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Concepts For Advanced Performance
Robert Mangine, M.Ed., PT, ATC
National Director Sports Residency Program
NovaCare Rehabilitation
Associate Athletic Director of Sports Medicine
University of Cincinnati
Department of Athletics
Adjunct Clinical Instructor of Orthopedics
University of Cincinnati
Department of Orthopedic Surgery
Objective Measures “The End All”
All”
•
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Advances in Rehabilitation
The commonly held belief is that restoration of
“measurable” structural and biomechanical parameters
to a joint indicates restoration of normal function.
INTRODUCTION:
Emerging clinical and basic science findings indicate a much
greater degree of underlying biological complexity in the joint.
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• Biomechanical studies
• Clinical studies
Evidence suggests that restoration of identifiable structural
abnormalities alone is not sufficient to restore a joint to its full
pre-injury level of physiologic function.
Rehabilitation Stages
Acute: immediate intervention, pain,
motion, early muscle loss
Intermediate: motion restoration, low
resistance program, core training
Advanced: performance training
Goal of this talk
Evaluation, determine return to play
Factor 1: Motion Associated
With Mechanism of Injury
Rotation is a critical motion
related to injury and includes
both tibial rotation and valgus
rotation. Advanced
rehabilitation recreates and
controls these mechanisms on
the patient as positions change.
A critical factor is preparation as
the body alters its position
during performance
Majority of injuries are noncontact, and occur due to poor
body control
Rotational concepts involve
Upper and Lower
Limb
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Factor 2 General Concept
Form vs. Function
Secondary Mechanisms of
Injury
Hyperextension
High load demand on
cruciates, not
protected by close
chain
Valgus / Varus
load application
rarely results in
sufficient force
unless accompanied
by a secondary load.
Sport vs. Physiology vs. Mechanics
Baseball
Soccer
Cheerleaders
Volleyball
Football
Hockey
Player = We teach Players a comprehensive
program of strengthening, agility, speed, and endurance
Factor 2:
Advance Reconditioning Training
Factor 2:
Comprehensive Approach
Return to Activity
Advance Training must
consider the patient goals
and activity level:
These are complex
interventions that failure
may result in salvage
surgery
–
Functional
Progression
SKILL
PHYSICAL FITNESS
TACTILE SENSING
PSYCHOLOGY FACTORS
Concept 1
Technical Skill
Rehabilitation teaches
ideal body movement
Quality repetitions,
replicating protective
movement
Age dependent
Injury dependent
Player = learns a systematic
Advance Training must
consider the patient goals
and activity level:
These are complex
interventions that failure
may result in salvage
surgery
–
Functional
Progression
SKILL
PHYSICAL FITNESS
TACTILE SENSING
PSYCHOLOGY FACTORS
Concept 2 Tactile Sensing:
Preparation for a Response
Design program to
correlate with
exercise demands
Follows the
scientific basis of
exercise physiology
Teach athlete a
reflex response to
external stimulation
form of self control
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Concept 3
Physical Fitness and ReRe-Conditioning
Exercise Physiology 101
50% Science/50% Art
Injury vs. Performance
Concept 4 Psychological
Qualities Functional Progression
Test and Measures
Performance: Functional
Screens
NFL Combine – Specific
Bench 225
Shuttle 20
40 Yard sprint
Additional elenemts
Pull ups
Body fat
Factor 3: Lower Limb Dynamic
Stabilization
Effective
Components
The mental aspect of
rehabilitation has
been shown to
influence speed and
efficiency
Plyometrics
Technique analysis
Strength training
Core Stability
Ineffective
Components
Lack landing/cutting
training
Balance training only
Resistance training
only
Rehab on the field
Everyone Makes a Big Deal of
Close Chain Training
So What, Only If It’
It’s Functional
Paine: reduced anterior
displacement by KT1000
Beynnon and Johnson,
Human model, CKC
activities reduced
stress on graft
Markoff: cadaveric
measurement
decreased shear, same
as Grood
Brace for Protection
No protection in hyperextension
or with rotation
Advanced Training
Exercises For Lower Extremity
Training
Comprehensive rehabilitation of the
lower extremity complex requires all
available techniques, the dependent
variable among patients is the ability to
follow up in a controlled manner. The
program must not only account for
effectiveness but also be practical and
easily implemented in a home or school
setting.
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Types of Flexibility
Types of Flexibility
Static Stretching:
Dynamic Flexibility:
Inhibition of tension receptors in our
muscles. When done properly, static
stretching slightly lessens the
sensitivity of tension receptors,
which allows the muscle to relax and
to be stretched to greater length.
Typically held for 10-30 seconds.
Actively moving a body part
through a range of motion
with momentum to help
improve neuromuscular
control, speed, and power
development.
KICKERS, they tend to do their
own thing
Research on Dynamic -v- Static
Dynamic -v- Static Stretching Warm-up: The
Effect on Power and Agility Performance
Danny J. McMillan, Josef H. Moore, Brian S. Hatler, and Dean C.
Taylor
Research on Dynamic -v- Static
Static and Dynamic Acute Stretching Effect on
Gymnasts Speed in Vaulting
Pediatric Exercise Science, 15, 383-91. Siatras, T.,
Papadopoulos, G., Mameletzi, D., Gerodimos, V., &
Kellis, S. (2003).
Conclusion: Gymnasts running speed during
Results/Conclusion: Tested in T-Shuttle (agility), underhand
MB toss (upper body power), and 5 step jump (lower body power).
All 3 trials showed dynamic significantly better
than static or no warm up.
Dynamic Warm Up
vaulting decreased after warm up with
static stretching compared with warm-up
alone or warm-up with dynamic stretch.
Advanced Training Strength
Olympic Lifts
Posterior Chain
Dead Lift
Stiff leg single leg dead lift
Single arm high pulls
Control weight overhead, serves multiple
purposes and balance functions
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Key to Success
Pick it up off the
floor
The Body
One Piece
Rarely Isolate
muscle complex
Strength Concept
Emphasize Posterior
Chain
Key to injury Prevention
( Hamstring, Gluteals,
Spinal mm)
1. Dead lifts
2. Reverse Hypers
3. Glut/Ham
4. Low intensity
Put it
overhead
Technique
critical
Bryan Mann, Development of the Posterior Chain, 2002
Posterior Chain Emphasis
Step 1, Early
Insert Stacy Andrews
Glut Ham machine
Step 2 Late
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Advanced Training
Limb Control Concept
Core Training Series
Total Lower Extremity
Training
Functional PNF patterns
Double leg bounding low
level Plyometrics
Single limb position 20% of
training time +++++++
Single Limb with external
stimulation
Use 3 to 4 exercises and keep sets and reps low,
Provide proper warm up
Trunk Control
Trunk displacement greater in athletes who suffered
knee ligament and ACL injuries
Advanced Training
Core Emphasis
The Effect of Core Proprioception
on Knee Injuries: Zazulak BT,
Hewett TE, et al AJSM, vol 35 2007
Impaired core propriception
measured by active repositioning
of the trunk, predicted knee
injuries in female but not males.
3.3 fold increase in injury
Each degree of error in repositioning
resulted in 3.3 fold increase in odds
ration of ligament/meniscal injury of
the knee
Dynamic Core Emphasis
Functional Options
Lateral displacement was the strongest predictor of
injury
Strength Training as Total Body
Movement and Functional Position
Lateral Core Movement
Train
movement not
MUSCLE
Lateral Trunk Movement
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Advanced Training
Strength Emphasis
High resistance leg Press
Limited Knee extension
Full ROM Hamstring
Hip work, Inner/Outer thigh
Squats partial vs. full
Periodization program alter 8
week cycles
Eccentric emphasis, single leg
High load after healing period
Advance Training
Neurological “Contributions”
Contributions”
Rich Interplay (Afferent to Efferent) enables
combination of Active & Passive Elements to
provide “Harmony of motion & function”
function”
Active - Muscular Stiffening of Joints (Eccentric is
absorbing energy), key to middle of range
Passive - Non Contractile Soft Tissues, key to End
Range
Affected by Magnitude of stretch, velocity of
stretch, and time
Time between stretch stimulus and shortening
response must be short
Patella monitored
Mechanoreceptor Anatomy
4 Types Receptors
1:Ruffini corpuscles (type
I: pressure)
2:Pacini corpuscles (type
II: velocity)
3:Golgi-Mazzoni
(type III: pressure)
4:Free nerve endings (type
IV: pain)
Nerve supply of the human knee and its functional importance*
John C. Kennedy,†
Kennedy,† MD et al.
Neurological Golgi Tendon Organs
(GTO)
One of two systems that monitor muscle
stiffness, the Muscle Spindle is the
other
Present in Tendon as a stretch receptor
in lower bundle to nerve ratio then first
theorized
Responds to stretch on Tendon
Response slower then muscle
The American Journal of Sports Medicine, Vol. 10, No.6
Advanced Training
Clinic to the Field
Successful Rehabilitation
transition clinic simulation to
field activity
1:Training technique
2:Start to push functional
conditioning
3: Mentally push athlete
4: Integrate strength and
position coach
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Plyometric Warm up Program
Trunk rotations
Trunk side bends
Trunk PNF patterns
Band Kicks
Double leg bounding
Jump Rope
Speed ladder
Use 3 to 4 exercises and keep sets and reps low,
this is warm up
Plyometric Intermediate
Cross over hops
Lateral cup or cone hops
Forward and lateral bag
hops
Lateral bag and ball toss
Lateral hop and 2
direction tubing
Plyometric Advanced
Dot drills
Continue trunk
program
Higher level box drills
Resistance front hop
Rotational position
landing
Advance Training
Speed of the GAME/Speed of INJURY
Reciprocal reaction: must
incorporate acceleration and
deceleration maneuver into
program
Power and endurance timing:
incorporation of closed chain
exercises to facilitate impact
loading
Compressive Loading: Incorporation
of closed chain exercise to
facilitate landing mechanics
Enhances neurological feedback
Advanced Training
Clinic to the Field
Successful Rehabilitation
transition clinic simulation to
field activity
1:Training technique
2:Start to push functional
conditioning
3: Mentally push athlete
4: Integrate strength and
position coach
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Advanced Training Session
AGILITY AND QUICKNESS PROGRAM
Station 1
Plyometric Intermediate
Dummy Exercises
A) Straight Line Bags
B) Crossing Bags
Cross over hops
Lateral cup or cone
hops
Forward and lateral
bag hops
Lateral bag and ball
toss
Lateral hop and 2
direction tubing
Station 2
Dot Drills
- Heel on each dot (start)
- 5 drills: 6 times each
- 1st day - 80 sec. or less
- 1st Mon- 65 - line & big
-60 - skilled
Station 3
A) Plyoboxes
up/down
side to side
10"
18"
Partner Lateral Cone Hop
Station 4
A) Plyoball Toss
Chest Pass
B) Plyoball Sit-Ups
Factor 9 Fatigue
Aerobic Reconditioning
Biomechanical Alterations
Functional aerobic
reconditioning
Simulate
Fatigue
Fatigue
Fatigue
FORM - FORM
Increase anterior shear force
Decreased proprioception
Decreased neuromuscular function
Late onset of lower extremity muscle
activation
Significant difference in the knee valgusvarus moment
Carry it for TIME and
DISTANCE
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Example of Running Program
w
e
e
k
Basketball Sprint Program
1) run 20 yrds in 4 sec.
2) repeat 15 times
20
1) run 40 yrds in 6.5 sec.
2) repeat 10 times
40
1) run 60 yrds in 9 sec.
2) repeat 8 times
1
w
e
e
k
1) run 20 yrds backward & uphill. BWK
2) repeat 15 times
1) run 20 yrds in 4 sec.
2). repeat 20 times
20
1) run 40 yrds in 6.5 sec.
2). repeat 15 times
40
1) run 60 yrds in 9 sec.
2). repeat 8 times
1) run 20 yrds in 4 sec.
2). repeat 20 times
1) run 40 yrds in 6.5 sec.
2). repeat 20 times
40
1) run 60 yrds in 9 sec.
2). repeat 10 times
4
60
1) run 20 yrds backward & uphill.
2) repeat 20 times
1) run 20 yrds in 4 sec.
2). repeat 25 times
Stairmaster
Band Training
Treadmill
20
3
w
e
e
k
Initiation of retro
training can occur by
60
1) run 20 yrds backward & uphill. BWK
2) repeat 20 times
2
w
e
e
k
Aerobic Reconditioning Retro
60
Progress to incline
BWK
Aquatic
20
1) run 40 yrds in 6.5 sec.
2). repeat 20 times
40
1) run 60 yrds in 9 sec.
2). repeat 10 times
60
1) run 20 yrds backward & uphill.
BWK
2) repeat 20 times
Return to Play Assessment
Return to Play Assessment
Subjective
Examination (I.e.
pain)
Baseline
Measurements
Joint Arthrometer
Functional Hop
Testing
Sports-Specific
Testing
Arthrometry testing
KT-1000 evaluation high
level reliability
Developed as a
measuring tool to aide
clinical manual exam
User dependent
Muscle evaluation
No one gold standard, must piece
together results and use expertise
Return to Play Assessment
Objective Muscle Evaluation
Functional Testing Critical to
Return to Play
Triple Hop
Distance
Many choices are
available:
MMT grading system
clinician dependent
Hand-Held
Dynomometer
Isokinetics dependent
on velocity of test
Single Leg Hop
Cross Over Hop
Time Hop
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Return to Play Assessment
Return to Play Criteria
Normal base
measurements
KT 1000 < 3 mm
Balance tests <20%
Isokinetic testing <10%
Functional Hop tests
<15%
Cornerback Assessment
Medical Clearance ≠ Return to Play
Return to Play
Position Specific
Differences exist between the
baseball thrower and the
quarterback in terms of
frequency and type
( pitches vs. passes and
number of type of pitches)
The Quarterback is exposed by
his position at the time of
release to traumatic impact
Contact from a anterior or
posterior blow results in high
skeletal forces with the arm
in a vulnerable angle
THANK YOU
Conclusion and Outcome
Clear understanding of
normal anatomy and
biomechanics
Restoration of normal
movement patterns
Selection of appropriate
exercise to restore normal
function
References
Kennedy JC, Alexander IJ, Hayes KC. Nerve supply of the human knee and its functional importance.
AJSM.1982; 10: 329 - 335
Mangine RE, Kremchek TE. Evaluation based protocol of the anterior cruciate ligament. J Sport
Rehabil.1997; 6; 157-181.
Barber SD, Noyes FR, Mangine RE, McCloskey JW, Hartman W. Quantitative assessment in normal an
anterior cruciate deficient knees. CORR. 1990; 255: 204-214
Noyes FR, Barber SD , Mangien RE. Abnormal lower limb symmetry determined by functional hop test
after anterior cruciate ligament rupture. AJSM. 1991; 19: 513-518
Wilk et al. The relationship between subjective knee scores, isokinetic testing, and functional testing in
the ACL reconstructed knee. JOSPT. 1994; 20: 60-73
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Factor 1 Functional Return Concepts
Rehabilitation starts
Immediately after the
injury we need a
aggressive plan that
starts in the acute
phase
Proper acute
intervention speeds
return
Sports, Work Related Function,
or activities of daily living
Compensation
with activities
of daily living
Rehabilitation is Performance
Training
Technical Skill
Ambulation patterns
Sports specific movements
Occupational specific
Tactical Sense
Proprioception
Kinesthetic awareness
Physical Fitness
Strength
Power
Speed and endurance
Psychological Qualities
Initial ligament injury occurs with
Tactical Sense
Re-injury
Meniscus tear
Arthritis
Factor 3: Lower Limb Dynamic
Stabilization
Basic Concepts
Advanced functional training is a integrated
approach of the neuromuscular system
Incorporate functional demands on the body
based on physiologically accepted concepts
Designed to improve performance and
prevention of repeat injury.
Control knee and ankle mobility to avoid
unwarranted motions
Return neuromuscular system function to load
demand
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