Brent Hisaka and James Faison present "Getting the Jump on Injuries: High Impact and Plyometric Training for Injury Prevention" at the UCSF Pediatric Musculoskeletal and Sports Medicine Conference 2023 in Berkeley, CA.
It is my pleasure to introduce to you again from yesterday, Brent Isaka. Uh He earned his bachelor's degree in exercise biology from the University of California Davis and he earned his doctorate of physical therapy at Samuel Merritt University. He's a board certified orthopedic clinical specialist as well. You met him yesterday as the outpatient physical therapy team lead for the pediatric limb lengthening and complex reconstruction center. Um He also works with us in the sports medicine center for young athletes and specializes in caring for Children who want to start maintain or return to an active lifestyle. Um Fun fact about Brent former weightlifter. So uh yeah, that's right. Um but he is particularly interested in sports of basketball, judo and weight lifting. Uh Mr Jamie Fazon is a physical therapy assistant and certified athletic trainer and certified strength and conditioning specialist at U CS N F Children's Hospital Sports Medicine Center for young athletes say that three times fast. Um He is passionate about working with pediatric athletes and educating them about how to exercise, stretch and take care of their bodies with a focus on getting them fit fast and strong. So with our last presentation of the day. Yeah, of the morning session. Sorry, wishful thinking. You got credit. See you later my day. Right. Hello everyone. I'm Jamie, I'm Brent. And we're going to be talking about taking that data that uh Miss Ariana just said and taking that and using that data that we get those images. How do we create a treatment plan to take someone out of a risky category into a less risky category, especially for post. So just like everyone else so far, no disclosures. Um And here are our objectives. First thing we gotta do when we're looking at this stuff, we want to define our terms. What is strength, what is power? What are plyometrics? Um We wanna give you guys some examples. Uh We want to describe some of the training principles that we're gonna be looking at and then talk a little bit more about the movement faults again, following up on some of these through lines that you've seen in a lot of these other presentations. So to start off with, we need to define what strength is. So strength for us in our setting is the ability of a muscle to perform contractile force against a resistance strength is. You see in some of these pictures, if someone's doing a side plank, they're demonstrating strength, but there's no speed involved. So strength is the ability to push against something using your muscles as a contractile force. But when we get into power that's where we're gonna see this kind of rate of force development come into play. So for any of you math or physics nerds out here, we have the technical definition of power is a change in work in a period of time. So we see that time come into place. Um So if we use work, if we have force as our proxy for work, like Mr Jamie talked about, you know, when we're looking at power, it's how much force can you produce in a given amount of time. So we can increase power either by having more force in a certain period of time or by making that force come out faster. So when we look at plyometrics, plyometrics is a term that we hear a lot in strength and conditioning and in sports. Um if you know high school age athletes, they talk about doing plio with their team. Plyometrics started in the 19 seventies typically or uh initially with track and field athletes. Um and the term plyometrics is actually Latin for measurable increases. But when we look at what our Plyometrics, actually, what it really is is it's a rapid centric muscle contraction followed by a rapid concentric muscle contraction. So a quick stretch and then a quick push, um usually these are done with the goals of increasing power. Um like we talked about and then a lot of people when they think about Plyometrics, they're just thinking about jumping. But what we'll talk about is how plyometrics is really as long as you're including this rapid stretch, uh rapid contraction, which is called the stretch shortening cycle. You are doing plyometric training. Um So examples of plyometric exercises, um typically for most people, it's jumping in for our, on our side. It's we really focus on the landing as we saw with Miss Ariana, the the movements that we're looking at, we're looking at good landing mechanics and deceleration. So the kids I'm working with are often thinking about how high I can jump. I'm looking at how low you can get on your landing because injuries happen at landing and deceleration. So examples of plyometrics are jumping rope, jumping jacks, those are ones that kids normally get things like jump squats being on the trampoline dance and uh of course sports participation in addition to that, there's even upper body plyometrics which will get into it uh later. Uh So it's important to remember that power and plyometrics are not the same. So for you as a clinician, you need to think about. When are you utilizing something that I'm just purely trying to produce power versus where am I trying to use that stretch shortening cycle um to do a true plyometric exercise. For example, if you do a jump with a counter movement where you have that quick stretch and then the release, you know, that's gonna be a plyometric exercise. However, if you're starting from a sitting position and go directly into the jump. You don't have that stretch shortening cycle, but you can still work on increasing the speed and subsequently the height of that jump. Um, and that would just be a power training exercise. So, one of the things that we'll talk about is, you know, when do we use which of those? Um, so when, why would we train, uh, uh power and Plyometrics in a physical therapy setting with young athletes? Well, the first for the kids that I'm working with and for the coaches and the parents, I label it as we're gonna improve performance. If we could get you to jump higher and run faster, then that makes it worth it. For us. On our side, we're thinking about injury prevention, especially in a physical therapy setting. Uh, we want to through physical therapy and athletic training and strength and conditioning, ready the body for the demands of their sport, right? So we want to specifically identify the, the uh, components of their sport and start readying them under our watchful supervision in a clinical setting before they go out and play. And my training for a young athlete that does swimming is gonna be a lot different than my athlete that does football and one that does martial arts, we try and we try and tailor our treatment to the athlete in the scenario with which they're going to be participating. And of course, on our side, we're often thinking about utilizing Plyometric principles and power exercises for rehabilitation of injury because it actually has beneficial outcomes from providing these uh these exercise stimuli under our supervision. Getting into some of the nitty gritty of the benefits of Plyometric training, you can see increased muscle thickness, uh increased tendon stiffness. So Carly kind of alluded to earlier that you know that B F R is not necessarily tackling the the tendon in the same way that the muscle is plyometrics is one of those ways uh that we can improve tendon stiffness, increased jump height, athletes love that increased throwing velocity, baseball players love that. And uh as Ariana mentioned, reduced risk of AC L injury, we're looking at these movement patterns trying to correct some of these patterns to rehabilitate an AC L injury or if we have someone that's coming in, help prevent an AC L injury. Um But one important thing to note is that that's a part part of a comprehensive program. So the Plyometrics and the power training is not the only thing that goes into AC L rehabilitation. Um but it is an important part of that program, we can also say improve functional performance following a lateral ankle spring. So again, trying to ready the athlete for the demands of their sport using something that kind of simulates, simulates their uh sports participation. So like I mentioned earlier, plyometrics are a part of most sports, I mean, some very, you know, every once in a while, we treat an athlete. If someone does archery, maybe there's not as much of a plyometric element. Certainly there's strength involved. But when we look at, um, the athletes that we're working with most commonly, we're going to see athletes who play basketball, uh, baseball, football and then even dance. When we work with ballerinas, we certainly need to work on jumping mechanics and double in single eight positions. Um, but this is a major component of sports and we would be remiss if under physical therapy, if we only addressed strength, we got them strong, but we never addressed any of these. And we use the data that Miss Ariana takes out the motion analysis lab to influence our, where we're gonna focus our time in a given session or even a given month in a given treatment um phase using our motion analysis data. So, like we said, it's not just jumping, we get that cock back phase of a pitch similarly in volleyball, that upper extremity that needs to generate power. So we can do plyometrics for that as well. All right. So before we start a jump program, there are some prerequisites for jumping. Um So oftentimes kids and parents especially and coaches as well think that kids, we just know how to run and we just know instinctively how to jump. But there are mechanical principles that we have to go over and review to make sure that somebody is ready to jump and ready to run. Now, learning, teaching a kid how to run is a whole separate talk. But with regard to jumping, we really look at the double leg squat is kind of the benchmark of movement that we need to do. Every squat or every jump starts and ends with a good squat. So here I'm coaching a young lady on how to perform squats and keep her knees out when she's doing that movement pattern. Of course, our young athletes, we want to build sufficient balance. Now, they don't need to be able to stand on a bosu ball and juggle with their eyes closed, right? We just need sufficient balance for their sport and for their age and for their ability type, my ballerinas and my gymnasts need exceptional amounts of balance and flexibility. But my offense alignment in football probably don't need as much of that dynamic balance. And then for us in our center, one of the first things that we're gonna address early early on, we want these movements to be pain free, especially if you're working with someone who's under the age of 18. But even when I used to work with adults, we want pain free movement uh patterns, we want pain free. If they're jumping and their knee hurts every time, then that's a, that's an identifier that we need to work with that more. Um We want our athletes to have full range emotion of that affected limb, especially if they're a post. Um And then of course that they're cleared by Dr Pandia, Doctor Watkins to actually start jumping. So we're not putting the cart before the horse without uh MD approval. Ok. So plyometric training, as I mentioned earlier, we should always consider it within the context of the athlete's age, their skill level, their injury history and then a number of different factors that are gonna, that all compromise their athletic development. So when I'm um Brent and I have a patient right now that we work with uh every week, week and he's this little nine year old kid and he comes in, in all Niners gear and he's like super buff and he loves to dab and do the gritty all the time. That's all he ever does in the clinic is do the little Fortnite dances. Now he's a super hard worker, but he's not a good mover. So we need to take this young man who had a meniscus repair from Doctor Pandia. We need to teach him how to move, right. He's really stocky and he's nine. So maybe doing a 24 inch box jump is not the best idea for him because the box would be up to his chin, right? So we need to look at that young person and see what plyometric principles. What level of athleticism are we gonna train this young man to get to and what level is safe. Sometimes there's exercises and especially if you watch people, people see an exercise on Instagram or they see it on tiktok, they see it on youtube of some Olympic athlete doing some crazy exercise. Kids want to do that, but it may not be right for them and where they're currently at in their athletic development. So for Brent and I Brent and I love teaching plyometrics, we love working with little kids. Most of the time we talk about plyometrics and, and sports training for young kids and coming up with a good plan, meeting that kid where they're at and looking at. OK. Where are they at now? And where do they want to get to? And how do we break that up into little chunks to get them to that spot is ultimately very important. And so that's where we get into our introductions to plyometrics. So this gets into kind of the things that both Ariana has talked about that we mentioned earlier in terms of, you know, maybe you don't want to start with a full plyometric movement. So you might start with just the shock absorption portion um with something like a drop squad where you'd start on the box, drop off and into our squat position. Again, this is assuming that they already have a good squat on the ground because if their squad is not good on the ground, if you put them on an elevated surface and have them drop into a squat, it's probably not gonna look very good, but we have no stretch shortening cycle. So it's not technically a plyometric, but we're working on that shock absorption that getting into that low position, improved hip and knee flexion angles. All of those things that are gonna set them up for success as they transition into more difficult movements. Similarly in a single leg position, instead of doing a single leg jump and hit land, which if any of you have ever done before, it is actually really difficult. We can start by kind of hopping from one leg onto the other one and working on that shock absorption in that manner. Again, we're not having that stretch shortening cycle on the the limb that we're landing on. So it's not technically a plyometric, but we're progressing from something more so that we can make sure that it's safe before we build up to something a little bit more complicated. And that drop squad in the forward leap and stick. We can take that young athlete that we're working with. We can have them do that one move and have them look in the mirror and we grade it and then they grade it and we come up with main making sure that we're maintaining good knee alignment, especially for our post op kiddos. Um We can make sure that there's good quality before we go into really explosive movements. Can you stand on one ft and can you hop onto the other foot kind of like what Doctor Watkins was talking about with the hop test that she was doing in clinic. Oftentimes we'll do an exercise in, in clinic and we'll train them and the doctors will do that in, in clinics so they can see what's their movement pattern look like. Is it good quality or is it poor quality? Oftentimes if you watch a bunch of kids run by on a soccer team, there's one kid that kind of runs kind of weird. There's one kid, one or two kids, you're like, that's not the and maybe you don't know their knee flexion angle at you know, act impact. But when, if that kid, if something's just not looking right, we need to break that down into its component parts and train each individual element to make sure that by the time they're discharged, they're good movers. So if we look at maybe one or even two steps further, now we have a box jump where, you know, we're initiating that counter movement, jumping up, but then we're reducing some of the impact by having them land on an elevated surface. So we don't have to go all the way up to the top of the arc and all the way down, which is a little bit harder, we can reduce some of that impact and focus on that initial counter movement. But then this goes back to one of the things I mentioned before is maybe they're having a difficult time with the counter movement. But we still want to work on that power generation that might be where you bring in the starting from a sitting position. So they don't have that counter movement and we still get to work on that rapid force production um without necessarily having that difficulty in the counter movement and we can work on that separately. So it's really important when you're looking at these things are the big concept that we're approaching from here as physical therapists, physical therapists, assistants, athletic trainers is we're trying to break the these things into component parts that are manageable for the individual and then put them together and make sure that they can do all of them safely together and then ultimately be able to have them do that without our supervision so that they can participate in their sport safely when we're actually when we're teaching those box jumps. This is actually not the box that we use. Um If you've ever jumped up on a box like this and missed and you just scrape the bananas out of the front of your shins. Um We have very, we have a soft, was called like a soft box or a, a Plyo box. And we actually have those grated. So we have a six inch one which is like little lady bitty, then 12 and 18, then 24. So we can take this basic exercise, we can increase the intensity of the exercise by increasing the challenge of the height with which people jump. We start with the little, the small six inch one. And if you're under the age of 18, if you're over the age of 18 and you just had knee surgery, jumping onto a box with two ft and landing, it is pretty scary. So we're there to work with them. We're standing right next to them and we're educating them, getting them over that hesitation and starting to use that leg starting with the squat and ending with the squat every time. So box jumps are great for building that strength, building, that explosiveness, but also building that confidence, trying to avoid some of that hesitation that comes after knee surgery. Um And then we would get into so if their, if their box jumps are starting to look good, then we would go to a double leg jump. So a double leg jump like a vertical jump or even a horizontal jump you and start on two legs, bend your knees, you're gonna drive up in the air and then land. We're always looking at the landing. So nice soft landing, no pitter pad of the landing and no weight shift off to the side. Um And these are all things that we do before we send them over to the motion analysis lab. Um in clinic, we can also do this. Some of these movement patterns. Take out an ipad and take a video of them doing it and do a little bit of some of the work that Miss Ariana does, we just won't get those joint specific angles. So again, we're looking at always progression. So after two legs, the next natural thing that comes is moving under one legs. So standing on one ft, jumping, landing, um prerequisite for this would they would be able to do a single leg squat with good control. If they have a hard time just squatting down on one leg without their knee going all over the place, then they're gonna have a really hard time doing a squat, a jump and then another squat from up in the air, we can look at adding in multidirectional components. You know, like Mr Jamie mentioned side to side forward, backwards rotation that can be done on two legs that can be done on one leg. When you look at sports, if you really break down those movement components, different sports have different requirements, but there's a lot of impact. It's rarely ever unip planner. There's change of direction, there's angles, there's rotation. So we need to really work on training all of that stuff in clinic um so that they can take that and be successful out on the field or on the court. So it's within these, these exercises that we just outlined that we can really start to get creative. I mean, this is what Brent and I do all day long is get creative with these young people uh that I'm working with. Um and one of the ways that we like to get creative with our exercises with Plyometrics isn't necessarily to add complexity onto it. But really change the variables of the exercise and the variables are for us, sets reps resistance and then rest interval. So even if you did the same exercise, even if you, you're doing three sets of five box jumps, if you decrease the rest interval and you drop that rest interval down, it changes the exercise fundamentally changes it by introducing fatigue into it for a power exercise. And for plyometrics, we want to actually allow enough time in between each exercise to have good quality reps and good explosion from the ground. Um But these are the variables with which we use and most of the time, uh oftentimes for some of these exercises and especially for younger kids, we don't even count reps, we just use do it for time. So then it's more of a start go. If we do 15 seconds, we're gonna do standing vertical, uh squat jumps, we're gonna do 15 seconds start and then I can watch them. The kid isn't worried about counting. They can actually just do the exercise until I say stop. And then we can really take, take that time to look at their knees, look at their feet, look at their landings and make sure they can have uh good quality with that movement. Pattern. One of the other things you might track if maybe you're in less of a rehabilitation setting and you're giving more someone, a performance program is how many ground contacts they're getting, basically how many times their feet are hitting the ground. Um So some research shows that 50 to 80 ground contacts in a session would be considered relatively low volume and 50 to 80 may sound like a lot. But like if you're doing something where you're jumping for 30 seconds, you can get a lot of ground contacts in, in 30 seconds. Um Whereas something like 200 plus ground contacts in a session would be considered high volume. If you're looking at more of that pure just power output training, usually the sets that are or the reps are in the range of like 3 to 5 and you can see how that would make sense if you're going full effort. Your goal is to create, generate as much power as you can. It's pretty difficult to do that for more than three or five reps in a row before you start to get a big detriment in your power output. Um Depending on the exercise, there's not really a magic number. A lot of you might hear. Oh, 30% of a one rep max is best for, for power generation. But depending on the exercise, the evidence shows that there's a pretty big spectrum, but usually it's in that lower percentage of a one, we max range and we may even see for the most part, most of the time it's 0%. You're just doing body weight, you're doing a squat jump or you're doing a single leg hop or something like that. So if you do have a specific exercise um that you're looking at generating power, you might look a little bit into, um you know, are there, there are certain um percentage ranges that are best for optimizing power. But at the end of the day, you're gonna look at the patient in front of you and look at what is this person ready for? Where can I start them off at and how can I progress them? All right. So, uh and then we get, as we progress into our plyometric development, um we have to really look at um as the exercise intensity increases, then we need to make sure that especially for my younger athletes that we keep good form and good technique with our movement patterns. As we push into that fatigue zone, as we push into that ultimate level of uh of athleticism, we, I'm constantly working with these young people on how do we do this with good form, good knee control and good landings, every rep, not just one rep or two reps, but make sure that you can do every rep with no faulty movement patterns because um because we want to make sure that we are getting them, getting them moving as optimally as possible. And as I increase the reps, I increase the rest interval in between those in between those. So sometimes we'll do, um, two sets of three of an exercise. But as I bump up those reps, if I do two sets of 15 or 20 as I'm doing higher stuff, I'm gonna incorporate almost a two or three minute rest interval in between that to make sure that the quality of the exercise stays high. We do want to touch on upper body app Plyometrics. The same principles apply. You know, you're gonna look at the movement that you wanna target and say, OK, may what are some prerequisites uh for this, this type of movement if you wanted to do a plyometric push up, you know, something where you're pushing, leaving the ground, you see all those people on the internet that jump, they're trying to clap as many times as they can before they hit the ground. Well, if you can't do a body weight push up, then doing a plyometric push up is gonna be bad news. Um Maybe you start with something like a med ball catch and throw where you don't have to tolerate the entire body weight. You can modulate the, the weight of the medicine ball and then we can do that rapid push and catch a lot of times we'll do something like that against like a rebounder where we can throw the ball bounces off the rebounder catch and absorb, push back and we get that repetitive kind of rapid, quick stretch and contract. Um kind of getting back to what I mentioned earlier where not everything is always a jump in land. We can take those same principles for things that we look at all the time. Take a baseball player that wants to increase generating power in their rotator cuff. Well, we may put them in a sport specific position and if they can tolerate and they can do good 90 90 external rotation with a resistance band, maybe we work on that quick lengthen contract to work on that generation of power and turn that from a strengthening exercise into more of a power based exercise. We talked on this a little bit, you know, just like with lower body plyometrics, we wanna make sure that they have sufficient range of motion, that their strength is good that they're pain free and that they can do the desired movement or a prerequisite desired movement with good technique. And of course, um if the doctors want them doing high intensity high speed stuff, we're probably not gonna do it in P T. Definitely not. Definitely. All right, we can see some other examples here. So now we're gonna get into actually utilizing the data and we're running short on time. So we're gonna have to fly through some of this stuff utilize when we get images back from the Motion analysis center. How do we use that to work on coming up with a treatment plan because it's one thing to analyze the movement and it's separate to fix the movement, right? If you analyze it and say that it's dysfunctional, we need a treatment plan and we need a rehab team that takes that data and actually makes it takes you out of risky category into a less risky category. And for us, video, video motion analysis really is the key we talked about this earlier. This is a young man. I worked with a couple of years ago and he's standing on the box, he jumps down, he goes up and then he goes vertical from there. And this is one of the reports that we get from the motion analysis lab that actually tells us some of the joint specific angles. So how do we take this data here? Their pre landing, their landing and their takeoff, take some of these joint specific angles and come up with a treatment plan on how to take someone out of a risky category. Some of the movement faults that we see all the time with young athletes is stiff landings, uneven weight, acceptance with their landing, meaning they're leaning to one side, uh uneven landing, meaning that they're, they're landing with the right than their left or pitter patting the landing. Um and then not utilizing proper joint specific deceleration strategies I E foot positioning, knee positioning, hip and pelvic positioning. And then trunk control and we can come up with treat. This is where the nuance of taking that data. How do we actually get them better at these movement patterns? Um This is where the nuance comes in. So this is a uh uh this is a young man here that I was working with and he was doing the lateral agility test and we don't have the joint angles on here. But this young man did everything very stiff. He was very stiff. He was very hesitant, not even hesitant to bend his knee, he just didn't really have good shock absorption. He actually was fairly, not very consistent with doing his exercises. Um And you can see when he's doing this lateral agility, he starts on one side side, shuffles onto his uh surgical leg and he plants and has to side shuffle out that he's not really accepting. He's not really getting into that knee flexion that Miss Ariano was talking about that for me, especially for young, some of the young fellow I'm working with. That's a major risk factor for future injury, not just of the knee, but also the ankle, your hip, your back. This is a young man. He's doing the triple hop assessment and you can see here he is landing in a much better position. This is the position that we train and this is the position we want our athletes to move in. So I know the picture is a little low on the, on the, on the screen here, but he has much better hip hinge and knee flexion. So, how do we work with some of these young people to help with these stiff landings? Um, if an athlete tends to land very stiff in their knees, we coach them on soft landings. It's one of the things I say all the time. Imagine a feather floating down from the sky and land on top of a marshmallow. That's how I want you to land. Your box jumps nice and soft, soft landings and um not land. Uh trying to land toe to heel. If you jump up in the air and you land right on your heels, it's not gonna feel good for anybody but some kids that is a movement pattern that they adapt over time. Is this real heavy or even heel first uh landing pattern? And that's something that we need to work on. Um, some of the drills that we use to, to get people out of a stiff landing is slow down their squats. We need to make sure that your squats are nice and slow and that you're actually getting active hip and knee flexion with your, with your squats just without take the jump completely out of it. And then all the way back to that first slide that we had try those drop squats. Can you stand on a box, drop off the box land with adequate hip and knee flexion and try and make it nice and soft and almost exaggerate that landing. So we'll also look at uneven weight acceptance that's shifting more onto one side than the other. Um And of course, for all of this stuff, visual feedback, especially in these initial learning phases is really important because you need the patient to be able to see it. Um a lot of times especially working with kids, they don't have a great awareness of where their body is. So if you say, hey, can you tell that you're shifted all the way away from your surgical side, they'll say no, this feels totally normal. So you have to be able to show them that the first step is that they have to be able to recognize it so that then they can understand your cues to correct it. So one way that is really helpful for doing that is either with a band or with a manual contact actually exaggerating their weight shift. So pushing them to their weight shift. So that then they have to drive out of it. And a lot of times when you exaggerate that movement more than they think they are already, they'll be like, oh now I see it and they can shift back to the middle and asymmetrical landing. So somebody who's landing kind of like right then left or left and right, oftentimes are non surgical side lands first and their surgical side, I actually couldn't find a really good image of this. So this is someone doing a uh a landing. Um If an athlete is landing on one ft first, then the other uh with double leg jumping, then the training should focus on. Oftentimes, I'll just say listen to your landing. If I'm standing across the gym and you're doing box jumps and I hear Bubu, every time you're asymmetrically landing, you want to jump with two ft at the same time and land on the box at the same instant because that asymmetrical landing is a again a risk factor for future injuries as well. Um So oftentimes all cute jump and land at the same time, both feet move together and they land especially double leg movement patterns. Um And I love the box jump up to train that kind of uh to train them out of that uh movement fault. Of course, we're looking at the hip and pelvic positioning again, we're gonna use a lot of mirror feedback for this. And then of course, the other thing is for any of these things you want to diagnose. Is this a neuromuscular control issue or is this a pure strength issue? Um You know, if they have good hip abduction strength and they're still getting a hip drop, then you're gonna look more on that neuromuscular feedback end. But if you're trying to have them do this and they're so weak, they can barely lift their leg out to the side, then it's gonna be difficult to expect them to be able to maintain a level pelvis in a loaded position. So we may do something like hip strengthening or again, some hip neuromuscular control exercises like a standing clamshell. We've talked a lot about the vagus knee position both yesterday and today. So that idea of um maintaining knee control and hip stability. Um And we don't, we've gone over this a couple of times here. So this concept of hip internal rotation, knee vagus and foot pronation. When we look at some of our young athletes, when we see them in video, we'll see hip internal rotation, knee and foot pronation. But oftentimes that's too quick to see unless you're doing videos. So we're, we utilize a video to determine what's that position. And sometimes it could be subtle with this young lady uh that I worked with. And um so we really rely on the data that we generate from our motion analysis lab. But then we take that data, it's not just sealed in a box. We use it to influence and to um identify movement faults so that we can come up with exercises, be creative, use our plyometric and power exercises to get them out of those risky categories. And you can see someone pre training and post training. So this is a young lady I worked with. Um she was actually uninjured. This is right when we opened the motion analysis lab, she had a history of ankle sprains. So the the picture on the left was her first day working with me, never worked with her before. And then at the end, that was her movement patterning at the end of eight weeks of training and it was a lot of squats CASS and band walks. And that's another young lady I worked with. If you guys have any questions about any of this stuff, email, email me or brand any time we're always on the computer. So.