Progression Criteria for Level 5: Step Downs Bilaterally No Pelvic drop No Medial collapse Trunk straight Hip strategy Christopher M. Powers, PhD, PT, FACSM, FAPTA

49 Level 6: Weightbearing (Double Limb Ballistic) Goals: Movement Re education Improve Muscle Performance (Strength, Power & Endurance) Movement Criteria Hip Stability Pelvis Stability Trunk Stability Active Shock Absorption Hip Strategy Progression Criteria for Level 6: Level 7: Weightbearing (Single Limb Ballistic) Consistent Performance of Program for about 4 weeks Goals: Movement Re education Improve Muscle Performance (Strength, Power & Endurance) Changing Movement Behavior Performance-Motor Learning Continuum Movement Retraining Principles PERFORMANCE (Encoding in Brain) (Consolidation) LEARNING (Retention) Christopher M. Powers, PhD, PT, FACSM, FAPTA

50 Feedback Concurrent Feedback (Verbal or Manual) A Critical Element of Movement Re education & Motor Learning Concurrent Feedback (Visual) Concurrent Feedback (Visual) Visual Feedback Training: Visual Visual Feedback Training: Visual Christopher M. Powers, PhD, PT, FACSM, FAPTA

51 Post Response Feedback Knowledge of Results Observation & Modeling Motivation Motivation Hip Stability Shock Absorption Hip Strategy Pelvis Stability Trunk Stability Total Score out of 10 total Adequate = 2 ; Borderline = 1 Inadequate = 0 Motivation Variability in Practice Hip Stability Shock Absorption Hip Strategy Pelvis Stability Trunk Stability Total Score out of 10 total Adequate = 2 ; Borderline = 1 Inadequate = 0 Christopher M. Powers, PhD, PT, FACSM, FAPTA

52 Variability in Practice Contextual Interference Transfer of Training Technique Part vs. Whole Training Verbal Feedback Internal vs. External Focus of Attention Internal vs. External Focus of Attention External focus of attention enhances motor learning by reducing the focus on the self and directing attention to the intended movement What feedback would you Give? Keep knees apart Bend knees Lean trunk forward Don t let your knees come forward of your toes Christopher M. Powers, PhD, PT, FACSM, FAPTA

53 External Focused Cues Avoid reference to body parts External Focus of Attention Put your shoe between the lines Spread the floor apart when you land Land softly Lean forward Sit back in the chair External Focus of Attention Stretch the band Land Softly Performance-Motor Learning Continuum PERFORMANCE (Encoding in Brain) (Consolidation) LEARNING (Retention) Heavy Feedback (Reduced) (Withdraw) No Feedback Level 8: Return to Sport Phase Maintenance Program At least 3 days/week (1 hour) 2 activation exercises On Field Sport Specific Drills Improve Sport Specific Skills Avoid Contact for 4 6 weeks 2 3 strengthening exercises 2 3 movement exercises Christopher M. Powers, PhD, PT, FACSM, FAPTA

54 Typical Time Progression for A Patient that Presents with: Significant Pain Significant weakness Activation (levels 1 3) 3 weeks Strength (levels 4 5) 8 weeks Poor mechanics Movement (levels 6 7) 8 weeks Accelerated Time Progression for A Patient that Presents with: Moderate or no Pain Moderate weakness Activation (levels 1 3) 3 weeks Double limb strength & Movement (levels 4 & 6) 4 weeks Poor mechanics Single limb strength & Movement (levels 5 & 7) 4 weeks Typical Progression for a Post op ACL Patient Activation (levels 1 3) Month 1 Strength (levels 4 5) Months 2 4 Movement (levels 6 7) Months 5 8 (or until ready) Christopher M. Powers, PhD, PT, FACSM, FAPTA