The Time Constrained Athlete:

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

Agenda 1. Time constrained athlete 2. Introduction to the human movement system 3. Human movement dysfunction 4. Corrective Exercise Continuum 5. Case Studies - 15 minute rehabilitation programs x 2 6. Open discussion

The Problem Time Crunch Suboptimal care

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

The Keys to Optimal Care Understanding Athletes needs Treatment or rehabilitation Knowledge pertaining to human movement system Flexibility in program design Willing to change mind-set Creativity in modality use

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

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

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. National Academy of Sports Medicine 2008

Dynamic Malalignments Dynamic malalignment (movement impairment syndromes) altered muscle recruitment patterns multi-segmental human movement system impairment

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 alignment and leads to injury

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

Common Injuries Foot/Ankle Plantar fascia Ankle sprains Sesamoiditis Achilles tendonitis Lower leg MTSS Post tib. Tendonitis Stress Fx Knee PFPS ACL OCD Patella tendonitis Osgood-Schlatter / Larsen-Johansson IT Band Bursitis Low Back Snapping hip Chronic strains SI joint pain Osteitis Pubis Facet syndrome Shoulder Impingement syndrome Biceps tendonitis Rotator cuff tendonitis Strain Subluxation / dislocation Elbow Epicondylitis / tendonitis UCL Pronator syndrome

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

Why Do We See Imbalances? Stability Mobility

Movement Assessments A movement assessment allows a Health and Fitness Professional to observe Human Movement System impairments. Determines what muscles are underactive and overactive and how that impacts a client s ability to move properly This information can then be correlated to subjective assessment findings, for a comprehensive representation of the client s functional status.

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 Position: Feet shoulder width apart Arms overhead ANTERIOR LATERAL POSTERIOR

Movement Compensations

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 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

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

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.

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

Double-leg Squat & Single-leg Squat

Assessment Modification Modifications to Overhead Squat: Elevating the heels Hands on the hips National Academy of Sports Medicine Movement Assessments

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 Self-Myofascial Release Manual Therapy Static Stretching Neuromuscular Stretching Manual Therapy Isolated Strengthening Positional Isometrics Integrated Dynamic Movement

Case Studies Two Case Studies Background Information Goals Lifestyle Medical history Video footage Movement Assessments Identify Movement compensation Design a CEx program

Case Study 1: Rachel s Bio Bio: Rachel Age: Sophomore Sport: Cross Country Recreation/Hobbies: Running, dancing, movies Problem: MTSS Occupation: Student Athlete Medical History: Good health, no previous surgeries or medication

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

Rachel s Overhead Squat

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

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

Rachel s Single Leg Squat

Rachel s Movement Analysis 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.

Analysis of Rachel: Program Design Overactive/Tight Lateral Gastrocnemius / Soleus Biceps femoris (short head) TFL Hip flexors (rectus femoris, psoas) Adductor complex Peroneals Vastus Lateralis Underactive/Weak Medial Gastrocnemius Anterior & posterior tibialis Medial hamstrings Vastus Medialis oblique Gluteus Medius / Maximus CEx Goal: 1. Prioritize issues 2. Regain LE muscle balance 3. Relieve lower extremity pain

15 Minute Corrective Exercise Program Integrate Inhibit: Gastrocnemius / Soleus, Biceps Femoris (short head), TFL/IT- Band Lengthen: Time Needed Activate: Integrate: 1-2 sets 10-15 reps 4/2/2 tempo 6 min 1-2 sets 10-15 reps slow tempo

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 10-15 reps 4/2/2 tempo 6 min 1-2 sets 10-15 reps slow tempo

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: Intrinsic Core Stabilizers, Gluteus Medius, Medial Gastrocnemius, Medial Hamstrings Integrate: 1-2 sets 10-15 reps 4/2/2 tempo 6 min 1-2 sets 10-15 reps slow tempo

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: Intrinsic Core Stabilizers, Gluteus Medius, Medial Gastrocnemius, Medial Hamstrings Integrate: Ball Squat with Overhead Press 1-2 sets 10-15 reps 4/2/2 tempo 6 min 1-2 sets 10-15 reps slow tempo

Case Study 2: Jeff s Bio Bio: Age: Senior Sport: Baseball Recreation/Hobbies: Hiking, working out, fishing Goal: Biceps tendinitis, impingement syndrome Occupation: Student Athlete Medical History: Good health, previous rotator cuff repair

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

Jeff s Overhead Squat

Analysis of Jeff s Movement Overhead Squat Assessment Checkpoints Movement Observation Left-Yes Right Yes Shoulder Arms Fall LPHC Excessive forward lean LPHC Low back arch Feet Turns out Feet Flatten Notes: Primary dysfunctions appear to present themselves at each Kinetic Chain Checkpoint. Consistent with the athlete s shoulder pain, we see compensation at the shoulder. Specifically right greater than left.

Analysis of Jeff: Program Design Overactive/Tight Latissimus Dorsi Pectoralis Major Pectoralis Minor Subscapularis Lateral gastrocnemius / soleus Hip flexors (TFL, rectus femoris, psoas) Underactive/Weak Middle/Lower Trapezius Serratus Anterior Rhomboids Posterior Rotator Cuff Gluteus medius/maximus Intrinsic core stabilizers CEx Goal: 1. Prioritize issues 2. Regain muscle balance in the upper 3. Alleviate shoulder pain

15 minute Corrective Exercise Program Integrate Inhibit: Latissimus Dorsi, Thoracic Spine, Pectoralis Major, Subscapularis Lengthen: Time Needed Activate: Integrate: 1-2 sets 10-15 reps 4/2/2 tempo 6 min 1-2 sets 10-15 reps slow tempo

15 minute Corrective Exercise Program Integrate Inhibit: Latissimus Dorsi, Thoracic Spine, Pectoralis Major, Subscapularis Lengthen: Latissimus Dorsi, Pectoralis Minor, Pectoralis Major, Subscapularis Time Needed Activate: Integrate: 1-2 sets 10-15 reps 4/2/2 tempo 6 min 1-2 sets 10-15 reps slow tempo

15 minute Corrective Exercise Program Integrate Inhibit: Latissimus Dorsi, Thoracic Spine, Pectoralis Major, Subscapularis Lengthen: Latissimus Dorsi, Pectoralis Minor, Pectoralis Major, Subscapularis Time Needed Activate: Middle / Lower Trapezius, Rhomboids, Serratus Anterior, External Rotators Integrate: 1-2 sets 10-15 reps 4/2/2 tempo 6 min 1-2 sets 10-15 reps slow tempo

15 minute Corrective Exercise Program Integrate Inhibit: Latissimus Dorsi, Thoracic Spine, Pectoralis Major, Subscapularis Lengthen: Latissimus Dorsi, Pectoralis Minor, Pectoralis Major, Subscapularis Time Needed Activate: Middle / Lower Trapezius, Rhomboids, Serratus Anterior, External Rotators Integrate: Single Leg squat w/ PNF pattern 1-2 sets 10-15 reps 4/2/2 tempo 6 min 1-2 sets 10-15 reps slow tempo

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 10-15 reps 4/2/2 tempo 6 min 1-2 sets 10-15 reps slow tempo

Summary Perform an integrated assessment to identify dysfunction Utilize rehab vs. biophysical modalities if possible Develop focused corrective exercise program based on assessment with given time frames Inhibit Lengthen Activate Integrate Inhibit: Myofascial Release to Overactive Muscles Lengthen: Stretching or Manual Therapy to Overactive Muscles Activate: Strengthening of Underactive Muscles Integrate: Dynamic /Functional Strengthening Movement

Thank You! Questions & Answers BOC Approved for 37 CEUs!! Contact Information joshua.stone@nasm.org facebook.com/nasmjosh facebook.com/correctiveexercise