Yudu - sportEX dynamics - 1999-2010

CONDITIONING THE AUTHOR

Ian Jeffreys is currently director of Sport Science and Athletic Performance at Coleg Powys in Brecon, Wales. He is the strength and conditioning coach for the Welsh Schools’ Rugby Union national team at Under 16 level, as well as working with athletes from a range of sports. Ian is an accredited member and director of the United Kingdom’s Strength and Conditioning Association, and a registered strength and conditioning coach with the British Olympic Association. He is a certified strength and conditioning specialist re-certified with distinction, a certified personal trainer and coach practitioner with the National Strength and Conditioning Association.

References 1. Bompa TO. Total training for young champions. Human Kinetics 1991. ISBN 073600212X 2. National Strength and Conditioning Association. Youth resistance train- ing: position statement paper and literature review. Strength and Conditioning Research 1996;18(1):62-75 3. Faigenbaum AD. Age and sex related differences and their implications for resistance training. Chapter in: Essentials of strength training and con- ditioning. Human Kinetics 2000. ISBN 0736000895 4. Bailey D and Martin A. Physical activity and skeletal health in adoles- cents. Pediatric Exercise 1994;6:330-347 5. Faigenbaum AD. Strength training for children and adolescents. Clinical Sports Medicine 2000;19(4):593-619 6. Blimke C. Resistance training during pre-adolescence. Issues and contro- versies. Sports Medicine 1993;15 389-407

7. Falk B and Tenerbaum G. The effectiveness of resistance training in chil- dren. A meta analysis. Sports Medicine 1996;22:176-186 8. Westcott WL and Faigenbaum AD. Clients who are pregnant older or pre- adolescent. Chapter in: NSCA’s essentials of personal training. Human Kinetics 2004. ISBN 0736000151 9. Pearson D, Faigenbaum A, Conley M and Kraemer WJ. The National Strength and Conditioning Association’s basic guidelines for the resistance training of athletes. Strength and Conditioning Journal 2000;22(4):14-27 10. Conroy B, Kraemer WJ, Maresh C et al. Bone mineral density in elite junior weightlifters. Medicine and Science in Sports and Exercise 1993;25:1103-1109 11. Faigenbaum AD and Schram J. Can resistance training reduce injuries in youth sports. Strength and Conditioning Journal 2004;26(3):16-21 12. Smith A, Andrish J and Micheli L. The prevention of sports injuries of children and adolescents. Medicine and Science in Sports and Exercise 1993;25(S8):1-7 13. Committee for the Development of Sport of the Council of Europe. Conclusion of an international seminar for children, Norway. CDDS 1982 14. Falk B and Mor G. The effects of resistance and martial arts training in 6-8 year old boys. Pediatric Exercise Science 1996;5:339-346 15. Faigenbaum AD, Westcott WL, Loud RL and Long C. The effects of dif- ferent resistance training protocols on muscular strength and endurance development in children. Pediatrics 1999;104(1):e5 16. Stone and Wathen. Roundtable discussion: Machines versus free weights. Strength and Conditioning Journal 2000;22(6)18-30 17. Faigenbaum AD, Milliken LA, Loud RL et al. Comparison of one and two days per week of strength training in children. Research Quarterly in Sport and Exercise 2002;73(4):416-424 18. Balyi I and Hamilton A. Long term athlete development update. FHS 2003;20:6-8

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■ Anterior Cruciate Ligament Rehabilitation ■ Rehabilitation for Shoulder Impingement ■ Hamstring Strain Rehabilitation

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Quadriceps stengthening ladder PRACTITIONER PROMPT

PATIENT ADVICE

Patellofemoral pain syndrome rehabilitation WWW.SPORTEX-MEDICINE.COM

Closed chain exercise progression Correct lower limb alignment must be emphasised at all times. The exercises should be pain free at all times. The patients should carry out 3x15 repetitions. The exer- cise should only be progressed when the patient can carry out 3x15 repetitions pain- free with correct lower limb alignment. The patient should start at the level they are able to achieve on assessment without pain and with correct alignment.

Hamstring injury rehabilitation Hop

One leg minisquat with weight

One leg minisquat without support

One leg minisquat with support

Bilateral minisquat with weight

Bilateral minisquat without support

Bilateral minisquat with support

Isometric squat against wall

Signs

Aggravating factor Pain

Tenderness Crepitus Giving way Effusion

Click/clunk Range of movement

PFPS Patella

Running, stairs, Jumping, landing, Standing, Quads activity, Musculo- eccentric quads eccentric quads knee ext Retero-patella

tendonitis Infra-patella Peripatella

Occasional With quads inhibition

Inferior pole

None None

Occasional small Tendinous/ thickening

Older patients None

syndrome apophysitis Hamstring strain

Infra-patella Pole patella, tibial tubercle

Fat pad

None None

Posterior

compartment None

Fat padIschiogluteal bursitis

None Decreased flexion, Decreased flexion, Decreased

Patella mobility Decreased medial Decreased caudally

cephallic

Quadriceps strength

Decreased/ inhibited

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Decreased/ inhibited

Decreased

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for special- ist medical advice in each individual case. To the extent permissable by law, the publisher, editors and contributors accept no liability for any loss, injury or damage howsoever incurred (including negli- gence) as a consequence, whether directly or indirectly, of the use of any person of the contents of this article.

Figure 6: Clinical signs of main causes of anterior knee pain Normal None

particularly squat particularly squat extension and rectus femoris length

Piriformis syndrome

Decreased

caud/ceph caud/ceph pathology

Lumbar spine

Sacroiliac joint pathology

Adverse

Decreased/ inhibited

tibial tubercle None

syndrome of thigh Tibial tubercle

Hamstring syndrome Ischial Pole patella,

thigh

Accurate diagnosis Establish correct diagnosis, differentiate between: ● Hamstring muscle strains ● Posterior compartment syndrome of the thigh ● Hamstring syndrome ● Ischiogluteal bursitis ● Adverse neuromeningeal tension ● Piriformis syndrome ● Lumbar spine pathology ● Sacroiliac joint pathology

Step down

Step up with weight

Step up

Treat pain and inflammation ● PRICE

Patella mobilisation ● Patella in groove/Ober’s position

● Mobilise into resistance Condition Fat pad Traction

Step down with weight

Flexibility ● ITB

Hamstring strengthening Progression of force application: ● mid-range isometric contractions ● mid-range multi-angle isometric contractions ● mid-range concentric-eccentric contractions, slow to fast velocities of contraction

Step-to (side to side)

● Rectus femoris ● Hamstrings ● Gastrocnemuis/Soleus

Control of lower limb alignment ● Gluteus medius coactivation

● outer-range isometric contractions ● outer-range multi-angle isometric contractions

Meniscal rehabilitation

Hamstring flexibility ● Appropriate healing time (14 days post-injury)

● outer-range concentric-eccentric contractions, slow to fast velocities of contraction

● Start partial weight bearing (maximum visual cues) ● Increase limb load ● Decrease visual cues ● Uneven/mobile surfaces ● Use of orthotics to control pronation

● Electrotherapeutic modalities ● Specific soft tissue mobilUisatise fons ● Transverse frictions

●

Patella taping r pain relief

● closed kinetic chain and sport specific actions ● application of force in functionally specific patterns

Menisectomy Phase 1: Maximum protection (3-7 days) Goals ● Protect wound ● Control inflammation ● Full knee extension ● Regain quadriceps control

● for biceps femoris a combination of hip exten- sion, abduction and lateral rotation along with knee flexion and tibial lateral rotation

● Use to facilitate quadriceps activation ● Check for allergic reaction ● Correct patella position

Site of pain on palpation

Plica

increasing intensity knee flex/ext knee flex/ext hamstrings

tendinuous hamstrings hamstrings None

IschialRarely tuberosity

Present

Decreased flexion Normal Piriformis

muscle Normal Lumbar spine Normal

Sacroiliac joint

neuromeningeal tension

(pain medial glide)

None None

Repetitive Effect of SLR Iliotibial band Repetitive

● for semitendinosus/semimembranosus a combination of hip extension, adduction and medial rotation along with knee flexion and tibial medial rotation

● Restore normal gait (elbow crutches first 1-2 days)

● Isolation of stretch to hamstring muscle

● Appropriate direction of stretch

● For biceps femoris a combi- nation of hip flexion, adduc- tion and medial rotation along with knee extension and tibial medial rotation

Onset of symptoms Effect of hamstring Effect of activity

syndrome friction syndrome Positive for

Medial patella Lateral patella Positive for

tuberosity Medial plica Lateral condyle femur/tibia

Tight posterior Negative Present

Positive for hamstrings

Rarely None Decreased extension

Positive for neural

Normal

Positive for neural

Positive for Gradual

Along courseWWW.SPORTEX-MEDICINE.COM of sciatic nerve neural

Gradual Gradual Decreased medially

Positive for neural

Gradual

and slump test (sudden/ traumatic contraction or gradual)

Sudden/traumatic Gradual

ROM - 0o - Pain free range (At 1 week, approximate range 0-120o) Treatment ● Heel slides ● Quadriceps sets, trophic stimulation as required ● Non weight bearing hamstring/gastrocnemius/soleus stretches ● Single leg raise - 4 planes ● Hip abduction/extension ● Patella mobilisations ● Non-operative leg/abdominal circuits ● Isokinetics non-operative leg

● For semitendinosus/semi- membranosus a combination of hip flexion, abduction and lateral rotation with knee extension and tibial lateral rotation

● Progess from sustained static stretches to controlled ballistic stretches

● Single leg raises - 4 planes ● Patella mobilisations ● Hydrotherapy at 4 weeks ● CPM pain free range (up to 0-90o)

Sudden or gradual Gradual

Phase 2: Moderate protection (7-21 days) Goals ● Increase lower extremity strength and ROM ROM - No limits Treatment ● Continue Phase 1 ● Angle specific isometrics knee flexion/extension (30o steps) ● Hydrotherapy, lower limb exercises ● Isokinetics (High speed > low speed) ● Bike ● Swimming, no breaststroke ● Closed kinetic chain exercises (initially bilateral > unilateral) ● Open kinetic chain exercises 0-90o (initially bilateral > unilateral) ● Step ups > step downs ● Calf work ● Proprioceptive work ● Commence jogging > running (pool>trampet>sand>grass) Weak, no pain

Decreased strength Pain increases with and painful

activity No effect No effect No effect

Sitting aggravates, movement eases

Increases with activity, decreases immediately with rest

Very specific activity will

aggravate, relief not immediate on cessation of activity

No effect (occasional, sudden)

Pain increases with activity

Advancement criteria Necessary strength, ROM, endurance and proprioception + no patellofemoral symptoms

Increases and decreases

with certain postures and activities

Weak, no pain (occasional, sudden) Weak no pain Increases and decreases

Phase 3: Minimum protection (21-42 days) Goals ● Safe and gradual return to activity ● Initiate isolated hamstring work ● Improve ROM, strength, endurance and proprioceptive Treatment ● Continue phase 1 and 2 ● Stairmaster ● Hamstring 0-60º ● Sprinting-acceleration/deceleration ● Agility work ● Sports-related drills

with certain postures and activities

Increases with activity, relief not immediate on cessation of activity

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Phase 2: Moderate protection (6-10 weeks) Goals ● Restore normal gait ● Avoid overstressing the repair ● Increase lower extremity strength and ROM ROM - No limits Treatment ● Continue Phase 1 ● Closed kinetic chain exercises 0-60o flexion ● Open kinetic chain exercises 0-90o (45-90o if associated cruciate involvement) ● Calf work ● Proprioceptive work

Advancement criteria Necessary strength, ROM, endurance and proprioception + no patellofemoral symptoms

Phase 3: Minimum protection (10-16 weeks) Goals ● Safe and gradual return to activity ● Initiate isolated hamstring work ● Improve ROM, strength, endurance and proprioceptive Treatment ● Continue phase 1 and 2 ● Stairmaster, stationary bike ● Hamstring 0-60o ● Swimming no breaststroke ● Commence running programme ● Commence functional progression

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Meniscal repair Phase 1: Maximum protection (0-6 weeks) Goals ● Protect repair ● Control inflammation ● Full knee extension ● Regain quadriceps control

ROM - 0-90o Treatment ● Heel slides 0-90o

● Quadriceps sets, trophic stimulation as required

● Non weight bearing gastrocnemius/soleus stretches, hamstring stretches

R PRACTITIONER PROMPT

ACL reconstruction rehabilitation – Part 2 2) Strength, fitness

PRACTITIONER PROMPT

and function Progressive resistive strengthening exercise ● Quadriceps - closed and open chain exercises (in appropriate

range of movement) ● Hamstrings - outer range strength and strength at high veloci- ty contractions ● Gastrocnemius ● Hip adductors & abductors - inner range strength to maintain joint alignment

training ● Static bike ● Rowing, stepper, cross trainers ● Challenge cardiovascular system - monitor heart rate and set appropriate targets ● Running at 12 weeks post op (if proprioception and dynamic control adequate) ● Sport specific training (if passed functional tests) 20-24 weeks post op

3) Functional testing

Screening criteria for functional performance testing ● No pain ● No effusion ● No crepitus ● Full active range of movement ● Symmetrical gait including stair ascent and descent

Progressive cardiovascular and functional

● Lower limb extensor muscle strength (isokinetic eccentric and concentric) LSI > 85% ● 1RM single leg press LSI > 125%

● Isometric 1/2 and 1/4 squat > 45 seconds with eyes closed or open

LSI = Limb symmetry index, divide mean of involved leg by mean of uninvolved leg x 100

M O B I L ISE

● ESIPAREHT Aim - 85% LSI

Error scoring Landing

Balance

Hop tests ● One leg hop for distance - stand on leg, hop as far as possible ● Timed one leg hop - time to hop 6m ● Triple one leg hop for distance - stand on leg hop for three hops as far as possible ● Cross over hop - stand on leg hop for three hops as far as pos- sible, crossing a centre line with each hop

●

N A L Y S E

Multiple single hop stabilisation test Set a 2.5cm target in a diagonal distance set at 50% of patient’s height. The patient must land onto the mark and hold the posi- tion for 5 seconds with hands always on iliac crests.

- not covering tape mark - stumbling on landing - foot not facing forwards - hands off iliac crests

Rehabilitation of the sporting back A

1. Analyse - techniques, training, coping strategies ● Gait analysis ● Orthotics ● On-site assessment

Mechanism of injury

Contributing causes Pain

Congenital defect

Rehabilitation of brachial plexus injury PRACTITIONER PROMPT

Differential diagnosis of nerve root versus brachial plexus lesions Cervical nerve root

Brachial plexus

2. Therapise - anti inflammatory and pain relieving measures ● NSAIDS ● ice packs ● ultrasound ● massage

Parasthaesia Tenderness

3. Mobilise - physiotherapy, osteopathy, chiropractic ● Restricted and dysfunctional segments

Range of movement Muscle power Reflexes

Provocation

- touch down with non-weight bearing limb - non-weight bearing limb touching weight- bearing limb

● Barrow zig-zag run Run right and left handed for timed symmetry score. Aim 85% LSI. STABALISE Start

- non-weight bearing limb moving into excessive flexion, extension or abduction - hands off iliac crests

4. Stabilise - core stability and sclerosant injection ● General exercise ● Specific exercise

5. Customise - sports specific exercise programmes

Specific myotome affected May be normal

Side flexion, rotation and extension with

Prolapsed disc, stenosis, degenerative disease, osteophytes, trauma

Sharp, burning dermatome distribution Dermatomal distribution Cervical spine Decreased

Congenital canal stenosis R

Treat pain ● Local ● Interferential ● Acupuncture ● Ice/heat

compression +ve. Neural tissue provocation increase symptoms. Neural tissue provocation test +ve

● Spinal ● Mobilise ● Stabilise ● Tape

● Trigger points ● Myofascial techniques ● Positional release ● Acupuncture

The key components in cervical spine rehabilitation are ● Prevent re-occurrence

The sporting back pain vortex

Training errors Poor technique Postural imbalance

●

CUS T

Finish 5m

M ISE

O WWW.SPORTEX-MEDICINE.COM

Lumbar segmental dysfunction

● Increase flexibility of the cervical spine and surrounding soft tissue ● Increase the functional strength of the stabilising muscles of the respective joints ● Improve proprioception of the cervical spine ● Correct abnormal mechanics ● Teach functional specific exercise relative to the individuals sport ● Provide psychological support

1 Prevention ● Full neuromuscular assessment of the cervical spine and shoulder girdle

Pain, burning in all dermatomes, +/- trapezius Can be all dermatomes of the arm

C O

Cervical spine and along nerve trunk 1st rib Decreased initially but may return as spasm settles Transient, all myotomes affected May be depressed

N Side flexion with compression or stretch may

test will be +ve and is an important part of the sub-acute stage of assessment

4. Proprioception ● Re-education of the normal feedback

mechanism for local joint control ● Use of ball to assist feedback training

● Neurological deficits require appropriate further investigations ie. x-ray, MRI, EMG ● Differentiate between spondylytic changes in cervical spine versus brachial plexus lesion

● Medical team supervising the player is happy that a full rehabilitation programme to cervical spine, thoracic spine and shoulder girdle has been completed ● Analyse any predisposing factors in technique for that particular sport

2 Improve flexibility ● Manual therapy to cervical spine, thoracic spine and upper limb biomechanical chain

DYSFUNCTION/ PAIN

Ligamentous LOW BACK

● Muscle techniques to maintain range of movement in the scalenii, sternocleido mastoid and trapezius muscles

Tonic muscle inhibition and antalgic postures

insufficiency and segmental instability

3 Increase functional strength ● Local stabilisation of cervical spine before global stabilisation

Muscle wasting and imbalance

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● Muscle techniques to maintain range of movement in the rotator cuff muscles ● Neural tissue mobilisation techniques to each neural pathway affected. Care must be taken in the acute stage of brachial plexus injury as this will increase pain

and control ● Glenohumeral joint ● Tape, manual facilitation ● Active joint centring ● Maintenance of alignment in functional retraining

● Scapular ● Tape, EMG, stimulation, manual facilitation

Retrain alignment

5 Correct abnormal biomechanics

● Ensure normal cervical, thoracic spine and shoulder girdle spine movement

● Physiotherapist discuss with player and coach potential faults in technique which may lead to recurring injury

6 Functional exercises ● Exercises must be specific to the player’s

● Increase lower trapezius and serratus anterior activity

● Reduce upper trapezius, rhomboids and levator scapulae activity

● Maintenance of alignment in func- tional retraining

● Re-educate deep neck flexor muscles – use of pressure biofeedback unit ● Local stabilisation of scapula muscles and shoulder girdle ● Increase isometric and isotonic strength of cervical spine - use of ball, theraband ● Maintain full muscle strength of rotator cuff muscles with functional control of cervical spine

● Trunk/lower limbs ● Deep abdominal control

● Gluteal control individual sport

● Exercises must be progressed from non- contact to contact drills

● Exercises must be completed at match- related speeds before return to match situation

● Full, specific fitness test, active and pas- sive before return to match situation

7 Psychological support ● Physiotherapist to liaise with doctor

responsible for player regarding poten- tial psychological problems post injury

● Whole kinetic chain ● Synergy between glenohumeral joint, scapular and trunk and pelvic stabilisers in functional retraining

● Physiotherapist to discuss with coaches potential problem if player suffers a sig- nificant neck injury

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WWW.SPORTEX-MEDICINE.COM Y U T R

Mobilise ● Spine ● Stiff thoracic spine

● Glenohumeral joint ● Capsulo-ligamentous restrictions

● Pelvis / Hips ● For better pelvic / lower limb control

hardening ● Integration of all of the above boxes

● Specific to sport/ functional activity

● Correction of sporting/ functional biomechanics

I T Functional

diagnoses ● Labral lesions ● Internal impingement ● Disorders of the passive restraints

● Acromio-clavicular joint ● Spinal, neural and cen- tral elements

● Long head of biceps/ biceps anchor

Also consider as possible other

Secondary impingement syndrome PRACTITIONER PROMPT

Stretch to the cervical spine, depression of shoulder, compression of cervical spine

REDUCE LOCAL PAIN

E X C

I T I

O R S Treatment Flexibility

Rehabilitation Rehabilitation schedule schedule

Phase 1(PRICE) Phase 2 (ROM) - PRICE - Exercise rehabilitation

- active and passive pain free range of movement stretches

Rehabilitation schedule

Phase 3 (Loading) Exercise rehabilitation

- PNF stretches Such as hold relax; contract relax. Or

- Hold, relax, hold, contract relax Endurance - - prone knee bends

- low impact step machine - static cycle - 400m walk

- step machine - static cycle

- rowing machine - hamstring run

Rehabilitation schedule

Phase 4 (sport specific) Exercise rehabilitation

- introduce flexibility exercises as stand alone programme

- teach pre-exercise stretching as part of warm-up programme

- step machine - static cycle

- rowing machine

- hamstring running drills - position running patterns

Resistance -

- seated hamstring curl * - standing hamstring curl * - prone hamstring curl * - leg press *

- dumbbell half squat * - dumbbell Romanian dead lift *

- seated hamstring curl * - standing hamstring curl * - prone hamstring curl * - leg press *

- dumbbell squat * - dumbbell straight leg dead lift * - barbell high pull

- dumbbell squat push press - barbell hang clean - barbell clean

- dumbbell squat jumps - dumbbell alternate single arm high pull

- dumbbell static lunge standing hip dips - dumbbell alternate single arm clean - dumbbell static lunge standing dead lifts - dumbbell dead lift and heel raise - dumbbell alternate leg lunges - dumbbell dead lift and heel raise

Other -

- running drills - trampet

- wobble board - ball skills

- ball skills

- controlled game - fitness testing

Key: * = exercises selected as an example in the exercise programme but can be combined with the additional exercises listed above within the appropriate phase.

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