5/29/16
Injuries inBasketball:FromtheAmateurAthlete
totheNBA
Philip A.Anloague, PT, DHSc,OCS, MTC.Universityof Dayton
Donald S.Strack,PT,DPT, OCS, FAAOMPT, ATC,Oklahoma CityThunder
Carl Eaton, PT, DPT, ATC, IndianaPacers
Objectives
• Compareandcontrasttheincidence,prevalence,andtrendsassociated
withcommonlyreportedbasketballrelatedinjurieswithothersports.
• Examinethecurrentresearch related tothepredictionofcommoninjuries
incollegiateandNBAplayersthroughfunctionaltesting,clinicalmeasures,
andpre-seasonassessment.
• Identifyhowthepathomechanics associatedwithlowerextremityinjuries
caninformthepractitionerindevelopingtreatmentstrategiestominimize
injuryrecurrence.
• Discriminatethecontroversiesandrecognizethelimitationsassociated
withdesigningrehabilitationprogramsandevaluatetreatmentoptionsand
determinebestpracticesfortreating lowerquarterinjuriesassociatedwith
basketballplayers.
InjuriesinBasketball
1
5/29/16
Starkey,C.Injuriesandillnessesinthenationalbasketball
association:a10-yearperspective(JournalofAthleticTraining,
2000)
Frequency
• Professional basketball has evolved
into acontact sport that emphasizes
athletic speed and power.
• Despite advances, there is no
evidence that the number of injuries
in professional basketball has
declined over the last decade.
• There was a 12.4% increase in game
related injuries. (1988 – 1997)
• NBA rate of game-related injury is
2xs that of collegiate players
(n=9904)
AnkleSprains
*942(9.4%)
Days Missed
5122(7.7%)
PFInflammation
803(8.1%)
*7569(11.5%)
LumbarStrain
491(5.0%)
3365(5.1%)
Knee Sprains
258(2.3%)
5712(8.6%)
1988 – 1997 (1094 Players )
G ames Mis s ed
InjuryintheNational
BasketballAssociation:
A17-YearOverview
(SportsHealth:A
Multidisciplinary
Approach,2010)
17.50%
8.80%
Patellofemoral
(11.9%)
7.40%
Ankle (13.2%)
6.60%
Knee (HS 3.3%)
Drakos ,MCet al.
Lumbar (7.9%)
ACLTearsinNBA
6
5
5
6
5
4
3
2
1
2
2
1
2
5/29/16
Harrisetal.Return-to-Sport andPerformance
AfterACLReconstruction inNBAPlayers.Sports
Health,2013
SPORTS HEALTH
• RTS:FiftyNBAplayers(86%),7FIBA/D-League
players(12%)
• 98%ofplayersRTSintheNBAtheseason
followingACLR
(11.6± 4.1monthsfrominjury).
• Twoplayers(3.1%)requiredrevisionACLR.
• Career lengthfollowingACLRwas4.3± 3.4years.
• 40%occurredinthe4 th quarter.BMI:25+/- 2.1
• Conclusion:There’shighRTSrateintheNBA
followingACLR.
ographic data of NBA players
n
players
r of ACL tearsa
y
y mass index, kg/m2
e
64
69
25.7 ± 3.5
25.0 ± 2.1
35
34
s of experience in NBA
CL tear
4.1 ± 3.0
Figure 2. Number of ACL tears per year in the NBA.
29
23
12
d
All-Stars
ry prior to ACL tear, US$
ming
on game
quarter
nd quarter
quarter
h quarter
on practice
on basketball
son basketball
sketball related
13 (20%)
1.73
45
11 (24%)
6 (13%)
10 (22%)
18 (40%)
4
10
8
2
ad a primary ACL tear; 2 players had bilateral
s ACL tears; 1 player had a primary and retear in the
ayer had a primary and 2 retears in the same knee.
were unable to return to play in the NBA but
urn to professional basketball in either the
league. Thus, the rate of return to professional
ll was 98%. The sole player who did not
g professional basketball anywhere tore his
L 3 years prior and successfully returned to the
njury but did not return after his most recent
y, he did return to professional baseball as a
inor leagues.
/12; 100%) returned to the NBA after ACL
ersus 95% (21/22) of forwards and 71%
s. Those unable to RTS in the NBA played in
or NBA D-league. Survival (participation in
ame in the regular season) within the NBA
econstruction is illustrated in Figure 3. The rate
reconstruction was 3.1% (2 players required
onstruction for ACL retear [3 knees; 1 player
ons]). Performance upon RTS following ACL
Figure 3. Number of players in the NBA before and after
ACL reconstruction (solid line) or post–index year for
controls (dashed line) (years 1-5).
reconstruction (Table 2) was significantly declined in the
following parameters (vs presurgery): mean games per season;
minutes, points, and rebounds per game; and field goal
percentage. In addition, there were significantly fewer players
selected for the All-Star team following ACL reconstruction
(vs preinjury). Nevertheless, annual salary was significantly
increased after ACL reconstruction.
The control population (Table 3) was not significantly different
from the case population (in comparison of year of ACL
reconstruction [cases] and index year [controls]) (P = 0.63 [age],
P = 0.24 [BMI], P = 0.72 [seasons NBA experience], P = 0.15
[salary], P = 0.00 [position]). Mean control player age was 25.5 ±
3.4 years. Mean BMI was 24.8 ± 2.2 kg/m2. Mean total number
of years played in the NBA was 9.7 ± 3.4 years. Seven control
players are still in the NBA. There were 23 forwards, 29 guards,
and 12 centers. There were 15 All-Stars in the control group.
Performance in the season following the index year in controls
(Table 3) was significantly declined for the following parameters:
mean games per season; points, rebounds, assists, blocks, and
steals per game; and field goal and free throw percentage.
In addition, there were significantly fewer All-Star selections
following the index year in controls. Nevertheless, annual salary
was significantly increased after the index year in controls.
Minhas SVetal. TheEffectofanOrthopaedic Surgical
ProcedureintheNationalBasketballAssociation.AJSM
RTP Rate
2016.
• Predictors NRTP: Age 30 years & BMI 27
kg/m 2
• Achilles tendon repair & arthroscopic
knee surgery had significantly greater
decline in post-op performance
outcomes at the 1- and 3-yrs and had
shorter career lengths.
• Minhas, 2015: Operatively treated LDH
players had adecline in PER (–1.76 ± 0.85
vs 0.42 ± 0.64, P = 0.049)
• Amin (2013) Achilles Rupture
565
98.1%
93.5% 90.2%
84.6% 81.5%
70.8%
• 7/18(39%)never returned
• 11/18(61%)played 1season
• 8/11played2seasons
1988 – 1997 (1094 Players )
27.92%
Prevalence ofbasketballrelated musculoskeletal
injuriesamonguniversity
players
(AJPHERD ,2012)
18.91%
15.31%
10.81%
Ankle Knee Back
Thigh
9%
Shoulder
8.10%
ELLAPEN TJ,etal.
Hand
3
5/29/16
Gordon etal.CollegeandProfessionalWomen’s
BasketballPlayers’LowerExtremityInjuries. Int J
ATHLETICTHERAPY&TRAINING ,2014
Carteretal.RiskofInjury inBasketball,Football,and
SoccerPlayers,Ages15YearsandOlder.JAT,2011
• Descriptive epidemiology study. US
2003-07
Injury Type
48.4%
• Rates of ER treated injuries resulting
from participation in basketball,
football, or soccer.
• Using the U.S.population as the
denominator demonstrated the highest
injury rate in basketball and the lowest
in soccer.
• Using hours ofparticipation as the
denominator demonstrated ahigher
injury rate in football than in basketball
or soccer for both nhales and females.
14.5%
11.0%10.8%
4.7%
1.3% 1.1%
Fletcheret al.EpidemiologicComparisonofInjuredHighSchool
BasketballAthletesReportingtoEmergencyDepartments&theAthletic
TrainingSetting.JAT,2014
• Design:Descriptiveepidemiologystudy.(2005-11)
• ER=1,514,957(95%confidenceinterval=1,337,441;1,692,474)
• InjuryType:Lacerations, Fractures
• AT Room:1,064,551(95%confidenceinterval=1,055,482;1,073,620)
• InjuryType:Sprains &Stains
4
5/29/16
HighSchoolBasketball
• Wang etal: High variations of postural sway in 1-leg standing test related to
increased prevalence of ankle injury in basketball players. ArchPM&R,
2006.
• McGuine et al: Pre-season balance measurement (postural sway) served as
a predictor of ankle sprain susceptibility. Clin J Sport Med, 2000
• Fu AS: Ankle repositioning errors and postural sway in stance increased in
basketball players with multiple ankle sprains. Am JSports Med, 2005
• Plisky et al: Components of the SEBT to be reliable and predictive measures
of lower extremity injury in high school basketball players. JOSPT, 2006
FunctionalTesting
•
Screen: IdentifyRisk
• Calculate Risk
•
Triage: Urgency
•
•
MovementandMotion
ComponentsofMovement/Motion
•
Continuum
•
Assistinprogramdesign
•
Createfunctionalbaseline
•
MonitorProgress
•
“Howdothepartsfit?”
MedicalScreen
(JohnsHopkins)
• Ascreeningtestisdonetodetectpotential healthdisordersordiseases
inpeoplewhodonothaveanysymptomsofdisease.
• Thegoalisearlydetectionandlifestylechangesorsurveillance,to
reducetheriskofdisease,ortodetectitearlyenoughtotreatitmost
effectively.
• “Screeningtestsarenotconsidereddiagnostic,butareusedtoidentify
asubsetofthepopulationwhoshouldhaveadditionaltestingto
determinethepresence orabsenceofdisease.”
5
5/29/16
Whatisnormalmovement?
TheUtilityofFunctionalMovement
Assessment andSelectClinical
Measures inPredicting
InjuryinNBAPlayers
•
Philip A.Anloague, University ofDayton
•
Donald S Strack, Oklahoma City Thunder
• Steve Short, Denver Nuggets
•
Carl Eaton, Indiana Pacers
FunctionalMovementScreen
• Purpose:
• AssessFundamentalMovementPatterns
• Fillsvoidbetweenpre-participation/pre-placementscreenings
andperformancetests
• Determine readinessforRTS
• Identifyrisk:Injurypreventionandperformancepredictability
• Assistwithfunctionalrecommendationsfordeveloping
programs/protocols
6
5/29/16
Author
Interrater Intrarater
51
ShultzSummaryofResults
Ka=0.38
ICC=0.6
Other
Livevs.VideoICC=
fromReliabilityStudies 0.92
ICC=0.81-0.91 Similar results
onFMS
regardless ofFMS
Smithetal.52 ICC=0.89
Gribble 20
Teyhen56
ICC=0.946
ICC=0.771
ICC=0.76
Onate 39
Elias15
experience
AT’swith>6
monthsexperience
AT’swith<6
monthsexperience
SummaryofResults
fromReliability
StudiesonFMS
ICC=0.74
ICC=0.98
ICC=0.92for
intersession
reliability
ICC=0.906
Schneiders50 ICC=0.971
SummaryFMSScoresfrom
PreviousStudies
Author
Kiesel etal
Peate etal
Chorba etal
Score
14
16
14
Subjects
NFL Players
Firefighters
Collegiate Female
Athletes
Chapmanetal
14
Elite Track &Field
Athletes
Teyhen etal
14
Military Personnel
Bardenett etal
O’Connoretal
Azzam MG etal.
Average
13.0
14
13.2
14.03
HS Athletes
Marines
NBAPlayers
• Theaveragecutscorefor
previous studies that
studied different
populations was 14.4
• Ability topredict injury is
inconsistent
• Maybemore effectivefor
identifying individuals with
anelevated riskof LE
injury, at leastin similar
cohorts
Azzam MGetal.TheFunctional MovementScreen
asapredictor ofinjury inprofessionalbasketball
playersCurrentOrthopaedic Practice,2015
• Preseason FMS: single NBA team over 4 seasons.
• Injury: musculoskeletal condition that prevented an athlete from participating
in practices or games > 1 wk
• 17/34 sustained injury
• Mean FMS = 13.2(range: 7-19; SD= 2.6)
• Injured players did not have asignificantly lower mean FMS score than noninjured players (P = 0.16)
• A positive correlation existed between the hurdle test and injury (P = 0.004);
however, no other sub-score of the FMS correlated with injury.
7
5/29/16
Y-Balance LowerQuarter
• Purpose:toassessmotorcontrolandfunctionalsymmetry.
• TheYBTallowsustoquarterthebodyandlookathowthecoreandeach
extremity functionunderbodyweightloads.
• TestingProcedures:
• 6practicetrials in3 directions
• 3trials RA, LA, RPM, LPM,RPL, LPL
• Scoring
• >4cmdifferencebetween R &Lis significant
• Composite = (Anterior + Posteriomedial + Posterolateral) X 100
(3xLimbLength
Author
Findings
Plis ky et al,2006
HS Bas ketball players with anterior reach dis tance difference > 4cm were 2.5xs more likelyto
s us tain LEinjury (P .05).
Trojian & McKeag
HS & intercollegiate athletes with apos itive SingleLeg Balance tes t who did not tape their
ankles had anincreas ed likelihood ofdeveloping ankles prains (8.82 (1.07 to 72.70))
Fullam K etal, 2014
Kinematic s tudy. Sagittal-plane hip-joint angular dis placement was greater, during the anterior
reach, with YBTwhen compared, on average, to the SEBT
W as s inger et al,
2014
Significant ↓ant reach direction &calculated overall s tanding balance after having U Efatigue
protocol. Sugges ts that dis tant fatigue has aneg impact on dynamic s tanding balance.
G arris on etal, 2015
Deficits inYBT anterior reach at12 weeks following ACL-R appear to identify thos e participants who may not achieve s ugges ted thres holds on hop meas ures at the time ofreturn to s ports .
KANG, M;etal. Relationship Between the Kinematics ofthe Trunk andLower
Extremityand Performance on the Y-BalanceTest. PM & R:Journal of Injury,
Function &Rehabilitation. 2015.
• OBJECTIVES:Toidentify the kinematicpredictors thatbest explain variancein
performanceon theYBT-LQ.
• Ankle DF:bestsingle predictorof normalized reachin the anterior direction (r2 =
0.50)
• Ankle DF&TrunkBB: explained 65%of thevariancein theanterior normalized reach.
• Hip Flexion:best single predictor ofposteromedial (r2=0.60)andposterolateral (r2=
0.71)normalized reaches.
• Hip Flexionwith ipsilateral and contralateraltrunk bending accountedfor69% and
80% ofthe varianceinthe posteromedial and posterolateral normalized reaches,
respectively.
8
randomized. Participants were asked to try again if they
placed the reach foot on the reach indicator for support,
Statistical Analyses
kicked the reach indicator for further reaching distance,
The assumption of normality of all variables was verified
lost their balance before returning to the start position (eg,
using the Kolmogorov–Smirnov test. The means and
contacting the ground with the reach foot or removing
standard deviations of the normalized reach distances and
hands from hips), or did not maintain contact between the
12,13
ankle kinematics in each direction during the YBT-LQ
heel of the stance limb and the stance platform.
For
and WBLT were determined. The correlation coefficient
normalization of the reach distance, the reach distance in
indicator as far as possible along the pipe each
without
heel-off
belimb
placed
on the
the wall
forthebalance.
Three
practice
trials
(r) and
proportion of
variance
(r2) explained
by the
direction
was divided by the
length from
relationship
betweenthen
resultsperformed
on the WBLT and
both
ankle
anterosuperior
iliac spine to the medial
malleolus
andand
then 3 test
(Figure 1).13 Six practice trials were given
to minimize
were
given,
trials were
for
the
dorsiflexion and the normalized reach distance in each
multiplied by 100.11–13 The mean value of the normalized
22
learning effects, and 3 successive test reach
trialsdistance
wereinthen
The mean
of on
thethe3YBT-LQ
trials was
calculated
direction
were examined
using for
simple
the 3 test trialsWBLT.
in each direction
was value
for data
analysis. data analysis.
performed in each direction. The order ofdetermined
directions
was
Measurement during the WBLT was performed using
randomized. Participants were asked to an
tryinclinometer
again if and
they
tape measure as described by Bennell etfor
al5 For
the WBLT, participants
placed the tested
placed the reach foot on the reach indicator
support,
Statistical
Analyses
foot on the floor with the great toe and center of the heel
kicked the reach indicator for further reaching
distance,
perpendicular to the wall. Participants were instructed to
The
assumption
lost their balance before returning to the start
position
(eg,
lunge forward so that their knee contacted
a line drawn of normality of all variables was verified
on theor
wall.
Foot position was moved
progressively
backusing
the Kolmogorov–Smirnov
test. The means and
contacting the ground with the reach foot
removing
ward in 1-cm increments until the knee could not touch
of the normalized reach distances and
hands from hips), or did not maintain contact
between
the
the wall
without heel
lift. Smallerstandard
increments deviations
of 0.1 mm
12,13 For
were subsequently
applied to achieve
maximal
ankle-DF in each direction during the YBT-LQ
ankle
kinematics
heel of the stance limb and the stance platform.
PROM without heel lift. For the WBLT, the examiner
WBLT were determined. The correlation coefficient
normalization of the reach distance, the reach
distance
in (Zebrisand
placed the
inclinometer
Medical GmbH, Isny,
(r)tuberosity
and theandproportion
of variance (r2) explained by the
15 cm below
read
each direction was divided by the limb Germany)
length from
the the tibial
the inclination of the tibia relative
to vertical from
the
relationship
results on the WBLT and both ankle
anterosuperior iliac spine to the medial malleolus
then from the wall to the greatbetween
ground, andand
the distance
toe
dorsiflexion
normalized
reach distance
ininclinometer
each
recorded
using a tape measure
(Figure 2). Duringand
the theFigure
multiplied by 100.11–13 The mean value ofwas
the
normalized
2 — Weight-bearing-lunge
test using (A)
WBLT, the opposite limb was placed
behind the
and (B) tape
measure.
The arrow indicates
distance
from wall
ontested
the YBT-LQ
were
examined
using
simple
reach distance in the 3 test trials in each
was 6 and thedirection
limbdirection
with 1 foot length,
hands were allowed to
to great toe using tape measure.
64
Kang et al
5/29/16
Kangetal.AssociationofAnkleKinematicsandPerformanceontheYBalanceTestWithInclinometerMeasurementsontheWeight-BearingLungeTest,2015
determined for data analysis.
Measurement during the WBLT was performed using
• WBLT results
were significantly
correlated
an inclinometer
and tape measure
as described by Benwith ankle
DFin 5all directions on the YBT-LQ
(P <.05).nell et al For the WBLT, participants placed the tested
foot on the floor with the great toe and center of the heel
• A strong correlation
between the
perpendicularwas
to thefound
wall. Participants
were instructed to
inclinometer
measurement
of the WBLT and
lunge
forward
so thatwhereas
their kneethe
contacted
ankle DF(r
= .74,
r2 =.55),
tape- a line drawn
on
the
wall.
Foot
position
was
moved
progressively
backmeasure results on the WBLT were
wardcorrelated
in 1-cm increments
untilDF
the(r=
knee
could not touch
moderately
with ankle
.64,
the wallthe
without
heel lift.
Smaller
increments of 0.1 mm
r2 = .40)during
anterior
reach
on the
YBT-LQ. were subsequently applied to achieve maximal ankle-DF
without
heel lift.reach
For the
WBLT, the examiner
• Only thePROM
normalized
anterior
distance
placed the
inclinometer
(Zebris
Medical GmbH, Isny,
was significantly
correlated
with
the results
Germany) 15(r
cm
below
tibial tuberosity
and read
for the inclinometer
= .68,
r2 the
= .46)and
the
2
tape measure
(r= .64,of
r the
= .41)
the WBLT.
the inclination
tibiaon
relative
to vertical from the
ground, and the distance from the wall Figure
to the1 —great
toe
(A) Anterior, (B) posteromedial, and (C) posterolateral reach directions on the Lower Quarter Y-Balance Test using
was recorded using a tape measure (Figure
2). During
the Y-Balance
test kit.the
Figure 2 — Weight-bearing-lunge test using (A) inclinometer
WBLT, the opposite limb was placed behind the tested
and (B) tape measure. The arrow indicates distance from wall
limb with 1 foot length,6 and the hands were allowed to
to great toe using tape measure.
OVERMOYER, GV;REISERII, RF. RELATIONSHIPSBETWEENLOWER-EXTREMITY
FLEXIBILITY, ASYMMETRIES, ANDTHEYBALANCE TEST. JournalofStrength&
Conditioning Research.2015
• Procedures:ConductedAROMmeasuresandcorrelatedwithYBTon20
activeyoungadults.
• Significantcorrelations(p≤0.05):
• AnkleFigure
DF AROM
knee flexion:
Ant, PL,andand
Composite
directional
scores
(r=0.4971 — at0°
(A) Anterior,
(B) posteromedial,
(C) posterolateral
reach
directions
on the Lower Quarter Y-Balance Test using
0.736).
the Y-Balance test kit.
• Ankle DF AROM at90° knee flexion: Ant,PL, PM, and Composite directional scores (r=
0.472-0.795).
• Hip flexion AROM: PL, PM, and Composite directional scores (r= 0.457-0.583).
• YBT may be related toLE flexibility deficit asymmetries
• Additional Tests
Assessing Movement
9
5/29/16
Inter-relatedFactorsontheContinuum of
Stability
Structural
Compliance
• Bony
Architecture
• Concave-Convex
Relationships
• Range ofMotion MuscleDensity MuscleStrength
MuscleStiffness Inhibition
• Flexibility
MotorControl
JointStiffness
• Facilitation
• Physiology
(Collagen)
• JointMobility
• Tension
Stiffness
Dynamic
LegStiffness
• Morphology
(bodytype)
• Neural Tension
Structural
Clinical
Measures:
“Drilling Down”
Stiffness
Compliance
Dynamic
TEYHEN DSetal.CLINICALMEASURESASSOCIATEDWITHDYNAMIC
BALANCEANDFUNCTIONALMOVEMENT. JournalofStrengthand
ConditioningResearch,2014
• Purpose:todeterminetheassociationbetweenspecificmeasures of
power,strength,flexibility,balance,andendurancecomparedwith
moreglobalmeasures usingtheYBTandFMS,inhealthysoldiers.
• Participants(n=64;53M,11W)healthyactivedutyservice
members(25.2+/- 3.8years,25.1+/- 3.1kgcenterdotm(-2)).
• AsignificantPearsonproductmomentcorrelation(r>0.2andp<
0.01)wasusedtonarrowthenumberofvariablesofinterest.
• Twohierarchicalstepwiseregressionanalyseswereperformedto
determinethemostparsimonioussetofvariablesassociated withthe
YBTandFMSperformancescores.
10
5/29/16
the
TM
Journal of Strength and Conditioning Research
| www.nsca.com
Results
1.
Superior YBT
•
•
FMS lunge
UE mobilitytests
• ↑ gastrocnemius flexibility
•
2.
↓ numberofhopsduringa6-mhop
test
Measures of Balance and Movement
Superior FMS
•
•
•
•
Figure 1. A multivariate model (R = 0.72, R2 = 0.51) that demonstrated improved performance on the Y-Balance Test was associated with better performance
on the functional movement screen in-line lunge, greater shoulder and upper trunk mobility on the FMS shoulder/trunk mobility test, increased ankle dorsiflexion
on the gastrocnemius flexibility test, and decreased number of hops during a 6-m timed hop test. Univariate relationships are provided in the figure.
↑ anteriorreachontheYBT
↑ distanceonthecrossoverhoptest
↑ hamstringflexibility
↑ levels ofself-reportedfunction
was the dependent measure. When FMS composite score
sequentially and assessed using 5 blocks, respectively. When
was the dependent measure, YBT scores were considered
FMS composite score was the dependent measure, the indepotential independent variables. However, FMS component
pendent measures of power, strength, flexibility, endurance,
scores were not included in this analysis. The original set of
balance, and the non-FMS functional movement measures
potential independent variables was narrowed to a smaller
with a correlation $0.20 were entered sequentially and asgroup of interest by only retaining those variables with a unisessed in 6 blocks, respectively. A significance level of p #
variate correlation with an absolute value $0.20.
0.05 was required to enter into the model, and p . 0.06 was
The independent variables with a correlation $0.20 were
the criterion for removal (66,67).
then entered into a hierarchical stepwise backwards regresDescriptive statistics between the predicted and measured
sion to determine the most parsimonious set of variables
values were calculated to provide an estimate of the error in
associated with dependent measure. When YBT normalized
the regression equation. Regression diagnostics were percomposite score was the dependent measure, the indepenformed to assess the resulting regression equation. The
dent measures of power, strength, flexibility,
endurance, and
desired minimum number of 60 participants for this study
Figure 2. A multivariate model (R = 0.70, R2 = 0.50) that demonstrated improved performance on the functional movement screen was associated with
functional
measures
a correlation
$0.20
werehoped
entered
was hop
determined
the
“ruleand
ofhigher
thumb”
approach
increased anterior
reach onwith
the Y-Balance
Test, greater
distances
on the crossover
test, greater using
hamstring
flexibility,
levels of
self-reportedfor
throughtheLEfunctionalscale
function on the lower extremity functional scale. Univariate relationships are provided in the figure.
T2
T3 F1
Form&Function
regression studies (63), which specifies the need for 15 par(r = 20.35, p = 0.004), and greater gastrocnemius flexibility
The hierarchical stepwise backwards regression analysis model (F = 11.813, p , 0.001) developed to
ticipantsTABLE
per 4.variable
in the final model. Additionally,
(r = 0.38, p = 0.004).
assess the association with functional movement screen composite scores.*
descriptive statistics were calculated to summarize the
Functional
Movement beta
Screen
Analysis
Unstandardized
(95%
Standardized
demographic and clinical measurements used in this study.
The mean FMS CI)
composite score was
2.0 points.
Variables
Mean (SD)
beta15.7 6 VIF
All statistical
analyses were performed using SPSS software,
Pearson product moment correlations (r $ 0.2, p # 0.01)
version Constant
17.0 (SPSS, Inc., Chicago, IL, USA).
NAyielded 19
26.46
(220.17–7.25)
potential
variables of interest (Table 2). The hierY-Balance Test average anterior normalized
65.9 (7.8)
0.12 (0.06–0.17)
0.47
1.239
archical stepwise backward linear regression analysis of the
RESULTScomposite (%)
remaining0.006
variables
resulted in 4 variables
Crossover
hop test (cm)
427.0 (103.6)
(0.001–0.01)
0.29 of interest
1.308 based
Y-Balance
Test Analysis
Hamstring flexibility (8)
48.5 (9.83)
20.085 (20.14–0.04)
20.38
1.176
on a significance
level of p # 0.05 to enter
the model
and p .
The mean
YBT
composite
reach scale
score (0–80)
was 241.3 6 23.3 cm,
Lower
extremity
functional
78.2 (2.5)
0.21 the
(0.04–0.39)
0.26 2). The
1.107
resulting
0.06 to remove
variable (Table 4; Figure
and the mean YBT normalized composite reach score was
4-variable model (F = 11.813, p , 0.001) had an R = 0.70,
*CIPearson
= confidence
interval;
VIF = variance
inflation(rfactor.
87.9 6 8.8%.
product
moment
correlations
$ 0.2,
R2 = 0.50, and an adjusted R2 = 0.45. The measured FMS
p # 0.01) yielded 13 variables of interest (Table 2). The
composite score was 15.7 6 2.0 points, and the predicted
hierarchical stepwise backward linear regression analysis of
FMS composite score was 15.7 6 1.4 points. The difference
the remaining variables resulted in 4 variables of interest
VOLUME 0 | NUMBER 0 | MONTH 2014 | 7
between the measured and predicted FMS score was 0.1 6
based on a significance level of p # 0.05 to enter the model
1.5 on the 21-point FMS scale. The 4-variable model had
and p . 0.06 to remove the variable (Table 3; Figure 1). The
a Durbin-Watson score of 1.96, and all VIF values were ,1.5;
resulting 4-variable model (F = 13.413, p , 0.001) has an R =
indicating acceptable and low levels of multicollinearity
0.72, R2 = 0.51, and an adjusted R2 = 0.47. The measured
within the final model. Better performance on FMS commean 6 SD YBT-normalized composite reach score was
posite scores was associated with greater anterior reach on
87.9 6 8.8%, and the predicted YBT-normalized composite
the YBT (r = 0.49, p , 0.001), greater distance measured for
reach score was 87.9 6 6.3%. The difference between the
crossover hop test (r = 0.24, p = 0.05), increased hamstring
measured and predicted Y-balance score was 0.00 6 6.1%.
flexibility (r = 20.28, p , 0.001), and higher levels of selfThe 4-variable model had a Durbin-Watson score of 1.7; all
reported lower-extremity function through the LEFS (r =
variance inflation factor (VIF) values were ,1.1; indicating
0.27, p = 0.03).
acceptable and low levels of multicollinearity within the final
model. Variables related to power, functional movement,
flexibility, and upper trunk mobility remained in the final
model. Better performance on the YBT composite score
normalized to leg length was associated with better performance on the FMS in-line lunge (r = 0.40, p = 0.001), FMS
shoulder/upper trunk mobility (r = 0.29, p = 0.017),
decreased number of hops required during a 6-m hop test
8
the
T4 F2
DISCUSSION
Understanding the relationship between self-report (LEFS)
and clinical measures that contribute to performance on the
YBT and FMS in healthy individuals may assist in the design
of preventive neuromuscular training programs for the lower
extremity that target impairments associated with decreased
TM
Journal of Strength and Conditioning Research
• Understandingwheremotioncomesfromandthetypeofmotion
thatisavailablethroughoutthekineticchain.
• NBAvsGeneralPopulation
Clinical Measures
• Lumbo-pelvic:
• Leg Length Inequality
• Hip Strength
• Hip Rotation ROM
• Knee Flexibility: 90/90
• Knee position: Valgus/Varus
• Tibial Varum
• Ankle DF
• Arch Mobility
• 1s t MTP DF
**Not intended to be all inclusive
11
5/29/16
Lumbo-pelvic
Considerations
•
LumbarPos ition:FunctionalScolios is
•
InfluenceofLegLength
•
Krawiec (2003)College
Athletes
•
RightAntInnom:73%
•
68%showinglongerleft
leg
•
RegionalCharacteris tics
12
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RegionalCharacteristics
HipRotation
AmericanAcademyofOrthopaedic Surgeons
Internal Rotation
45º
ExternalRotation
45º
Angle ofVersion
Angle ofTorsion
Craig’s Test (Ryder’s)
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5/29/16
90/90
Mageeandothers.
Normal
20º
Functional
30º
41º- 28º
Teyhen etal,2014
48.4º (9.6)
ActiveDutyService
Herrington,2013
66.8- 53.4
13.4° ± 9° with
Pelvic Tilt
Original article
Tibial (Tibiofibular)
Varum
•
Tomaro,1995(UnilateralOveruse)
• ↑Tibial Varum
• Involved=5.3º
• Uninvolved=4.0º
•
Beynnon etal,2001(anklesprains)
• ↑Tibial Varum
TibiofibularVarum
McPoil (Relaxed)
Lohmann (STN)
• Involved=6.6º
• Uninvolved=5.4º
• Talar TiltTest (Laxity)
5.8º
4.62º
Figure 1 Testing situation. Players started at an angle of approximately 33° on the long axis of the runway. They were instructed to try to fake
the defender into going to one side while cutting to the other. The defender was completely static and adjusted her position between the trials so
the players hit the force platforms with their normal sidestep cutting technique.
the potential for variation and change in the technique parameters. Regression analyses were also used to see how well the
moment arm and the magnitude of the GRF could predict the
maximum knee abduction moment calculated using inverse
dynamics during the first 100 ms.
RESULTS
The regression of technique variables and maximum knee
abduction moment during the first 100 ms of the stance phase
had an R2 of 0.62 with p<0.001. Speed of torso rotation, knee
flexion and cut time were excluded from the final regression
Genu
Varum/Valgum
Figure 2 Technique factors described at initial contact. (A) Width of cut; (B) hip abduction; (C) foot rotation; (D) torso rotation and hip internal
rotation; (E) torso lateral flexion and knee valgus and (F) knee flexion. Additional technique factors were approach speed, cutting angle, cut time
and speed of torso rotation.
Kristianslund E, et al. Br J Sports Med 2014;48:779–783. doi:10.1136/bjsports-2012-091370
3 of 6
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1st MTPDorsiflexion
1 st MTPDorsiflexion (HalluxExtension)
Bojsen-Moller (1979)
60º
Root(1977); Dananberg (1993);Gatt 65º
(2014)
Laird(1972)
50º
• Gatt etal.2014,
• Bevanet al2004
AmericanAcademyofOrthopaedic Surgeons
AnkleRangeofMotion Dorsiflexion
20º
*MinimumDFRequiredforNormalGait
10º
Plantarflexion
Inversion
Eversion
50º
35º
15º
WeightBearingAnkle
Dorsiflexion
• Fongetal. (2011):Riskfactorsfor
ACL
• PFextensibility &DF ROM
• Boling et al.(2009):Risk factorsfor
PFPS
Dom
NDom
Rabinetal.
50.4(+/- 6.6)
56.3(+/- 7.3)
Dilletal
50.8465.16c
Teyhen etal
34.2(+/- 6.1)½kneeling
• ↓decreasedkneeflexionangle
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NavicularDrop
• Bolingetal.2009
• NDis riskfactorforPFPS
• ↓decreasedkneeflexionangle
• MoenMHetal,2012
• PositiveNDassociated withMTSS.
• Eslami etal, 2014
• ↑NDassociated with↑ peakankle&
knee jointmoments
• NDexplained 28%- 38%ofthevariability
formeasuresoftibial internalrotation
excursion,peak knee adductionmoment
andpeak ankle inversionmoments
ArchHeightIndex
• Ratio ofthe height ofthe
dorsum ofthe foot(50% of
footlength) tothe truncated
footlength (calcaneusto1s t
MetHead).
• Normalizes archheight to foot
length.
Figure 2. Radiographic correlation of arch height index measurements
AH I
<.275 Planus
>.356 Cavus
Avg = .316 - .340
• During walking, archheight
RESULTS AND DISCUSSION
were measured
foreight
multiple conditions and cases with intent to find the most reliable, salient and objective assessment of
Arch H
decreased11 to15% toitsParameters
arch height. Table 1Dsummarizes
the results.
ifference
minimum at74to 85%of • The variability introduced during pronation and supination demonstrates the importance of having the patient maintain a
Arch
Rigidity
=Clos
er angle.
Avg=.913 (.053)
comfortable, repeatable
base
of support, angleRigid
of stance
and foot
stance(Cashmere etal., 1999;
•
Comparing supported
trials,
Index and unsupportedto
1 an additional drop in arch height is observed in the latter. Thus, the unsupported
Huntet 19al., 2001)
condition should be used to properly identify and observe the morphology of highly flexible feet.
Arch
Stiffnes sis noted when loading beyond 50%BW. Due to the unsteady posture required for such measures,
•
Little additional
deformation
observation of 100%BW is deemed unnecessary.
•
To compare arch height between subjects of varying size, arch height measurements are normalized by the truncated foot length
to give an Arch Height Index (AHI).
Table 1. Parameters of Arch Height: Measurements and their Intra-Rater correlation values. *For the AHI, use AH@ ½ sitting FL
SUPPORTED(10%)
SUPPORTED(50%)
Sitting
RCSP
Pronated
Supinated
SUPPORTED(100%)
RCSP
UNSUPPORTED(50%) RCSP
Pronated
Supinated
UNSUPPORTED(100%) RCSP
FL
ICC(2,1)
0.996
0.998
0.920
0.971
0.998
0.999
0.999
0.977
0.829
TrFL
mean
26.10
26.66
26.70
26.37
26.67
26.68
26.73
26.42
26.36
ICC
0.993
0.988
0.920
0.950
0.913
0.879
0.882
0.942
0.973
mean
18.93
19.46
19.54
19.20
19.53
19.55
19.60
19.21
19.51
AH at 1/2sittingFL
ICC
mean
0.980
6.87
0.984
6.47
0.993
6.41
0.970
6.62
0.979
6.41
0.984
6.42
0.992
6.37
0.954
6.54
0.930
6.40
AH at 1/2currentFL
ICC
mean
0.980
6.87
0.988
6.34
0.878
6.24
0.962
6.56
0.977
6.29
0.985
6.28
0.992
6.20
0.945
6.49
0.910
6.26
AHI: AH/TrFL*
ICC
mean
0.981
0.36
0.960
0.33
0.33
0.34
0.953
0.33
0.960
0.33
0.33
0.34
0.867
0.33
SUMMARY
A portable, intuitive, low-maintenance instrument for quantification of the arch height was designed and built with the unique ability to
accommodate all foot types. Multiple parameters were polled and found to be intra-rater reliable. Currently, inter-rater reliability is
being investigated.
REFERENCES
Denegar, C.R., Ball, D.W. (1993). J. Sport Rehabil, 2, 35-42
Saltzman, C.L et al (1995). Arch Phys Med Rehabil. 76, 45-49
Williams, D.S., McClay I.S. (2000). Phys Ther. 80, 864-871
ArchHeight Index
• Purpose:Identifycavus
orplanus archtype.
Assessarchmobility,
rigidity,andstiffness.
• Planus vCavus
• MobilityvStability
• Compliance vStiffness
16
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RelationshipBetweenTalocrural andMidtarsal
(ObliqueAxis)Joints
Talocrural andMTJRelationships and
Overpronation
Trends,KeyFindings,and
Application
*unpublis hed data. Current findings are infinal write up.
17
5/29/16
Methods
● Rostersfor2-3NBATeams
● Measurementstakenpre-season
● Gamesmissed duringseasonwerereportedbyteam’s
medicalstaff
● Gamesmissed correlated withpre-seasonmeasurements
● UseofSPSSsoftwareutilizingmultiplet-testsand
pearsoncorrelationstodeterminestatisticalrelationships
KeyFindings&Trends
•
•
•
•
•
•
•
FMS&DichotomousInjury
FMS&ClinicalMeasures
FMSCompositeandArchMeasurements
FrontCourtvsBackCourtPlayers
YBTandNavicularDrop
LESS
OngoingResearch
DesigningEvidenceInformed
Treatment&RehabPrograms
Carl Eaton, PT, DPT, ATC, IndianaPacers
18
5/29/16
Objectives
• Identifyhowthepathomechanics associatedwithlowerextremity
injuriescaninformthepractitionerindevelopingtreatmentstrategies
tominimizeinjuryrecurrence.
• Discriminatethecontroversiesandrecognizethelimitations
associatedwithdesigningrehabilitationprograms andevaluate
treatment optionsanddeterminebestpracticesfortreatinglower
quarter injuriesassociatedwithbasketballplayers.
Introduction
• Specificpopulation
• Males19-40yearsold
• Themaingoaloftheentireorganizationiswinningbasketballgames.
EvidenceBased
Medicine
The practiceofevidence based
medicine meansintegrating
individualclinicalexpertisewiththe
bestavailable external clinical
evidence fromsystematicresearch.
-Sackettet alfromBMJJanuary
1996
19
5/29/16
MANUALTHERAPY
INTERVENTION
WhyManualTherapy?
• EffectiveTreatment- Availableevidencesuggests
(MT)aseffectiveinthetreatmentof
musculoskeletaldisorders.
Dysfunction
Author
LowBackPain
• Moreover,recentstudieshaveprovidedeven
strongerevidencewhenparticipantsareclassified
into sub-groups(Childs etal.,2004;Clelandetal.,
2006
Licciardone etal.,2003
Childsetal.,2004
CarpalTunnel
Rozmaryn etal.,1998;
Akalin etal., 2002
Knee
Osteoarthritis
Deyle etal., 2000.Many
others…
• CombinedMechanisms:biomechanical(Galetal.,
1997;Coppieters andButler, 2007)and
neurophysiologicaleffects(Vicenzino etal.,1998;
Suter etal.,1999;Dishman andBulbulian, 2000;
DeVocht etal.,2005)
HipOsteoarthritis MacDonaldetal.,2006.
Manyothers…
Weir A et al. Manual or exercise therapy forlong- standing adductor-related
groin pain: arandomised controlled clinical trial. Manual Therapy 2011
(Cochrane Review)
• (54participants)foundnosignificantdifferencesat16-weekfollow-upbetweenamulti-modaltreatment
(heat,manualtherapyandstretching)andexercisetherapy(thesame interventionasintheabovestudy)
• outcomes of s ucces s fultreatment
(14/ 26 (54%) vers us 12/ 22 (55%); RR 0.99, 95% CI0.59 to 1.66, P =0.96) and
• return tofull s ports participation (13/ 26 (50%) vers us 12/ 22 (55%); RR 0.92, 95% CI 0.53 to1.58, P=0.75).
• Thosereturningtofullsportsparticipationreturnedonaverage4.5weeksearlierafterreceivingmulti-modal
therapy(meandifference-4.50weeks,95%CI-8.60to-0.40,P=0.03)thanthoseintheexercisetherapy
group.
• Thisstudyreportedthattherewerenocomplicationsorsideeffectsfoundineitherinterventiongroup.
20
5/29/16
AnkleJointMobility
• Kavanagh: Distal TFmobilization. Significantly greater amount of
movement per unit force occurred in one third of the patients with
acutely sprained ankles (P= 0.01%, P= 0.09 %), 1999.
• Hubbard: fibulae in sub-acutely sprained ankles appear to be
positioned more anteriorly compared to the contralateral ankles,
2006
• Fujii: Cyclic loading to the distal fibula is effective for increasing the
range of ankle dorsiflexion. Itappears that distal tibiofibular JM has
the potential to improve limitation of ankle dorsiflexion
• Gilbreath: Mobilization improved sport related activities (FAAMSport consists of 8-items pertaining to sport-specific tasks)
BiomechanicalEffect
• Joint Biased MT (Gal et al., 1997; Colloca et al., 2006)
• Transient
• Nerve Biased MT (Coppieters and Alshami, 2007; Coppieters and Butler,
2007
• Collectively, the literature suggests a biomechanical effect of MT.
• Difficult tostudy.
• A mechanical forceis necessary to initiate a chain of neurophysiological
responses which produce the outcomes associated with MT.
StudiesonSoftTissue Mobilization
Study
Subjects
Key Findings
Robertson
Cyclers
↓Fatigue Index
Levied etal
DanceStudents
↓cortisol,anxiety
Nordschow &Bierman
Normal Subjects
↑LumbarROM
Wiktorsson-Molleretal
HealthyMales
↑AnkleDF ROM;
Bell,Dubrovsky,Hansen&
Kristensen,Hovind &Nielsen
Athletes, HealthyVolunteers
↑Blood Flow(Venous,Arterial)
Weinbergetal
UniversityStudents
↑POMS
Hemmings
Boxers
Perceived Recovery
21
5/29/16
Chemical and Neurologic Pathways
Chemical
• Musculoskelet al injuries induce
an inflammatory response in
the periphery which initiates
the healing process and
influences pain processing.
• Inflammatory mediators and
peripheral nociceptors interact
in response to injury and MT
may directly affect this
process.
Neurologic
• MT has been suggested to act as a
counter irritant to modulate pain
(Boal and Gillette, 2004) and joint
biased MT is speculated to
‘‘bombard the central nervous
system with sensory input from
the muscle proprioceptors (Pickar
and Wheeler, 2001).’’
Subsequently, a spinal cord
mediated mechanism of MT must
be considered and is accounted
for in the model.
Mechanotransduction
• Theprocessbywhichthebodyconvertsmechanicalloadinginto
cellularresponses
Detectingsubtlechanges
•
•
•
•
Eliteathletes
NBAseason
Successandwinning
Intraexaminerexperience
22
5/29/16
Tissue Mechanics
• Biorheology
• StressRiser
• TissueCompliance/Stiffness
Biorheology
• Thestudyofdeformationandflowpropertiesofbiologicalsystemsor
materials.
StressDistributionThroughoutTissue
• StressRiser:
• Non-UniformForceTransmission
• Arndt et al.AsymmetricalLoading oftheHumanTriceps Surae:I.Mediolateral
ForceDifferencesin theAchilles Tendon. Foot& Ankle International, 1999
23
5/29/16
Tissue Compliance/Stiffness
• Ameasureofeaseofwhichasubstancedeforms.Theoppositeof
stiffness.
UTILIZATIONOFTHERAPEUTIC
EXERCISE
TRANSITIONOFMANUALPHYSICALTHERAPYTOSTRENGTHENING&
CONDITIONING
UtilizationofTherapeuticExercise
Progressionofanklemobility
treatment between tableand
weightroom
Progressionoflumbarspine
between tableandweightroom
24
5/29/16
UTILIZATION OFTHERAPEUTIC
EXERCISE
TRANSITIONOFMANUALPHYSICALTHERAPYTOSTRENGTHENING&
CONDITIONING
Donald S.Strack,PT,DPT, OCS, FAAOMPT, ATC,Oklahoma CityThunder
FromManualTherapytoTherapeuticExercise
• Knee
• Ankle
UniqueConsiderationsinElite Level
Basketball
•
•
•
•
•
•
Investment
Stakeholders
Decisionmaking
Mediascrutiny
Stresses
Lifestyle
25
5/29/16
Managementofthe
IntercollegiateandProfessional
Athlete
Best practicesthrough aCase StudyApproach
RehabilitationandReturntoSportFollowing
AthleticPubalgia Surgery:ACaseReport
•
•
•
•
•
•
•
History
MechanismofInjury
Examinationfindings
SurgicalIntervention
Rehabilitation
Outcomemeasurements
Functionalreturntoplay
CohortBasedCaseSeries: KneeDysfunction
26
5/29/16
ConsiderationsintheDiagnosis andReturntoSportofa
ProfessionalBasketballPlayerwithaPlantaris TendonRupture
• Introduction andBackground
• Case Description
• Imaging
• Initial Examination
• Intervention
• Return toPlay
• Discussion
• AnatomicalVariation
• Imaging
• Rehabilitation
27