ACL Injury Prevention Program

ACL Injury Prevention Program Kinetic Physical Therapy Adolescent Sports Medicine Developed by Michelle Feairheller MPT, DPT, OCS, CSCS, Greg Macionsky ATC, and Kristyn Kauffman BS 2014

ACL Injury Prevention Program The anterior cruciate ligament (ACL) plays an important role in stabilizing the knee during running, jumping, cutting, and pivoting activities. 1 The ACL s primary role is to limit excessive movement between the tibia (shin bone) and femur (thigh bone). Additionally, this ligament stabilizes the knee during varus (knee moving outward), valgus (knee moving inward), and rotational movements. An intact ACL also protects the meniscus by decreasing sliding forces through the meniscus as well as limiting wear and tear. 2 Due to the complexity of its role, recovering from an ACL tear is a difficult process. A full return to sports can take up to one year. Suffering an ACL injury predisposes the athlete to re-injury and osteoarthritis. Each year 250,000 ACL injuries occur in the United States. 3 Studies have shown that 20.5 percent of all knee injuries at the high school level involve the ACL. 4 Other studies have found this number to be even higher, comprising 50 percent or more of all knee injuries. 4 The cost of an ACL injury is substantial. Conservative estimates place the total cost of surgery and rehabilitation between $17,000 and $25,000 per injury. 5 This places a financial burden not only on the individual and the insurance companies, but on the entire health care system, with an annual cost of nearly two billion dollars. To decrease the financial strain, measures must be taken to reduce the frequency of ACL tears and improve the rehabilitative outcomes associated with this injury. Approximately 80 percent of ACL tears are non-contact in nature. Mechanisms of non-contact ACL injuries may include: landing from a jump, decelerating, or cutting without contact from an opposing player or other obstacle. 2 One study found that ACL injuries comprise 2.6 percent of all injuries across collegiate sports, however, this rate is significantly higher in women s athletics. 5 Female athletes are four to six times more likely to sustain an ACL injury compared to male athletes. 6 Nearly 5 percent of all injuries in women s collegiate basketball and gymnastics are ACL tears and a similar elevated risk is also present in women s lacrosse and soccer. 3,5 Because the majority of these injuries are suffered without contact, it is possible to prevent them through a well-designed injury prevention program. The literature discusses a number of factors that contribute to non-contact ACL ruptures including: improper landing mechanics, inability to properly utilize the trunk and posterior chain musculature (hamstring, gluteal, and calf), and dominant leg tendencies. 1,2. By reducing the impact of controllable factors, progress can be made toward lowering the annual rate of ACL injuries. Female athletes tend to be quadriceps dominant during jumping activities. 6 As a result, the athlete will land with the knee in an extended knee position and inwardly rotated. This quadriceps dominant landing position is commonly linked to ACL injuries. Utilization

of the hamstring, gluteal, and calf muscles during landing can minimize quadriceps dominance, enhance knee positioning at landing, and thus reduce strain on the ACL. The ideal landing position is one with increased hip and knee flexion that softens the landing and places the athlete in a more mechanically advantageous position. 5 The hamstrings are especially important because they supplement the ACL. By reducing anterior shear forces at the knee during dynamic movements, the amount of stress on the ACL is reduced. Due to growth and developmental factors, female athletes have difficulty controlling the trunk and activating the core muscles when cutting, jumping, and landing. 6 Core instability makes it more difficult for a female athlete to control her center of mass, which decreases her balance and control of the lower extremity. 6 Decreased trunk control leads to an inability to prevent body weight from shifting away from the base of support during athletic movements, thus contributing to an increased risk of ACL injury. 2 Female athletes are also more likely to be limb dominant (one leg is stronger than the other). This leads to unequal weight transfer when cutting, jumping, or landing. Unequal distribution of body weight has been observed to increase the risk of ACL injuries. Educating athletes on these factors in addition to injury prevention programs designed to address muscular weakness and altered mechanics, is a crucial component in reducing ACL injuries. Some factors leading to injury may be beyond an individual s control. By recognizing these factors, strategies can be employed to decrease the likelihood of injury. Some of these include: weather, playing surfaces, hormones (in females), timing and rate of growth, and mechanical disadvantages between genders. ACL injury prevention programs are 70 percent when implemented correctly. 7 The Adolescent Sports Medicine Program at Kinetic Physical Therapy has created an evidence-based ACL Injury Prevention Program designed to decrease the likelihood of ACL injury. These include: strengthening of the posterior chain musculature (hamstring, gluteal, and calf), balance and plyometric training, and patient education on jumping and landing mechanics. The program was designed with limited equipment to allow for easy completion and increased athlete compliance. Like any program, compliance is of the utmost importance. Without consistent completion, it is difficult to develop the necessary strength, balance, and proprioception needed to reduce the likelihood of an ACL Injury.

References 1) Munro A, Herrington L, Comfort P. Comparison of landing knee valgus angle between female basketball and football athletes: Possible implications for anterior cruciate ligament and patellofemoral joint injury rates. Physical Therapy in Sport. 2012;13:259-264. 2) Dharamsi A, LaBella C. Prevention of ACL injuries in adolescent female athletes. Contemporary Pediatrics. July 2013; 12-20. 3) Jacinda Silvers H, Mandelbaum BR. Prevention of anterior cruciate ligament injury in the female athlete. Br J Sports Med. 2007;41:i52-i59. 4) Joseph A, Collins C, Henke N, Yard E, Fields S, Comstock R. A Multisport Comparison of Anterior Cruciate Ligament Injuries in High School Athletics. Journal of Athletic Training. 2013;48(6):810-817. 5) Hootman J, Dick R, Agel J. Epidemiology of Collegiate Injuries for 15 Sports: Summary and Recommendations for Injury Prevention Initiatives. Journal of Athletic Training. 2007;42(2):311-319. 6) Hewett T, Ford K, Hoogenboom B, Myer G. Understanding and Preventing ACL Injuries: Current Biomechanical and Epidemiological Considerations Update 2010. North American Journal of Sports Physical Therapy. 2010;4(5):234-251. 7) Carter C, Micheli L. Prevention of Anterior Cruciate Ligament Injuries. Pediatric Annals. 2012;41(11):447

The Kinetic Physical Therapy ACL Injury Prevention Program Follow this schedule to maximize your injury prevention potential: Dynamic Warm-up: Complete this portion of the program before ALL athletic activities. This should take about 10 minutes and should be completed before the strength program. Strength and Proprioception Program: Complete this portion of the program 2-3 times per week after warmups and before you are tired. You may complete this portion of the program on practice days. This should take about 15-20 minutes. Plyometric Program: Complete this portion of the program 2 times per week with emphasis on control. The plyometric program should be completed on an off-day or after a warm-up and before a light practice day. This should take about 5-10 minutes. Cool-down/Static Stretching: Complete a cool-down stretch after ALL activity. This should take about 10 minutes. This may also include foam rolling, stick rolling, and use of tennis/lacrosse ball for soft tissue work. *Remember: This program should be a priority and is arguably more important than skills practice. You are capable of preventing most ACL tears as well as other overuse and acute injuries if you develop proper lower body control and awareness. This program was designed to require minimal to no equipment so an entire team can complete it at the same time. This program does not replace your normal strength training routine but is a supplement to it. You may complete all power lifting after your warm-up and before your injury prevention exercises. Other strength training may be completed at any point during your injury prevention exercises. This program is designed in conjunction with current research as well as numerous programs that have been proven to prevent ACL tears. Days should not be skipped. This program may be most effective if completed consistently for 6-8 weeks during the preseason and intermittently throughout the season. Focus on proper knee control with ALL squatting, jumping, and landing. The quality of your movements is more important than the quantity. Make sure you practice sitting your hips back and keep knees forward at all times. Do not let your knees come forward past your toes or in towards each other. If you practice this, you are more likely to improve your knee control during games and practices, and protect your ACL from injury. If you have pain while completing any portion of this program, please contact your healthcare provider.

Abnormal Jumping, Landing, and Squatting Mechanics Ligament Dominance Lower extremity valgus at landing (knees collapse inward) Not utilizing the hamstrings to effectively assist the ACL when landing Reliance on ligaments to stabilize knee Quadriceps Dominance Landing in an extended knee position Quadriceps muscles stabilize the knee Underutilization of the hamstring, calf, and gluteal muscles to soften landing Leg Dominance or Residual Injury Deficits Unequal weight transfer when jumping, landing, or cutting Center of mass unequally distributed between legs (causing an inward collapse at knee) Trunk Dominance (Core Dysfunction) Inability to effectively control body weight from moving off center when jumping, cutting, or landing Decreased balance and knee control Knee collapses inward upon landing, jumping, or cutting Correct Landing Mechanics Sit back into your hips (Rely appropriately on quadriceps, hamstrings, glutes, and ligaments to stabilize knee) Chest and head are upright Angle of shins is parallel to trunk angle Center of mass is equally distributed between both legs Do not allow knees to come forward past your toes or cave inward (proper utilization of hamstring, calf, and gluteal muscles)

ACL Injury Prevention: Dynamic Warm-Up Dynamic Stretches: The purpose of a dynamic warm-up is to increase your heart rate, core temperature, blood flow, flexibility, mental focus, and to effectively activate your neuromuscular system to prepare for athletic participation. Research has proven dynamic warm-ups to be more effective than static stretching prior to activity to improve performance and injury prevention. This should take about 10 minutes. Walking Knee Hug Walking Ankle Pull Inverted Hamstring Inchworm Reverse Lunge with Elbow to Instep Spiderman Squat down slightly and bend your right knee up towards your chest. Grab ahold of your knee and pull towards your chest without moving your pelvis or leaning back. Stand up tall, squeeze your left glute, and drive your left foot into the ground. Hold for 3 seconds. Take a step forward with the right foot and repeat with left side. Perform 10 steps. Squat down slightly and reach your right ankle back towards your right glute. Grab ahold of your ankle with your right hand and stand up tall. Reach your left arm straight up overhead. Hold for 3 seconds. Take a step forward with right foot and repeat with left side. Perform 10 steps. Standing on right leg only, bend over from the waist and kick the left heel towards the sky. Maintain a straight line from ear through hip, knee and ankle. Hold in the stretch for 3 seconds then hinge from the hips to return to a stand. Take a step forward with left leg and repeat movement on left leg. Perform 10 total. Get into a plank position with straight arms. Walk hands out a few inches then slowly inch your feet up towards your hands. Press heels into ground and keep legs straight. When you have inched up as far as you can, walk hands back out and repeat. Perform 10 times. Step backward with your left foot into a lunge. Place your left hand on the ground and your right elbow to the inside of your right foot. Hold for 3 seconds. Rotate your right arm and chest to the sky. Hold for 3 seconds. Place your right hand outside your right foot and push your hips to the sky. Hold for 3 seconds. Stand up tall and repeat with other side. Perform 8 total. Get into a plank position with straight arms. Bring right foot up next to your right hand. Keep knee in and toes straight forward. Dip hips down and pick head up. Hold for 3 seconds. Bring leg back to the start and switch legs. Perform 16 total.

Neuromuscular Activation Drills: The neuromuscular activation drills are part of the dynamic warm-up, designed to be completed at the end to effectively wake up your body and prepare your body for sport specific movements. B-Skips Lateral Shuffle to High Knees Backward Running Drive your right knee up and left arm drives forward. Take a small hop and perform the same movement on the other side. When your knee is in the air, straighten your leg before returning it to the ground. Continue skipping for 20 yards. Complete two times. Side shuffle with quick feet for 10 yards. Quick turn to face forward and perform high knees for 10 yards. Keep trunk and hips stable. Perform entire activity twice. Run backwards for 20 yards while staying on your toes with your knees slightly bent at all times. Do not let you knee snap back or lean too far forward. Keep your head up. Complete three times.

ACL Injury Prevention: Strengthening Program Strength training: The strengthening portion of the ACL injury prevention program is geared towards strength, endurance, and activation patterns of the hamstrings, glutes, and core. Most ACL tears result from poor timing between the hamstrings and quadriceps as well as poor knee control due to core and hip weakness. Phase 1: Complete this portion during weeks 1 and 2 Glute Bridge Squat with Miniband Miniband Walks Lunges Plank Side Plank Lie on your back with knees bent. Squeeze your glutes and relax your hamstrings. Drive through your heels and bridge up off the ground by using only your glute muscles. Do not arch your low back to get more height. Hold for 5 seconds at the top then lower back down. Complete 3x15. Place a miniband just above your knees. Stand with feet hip width apart and toes pointed straight forward. Pull knees out slightly against the band. Sit hips down and back into a squat as if you are sitting in a chair. Keep trunk upright. Make sure knees stay in line with your feet. Do not let the band pull knees inwards towards each other and do not let knees go forward past your toes. Pause at the bottom. Complete 3x15. Keep abs tight by gently drawing belly button up and in. Maintain good posture with a resistance band around your knees. Sit hips down and back into a small squat. Rotate knees out into the band and hold them there throughout the exercise. Take small steps to the side. Try to keep tension on the band. Don t lean to the side as you move. Repeat 20 steps to the right and then 20 steps to the left x 3 laps. Stand tall with good posture. Keep feet pointed straight ahead. Lunge forward with one leg. Bend both legs and sink hips straight down. Do not allow your trunk to lean forward or your front knee to go over your toes. Pause at the bottom. Push off front leg to return to the start position. Repeat movement with other leg leading. Perform 2x20. Lie on your stomach with your elbows under your shoulders. Keep feet together. Press your elbows into the floor. Draw your abdominals tight and keep your back flat as you prop yourself up onto your elbows and toes. Hold for 20 seconds. Do not let your low back sag towards the floor. Complete 3 times. Position yourself on your side with your elbow under your shoulder and legs stacked. Make sure your head, hips, and toes are in one straight line. Lift your hips up off the ground and squeeze your glutes. Hold for 25 seconds. Complete 3 on each side.

Phase 2: Complete this portion during weeks 3 and 4 Glute Bridge Skater Deadlift Hamstring Curl Lie flat on your back with knees bent, one foot flat on the floor, and the other knee straight with thighs level. Gently draw abdominals up and in. Squeeze your glute hard and bridge hips up. Keep abs tight, hips level, and low back flat. Hold for 5 seconds, repeat 10 times. Complete 3 sets on each leg. Stand with a miniband just above your knees. Sit hips down and back into a single leg squat. Do not let you knee collapse inward as you reach your other leg back and away from you. Complete 3 sets of 15 on each leg. Pull abs tight by drawing belly button gently up and in. Stand on one foot with a soft knee. Hinge at your hips and sit your weight backwards to lower your chest towards the ground. Keep back leg in line with your body and make sure hips stay level. Complete 2x12 on each leg. Lie flat on your back with knees straight and feet flat on the ball. Gently draw abdominals up and in. Bridge your body up off the floor. Keep abs tight, hips level, and low back flat. Bend both knees and pull feet towards glutes. Pause for one second and slowly return to the start position. Focus is on keeping hips level and not arching your low back. Repeat 3 sets of 10 repetitions. Plank with Taps *If you do not have a ball, slowly walk your feet out and then back in as far as you can go with good hip/core control. You can also do this on a hardwood floor in socks. * Hold the plank position. Lift one leg up and out to the side, tapping your foot on the floor. Repeat 15 times each side, 3 repetitions. Side Plank with Rotation Start in a side plank with top arm straight up towards the ceiling. While keeping abs pulled tight, rotate top arm down and under like you are attempting to reach behind your back at the level of your hip. Pause and return to start position. Complete 3x10.

Phase 3: Complete this portion during weeks 4 and 5 Deadlift with Reach Russian Hamstring Heel Raise Pull abs tight by drawing belly button up and in. Stand on one foot. Slowly lift one leg off the floor and keep back/leg straight and lower chest towards the floor. Keep chin tucked. Go as far as you can without losing balance and while keeping knees straight/back flat. When you are at the lowest point in the movement, lift arms straight up and reach long from hands to feet. Pause for 3 seconds. Lower arms back down and pull from your glute/back of leg to stand up tall. Complete 2x15 on each leg. Start in a kneeling position with your ankles fixed. Lower your trunk and hips forward as one unit. Before the point at which you will fall, pull yourself back up to neutral. Complete 4x8. Stand on one leg with the other leg bent to 90 at the hip, knee, and ankle. Maintain that position as you raise yourself up on your toes. Pause, then lower back down slowly. Complete 2x15 on each leg. Squat Position yourself on one foot and hover the other foot just off the ground in line with your body. Slowly lower down into a single leg squat position. Sit your hips down and back but keep chest upright. Do not let knees go forward past your toes or let your knee cave inward. Complete 3x15 on each leg. Plank with Reaches Side Plank Maintain a good plank position with feet separated slightly wider than normal. Slowly reach one arm straight out overhead, pause, return to a neutral position, and alternate sides. Repeat 3x12 reaches. Position yourself on your side and lift hips up into a lateral plank. Lift your top leg up to about hip height. Do not let your hips drop towards the floor. Hold for 20 seconds, complete 3 on each side.

ACL Injury Prevention: Plyometric Training Plyometric training: The plyometric portion of the ACL injury prevention program is designed to reinforce knee control and proper lower extremity alignment during high impact activities. Plyometric drills allow the athlete to focus on control during eccentric (slowing down) motions in a controlled environment. Phase 1: Complete this portion during weeks 1 and 2 Drop Squat Squat Jump (no countermovement) Squat Jump (with countermovement) Forward Broad Jump Side Broad Jump Diagonal Jump Stand tall with arms out in front of you. Pretend as if the rug is getting pulled out from underneath you and catch yourself in a squat. Complete 12 times, rest for 20 seconds, then complete another set of 12. Stand tall with hands behind head. Squat down, pause for 5 seconds. Jump up as high as you can and land softly back down into a squat. Complete 2x8 jumps with 30 second rests between sets. In one motion squat down and explode upward as high as you can. Land softly back down in a squat. Arms should drive up and down with your movement. Complete 2x8 jumps with 30 second rests between sets. Squat down and jump forward as far as you can. Land softly and repeat; totaling 5 jumps forward. Complete 2 times with 30 second rests between sets. Squat down and jump sideways as far as you can. Land softly and repeat. Jump 5 times to the left and then jump 5 times to the right. Complete twice with 30 second rests between sets. Squat down and jump forward and diagonal to the right. Land softly, and then jump forward and diagonal to the left. Continue zigzagging for 20 yards. Complete 2 times with 15 second rest between sets. 180⁰ Jump Perform a squat jump and twist body 180 so that you are facing the opposite direction when you land. Land softly then jump back to the start position. Complete 6 jumps back and forth. Rest for 30 seconds. Now jump in the opposite direction and perform 6 more.

Phase 2: Complete this portion during weeks 3 and 4 Single to Double Leg Drop Squat Stand on one leg with arms straight out in front of you. Perform a drop squat and catch yourself on both legs. Complete 6 times starting on each leg. Double to Drop Squat Stand on both legs with arms straight out in front of you. Perform a drop squat and catch yourself on one leg. Complete 6 landing on right leg and 6 landing on left leg. Single to Double Leg Squat Jump Squat down on one leg and explode upwards as high as you can. Land softly with weight distributed on both legs equally. Perform 2x6 on each leg with a 30 second rest between sets. Double to Squat Jump Squat down on both legs and explode upwards. Land softly into a squat on right leg only. Perform 6 jumps then perform 6 jumps landing on left leg. Complete 2 sets with a 30 second rest between sets. Split- Stance Jumps Stagger feet into a split-squat position. Bend both knees and lower yourself towards the ground. Explode upwards as high as you can and land softly back down into split-squat. Perform 6 times then switch which leg is in front and perform 6 more. Complete 2 sets with 45 second rests between sets. Start Finish Alternating Split- Stance Jumps Similar to the split-stance jumps you are going to jump from a splitsquat position. Switch legs in the air so that you are going to land with the lead leg in the back and the rear leg in the front. Jump up and alternate legs again. Continue jumping 12 times. Complete 2 times with 45 second rest between sets. Start Finish Forward Bounding Forward bounding is an exaggerated run. Push off right leg to leap forward and land on left. Now, push off left leg and leap onto right leg. Continue alternating 10 times. Complete 2 sets with 30 second rests between sets. Side Bounding Push off right leg to leap sideways to the left and land on left leg. Now, push off left leg leaping back onto your right leg. Perform 10 times back and forth. Complete 2 sets with 30 second rest between sets.

Phase 3: Complete this portion during weeks 5 and 6 Drop Squat Stand on right leg with arms out in front of you. Perform a drop squat and catch yourself on your right leg only. Complete 12 times on each leg. Squat Jump (with countermovement) Stand on one leg, squat down and explode upward as high as you can, land softly in a squat on the same leg. Reset yourself then jump again. Complete 2x8 on each leg with 45 second rest between sets. Forward Hop Stand on right leg, squat down and jump forward as far as you can, and land on softly your right leg. Reset, and then jump again. Complete 3x5 jumps with each leg, rest 1 minute between sets. Side Hop Medial hops: Stand on right leg, squat down and jump sideways to the left as far as you can, and land softly on your right leg. Reset, and then jump again. Complete 2x5 jumps on each leg with 1 minute rest between sets. Lateral hops: Stand on right leg, squat down and jump sideways to the right as far as you can, and land softly on your right leg. Reset, and then jump again. Complete 2x5 jumps on each leg with 1 minute rest between sets. 180⁰ Hop Stand on right leg, squat down, jump up and twist in the air 180 so that you land on right leg facing the opposite direction. Jump back to the start position. Perform 10 jumps back and forth. Complete twice on each leg, resting 1 minute between sets. Diagonal Bounding: Hold Stand on right leg, jump forward and diagonal to the left, and land on left leg. Hold your landing for a few seconds. Reset. Jump off left leg forward and diagonal to the right and land on right leg. Continue alternating for 20 yards. Rest for 30 seconds then complete again. Hold Hold Start Diagonal Bounding: Quick, Hold Stand on right leg, jump forward and diagonal to the left, land on left leg and quickly push off to jump forward and diagonal to the right landing on right leg, and hold the landing for a few seconds. Reset. Perform again, continuing for 20 yards. Rest for 30 seconds then complete again. Quick Hold Quick Start

ACL Injury Prevention: Flexibility Program Choose 3 stretches to complete AFTER activity Wall Calf Stretches Hamstring Stretch Quadriceps Stretch Kneeling Hip Flexor Stretch Kneeling IT-Band Stretch Cross body IT-Band Stretch Piriformis Stretch Straight knee: Stand facing a wall with the leg to be stretched out straight behind you. Keep toes pointing straight and heels down. Bend front knee and lean forward into the wall until a stretch is felt in your calf. Hold for 30 seconds and complete on each leg. Sit in good upright posture on the edge of a couch, bench, or bed. Tighten your quad muscle on the top of your thigh. Lean forward from your waist without slouching. Use your hands to press gently on the top of your thigh to help keep your knee straight. Hold for 30 seconds and complete on each leg. Lie on your left side. Bend knees up towards your chest. Keep your trunk stable and reach your left ankle back and grasp it with your right hand. Without arching your low back, gently pull your thigh backwards. Hold for 30 seconds and complete on each leg. In a half kneeling position (with one leg in front of the other), complete a posterior pelvic tilt by attempting to tuck your glutes under you and flatten out your low back. Gently draw your abdominals up and in until a stretch is felt in the thigh you are kneeling on. Hold for 30 seconds and complete on each leg. In a half kneeling position (with one leg in front of the other), complete a posterior pelvic tilt by attempting to tuck your glutes under you and flatten out your low back. Gently draw your abdominals up and in until a stretch is felt in the thigh you are kneeling on. Reach the arm of your down knee over your head and lean to the side. Hold for 30 seconds and complete on each leg. Lie on your back with a dog leash, rope, bed sheet, or robe tie around your involved foot. Gently pull leg up and across your body until a stretch is felt on the outside or back of your hip or thigh. Hold for 30 seconds and complete on each leg. Lie on your back with one leg crossed over the other and your ankle resting on your other knee. Gently pull your legs up towards your chest by placing both hands on the back of the bottom leg (one hand should reach through your legs). Relax your head/neck downwards. Hold for 30 seconds and complete on each leg.

Trigger Point Release: complete this on problem areas as a cool-down or warm-up Calf Hip Flexor Quadriceps Piriformis & Glutes Start in long sitting with the back of your calves positioned on the foam roller and your hands on the floor. Cross one leg over the other at the ankles to increase your leverage. Your body should be supported by your hands. Use your hands to roll the back calves up and down on the foam roller. This may be uncomfortable. Roll to your tolerance with a goal of about 20-30 rolls. If you find a particularly sensitive location, hold that spot against the foam roller and pump your foot and ankle up/down 10 times. Lie on your stomach with a tennis or lacrosse ball positioned under your iliopsoas muscle (deep muscle between hip bone and ribs outside of belly button). Place the ball in a sensitive location and hold this spot for 10-20 seconds. Repeat for 2 minutes each side. You can complete this with your legs bent or straight depending on the amount of sensitivity. Make sure to breathe deeply. For advanced soft tissue release, slowly rotate a bent knee inwards and outwards. Start face down with the front of one or both thighs positioned on the foam roller. Your body should be supported by your forearms/elbows. Use your elbows to roll the front of your thigh up and down on the foam roller. This may be uncomfortable. Roll to your tolerance with a goal of about 20-30 rolls. If you find a particularly sensitive location, hold that spot against the foam roller and slowly straighten/bend your knee. Lie on your back with a tennis or lacrosse ball positioned under your glute muscles. Roll ball around your glutes from the outside of you hip towards sacrum (the lower portion of your spine between your glutes). If you find a particularly sensitive location, hold this spot for 10-20 seconds. Repeat for 2 minutes each side. You can complete this with your legs bent or straight depending on the amount of sensitivity. Make sure to breathe deeply.