8/28/2015
Performance Enhancement Training for the Post‐ Rehabilitated Knee LI District APTA September 17, 2015 Robert A. Panariello MS, PT, ATC, CSCS Professional Physical Therapy Professional Athletic Performance Center New York, New York
“If you do what you’ve always done, you’ll get what you’ve always gotten” Timothy J. Stump MS, PT, USAW
“In a competitive atmosphere, to stay the same is to regress” – NFL Hall of Fame Coach Bill Parcells
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Athletic Performance Enhancement Training for the Post‐Rehabilitated Shoulder LI District APTA September 17, 2015 Robert A. Panariello MS, PT, ATC, CSCS Chief Clinical Officer Professional Physical Therapy Professional Athletic Performance Center
Post‐Rehabilitated Shoulder • Post‐surgical • Non‐op shoulder • DC’d from Rehabilitation with no deficits • Cleared to resume training* – Off Season
• Cleared to resume in‐ season competition
Training the Post‐Rehabilitated Shoulder • Throwing athletes • Non‐ throwing athletes • Rotator Cuff pathology – Anterior instability – Posterior instability • SLAP lesions • Performance Training – Lifting Weights – Arm deceleration techniques
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Rotator Cuff Pathology • Rotator Cuff – Supraspinatus* – Infraspinatus – Subscapularis – Teres Minor
• Concomitant Injury – Anterior Capsule (Instability) – Posterior Capsule (Instability) – Labral tear
Labrum of the Shoulder • Labrum – Ring of fibrocartilage around the glenoid rim – Deepens the glenoid cavity and increases the joint surface area – Anchoring point for ligaments – Biceps inserts at the 12 o’clock position
SLAP Tear • “SLAP” Tear was a coined term by Dr. Steve Snyder • Superior Labrum Anterior to Posterior • 10 – 2 O’clock position • Not all SLAP tears require surgical intervention
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Athletic Performance • The world’s greatest athletes are those that apply the greatest amount of force into the ground surface area in the least amount of time Al Vermeil Don Chu Ralph Mann
Strength Training for the Post‐ Rehabilitated Shoulder • • • • •
Proximal‐to‐distal kinematic sequencing Legs Velocity Torso/CORE Hips Shoulders – Scapular – Rotator Cuff – Arms, Wrist, Hand
The Lower Extremity Contribution to Pitching • Pitchers with greater leg drive will produce greater wrist velocities • Lower Extremity muscles most active during pitching MacWilliams AJSM 1998
– Quadriceps (*Rectus femoris) – Biceps femoris – Gluteus maximus (Pelvic axial rotation velocity) – Adductors Yamanouchi Kurume Med J 1998 Campbell J Strength Cond Res 2010
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Strength and Power Training for the Post‐Rehabilitated Shoulder • The Physical Qualities of Strength – Strength is the foundation of all other physical qualities – Each physical quality is dependent upon it’s preceding physical quality – All physical qualities may be trained simultaneously, however, the training block emphasis is placed Vermeil’s Hierarchy of Athletic Development upon a single physical quality
Upper Extremity Weight Room Exercises • Bench Press Exercise
Fun and Fitness Kids Weight Bench Set
Exercise Modifications for the Post‐ Rehabilitation Shoulder • Bench Press – Rotator Cuff Injury and Shoulder Impingement – Anterior Shoulder Instability and SLAP Lesions – Posterior Shoulder Instability Fees et al AJSM 1993
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BENCH PRESS Rotator Cuff Injury and Impingement • Narrow Hand Spacing – No wider than 1.5 times biacrominal width
• Narrow hand spacing – Minimizes peak shoulder torque while pressing – Reduces anterior/posterior rotator cuff and biceps tendon requirements for humeral head stabilization – Maintains shoulder abduction to less than 45 degrees ‐ decreases compressive forces at the distal clavicle “Distal Clavicular Osteolysis”
Shoulder Bi‐acromial Width
Bench Press Grip • 1.5 Times Bi‐acrominal grip
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Bench Press Modifications Hand Position • Overhand grip (pronated position) • Internal rotation moves biceps tendon from under acromion • Positions supraspinatus muscle portion of RC beneath the anterior acromion
Bench Press Modifications Hand Position • Underhand/Reverse Grip (supinated position) • Places long head of biceps under the acromion during the pressing motion • Supraspinatus is rotated posteriorly from the acromion
Football bar
Bench Press Modifications Anterior Shoulder Instability and SLAP Lesions • Mandatory “handoff” of the bar with all sets – Eliminates risk of subluxation/dislocation during removal/return of bar
• Alternate “flat” and “decline” bench positions with less than 1.5 times biacrominal width grip – Maintains shoulder position below • 90 degrees flexion • 45 degrees abduction • Neutral external rotation* – Football bar
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Bench Press Modifications Rotator Cuff Injury and Impingement • Maintains shoulder extension at less than 15 degrees • The bar “touch” point is superior to the xiphoid process, decreasing the net torque on the shoulder
80 ABD
NO
YES
BENCH PRESS Posterior Shoulder Instability • Wide bar grip • Horizontal abduction of greater than 15 degrees at start of concentric phase of lift • Horizontal adduction less than 20 degrees at finishing position • Mandatory “handoffs” for all lifts
>15 Eccentric ‐> Deceleration (i.e. landing) – Ascent ‐> Concentric ‐> force applied to the GSA
• Two (2) Questions – How do I eliminate the “shift” during the descent? – How deep do I squat?
“Posting” for the Squat Exercise • Often when performing the squat exercise, the athlete will “shift” their body away from the injured/surgical knee during the decent phase of the exercise. “Posting” the non‐op leg assists in correcting this shift.
Post-op knee
Shifting away from the surgical extremity
Non-op Knee
Posting the “good” extremity to correct the exercise “shift”
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How Deep Do I Squat?
Maximum Quadriceps Activity During Squat Exercise Muscle Rectus Femoris
Vastus Medialis
Vastus Lateralis
Knee Flex/Knee Ext
Squat (Degrees)
Knee Descent
83 - 95
Knee Ascent
95 - 83
Knee Descent
71 - 95
Knee Ascent
59 - 95
Knee Decent
69 – 95
Knee Ascent
55 - 95
KF = Eccentric Decent KE = Concentric Ascent
Vertical Hip Height (Strength) in Sprinting • Appropriate vertical hip height: – Decreases ground contact times (i.e. properly inflated tire) – Allows the hamstrings to work as a hip extensor vs. a knee flexor (increased “pawing”)
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The Physical Quality of Power • The rate at which work is done per unit of time • Power = Force X Distance/Time
The Physical Quality of Power • Maximal Strength must be combined with either power (explosive strength) and/or reactive strength to enhance optimal athletic Harris 2000, Tricoli 2005 performance • P = F X D/T Velocity Component – Acceleration – Rate of Force Production (RFP) – The Co‐activation index is reduced with high speed training
The Physical Qualities of Strength vs. Power • ACL Reconstructions • 6 Months Post –op – MVIC (Strength) ‐ 97% Pre‐injury level – Rate of Force Development (RFD) – 63% Pre‐injury level Angelozzi JOSPT 2012
• 12 Months Post –op – Rate of Force Development (RFD) –attained or exceeded 90% Pre‐injury level Angelozzi JOSPT 2012
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The Physical Quality of Power • Acceleration – transpires from a “preparatory” slower movement velocity followed by a higher velocity movement – i.e. NASCAR
• Olympic Weightlifting – 1st Pull transition to the 2nd pull – Requires bar acceleration from a slower preliminary speed
Peak Power Output 4,000 3,500 Power (W)
3,000 2,500 2,000
Power Clean
1,500
Hang Power Clean Mid-thigh Power Clean
1,000
Mid-thigh Clean Pull
500 0 Power Clean
Hang Mid-thighMid-thigh Power Power Clean Pull clean Clean
Comfort JSCR 2011
The Physical Quality of Power • The Rate of Force Development (RFD)
FORCE (N)
Time to develop muscular strength in sports Time for Max Contraction Strength MVIC Aagaard Appl Physiol 2006
200 ms or 300 ms or less greater
TIME
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The Physical Quality of Power • Rate of Force Development (RFD) • ACL Reconstructions – Pre‐injury RFD levels take a year to return Angelozzi JOSPT 2012 • RFD – No preparatory bar movement. Initial bar velocity is zero i.e. Drag Race Car • Olympic lifts from blocks – – – – –
Below the knee At the knee Above the knee Mid‐thigh At the hips (Power Position)
Comparison of Peak Rate of Force Development (RFD) Rate of Force Development (N/s)
16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0
Power Clean Hang Power Clean Mid-thigh Power Clean Mid-thigh Clean Pull
Power Hang MidClean Power thigh Clean Power Clean
Midthigh Clean Pull
Comfort JSCR 2011
Peak Rate of Force Development (RFD) for Different Activities 300
Time (milliseconds)
250 200 Mid-thigh Clean Pull
150
Vertical Jump Countermovement Jump
100
Kawamori JSCR 2006
50 0 MTCP
VJ
CMJ
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Comparison of Peak Ground Reaction Forces 3,000
Force (N)
2,500 2,000 1,500
Power Clean Hang Power Clean Mid-thigh Power clean Mid-thigh Clean Pull
1,000 500 0 Power Clean
Hang Power Clean
MidMidthigh thigh Pull Power Clean
Comfort JSCR 2011
The Physical Quality of Elastic/Reactive Strength • Elastic/Reactive Strength incorporates the Stretch Shortening Cycle (SSC) • Accomplished by ‘shock” or “Plyometric” type training • Short Amortization Phase – Requires muscle and joint “stiffness”
• Olympic Lifts – Barbell requires a second knee bend to clear the knees – 2nd knee bend produces a SSC/RS quality at the Achilles and Patella Tendons enhancing the neuromuscular training of the musculoskeletal system for enhanced force output
Elastic (Strength) Energy
When running tendon is the primary site for the storage of elastic energy (EE) During the SSC storage of potential/EE during the eccentric contraction is utilized as kinetic/EE during the concentric contraction Tendon stretches, recoils, and releases EE At least half of the EE utilized for body propulsion comes from the Achilles and foot tendons!
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Single Leg Hop Test • ACLR extremity had a great asymmetry compared to the non‐involved extremity • The non‐involved extremity performance was less than that of those in the control group Schmitt JOSPT 2012
Ground Contact Time
Ground Reaction Times (EE) in the Post‐Operative Knee
The absence of appropriate levels of elastic strength and stiffness will result in increased ground contact times during the stance phase of the running gait cycle. A protective mechanism of increased ankle plantar flexion occurs at ground contact: Dampens the ground contact forces in an attempt to reduce impact forces upon the knee Negative affect on EE, power, and speed production
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Restoring Elastic/Reactive Strength Qualities • Initiate Ankling Drills – Restoring the elastic strength properties of the Achilles tendon
• Initiate Mach Drills (“A” Series) – “A” Walks, Skips, and Runs • Also restores full knee flexion AROM
• Progress to Olympic Lifts and/or components of the Olympic Lifts (i.e. pulls)
Summary • Restore AROM Knee Flexion • Proper heel placement at inferior fold of the glut • Establishes a proper and efficient swing phased during the running gait cycle
• Restore the Physical Quality of Strength • Foundation of the Physical qualities of Strength • Establishes Muscle and Joint Stiffness (prerequisite for SSC) • Applied force into the ground surface area
Summary • Restore the Physical Quality of Power – Acceleration – Rate of Force Development
• Restore Elastic/Reactive Strength qualities • Reduced ground contact times • Physiological energy efficiency
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