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John Hill, DO,FACSM, FAAFP University of Colorado Director of Primary Care Sports Medicine Fellowship Saturday, May 17, 2014.

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Presentation on theme: "John Hill, DO,FACSM, FAAFP University of Colorado Director of Primary Care Sports Medicine Fellowship Saturday, May 17, 2014."— Presentation transcript:

1 John Hill, DO,FACSM, FAAFP University of Colorado Director of Primary Care Sports Medicine Fellowship Saturday, May 17, 2014

2 Better perform a focused hip examination Recognize and manage improper running biomechanics to prevent injuries Discuss how core stability impacts many running injuries Apply these principles to return the “athlete” back to running

3 You will understand that running is not evil Most of us were born to run!

4 Newton Shoes: Physician Advisory Board MuscleSound: Physician advisor for software development to determine muscle glycogen content using Ultrasound.

5 After running more than 28 hours, I am still smiling, why…. I finally learned what I am going to teach you

6 Tarahumara runner Arnulfo Quimare and Ultra-running legend Scott Jurek

7 Flexed at the waist Heel strike Over striding Low arm position Hip drops with each step Knee collapses in valgus No smile on his face, this dude is suffering

8 copes with impact and takeoff --extends from spine to foot

9 swing support takeoff foot strike 1.Foot strike 2.Support 3.Take-off 4.Swing

10 Intra-articular Chondral Labral Capsular Extra-articular Systemic

11 Snapping hip ITB tendinitis Bursitis Flexor tendinosis SI joint pain Hamstring strain Soft tissue impingement Iliopsoas Athletic pubalgia Hernia Adductor tendinosis

12 Developmental Dysplasia of the Hip Legg Calve Perthes Disease Slipped Capital Epiphysis Previous Trauma


14 History: symptom response Functional Movement Screen Weight Bearing tests AROM PROM with over pressure – Flexion/Abduction Manual muscle testing Distraction/Compression with movement Ligament evaluation Marching test for sacroiliac movement FABER


16 Active/Passive: Flexion (110-120’) Extension (10-15’) Abduction (30-50’) Adduction (30’) Internal Rotation (0-50’) sup/prone External Rotation (30-90’) sup/prone

17 Flexion: Psoas, Iliacus, rectus femoris, sartorius, pectineus, adductor long/brev, gracilis Extension: Biceps femoris, semimembranosus, semitendinosus, glut max, glut med (posterior part), adductor magnus (ischiocondylar part) Adduction: Adductor longus, adductor brevis, adductor magnus, gracilis, pectineus

18 Abduction: Tensor fascia latae, glut minimus, glut medius, glut maximus, sartorius Internal Rotation: Adductor long/brev/magnus, Glut med (anterior part), glut minimus (anterior part), tensor fascia latae, pectineus, gracilis. External Rotation Glut max, obturator int/ext, quadratus femoris, piriformis, gemellus sup/inf, sartorius, glut med (posterior part)

19 Flexion / Adduction / IR

20 Flexion / Abduction / ER


22 Gluteus Medius Strength Test Gluteus Maximus Strength Test Adductor Testing Piriformis Test + if pain with stretching piriformis muscle Fulcrum Test + if pain is elicited Site of pain is usually near site of stress fracture

23 First recognized importance in late 1980s and early 1990s General population: multiple exercise programs and equipment focused on core stability and benefits of improving stability

24 First recognized importance in late 1980s and early 1990s General population: multiple exercise programs and equipment focused on core stability and benefits of improving stability Does this apply to runners?

25 No universally accepted definition of core stability Kibler: “The ability to control the position and motion of the trunk over the pelvis to allow optimum production, transfer, and control of force and motion to the terminal segment in integrated kinetic chain activities”

26 Includes the spine, hips, pelvis, proximal lower limbs, and abdominal region

27 Abdomina ls Paraspinals and Gluteals Diaphrag m Pelvic Floor and Hip Girdle Musculature

28 Strength of the core muscles: Allows the system to mechanically stabilize the spine  then distribute and deliver compressive, translational, and shear forces to and from the rest of the body

29 Plyometric training: Involves exercises in which the active muscles are stretched prior to shortening Usually requires explosive strength training Invokes specific neural adaptations (ie, increased activation of motor units) Less muscle hypertrophy than static strength training Running is a plyometric activity

30 Rehab from injuries: Benefits from strength exercises Benefits from plyometric training Integration of the two improves your results

31 Return to running after an injury: Must be able to demonstrate competence with plyometric exercise (proper running form) To perform plyometric exercises safely, must increase core stability with static load strength training

32 Prevention of injury Treatment of injuries Effect on performance

33 Back pain: delays in trunk motor control reflex are predisposing factor (Cholewicki, 2005) Patellofemoral pain: weakness in the gluteus medius predisposes to PFS (Willson, 2011) Hamstring injuries: early fatigue in abdominal muscles likely a contributor (Devlin, 2000) Knee Ligament injury: increased trunk displacement and decreased proprioception on testing predicted knee ligament injury for females, not males (Zazulak, 2007)

34 Wide variety of movements associated with sports  need sufficient strength in hip and trunk muscles in all three planes of motion Contribution of specific muscles depends on direction and magnitude of trunk loading (Cholewicki 2002)

35 Athletes may have good core strength when tested by low exertion exams Need to do more functional testing Remember, this person is not just walking around the house and going to the grocery store

36 3 tests 1. Pelvic alignment 2. Single leg squat and hop test 3. Side plank with side leg raise

37 Good pelvic alignment: horizontal waist Poor pelvic Alignmen t: forward pelvic tilt

38 Pelvic tilt Forward tilt: often see weakness in quadratus lumborum, rectus abdominis, and obliques

39 Single Leg Squat Global core stability Should see alignment maintained between hip, knee, and ankle Watch for contralateral hip dropping and knee moving into valgus If single leg squat performed competently, move on to lateral step down test

40 Single leg squat Good limb alignment Single leg squat Valgus collapse of knee Single leg side step Good limb alignment

41 Hop test Similar to single leg squat, more dynamic Requires neuromuscular control, core strength and stability Evaluate knee alignment, height of jump, and stable, aligned soft landing

42 Side plank Both sides Measures lateral core strength—Quadratus lumborum Examiner notes how long patient can hold position Ideal length of holding: 45-60 seconds

43 Side plank

44 Side leg raise No trunk flexion Upper leg abducted completely with maximal hip external rotation (toe pointed to ceiling) Fully recruits gluteus medius Examiner resists motion and evaluates strength

45 Side leg raise

46 Combining exercises If proficient with both side plank and side leg raise  combine these exercises Assess neuromuscular coordination, hip adductor strength, and abnormal recruitment of the iliopsoas Weak abductors  recruit iliopsoas and see forward flexion at waist Goal to perform 30 on each side

47 Combined side plank and side leg raise

48 Clinicians should not assume athletes are more competent with dynamic core stability than the general population Dynamic testing can unmask subtle deficiencies

49 Important to achieve adequate static core strength prior to pushing dynamic, plyometric rehab Often therapist or athlete will push dynamic plyometric rehab too soon  re-injury Need at least 3 sets of 15 with combined activity to progress to plyometric rehab

50 Important to maintain once athlete returned to sport Continue 3 sets of 30 of the combined side plank and side leg raise on each side, 3 days per week

51 The focused hip examination often reveals where the problem is It is all about the biomechanics, recognize and manage improper running form Assess core stability and first fix the weakness in their static hip stabilizers Before returning a runner back to running (plyometrics) make sure their static hip stabilizers are strong

52 Akuthota V, Ferreiro A, Moore T, et al. Core stability exercise principles. Curr Sports Med Rep. 2008; 7:39-44. Bonacci J, Green D, Saunders PU, et al. Plyometric training as an intervention to correct altered neuromotor control during running after cycling in triathletes: a preliminary randomised controlled trial. Phys Ther Sport. 2011; 12:15-21. Chelly MS, Ghenem MA, Abid K, et al. Effects of in-season short-term plyometric training program on leg power, jump, and sprint performance of soccer players. J Strength Cond Res. 2010; 24:2670-6. Cholewicki J, Silfies SP, Shah RA, et al. Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine. 2005; 30:2614-20. Devlin L. Recurrent posterior thigh symptoms detrimental to performance in rugby union: predisposing factors. Sports Med. 2000; 29:273-87. DiStefano LJ, Padua DA, Blackburn JT, et al. Integrated injury prevention program improves balance and vertical jump height in children. J Strength Cond Res. 2010; 24:332-42. Earl J, Hoch A. A proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndrome. Am J Sports Med. 2011; 39:154-63. Hewett TE, Lindenfeld TN, Riccobene JV, et al. The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. Am J Sports Med. 1999; 27:699-706. Hölmich P, Larsen K, Krogsgaard K, et al. Exercise program for prevention of groin pain in football players: a cluster-randomized trial. Scand J Med Sci Sports. 2010; 20:814-21. Kibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports Med. 2006; 36:189-98. Kiesel K, Plisky P, Butler R. Functional movement test scores improve following a standardized off-season intervention program in professional football players. Scand J Med Sci Sports. 2011; 21:287-92.

53 Kiesel K, Plisky P, Voight M. Can serious injury in professional football be predicted by a preseason functional movement screen? N Am J Sports Phys Ther. 2007; 2:147-58. Leetun DT, Ireland ML, Willson JD, et al. Core stability measures as risk factors for lower extremity injury in athletes. Med Sci Sports Exerc. 2004; 36:926-34. Markovic G, Jukic I, Milanovic D, et al. Effects of sprint and plyometric training on muscle function and athletic performance. J Strenth Cond Res. 2007; 21:543-9. Markovic G. Does plyometric training improve vertical jump height? A meta-analytical review. Br J Sports Med. 2007; 41:349-55. Nesser TW, Huxel KC, Tincher JL, et al. The relationship between core stability and performance in division I football players. J Strength Cond Res. 2008; 22:1750-4. Okada T, Huxel KC, Nesser TW. Relationship between core stability, functional movement, and performance. J Strength Cond Res. 2011; 25:252-61. Saunders PU, Telford RD, Pyne DB, et al. Short-term plyometric training improves running economy in highly trained middle and long distance runners. J Strength Cond Res. 2006; 20:947- 54. Sharrock C, Cropper J, Mostad J, et al. A pilot study of core stability and athletic performance: is there a relationship? Int J Sports Phys Ther. 2011; 6:63-74. Willson JD, Dernozek TW, Arndt RL, et al. Gluteal muscle activation during running in females with and without patellofemoral pain syndrome. Clin Biomech. 2011; 26:735-40. Zazulak BT, Hewett TE, Reeves NP, et al. Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiologic study. Am J Sports Med. 2007; 35:1123-30.

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