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Dynamic Stretchingand Other Keys to Lower Extremity Injury Prevention

Jaime Holt, PT, MPT, SCS, CSCSHolt Physical Therapy & Performance Training

jaimeholtpt@gmail.comTwitter: @HOLTPT1

biography

APTA Sports Certified Specialist

NSCA Certified Strength and Conditioning Specialist

Owner and Sports Orthopaedic PT at Holt Physical Therapy & Performance Training

PT Consultant NHL Carolina Hurricanes (2007 –2014)

Provider Disclaimer

• Allied Health Education and the presenter of this webinar do not have any financial or other associations with the manufacturers of any products or suppliers of commercial services that may be discussed or displayed in this presentation.

• There was no commercial support for this presentation.

• The views expressed in this presentation are the views and opinions of the presenter.

• Participants must use discretion when using the information contained in this presentation.

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biography

East Carolina University

BS Exercise Physiology 1995

MS Adapted Physical Education 1997

MPT Physical Therapy 1999

mentors

Pete Friesen

Doug Geiger

Gary Gray

Walt Jenkins

Bill Moore

Kevin Wilk

Co-workers

Patients!!

outline

Etiology and Incidence of Lower Extremity Injuries

Functional Lower Extremity Anatomy

Dynamic Warm Up

Hip Activation Exercises

Isometric Lower Extremity Strengthening

Maintaining Tissue Mobility

Active Isolated Stretching

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etiology and incidence of lower extremity injuries

Depends on what type of clients you see.....

Geriatric: OA, DJD, TKR, THR

Athletic: Ligamentous injuries, meniscal injuries, hip labral injuries

Youth: OSD, anterior knee pain, snapping hip sx

etiology and incidence of lower extremity injuries

65,000-75,000 ACL surgeries annually

850,000 meniscus surgeries annually

4.5 million Americans living with TKR

Annual TKR have doubled over the past decade

959,000 THR annually

Hip scopes will double by 2012 (Schiff)

functional movement screen

Gray Cook designed

It is a screening tool, not a diagnostic or treatment tool

Their are 5 basic principles of the FMS

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Principle #1

Basic bodyweight movement patterns should not cause pain.

If we continue through this pain, compensatory and altered movement patterns could develop

Principle #2

Gross limitation of basic movement patterns can cause compensatory patterning

Can lead to poor efficiency, secondary problems and increased injury risk

Principle #3

Fundamental movement patterns should be mostly symmetrical.

Most activities have a unilateral dominance, but should be as symmetrical as possible to decrease injury risk

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Principle #4

Fundamental movement capabilities should precede performance based capability.

Example: Golf Swing

Principle #5

Fundamental movement capability should mostly precede complex movement activity or skills.

Need to form a neuromuscular foundation for advanced activities

Will reduce the need for compensation and substitution

fms test list

Deep squat movement pattern

Hurdle step movement pattern

Inline lunge movement pattern

Shoulder mobility reaching movement pattern

Impingement clearing exam

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fms test list

Active SLR movement pattern

Trunk stability push up movement pattern

Prone press up clearing exam

Rotary stability movement pattern

Posterior rocking clearing test

fms supporting research

Chorba, Chorba, Bouillon, et al North American Journal of Sports Physical Therapy, June 2010

Sample: 38 female collegiate athletes

Score of 14 or less on the FMS resulted in 4 fold increase in risk of LE injury

FMS identifies compensatory movement patterns

y balance test

Dynamic test that requires strength, flexibility and proprioception used to assess physical performance, identify chronic ankle instability and identify athletes at greater risk for LE injury.

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y Balance

Measure left and right limbs in three directions

y Balance

3 attempts at each direction

Take the highest distance reached

Want less than 5% deficit

y balance supporting research

Plisky, Gorman, Butler et al. North American Journal of Sports Physical Therapy, May 2009

Sampled 15 male collegiate soccer players

Good to excellent intra and inter rater reliability

Conclusion: reliable test for measuring single limb excursion distances while performing dynamic balance testing

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functional lower extremity anatomy

functional lower extremity anatomy

functional lower extremity anatomy

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functional lower extremity anatomy

functional lower extremity anatomy

functional lower extremity anatomy

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dynamic warm-up

Purpose: To prepare the body for the athletic demands that are about to be placed on the skeletal, muscular, proprioceptive and cardiovascular systems.

supporting research

A dynamic warm up model increases quadriceps strength and hamstring flexibility. Aguilar, DiStefano, Brown, et al. J of Strength & Conditioning Research; April 2012.

Supporting research

Groups: CON, DWU, SWU

measured strength, flexibility and vertical jump

CON and SWU did not significantly affect flexibility, strength or vertical jump

DWU significantly improved in eccentric quad strength, HS flexibility

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Supporting research

The Acute effects of static stretching on the sprint performance of collegiate men in the 60- and 100-m dash after a dynamic warm up. Kistler, Walsh, Horn and Cox, J of Strength & Conditioning research; Sept 2010.

supporting research

Results: static stretching group significantly slower in 20-40m of the sprint trials

After first 40 m, no additional inhibition of performance

Athletes never gained back the time that was originally lost in the 20-40m portions

supporting research

Effects of static stretching on repeated sprint and change of direction performance. Beckett, Schneiker, et al. Medicine and Sciences in Sports and Exercise. 2009.

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supporting research

12 male team sport athletes

3 sets of 6 max sprints with 4:00 recovery

Rest group and static stretch group

looked at change of direction and repeated sprint ability

SS group had slower times in both COD and RSA

less so in COD

practical applications

Great way to warm up the athlete/client both physically and mentally

Works on stretching, strengthening and proprioceptive/balance all at the same time

Puts the athletic body through more functional patterns to prepare it for athletic maneuvers

Video

Knee Hugs

Butt Kicks

Straight Leg March

Leg Cradle

Inverted Toe Touch

Lunge with Rotation

Lunge with Opposite Arm Reach

Lunge with Same Arm Reach

Harry’s Frog Walk

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Hip activation exercises

Purpose: Activate the hip musculature to get ready for athletic movements, as well as assist in injury prevention.

supporting research

Hip posterolateral musculature strengthening in sedentary women with patellofemoral pain syndrome: A randomized clinical trial with 1 year follow up. Fukuda, Melo, et al. J Ortho Sports Phys Ther; August 2012.

supporting research

44 sedentary women ages 20-40 dx of UPFPS

KE and KHE groups

KHE group added hip abd, lateral rotators and hip extensor strengthening

Compared to KE group, KHE had less pain and better function at 3, 6 and 12 month follow ups

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supporting research

The effects of isolated hip abductor and external rotator muscle strengthening on pain, health status, and hip strength in females with PFP: Randomized controlled trial. Khayambashi, Mohammadkhani et al. J of Orthopedic and Sports PT; January 2012

supporting research

28 females divided into exercise group and non exercise group

8 week and 6 month follow up: exercise group showed significant improvement in pain, health status and hip strength and function

supporting research

Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with PFPS. Dolak, Silkman, McKeon; J Orthopedics and Sports PT; September 2011.

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supporting research

33 females with PFPS: hip group or quad group for 4 weeks, then 4 weeks of similar functional weight bearing exercises.

After 4 weeks, hip group had significantly less pain than knee group.

After 8 weeks, hip group had 21% increase in strength and knee group had no change

Both rehab programs improved function and decreased pain, but hip group may allow for earlier pain relief

supporting research

Hip Strength and Hip and Knee Kinematics During Stair Descent in Females With and Without Patellofemoral Pain Syndrome. Bogla, Malone, et al. JOSPT, January 2008.

Females with PFPS had less strength in hip muscles

No diff in onset activation of VM and VL

All subjects had delay in GM onset compared to vastii

Suggested adding hip ER strength is beneficial

Effects of Dynamic Stretching and GolfPerformance and Fatigue

Ward, Balmelli, Lebon International Journal of Exercise Science 2015

9 simulated holes

DS group and control group

A DS routine performed throughout a round of golf has no influence on performance, or detrimental effects due to fatigue. It may prove to reduce the risk of injury during golf

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Efficacy of Hip Strengthening Exercises Compared with Leg Strengthening Exercises on Knee Pain, Function and Quality of Life in Patients with Knee

OA

Lun, Marsh, Bray, Lindsay, etc: Clinical Journal of Sports Medicine: 1/14/15

Interventions: Thirty-seven and 35 patients with KOA were randomly assigned to either a 12-week hip or leg strengthening exercise program, respectively. Both exercise programs consisted of strengthening and flexibility exercises, which were completed 3 to 5 days a week. The first 3 weeks of exercise were supervised and the remaining 9 weeks consisted of at-home exercise.

Main Outcome Measures: Knee Injury and Osteoarthritis Score (KOOS) and Western Ontario McMaster Arthritis Index (WOMAC) questionnaires, 6-minute walk test, hip and knee range of motion (ROM), and hip and leg muscle strength.

Results: Statistically and clinically significant improvements in the KOOS and WOMAC pain subscale scores were observed in both the hip and leg strengthening programs. There was no statistical difference in the change in scores observed between the 2 groups. Equal improvements in the KOOS and WOMAC function and QOL subscales were observed for both programs. There was no change in hip and knee ROM or hip and leg strength in either group.

Conclusions: Isolated hip and leg strengthening exercise programs seem to similarly improve knee pain, function, and QOL in patients with KOA.

Clinical Relevance: The results of this study show that both hip and leg strengthening exercises improve pain and QOL in patients with KOA and should be incorporated into the exercise prescription of patients with KOA.

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practical applications

Great way to warm up the hips, glutes, quads and hip rotator musculature.

We need these muscles activated and stronger to stabilize the lower extremity, assist with balance, promote increased strength and power output.

Increased hip stability will reduce risk of injuries.

Videos

Cowboy Walks

Lateral Slides

Single Leg Mini Band 3 Way

Hip Rotation

isometric lower extremity strengthening

Purpose: Safe and effective way to strengthen entire lower extremity chain when rehabilitating an injury or as an adjunct to training.

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supporting research

Role of Muscle Strengthening Exercise on Osteoarthritis of the Knee Joint. Azad, Nabi, et al; Journal of Medicine; 2011.

supporting research

106 patients: NSAIDs only, exercise with NSAIDs

Exercise consisted of LE isometric exercises

WOMAC scores were significantly better in the exercise and NSAIDs group

practical applications

You can do these exercises with patients very early on after surgery.

Think of these as we do wall isometrics for cuff patients.

Watch for weight shifting

Great way to get the muscles activated in a safe fashion.

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Wall sit

Build up to 2:30

Sustained anterior lunge

Build up to 1:15 ea leg

sustained split squat

Build up to :45 sec ea

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isometric calf raise

Build up to 2:00

100 body weight squats

Harry’s Yoga

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maintaining tissue mobility

Purpose: Create an environment where tissues are at maximum efficiency and ROM/power output.

supporting research

Effectiveness of foam rolling in combination with a static stretching protocol of the hamstrings. Mohr. Oklahoma State University. 2011.

supporting research

40 subjects: stretch only, foam roll and stretch, foam roll only, control group

6 sessions over 2 weeks

All groups had greater ROM gains than control group, but foam roll and stretch group had the biggest gains.

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Practical applications

With either an injury or extensive training, our tissues are not lined up in the most efficient ways causing inefficient movement patterns.

Will also cause pain and compensatory movements potentially leading to other injuries.

We have to take care of our bodies if we expect to get the most out of them!

Sx: decreased ROM, muscle weakness/pain, paresthesias, compensatory patterning

Videos

Foam Roller IT Band

Foam Roller Lateral Quad

Foam Roll Piriformis

Foam Roller Quad/Hip Flexor

active isolated stretching

Purpose: Obtain maximal post work out ROM and soft tissue elasticity gains to decrease overall pressure on joints.

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supporting research

Mattes: Basic principle of AIS is that by contracting an agonist muscle, the antagonist will relax through reciprocal inhibition and lengthen without increasing muscle tension.

practical applications

This is a better, more effective way for our clients to stretch AFTER the have finished their competition.

Needs to be part of every patient/athlete’s gym bag and exercise routine.

Tricks the agonist muscle into elongating.

supporting research

Mohr 2011 The muscle spindles are a critical part of the proprioceptive system and informs other neurons of the length of the muscles and the velocity of the stretch.

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Videos

AIS Hamstring

AIS Hip Adduction

AIS Hip Flexor

Self Hip Flexor Release

Large Case Study

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Dynamic Warm Up: CrossFit

Great for PT business!

They place high demand loads on their bodies but typically do not prepare their body

Go through tremendous ranges of motion with a load and for speed

Recipe for problems!

Dynamic Warm Up: CrossFit

In Raleigh, NC area, there are 40+ CrossFits. My prediction is there will only be 15 good ones in 3 years.

CrossFit is $$$

Can market to your local CrossFit to teach the group this specific dynamic warm up

https://www.youtube.com/watch?v=Ar0-cgfGvYY&feature=youtu.be

questions?

jaimeholtpt@gmail.comTwitter: @HOLTPT1Instagram: holt_pt

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