1

Recent Advances in the Rehab of Recent Advances in the Rehab of ACL Ligament InjuriesACL Ligament Injuries

NonNon‐‐ contact injuries 67% contact injuries 67% Greater during competition Greater during competition 82.3%82.3%

Last 15min 35% Last 15min 35% 

Strong Evidence for Strong Evidence for increased hip adduction increased hip adduction momentmoment

Females 5Females 5‐‐9 times greater 9 times greater incidence of ACL tearsincidence of ACL tears

Wider PelvisWider Pelvis

Increased Q angleIncreased Q angle

Mechanism of InjuryMechanism of Injury

Typically nonTypically non--contact contact deceleration deceleration situation with situation with hyperextension hyperextension or rotational or rotational componentcomponent

***Rotational ***Rotational Component****Component****

Mechanics of ACL Tears Mechanics of ACL Tears HyperextensionHyperextension

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ACL common in the Female Soccer ACL common in the Female Soccer PlayerPlayer

Factors in Females for Factors in Females for increased riskincreased risk

‐‐Posture of the knee in landing Posture of the knee in landing –– valgus / hypervalgus / hyper‐‐extensionextension

‐‐Dominant leg over usedDominant leg over usedDominant leg over usedDominant leg over used

--Over powering Quad strength Over powering Quad strength –– Hamstring less effective in Hamstring less effective in reducing anterior reducing anterior translations when knee is translations when knee is extended most protective extended most protective 1515‐‐30 degrees flex30 degrees flex

Perturbation training improves knee kinematics and reduces muscle co‐contraction after complete unilateral ACL ruptureChmielewski, Hurd, Rudolph Axe, Synder‐Mackler  Physical Therapy 2005 Aug  

– Perturbation training reduced quadriceps femoris‐hamstring muscle and quad‐gastroc muscle co‐contraction 

– Prior to training potential copers stiffened their knees with higher co‐contraction and slightly lower peak flexion anglesg y p g

Increased Increased compressive forcescompressive forces from strong cofrom strong co‐‐contraction can contraction can contribute to degeneration of articular cartilagecontribute to degeneration of articular cartilage

– The use of joint stiffening strategy = unopposed quad contraction that can cause anterior tibial translation = increased shear forcesshear forces with over with over powering Quad powering Quad 

– Normal knee kinematics = knee flexion angles increased in copers

Single Leg Hop

Single Leg Hop on Unstable surface

Straight leg position d t b i idoes not bring in hamstring protection

20-30 Degree Angle

is necessary for hamstring activation

Poor angle

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Forces to ACL NWBE vs WBE

ACL loading occurs primarily between 0 – 50E knee flexion.  50‐100E knee flexion reduces ACL strain

Higher ACL loads between 0 and 30E peak 150N in NWBE  compared to 50N WBE

Squatting and Lunge techniques can alter ACL strain 

– Forward trunk tilt recruits the hamstrings = reduced anterior tibial translations compared to a erect trunk

– Anterior knee movement beyond the toes 8cm = increase ACL loading during squat and lunge 

ACL ReconstructionThe primary goal of the reconstruction is to restore stability to the knee and restore its function allowing the patient to return to normal activities, including sports and prevent OA 

Dynamic function of all of the complex neuromuscular control mechanisms, including neuroproprioceptive output characteristics from the limb as well as cerebral and cerebellar sequencing of motor unit q gcontractions, spinal vestibular reflex mechanisms, dynamic muscle strength, and endurance

Recent work has indicated that weakness of the quadriceps after reconstruction of the anterior cruciate ligament primarily reflects a deficit in neural activator drive from the central nervous system rather than a pure muscle weakness – neuromuscular rehab

ACL PostACL Post‐‐op Results op Results 

Rehabilitation out comes:Rehabilitation out comes:

2020‐‐37% Professional 37% Professional football players never football players never return to prior level of return to prior level of functionfunction

24% re24% re‐‐injury rate of injury rate of reconstructed knee reconstructed knee 

24% injury rate of 24% injury rate of contralateral kneecontralateral knee

49% overall of re49% overall of re injury of theinjury of theReview of 48 studies Review of 48 studies –– more more than 5700 patients 63% than 5700 patients 63% returned to prereturned to pre‐‐injury levels injury levels & 2/3’s were not back 12 & 2/3’s were not back 12 months postmonths post‐‐op.op.

44% returned to 44% returned to competitive sportscompetitive sportsArdern et al  Br J  Sports Med 2011Ardern et al  Br J  Sports Med 2011

49% overall of re49% overall of re‐‐injury of the injury of the ACL reconstruction or ACL ACL reconstruction or ACL rupture to the contralateral rupture to the contralateral kneeknee

4040‐‐90% of patients exhibiting 90% of patients exhibiting radiographic OA 7radiographic OA 7‐‐12yrs 12yrs following the surgeryfollowing the surgery

BarberBarber‐‐Westin, Noyes   Objective criteria for return Westin, Noyes   Objective criteria for return to sport following ACL & reto sport following ACL & re‐‐injury rates a injury rates a systematic review  Phys SportsMed 2011systematic review  Phys SportsMed 2011

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ACL Rehab Based on Healing LigamentACL Rehab Based on Healing Ligament

Week 1Week 1‐‐2 2 No aggressive passive movement No aggressive passive movement –– grade II mobilization large amplitudegrade II mobilization large amplitudeRussian current and Isometric exercises Russian current and Isometric exercises Hip strengthening exercises Hip strengthening exercises –– posteriorposterior‐‐laterallateralTrunk endurance exercises Trunk endurance exercises Low Load Prolonged Stretch into extensionLow Load Prolonged Stretch into extensionActive Flexion exercisesActive Flexion exercises bicyclebicycleActive Flexion exercises Active Flexion exercises ‐‐ bicyclebicycle

Week 2Week 2‐‐66CKC exercises for strengthening CKC exercises for strengthening ––single leg squatsingle leg squat‐‐ leg press, Dyn Edge, Lunges, leg press, Dyn Edge, Lunges, Eccentric loadingEccentric loadingPerturbation exercises Perturbation exercises –– balance training balance training ‐‐ vestibular vestibular Passive stretch Passive stretch –– joint mobs into extension and flexion joint mobs into extension and flexion –– Grade III end of rangeGrade III end of range

Week 7Week 7‐‐1616Complex surfaces Complex surfaces –– perturbation and vestibular exercisesperturbation and vestibular exercisesHopping one foot to next Hopping one foot to next –– 30 E flexion angle, Balance complex surfaces30 E flexion angle, Balance complex surfaces

Week 16 Week 16 OKC strengthening QuadsOKC strengthening Quads

Week 17Week 17‐‐24 24 Plyometric exercises (jump training) Plyometric exercises (jump training) –– Aggressive weight training Aggressive weight training 

Balance in the Athlete

Four Systems– Strength of the Hip and Lower Leg

Eccentric loading

Dynamic and Static LE testingDynamic and Static LE testing

– Somatosensory Star Excursion Balance TestStar Excursion Balance Test

– Vision

– Vestibular

Early application of Negative Work via Eccentric Ergometry Following ACL

Case study JOSPT May 2006 Gerber et al.

Semi‐tendinosus‐gracilis autograft initially and then Patella‐tendon after 2nd tear.

3 weeks post‐op patient started an eccentric exercise3 weeks post op patient started an eccentric exercise program for 31 wks over 12 weeks after the repair and 33 sessions after the revision.

Quad strength increased 28% while protecting the repair no anterior shear force

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Eccentric Loading Roi et al described an case of an elite soccer player returning to competition 77 days after ACL surgery by using eccentric resistance training program. 

In 12 weeks quadriceps size and volume increased 28% in the surgically repaired kknee15 weeks post‐surgery the quadriceps strength was 20% greater than pre‐operative measures.Quadriceps atrophy and strength deficits are the greatest during the first 3 months following ACL repair

Histological Changes with Eccentric LoadingPositive changes in tissue structure and mechanical properties as a result of 

eccentric training have been previously described by Shalabi 

Evaluated 25 patients with chronic Achilles tendinopathy before and after an eccentric program using the Alfredson protocol. 12 reps 12 Sets over 12 weeks

Subjects’ tendon volume and intra‐tendinous signal were d i MRI b th d d ith t imeasured via MRI both were decreased with eccentric ex

Improved pain and reduction in fluid content within the tendon may suggest increased healthy collagen deposition. 

Ohberg  found a decrease in tendon thickness and normalized tendon structure measured by ultrasound

Langberg found that Type I collagen synthesis increasedafter eccentric training in a group of twelve soccer players with unilateral  Achilles tendinosis indication of tendon healing. (Initial collagen Type III

Eccentric Loading to Hamstring Strains

Eccentric loading of the hamstrings is performed in the OKC Non wt bearing low velocity eccentric loading exercises– Stiff leg dead lifts– Nordic hamstring exercise– Eccentric backward steps– Eccentric forward pulls– Eccentric Lunge drops - forward flexion with wt ball– Eccentric loading more effective greater changes in neural activation and hypertrophy

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The Role & Implication of Eccentric training in athletic rehab tendinopathy hamstring strains & ACL reconstruction

Lorenz D & Reiman M Internat J Sports PT March 2011

– Eccentric forward pulls Forward flexion with wt ball

Nordic hamstring exercise Eccentric backward steps Stiff leg dead liftsNordic hamstring exercise Eccentric backward steps Stiff leg dead lifts

Dynamic and Static Movement Testing

Eccentric– Step-Down Test– Jump Down Test– Full Squat TestFull Squat Test – Single Leg Squat Test – Unstable knee– Knee Flexion Angles - Hop Test unstable surface R-L –

Activation of hamstrings

Isometric– Single Leg bridge with Dorsi-flexed Ankle – Side Plank Test

Step Down Step Down –– TestTest

Stool or step 8‐inch (20.3 cm)  

Lower R/L leg, so heel touches the ground return to platform touch top of platform

Continue sequence for 30 seconds

C i i hCriteria to watchDo not push off ground as lowering heel/touching

Heel must make contact with slight hesitation both @ down phase & start  phase

Do not allow vaulting up with their touch leg

Greater than 10% difference is significant

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Jump Down   Step down TestsJump Down   Step down TestsValgus Knee  HyperValgus Knee  Hyper‐‐extended   Varus Kneeextended   Varus Knee

Pronated Foot PositionPronated Foot Position

Full & Single Leg Squat in Sports

Lateral shiftSingle leg squat knee over foot

Restricted mobilityFull squat Full Range

Restoring Neuromuscular ControlRestoring Neuromuscular ControlBalance in the Athlete Balance in the Athlete 

SomatosensorySomatosensory-- Vestibular Vestibular –– VisionVisionyyThe muscle must be set on a higher state of readiness to The muscle must be set on a higher state of readiness to 

prevent injury by protecting joints from perturbation forces prevent injury by protecting joints from perturbation forces and be able to perform exceptionally skilled activities and be able to perform exceptionally skilled activities 

performed at high velocities. This higher state of readiness performed at high velocities. This higher state of readiness of the neural control of the musculoskeletal system can be of the neural control of the musculoskeletal system can be 

achieved through neuromuscular training such as achieved through neuromuscular training such as perturbation, plyometrics and vestibular exercisesperturbation, plyometrics and vestibular exercises..

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Neuromuscular ControlNeuromuscular Control

Defined: Defined: subconscious subconscious integration of sensory integration of sensory information that is information that is processed by the processed by the CNS resulting in CNS resulting in controlled, controlled, coordinated muscular coordinated muscular activityactivity

Neuromuscular Control Neuromuscular Control

Interpret Sensory input from the environmentInterpret Sensory input from the environment

Somatosensory Somatosensory –– mechanoreceptorsmechanoreceptorsJoints (Ruffini receptors, golgi tendon organ)Joints (Ruffini receptors, golgi tendon organ)

–– PerturbationPerturbationMuscles (muscle spindles, GTO) Muscles (muscle spindles, GTO) ( p )( p )

–– PlyometricsPlyometrics

Vestibular apparatusVestibular apparatus

Vision Vision –– EyesEyes

Somatosensory TestingSomatosensory TestingStar Excursion Balance Test Star Excursion Balance Test 

Reach Test to Predict LE Injures in Basketball PlayersReach Test to Predict LE Injures in Basketball PlayersPlisky et al. J Orthop Sports Phys Ther 2006;36(12):911-919

Results: The reliability of the SEBT components ranged from 0.82 to 0.87  and was 0.99 for the measurement of limb 

length.

Athletes with anterior right/left reach distance difference greater than 4 cm were 2.5 times more likely to sustain

Incorporated into pre‐participation physical examinations to identify basketball players who are at increased risk for injury.

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Reach TestReach Test

Composite reach distance was the sum of the 3 reach directions divided by 3 times limb length, then multiplied by g , p y100.

Girls – (Basketball) with a composite reach distance less than 94.0% of their limb length were 6.5 times more likely to have a lower extremity injury (P.05).

Classic Test for Sensory Integration and Balance CTSIBSomatosensory Somatosensory –– Vestibular Vestibular –– Vision combined testVision combined test

BESS test BESS test –– balance error scoring system = 9 or less balance error scoring system = 9 or less

Errors: Errors: --Opening eyes, lifting hands from hip, touchdown of nonOpening eyes, lifting hands from hip, touchdown of non--stance stance

foot, step, hop, or other movement on stance foot or feetfoot, step, hop, or other movement on stance foot or feet--lifting forefoot or heel, moving hip into more than 30E flexion or lifting forefoot or heel, moving hip into more than 30E flexion or

abduction, remaining out of position for longer than 5 secondsabduction, remaining out of position for longer than 5 seconds

Comparison of Static and Dynamic Balance in Female Collegiate Soccer, Comparison of Static and Dynamic Balance in Female Collegiate Soccer, Basketball & GymnasticsBasketball & GymnasticsBressel et al J of Athletic Training 2007Bressel et al J of Athletic Training 2007

Theory of neuroTheory of neuro--muscular mechanisms in muscular mechanisms in perturbation training: “Readinessperturbation training: “Readiness””

Johansson and SjolanderJohansson and Sjolander

Neuromuscular training results in Neuromuscular training results in more efficient more efficient processing of sensory input processing of sensory input as well asas well as faster faster selection of the correct motor program resultingselection of the correct motor program resultingselection of the correct motor program resulting selection of the correct motor program resulting in relatively fast but more appropriate movementin relatively fast but more appropriate movement

Results in a Results in a higher state of readiness of higher state of readiness of muscles and joints to respond to perturbing muscles and joints to respond to perturbing forces applied to the joints.forces applied to the joints.

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Somatosensory SystemSomatosensory System

MechanoMechano‐‐receptorsreceptorsMechanoreceptors rapidly and slowly adapting Mechanoreceptors rapidly and slowly adapting receptorsreceptors–– Pacinian rapidly adapting sense sudden movement acceleration or Pacinian rapidly adapting sense sudden movement acceleration or

decelerationdeceleration–– Ruffini & Golgi Tendon slowly adapting Ruffini & Golgi Tendon slowly adapting –– sense joint positionsense joint position–– Training must be performed thruTraining must be performed thru--out the ROM: out the ROM:

Proprioceptors are activated selectively at specific anglesProprioceptors are activated selectively at specific anglesp p y p gp p y p g

Protective mechanismProtective mechanism thru reflexes between the thru reflexes between the ligament and the muscles eg. ACL/Hamsligament and the muscles eg. ACL/Hams

Signals the endSignals the end--range of joint motion facilitating range of joint motion facilitating protective reflexesprotective reflexes

Muscle fatigue and Injury alters Mechanoreceptor input Muscle fatigue and Injury alters Mechanoreceptor input

Training the Somatosensory System Training the Somatosensory System Perturbation TrainingPerturbation Training

Johansson suggested by Johansson suggested by stimulation of stimulation of mechanoreceptors increases mechanoreceptors increases gamma motor activity gamma motor activity increasing muscle spindles increasing muscle spindles sensitivity.sensitivity.Caratta et al Knee Surg Sports Trauma Caratta et al Knee Surg Sports Trauma hhArthr 96Arthr 96

600 soccer/3seasons 300 trained traditional600 soccer/3seasons 300 trained traditional300 proprioceptive training 300 proprioceptive training 

70 ACL tears trad. and 10 ACL tears balance 70 ACL tears trad. and 10 ACL tears balance groupgroup

5 levels of difficulty5 levels of difficultyEach phase of training 3Each phase of training 3--6 days6 daysAll training sessions lasted 30 daysAll training sessions lasted 30 days20 minutes per day20 minutes per day

Perturbation StrategiesPerturbation Strategies

Progressively more challenging Progressively more challenging perturbing forcesperturbing forces

Phase one Phase one –– Perturbation in all directionsPerturbation in all directions

–– Flexion anglesFlexion angles

–– Single leg stanceSingle leg stance

Phase twoPhase two–– Add light sports specific activity Add light sports specific activity 

during perturbationduring perturbation

–– Throwing ball into plyobackThrowing ball into plyoback

–– SL stance SL stance –– kicking kicking ‐‐ reachingreaching

Phase threePhase three–– Increase difficulty of Increase difficulty of 

perturbation by Jumping on to perturbation by Jumping on to unstable surfaceunstable surface

–– Hopping from one foot to the Hopping from one foot to the otherother

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Advance Training Jumping On to Advance Training Jumping On to Unstable surfaceUnstable surface

Neuromuscular Training Muscle Spindle Neuromuscular Training Muscle Spindle Plyometrics PrerequisitesPlyometrics Prerequisites

Strength base Strength base –– Power Squat 60 % body wt.Power Squat 60 % body wt.One leg half squat One leg half squat –– balance & quad strengthbalance & quad strengthStork balance test Eyes open / closedStork balance test Eyes open / closedGood Quad strength MMTGood Quad strength MMTggNo patella femoral pain / poor alignmentNo patella femoral pain / poor alignmentGood landing surface/shoesGood landing surface/shoesNo acute injuries to the foot or ankleNo acute injuries to the foot or ankle

Plyometrics TrainingPlyometrics Training

Stretch Reflex or MyotacticStretch Reflex or Myotactic–– Intrafusal fibers Intrafusal fibers / muscle spindle responds to the rate at / muscle spindle responds to the rate at which the muscle is stretchedwhich the muscle is stretched

Stronger muscle contraction to reduce theStronger muscle contraction to reduce theStronger muscle contraction to reduce the Stronger muscle contraction to reduce the stretchstretch

Stretch shortening cycle Stretch shortening cycle –– rapid deceleration rapid deceleration followed by an immediate rapid accelerationfollowed by an immediate rapid acceleration

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Types of PlyometricsTypes of Plyometrics

Natural Plyometrics Natural Plyometrics ––hopping jumpinghopping jumpingDepth Jumping Depth Jumping –– Only for specific Only for specific

athletes 220lbs no higher athletes 220lbs no higher than 18 inchesthan 18 inches

Explosive jump Explosive jump –– landing mechanicslanding mechanics

Low intensityLow intensity–– Skipping drills, 8 inch Skipping drills, 8 inch

cone hops cone hops –– Lateral boundingLateral bounding

Shuttle 2000 MVPShuttle 2000 MVPVertamaxVertamax

Plyometric Training in Female AthletesPlyometric Training in Female Athletes

Decreased impact forces and increased hamstring Decreased impact forces and increased hamstring torque  AJSM  1996torque  AJSM  1996Hewett, Stroupe, Nance, NoyesHewett, Stroupe, Nance, Noyes

Teaching neuromuscular control of the LE duringTeaching neuromuscular control of the LE duringTeaching neuromuscular control of the LE during Teaching neuromuscular control of the LE during landing and to increase vertical jump landing and to increase vertical jump ResultsResults

After training peak landing forces dec.22% and knee After training peak landing forces dec.22% and knee add & abd moments dec. 50% add & abd moments dec. 50% 

Hamstring power inc. 44% Peak torque ratio Hamstring power inc. 44% Peak torque ratio hams/quad inc. 13%hams/quad inc. 13%

Plyometric TrainingPlyometric Training

4848--72 hours 72 hours recoveryrecovery

2x per week2x per week

6060 90 d90 d6060--90 seconds 90 seconds per exerciseper exercise

5050--100 seconds 100 seconds restrest

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Plyometrics Plyometrics

Plyometric Drills Sports SpecificPlyometric Drills Sports Specific

Balance in the AthleteThe Missing Link

Vestibular (inner ear) CNS

Vision = Three visual oculomotor systems Saccades – smooth pursuit- optokinetic

VOR perception of linear and angular accelerations

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Vestibular SystemVestibular System

Head Head –– Eye coordination mediated by vestibular SystemEye coordination mediated by vestibular SystemVestibular receptors in the inner ear can provide an exquisitely accurate Vestibular receptors in the inner ear can provide an exquisitely accurate representation of head motion in 3 dimensionsrepresentation of head motion in 3 dimensionsPosition of head in reference Position of head in reference  to gravityto gravity

Speed Speed –– Direction Direction  AccelerationAccelerationVOR primary mechanism for GAZE stabilityVOR primary mechanism for GAZE stability

Perception of linear and angular accelerationPerception of linear and angular acceleration

Vestibulo‐0cular Reflex is a system that maintains the stability of the visual field in response to acceleration of the head in a particular direction. Running velocities head acceleration up to 6000 deg/sec

Neural Pathway of VisionCones provide color

vision and areC responsible for acuity (detailed) vision. Fovea

Rods provide night p gvision, peripheral vision, and detect motion

Peripheral Retina

Visual  neural impulses propagate through the optic nerves to the brain centers 

nerve fiber layer

Rods black

Cones red-green

ganglioncells

Visual Workspace and Motor Performance

The spatial environment within which objects and locations exist

Gaze is the ability to bring the critical information required to perform well onto the part of the

th f

Human retina

eye, the fovea,

– that sees with clear acuity.

– for prolonged durations even as they move dynamically in cluttered and difficult environments

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Visual Perception

Visual perception = capture the light with our eyes. – Complex NMC of the extra ocular muscles is required for foveal

visual perception (cones) A useful analogy is to recall that camera person must first point and focus the camera in order to get a nice detailed color picture.

Smooth pursuit system allows fixation of gaze onto aSmooth pursuit system allows fixation of gaze onto a moving object with a frequency of less than 1.2 Hz. = rods

Optokinetic eye movement of equal velocity & opposite direction of head movements

Saccades are used to catch the foveal vision up to faster moving targets or move between targets. While slower to initiate they move the eye at much higher speeds than smooth pursuits.

Visual Angle

Small area on the fovea where we are able to see clearly is 20 – 30 of visual angle

Estimate the size of this area by holding your thumb in front of you at arms length. The widththumb in front of you at arms length. The width of your thumb is about 20 of visual angle projected into space.

The athlete must move their gaze purposely to see the different aspects of a scene with full acuity

Quiet Eye: Is the Final fixation or tracking gaze that is located on a specific location or object in the visuomotor workspace within 30 of visual angle for a minimum of 100ms. (1000ms in one second) Dr. Vickers

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Quiet Eye – Final Gaze

Since the Quiet Eye has been shown in elite athletes to be earlier and longer than that of athletes with lower skill levels Dr. Vickers

It is trainable large increases in performance

The quiet eye is an objective measure of optimal perceptual-motor coordination

The Quiet Eye =

prof golfers longer 500 msec

amateur 250-300 msec

Final Gaze – Quiet Eye‐ DVAAre we helping are athletes see better? 

Seeing the TargetWhat is wrong with Andy’s eyes

Where is the ball?

Roger Federer Vision SystemWatch the ball from the back of the racket

Watch for the contact instead of trying to impossibly watch the ball all the way in.

Keep the head still to the

f ll th h

Keeps the head and eyes still longer before contact and makes it easier for you to prevent the head from jerking

forward during the swing.

follow through

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Balance in the Athlete 

Walking on the balance beam is affected by loss of vestibular function – Compromise of the athletes ability to use the somatosensory  information to control posture – Requires hip or step strategy for center of mass control

Vergence/Teaming

Ability to point both eyes simultaneously on targetOnly automatic in about 30% of

l tipopulationIf one eye off target then not true binocular vision and inaccurate depth perception

Testing the Three Visual Oculomotor Sytems

Vestibular Ocular Reflex

– Saccades

– Smooth Pursuit

Optokinetic– Optokinetic

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Head Thrust Test for Identifying Head Thrust Test for Identifying Vestibular HypofunctionVestibular Hypofunction

Normal Head Thrust ANormal Head Thrust A--BBAA-- Initial starting position eyes are focused on a target cervical Initial starting position eyes are focused on a target cervical

flexion Bflexion B-- Turning to the left upon stopping the head turn eyes are Turning to the left upon stopping the head turn eyes are still on targetstill on targetAbnormal Head Thrust CAbnormal Head Thrust C--E E

CC-- Initial starting position DInitial starting position D-- turned to right eyes are not on target turned to right eyes are not on target EE--eyes make a corrective saccade bring eyes back to targeteyes make a corrective saccade bring eyes back to target

Dynamic Visual AcuityDynamic Visual Acuity

Head movesHead moves

Eyes on targetEyes on target

1Hz combo VOR & COR1Hz combo VOR & COR

3 Hz purely VOR3 Hz purely VOR

Can quantify with eye Can quantify with eye chartchart

Up to 2 line changes (i.e. Up to 2 line changes (i.e. 20/20 20/20 20/50) is WNL 20/50) is WNL Herdman et al 1998Herdman et al 1998

Smooth PursuitSmooth Pursuit Exercise &Exercise & Test for CNS DysfunctionTest for CNS Dysfunction

Head stillHead stillEyes follow target through 20Eyes follow target through 20--40 deg/sec through narrow arc40 deg/sec through narrow arcUnable to maintain image Unable to maintain image on retina over 150on retina over 15000 sec = sec = 15mph15mphTest look for over shoot and/or Test look for over shoot and/or nystagmus of the eyes when nystagmus of the eyes when following a targetfollowing a target

Deteriorates with ageDeteriorates with ageDetects spins of an object, Detects spins of an object, acceleration or decreases in acceleration or decreases in speedspeed

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Saccades Exercise and Test for CNS DysfunctionSaccades Exercise and Test for CNS Dysfunction

Head StillHead StillBallistic eye movements Ballistic eye movements reach speeds excess of reach speeds excess of

900900--100010000/0/sec = 90 sec = 90 mph (145 kph)mph (145 kph)

Important for high velocity Important for high velocity objects such as in baseball, objects such as in baseball, hockey puck, tennis ball, hockey puck, tennis ball, lacrosse, handball etc. lacrosse, handball etc. Test look for over shoot Test look for over shoot and/or nystagmus of the and/or nystagmus of the eyes when moving from eyes when moving from targetstargets

Vestibular  TestingPeripheral  

1‐ Classic Test for Sensory Integration and Balance CTSIB

Eyes open / Eyes closed/ Firm surface / Soft foam ‐ R‐L single leg  

2‐Rhomberg patient stands feet together arms crossed with the eyes closed to see if the patient can maintain balance. 60 sec

It tests vestibular (primarily otolith organs) and proprioceptive balance pathways. The vestibulospinal pathway can be isolated by having the patient stand on a foam surface t i i i i ti i tto minimize proprioceptive input.

3‐ Sharpened‐ Advanced Rhomberg – Feet ‐ Tandem extend head – close eyes –then to single leg

60 sec hold times except single leg (10sec)4‐ Fukuda Test – March Test the patient steps in place with the eyes closed for 

one minute. The patient may turn towards the side of the lesion. It is important to note though that right handed people often drift to the left somewhat with this test. 

5‐ Past Pointing The past‐pointing test is primarily (though not completely) a test of proprioception, and it involves having the patient repeatedly bring his finger to a remembered position with his eyes closed. Patients with vestibular pathology may point more to the side with the lesion.

Vestibular Dysfunction = Physical Limitations in the Athlete 

Unable to focus with quick head movementsPoor hand‐eye coordinationPoor balance compensations hip and step strategies – Make compensations that reduce the athletes agility, 

speed, and performancespeed, and performance– May cause injury

Maintenance of GAZE and Posture interaction of inputs from;– Vestibular– Visual– Somatosensory 

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Patient Case Patient Case -- DancerDancer

PostPost‐‐op ACL reconstructionop ACL reconstruction

4 weeks post4 weeks post‐‐opop

Weakness of the Quads and HamstringsWeakness of the Quads and Hamstrings

Poor balance Poor balance –– history of inner ear infections history of inner ear infections and minor concussions and minor concussions 

Weak posterior hip musclesWeak posterior hip muscles

Hip Strengthening External RotationHip Strengthening External Rotation

Perturbation Training Shuttle BalancePerturbation Training Shuttle Balance

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Balance Positions Balance Positions

Balance & Vestibular TrainingBalance & Vestibular Training

Dynamic Edge Dynamic Edge –– Quad strengthening and Quad strengthening and endurance training & balance trainingendurance training & balance training

Advanced Perturbation TrainingAdvanced Perturbation TrainingPlace kicker football Torn RectusPlace kicker football Torn Rectus

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Sports Specific Rehab DrillsSports Specific Rehab Drills

Sports Specific Rehab DrillsSports Specific Rehab Drills

See Fred Impact

Using Binocular vision

perceives the exact

distance the ball is to

the club

Quiet Eye maintains object

on the fovea directly after

ball contact saccades &

visual pursuit allows him

to follow the ball

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Theoretical VOR in Swing

Take Away Address Follow Through

See Fred After Impact

Uses Saccade to locate rapidly moving ball

See Fred Follow Through

Smooth Visual Pursuittracks ball to groundProvides visual feedback on shot Helps preview next liePrevents anxiety in amateurs

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Vision and Putting for the Elite Golfer

1-Fixation of the hole

longer and uses slow

Saccades of about 500 ms between the hole & ball

2-Directed 2-3 fixations to the hole & ball or club, with saccades linking thesaccades linking the fixations

3- During the stroke maintained quiet eye on the top or back of the ball thru the back swing and forward swing

4- At contact the quiet eye remained on the putting surface for 250ms.

Location of Gaze -Top or Behind the ball

Quiet Eye Drills

Tack & Detect Drill write # 1Tack & Detect Drill write # 1--20 on the 20 on the volleyball receiver calls out the # before volleyball receiver calls out the # before passing it passing it –– progress to letters progress to letters ––combination of bothcombination of both

Volleyball Track and detect drill with barrierVolleyball Track and detect drill with barrier

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Tennis Quiet Eye Drills

Track & Detect drill with a barrier – Net in tennis is covered with a sheet, ball is served from behind the covered barrier receiver tracks ball in flight calls out # orreceiver tracks ball in flight calls out # or letter - Tennis

Track & detect - full body turn 180 degrees after serving called out letters and numbers – Volleyball

Neuromuscular Training SummaryNeuromuscular Training Summary

PrePre‐‐season neuromuscular season neuromuscular training (perturbation) & training (perturbation) & plyometrics can decrease plyometrics can decrease knee injury rates in females knee injury rates in females 

L i j t i litL i j t i lit

Silvers, Mandelbaum, Clin J Silvers, Mandelbaum, Clin J Sport Med, 11, 2001Sport Med, 11, 2001

Heidt, et al, Am J Sports Med, Heidt, et al, Am J Sports Med, 28, 200028, 2000

Lower injury rates in elite Lower injury rates in elite players compared to less players compared to less skilled players skilled players 

PrePre‐‐season conditioning season conditioning and fitness can reduce and fitness can reduce overall injury rates overall injury rates 

Junge, et al, Am J Sports Junge, et al, Am J Sports Med, 30, 2002Med, 30, 2002

Junge, Chomiak, et al, Am J Junge, Chomiak, et al, Am J Sports Med, 28, 2000Sports Med, 28, 2000

Sport Specific RehabSport Specific RehabRestoring Balance in the AthleteRestoring Balance in the Athlete

Strength training to reduce Muscle Strength training to reduce Muscle ImbalancesImbalances

Perturbation trainingPerturbation training

i i h ib l Oi i h ib l OTraining the Vestibular system VORTraining the Vestibular system VOR

Plyometrics Plyometrics ––Explosive powerExplosive power

–– Agility training combination of all the aboveAgility training combination of all the above