Movement Pa+ern Analysis and Training in Athletes 02/13/2016

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1 Objec:ves Movement Pa+ern Analysis and Training in Athletes Department of Physical Therapy and Human Movement Sciences Appreciate the importance of movement pa+ern analysis and training in treahng athletes with musculoskeletal condihons Apply movement biomechanical principles in idenhfying faulty movement pa+erns during funchonal achvihes, such as running and swimming. Examples of videoenhanced movement analysis will be discussed Implement effechve and efficient movement and motor control training based on movement analysis findings Injuries in Athletes Traumatic injuries: acute sudden force Overuse injuries: Ø More common than traumatic injuries Ø Mild, low-grade, repeated stress without adequate recovery time Ø Often attributed to training errors or overtraining Ø Frequently caused by suboptimal movement patterns Ø Can use treatment direction test (TDT) to validate hypothesis and guide treatment (Vicenzino, 2004) Overuse Injuries in Athletes Sub-op:mal movement pa+erns Abnormal or excessive :ssue stress Pain and compensatory movements to avoid pain Assessment History and mechanism of injury Pain intensity and nature, aggravating/relieving factors Strength Flexibility ROM Special tests Functional testing Patient reported outcomes Movement analysis Assessment History and mechanism of injury Pain intensity and nature, aggravating/relieving factors Movement analysis Strength Flexibility ROM Special tests Functional testing Patient reported outcomes Northwestern University 1

2 Example 1: Running 26 y/o female Left patellofemoral pain (PFP) while training for marathon Deep ache and pressure pain around anterior knee 5/10 on numeric pain rating scale (NPRS) Pain comes on after 1 mile of running at 2-3/10 on NPRS, needs to stop at Mile 15 (5/10 pain) After a long run, it takes one day for pain to completely subside Anxious to continue training with minimal pain and worried that she may not be able to complete the race Example 1: Running Previous therapeutic attempts to relieve pain Icing and pain meds patellofemoral taping with Leuokotape Cho-Pat strap Increase step rate (cadence) by 6-7% (from 150 to 160) Engaging core muscles while running ( Static posture observation: normal spinal and pelvic alignment, level pelvis and hip landmarks (IC, ASIS, PSIS, GT), symmetrical quad muscle bulk, within-normal limit knee and foot/ankle alignment Running brings on the pain and the symptoms are unilateral, so let s look at how she runs. Zoom in the foot and the pelvis using ipad Northwestern University 2

3 Freeze frame L R LeT LE painful side Right LE healthy side Freeze frame Tight rectus femoris or iliopsoas may limit hip extension and leads to compensatory anterior pelvic tilt and lumbar extension L R LeT LE painful side Right LE healthy side (Neumann, 2010) Northwestern University 3

4 Diminished left hip extension during push-off leads to compensatory right trunk counter-rotation Arm swing can be the canary in the coal mine Left hip trendelenburg (contralateral pelvic drop) may indicate weak Gluteus Medius muscle. Potential more reliance on Tensor Fascia Latae (TFL) to create hip abduction torque during running TFL actions = flexion, abduction, and MR Overactive TFL will lead to limited hip extension and excessive femoral MR Excessive contralateral pelvic drop also may lead to increased tensile stress on ITB and pull on the patellar lateral retinaculum è alter patellofemoral tracking Narrow stance (step width) increase the hip adduction angle and eccentric demand on Gluteus Medius (Fredericson, 2000) Normal step width Narrow step width Why left foot pronation? (1) Too much right trunk rotation (2) Left femoral MR Excessive tension on rectus femoris increases patellofemoral joint compression force F PT F Q PFJRF Greater quadriceps force/tension during running may elevate PF joint stress Asking the patient to walk with anteriorly vs. posteriorly tilted pelvis è drastic difference in pain level è Anterior tilt abolished the pain (lowering tension on RF) Treatment direction test (TDT) confirming the hypothesis Northwestern University 4

5 Selective Physical Examination Lumbar screen: (-) Rectus femoris and iliopsoas flexibility by modified Thomas test è More rectus femoris restriction noted, left much worse than right Gluteus Medius strength test in sidelying and in single limb stance è Left Gluteus Medius muscle weakness and compensatory hip flexion by TFL noted Interventions Flexibility work on rectus femoris Soft tissue mobilization on superior retinaculum Hip mobilization anterior glide Gluteus medius strengthening in non-weight bearing and weightbearing Running Retraining Slight anterior trunk lean to reduce PF joint stress, because center of mass is placed anterior to the knee axis of rotation, creating an external extension moment extended (4 ) self-selected (7 ) Running Retraining Currently, her stride is not excessively long, but may be too long to accommodate tight hip flexors ètemporarily shorten stride length to lower the demand on hip extension range of motion Slightly increase step width (stance width) to minimize stretch on ITB and demand on Gluteus Medius flexed (14 ) PF joint stress in MPa (Teng, 2014) Outcomes She ran a 3:35 marathon, her personal best Take Home Message Chronic overuse injury is likely caused by faculty movement pa+erns Movement analysis of the movement that causes pain will guide effechve intervenhon addressing the underlying biomechanical dysfunchon Video-enhanced movement analysis (apps, e.g. Hudl Technique or Coach s Eye) is a simple and valuable tool for idenhfying movement dysfunchon Northwestern University 5

6 References Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA. Hip abductor weakness in distance runners with iliohbial band syndrome. Clin J Sport Med Off J Can Acad Sport Med. 2000;10(3): Neumann DA. Kinesiology of the Musculoskeletal System: Founda?ons for Rehabilita?on. 2nd ed. Mosby; Teng H-L, Powers CM. Sagi+al plane trunk posture influences patellofemoral joint stress during running. J Orthop Sports Phys Ther. 2014;44(10): doi: /jospt Vicenzino B. Foot orthohcs in the treatment of lower limb condihons: a musculoskeletal physiotherapy perspechve. Man Ther. 2004;9(4): doi: /j.math Northwestern University 6