1

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

Concepts For Advanced PerformanceConcepts For Advanced Performance

manginre@ucmail.uc.edu

Objective Measures Objective Measures ““The End AllThe End All””

•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.

�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.

Advances in RehabilitationAdvances in Rehabilitation

33•• Biomechanical studiesBiomechanical studies

•• Clinical studiesClinical studies

Rehabilitation StagesRehabilitation 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 Factor 1: Motion Associated

With Mechanism of InjuryWith Mechanism of Injury

Rotation is a critical motion related to injury and includes both tibial rotation and valgusrotation. 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 non-contact, and occur due to poor body control

Rotational concepts involve

Upper and Lower

Limb

2

Secondary Mechanisms of Secondary Mechanisms of

InjuryInjury

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.

Factor 2 General ConceptFactor 2 General Concept

Form vs. FunctionForm vs. Function

Baseball

Soccer

Cheerleaders

Volleyball

Football

Hockey

Sport vs. Physiology vs. Mechanics

Player = We teach Players a comprehensive

program of strengthening, agility, speed, and endurance

Factor 2:Factor 2:

Advance Reconditioning TrainingAdvance Reconditioning Training

Return to ActivityReturn 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

Factor 2:Factor 2:

Comprehensive ApproachComprehensive Approach

� 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 1Concept 1

Technical SkillTechnical Skill

Rehabilitation teaches

ideal body movement

Quality repetitions,

replicating protective

movement

Age dependent

Injury dependent

Player = learns a systematic

form of self control

Concept 2 Tactile Sensing:Concept 2 Tactile Sensing:

Preparation for a ResponsePreparation 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

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Concept 3 Concept 3

Physical Fitness and RePhysical Fitness and Re--ConditioningConditioning

Exercise Physiology 101

50% Science/50% Art

Injury vs. Performance

Test and MeasuresTest and MeasuresPerformance: Functional

Screens

NFL Combine – Specific

Bench 225

Shuttle 20

40 Yard sprint

Additional elenemts

Pull ups

Body fat

Concept 4 Psychological Concept 4 Psychological

Qualities Functional ProgressionQualities Functional Progression

The mental aspect of

rehabilitation has

been shown to

influence speed and

efficiency

Rehab on the field

Factor 3: Lower Limb Dynamic Factor 3: Lower Limb Dynamic

StabilizationStabilization

Effective

Components

Plyometrics

Technique analysis

Strength training

Core Stability

Ineffective

Components

Lack landing/cutting

training

Balance training only

Resistance training

only

Everyone Makes a Big Deal of Everyone Makes a Big Deal of

Close Chain TrainingClose Chain Training

So What, Only If ItSo What, Only If It’’s Functionals Functional

Paine: reduced anterior displacement by KT-1000

Beynnon and Johnson, Human model, CKC activities reduced stress on graft

Markoff: cadaveric measurement decreased shear, same as Grood

No protection in hyperextensionNo protection in hyperextension

or with rotationor with rotation

Brace for Protection

Advanced TrainingAdvanced Training

Exercises For Lower Extremity Exercises For Lower Extremity

TrainingTraining

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 FlexibilityTypes of Flexibility

Static Stretching:

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.

KICKERS, they tend to do their

own thing

Types of FlexibilityTypes of Flexibility

Dynamic Flexibility:

Actively moving a body part

through a range of motion

with momentum to help

improve neuromuscular

control, speed, and power

development.

Research on Dynamic Research on Dynamic --vv-- StaticStatic

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

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.

Research on Dynamic Research on Dynamic --vv-- Static 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

vaulting decreased after warm up with

static stretching compared with warm-up

alone or warm-up with dynamic stretch.

Dynamic Warm UpDynamic Warm Up Advanced Training StrengthAdvanced 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 SuccessKey to Success

Pick it up off the floor

The Body

One Piece

Rarely Isolate muscle complex

Put it

overhead

Technique

critical

Strength ConceptStrength Concept

Emphasize Posterior Chain

Key to injury Prevention

( Hamstring, Gluteals, Spinal mm)

1. Dead lifts

2. Reverse Hypers

3. Glut/Ham

4. Low intensity

Bryan Mann, Development of the Posterior Chain, 2002

Insert Stacy Andrews

Glut Ham machine

Posterior Chain EmphasisPosterior Chain Emphasis

Step 1, Early

Step 2 Late

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Advanced Training Advanced Training

Limb Control ConceptLimb 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

Advanced Training Advanced Training

Core EmphasisCore Emphasis

The Effect of Core Proprioception on Knee Injuries: Zazulak BT, Hewett TE, et al AJSM, vol 35 2007

Impaired core propriceptionmeasured 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

Trunk ControlTrunk Control

Trunk displacement greater in athletes who suffered

knee ligament and ACL injuries

Lateral displacement was the strongest predictor of

injury

Dynamic Core EmphasisDynamic Core Emphasis

Functional Options

Strength Training as Total Body Strength Training as Total Body

Movement and Functional PositionMovement and Functional Position

Train

movement not

MUSCLE

Lateral Core MovementLateral Core Movement

Lateral Trunk Movement

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Advanced TrainingAdvanced Training

Strength EmphasisStrength EmphasisHigh 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

Patella monitored

Advance TrainingAdvance Training

Neurological Neurological ““ContributionsContributions””

Rich Interplay (Afferent to Efferent) enables Rich Interplay (Afferent to Efferent) enables combination of Active & Passive Elements to combination of Active & Passive Elements to provide provide ““Harmony of motion & functionHarmony of motion & 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

Mechanoreceptor AnatomyMechanoreceptor Anatomy

4 Types Receptors1: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*Nerve supply of the human knee and its functional importance*

John C. Kennedy,John C. Kennedy,†† MD et al.MD et al.

The American Journal of Sports Medicine, Vol. 10, No.6The American Journal of Sports Medicine, Vol. 10, No.6

Neurological Golgi Tendon OrgansNeurological Golgi Tendon Organs

(GTO)(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

Advanced Training Advanced Training

Clinic to the FieldClinic 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 ProgramPlyometric 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 IntermediatePlyometric 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

Advance TrainingAdvance Training

Speed of the GAME/Speed of INJURYSpeed 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

Plyometric AdvancedPlyometric Advanced

Dot drills

Continue trunk

program

Higher level box drills

Resistance front hop

Rotational position

landing

Advanced Training Advanced Training

Clinic to the FieldClinic 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 IntermediatePlyometric 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

Station 1

Dummy Exercises

A) Straight Line Bags

B) Crossing Bags

AGILITY AND QUICKNESS PROGRAM

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

� � � � � � � � � �

Partner Lateral Cone Hop

� � � � � � � � � �

Station 4

A) Plyoball Toss

Chest Pass

B) Plyoball Sit-Ups

10"

18"

Advanced Training Session

Factor 9 FatigueFactor 9 Fatigue

Biomechanical Alterations

Increase anterior shear force

Decreased proprioception

Decreased neuromuscular function

Late onset of lower extremity muscle

activation

Significant difference in the knee valgus-

varus moment

Aerobic ReconditioningAerobic Reconditioning

Functional aerobic

reconditioning

Simulate

Fatigue

Fatigue

Fatigue

FORM - FORM

Carry it for TIME and Carry it for TIME and

DISTANCEDISTANCE

10

1) run 20 yrds in 4 sec.2) repeat 15 times

1) run 40 yrds in 6.5 sec.2) repeat 10 times

1) run 60 yrds in 9 sec. 2) repeat 8 times

1) run 20 yrds backward & uphill. 2) repeat 15 times

w

e

e

k

1

w

e

e

k

2

w

e

e

k

3

w

e

e

k

4

1) run 20 yrds in 4 sec.2). repeat 20 times

1) run 40 yrds in 6.5 sec.2). repeat 15 times

1) run 60 yrds in 9 sec. 2). repeat 8 times

1) run 20 yrds backward & uphill. 2) repeat 20 times

1) run 20 yrds in 4 sec.2). repeat 20 times

1) run 40 yrds in 6.5 sec.2). repeat 20 times

1) run 60 yrds in 9 sec. 2). repeat 10 times

1) run 20 yrds backward & uphill. 2) repeat 20 times

1) run 20 yrds in 4 sec.2). repeat 25 times

1) run 40 yrds in 6.5 sec.2). repeat 20 times

1) run 60 yrds in 9 sec. 2). repeat 10 times

1) run 20 yrds backward & uphill. 2) repeat 20 times

20

40

60

BWK

20

40

60

BWK

BWK

60

40

20

60

40

20

BWK

Example of Running Program

Basketball Sprint Program

Aerobic Reconditioning RetroAerobic Reconditioning Retro

Initiation of retro

training can occur by

Stairmaster

Band Training

Treadmill

Progress to incline

Aquatic

Return to Play AssessmentReturn to Play Assessment

Subjective

Examination (I.e.

pain)

Baseline

Measurements

Muscle evaluation

Joint Arthrometer

Functional Hop

Testing

Sports-Specific

Testing

No one gold standard, must piece

together results and use expertise

Return to Play AssessmentReturn to Play AssessmentArthrometryArthrometry testingtesting

KT-1000 evaluation high

level reliability

Developed as a

measuring tool to aide

clinical manual exam

User dependent

Return to Play AssessmentReturn to Play AssessmentObjective Muscle EvaluationObjective Muscle Evaluation

Many choices are

available:

MMT grading system

clinician dependent

Hand-Held

Dynomometer

Isokinetics dependent

on velocity of test

Functional Testing Critical to Functional Testing Critical to

Return to PlayReturn to Play

Single Leg Hop

Cross Over Hop

Time Hop

Triple Hop

Distance

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Return to Play AssessmentReturn to Play Assessment

Medical Clearance ≠ Return to Play

Cornerback Assessment

Return to Play CriteriaReturn to Play Criteria

Normal base

measurements

KT 1000 < 3 mm

Balance tests <20%

Isokinetic testing <10%

Functional Hop tests

<15%

Return to PlayReturn to Play

Position SpecificPosition 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

Conclusion and OutcomeConclusion and Outcome

Clear understanding of normal anatomy and biomechanics

Restoration of normal movement patterns

Selection of appropriate exercise to restore normal function

THANK YOUTHANK YOU ReferencesReferences

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 ConceptsFactor 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

Initial ligament injury occurs withInitial ligament injury occurs with

Sports, Work Related Function,

or activities of daily living

Compensation

with activities

of daily living Re-injury

Meniscus tear

Arthritis

Rehabilitation is Performance Rehabilitation is Performance

TrainingTraining

Technical Skill

Ambulation patterns

Sports specific movements

Occupational specific

Tactical Sense

Proprioception

Kinesthetic awareness

Physical Fitness

Strength

Power

Speed and endurance

Psychological QualitiesTactical Sense

Factor 3: Lower Limb Dynamic Factor 3: Lower Limb Dynamic

StabilizationStabilizationBasic ConceptsBasic 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