Ariana Gomez presents "Moving on Up: Use of Motion Analysis in Returning to Sport from Lower Extremity Injuries" at the UCSF Pediatric Musculoskeletal and Sports Medicine Conference 2023 in Berkeley, CA.
All right. So to keep us on time, we will start with our next two presentations. Uh I'd like to introduce Ariana Gomez. Uh She earned her undergraduate degree from San Diego State University in 2015. And she received her doctorate in physical therapy from Samuel Merritt University in May 2022. And if you didn't know there are lots of us from Samuel Merritt. We are everywhere. Um She's our current sports physical therapy resident at Sports Medicine Center for young athletes. Um And I'd like to say she's an absolute pleasure to work with and she has some off the chart basketball skills. So without further ado Ariana. Yes. All right. Hi, everyone. Um Like Tom said, my name is Ariana Gomez and I am the sports resident at the um Moana Creek location. And today I will be talking about the um motion analysis lab and how we use that to assess our patients readiness to return to sport. I do have Nara Bati also um presented on this slide um because he helped me a lot with um this presentation. So I wanted to acknowledge that. And so without further ado, there are no disclosures and then these are objectives and then the agenda for today. So to start, there is an estimated 40 million school age Children between the ages of 5 to 18 years old actually participating annually in sports in the US. Researchers have also estimated that athletes will sustain approximately four million sport related injuries annually costing roughly $2 billion in medical bills and lower extremity injuries are among the most common. Accounting for over 60% of the overall injury burden in youth sports. The highest rate of injury and overall injury burden in both boys and girls are reported to be on team sports. So males in particular um have the highest rate of injuries in sports such as ice hockey, rugby, basketball, soccer, wrestling, running, and football. And then we have our female athletes who have a high sport specific injury rate that you see in basketball, soccer, ice hockey, European handball, running and field hockey. And here are just two great examples of some of the many, many ways our young athletes may injure themselves in a game. And so there is a lot of research that discusses the differences among genders and the risk of injury. And in this particular article by Fawcett, he highlights or they highlight the female athletes have up to a 10 fold, increased risk of injury compared to their male counterparts. And among those injuries that we see are anterior cruciate ligament sprains, paella for pain and ankle injuries, which is everything we talked about earlier today. And so now I will be transitioning and talking more specifically about AC L injuries due to the fact that we do see more postoperative um AC L reconstruction being the most common injury that we see in our motion analysis lab, but we do see other lower extremity injuries as well. So um an injury of the anterior cruciate ligament is a common injury in athletes participating in those landing and pivoting type sports. A total number of AC L injuries that have been reported have actually demonstrated that 72% of all AC L terrors are actually noncontact and our thoughts to occur within the 1st 40 milliseconds of the foot making contact with the ground. Now, that is a big statistic that I want you all to remember and think about because it's just amazing to see that we have been able to pinpoint that exact moment of when we um actually are at the highest risk of an AC L tear. And it's really crucial in understanding how the injury happens and where it's coming from. And so there has been a threefold increase in AC L repairs in patients that are younger than or equal to 20 years old. They have a higher participate, participation rate in sports and also they specialize in their sports and they participate in sports year round. And I can tell you that this is something that we see most commonly in our clinic, we see a lot of patients um doing sports year round and also specializing in their sport. And so we wanna make sure that we're acknowledging that and educating our patients and the parents about this potential risk. And so we can note that AC L injury risk is actually very intrinsic and it's a multifactorial cause can be either anatomical, biomechanical, hormonal and um neuromuscular. And so, in a study, in a 2022 study by, they assess the mechanical components to a noncontact ac L injury and describe that the primary force responsible for this type of injury is in fact an Axio compressive force that happens within the initial contact of the ground. Now they play the scenario in a safe landing position. The four ft is what touches the ground and allows the calf muscle to absorb that impulsive ground, ground reaction force. And we want to think about it a lot like a car crash where the airbag is diminishing that impact force before they actually reach the passenger. And so the gas rock actually acts a lot like that. It acts like an accord and flexing both the ankle and the knees, thus allowing the leg to absorb those ground reaction forces. However, if we think about a landing where they are landing flat footed and they are have minimal knee flexion that actually renders the calf ineffective at dissipating those ground reaction forces and the forces are then transmitted straight to the knee. And I did wanna highlight this other risk factor that Doctor Pandia actually mentioned in his presentation. And it's the very own dynamic valgus where um in this article, they defined it as a combination of increased hip abduction and internal rotation, decreased knee flexion, increased knee abduction and internal or external tibial rotation. And that really makes a lot of sense because the AC L S primary job is not only to re uh provide restraint of anterior translation of the tibia, but it also helps prevent excessive tibial, medial and lateral rotation as well as various syagrus stresses. So when reviewing AC L injury, videos, knee flexion of less than 30 degrees is actually considered a quote unquote stiff knee. And because of this extended position, it doesn't really allow the proper activation of the hamstring and the quadriceps muscles. And so this position also has shown to have a high increased likelihood of having that dynamic knee vagus. Um In a study that looked at drop jump testing, researchers have noted that there has been an increase that those that showed an increased hip internal rotation during that early landing phase actually puts the at at an eight times more likely risk to have a second AC L tear. And there have been shown that there are fewer AC L injuries that are associated with greater peak knee flexion, lower peak knee valgus reduced knee abduction moment during cutting maneuvers. And A greater hip and knee flexion when for instance, performing a stop jump task. While there is no definitive link between gender and rates of AC L injuries, landing, cutting and pivoting type maneuvers have been shown to differ between male and female athletes. And um I won't really go into much specifics, but you can see that males have a um better like peak knee flexion angle. So they have more knee flexion, they have a lower peak vagus and also reduced knee adduction moment compared to females. So the rates of athletes actually returning to play after an AC L reconstruction, they are relatively high, but they vary depending on sex, age graph type, functional performance at discharge as well as their psychological health. And so this image, I love this image because it shows how all of these factors may play a role in the likelihood of our athlete actually returning the sport. And while we cannot control all these factors, um it's important to see all of our athletes in this very holistic frame. So that way we can treat them and meet them where they're at. And it has been seen in the research that um roughly our athletes are returning to sport at around 10.4 months. So many of our athletes actually have this really big expectation that they're going to be returning to their preinjury levels. In fact, 91% expect to for them to return to their preinjury levels. And in an article by there is A S M L analysis and they found that 81% actually return to any type of sport, 65% to their preinjury level of sport and 55% return to competitive sport. So we can clearly see that there's this big discrepancy and between the expectations and the actual return to sport rates. So even though we may successfully be able to get our patients to return to sport after an AC L tear, there is still a lot of research out there stating that there's a high risk for a repair, whatever it is, whether contralateral ipsilateral. So, um it's seen that AC L graphs and contralateral AC L tears are 2 to 3 times more likely to happen in pediatrics compared to adults. And um yes, this could be very much contributed by the fact that Children are much more active than us. But um it has also seen that in high school aged kids that reacher rates of 7.5% are ipsilateral and 19% are as contralateral. So I didn't mention that roughly the average is an athlete to return to a sport at around 10 months. But research has shown that time is a major component in returning to sport. And in fact, it's the only significant predictor of a second AC L tear. So we can see this in our elite athletes, we have Tom Brady who is considered one of the best quarterbacks of all time had a long career after sustaining an AC L injury back in 2008. And in his recovery, he took roughly 11 months or at least a full season. And then we also have our very own Clay Thompson who is doing amazing. He scored 33 points on Tuesday, but let's just forget about the fact that they lost recently. But, um, so yeah, he's doing really well and he also sustained an AC L injury and took roughly a year to return and then didn't return to full competition until two years later. So even though we are looking at elite adult athletes, um there's still someone that we can utilize as a perfect examples for our young athletes that are coming in with the same injury. And so going back to the research, the Delaware Oslo AC O Court, her study had actually showed that if, if there's a 51% reduction in re injury for every month, they re the return to sport is actually delayed. And so, um it all had stated that there's actually a seven time increased risk of new AC L injuries for athletes that are returning to sport prior to nine months. And so how really, how much really is our the decision making for having them return at nine months, 10 months, 12 months. And so at minimum, we wanna be able to do a battery of tests that we could perform in clinic, whether it's hop testing, uh or quadri isokinetic string tank testing. And I know that we all don't have like the isokinetic test, but we can use handheld dynamometer to define how strong their quad and their hamstrings are. And um looking at this, we also do this in the motion analysis lab too. So we're gonna go over um what we look into right for AC L repairs and having them successfully return to sport. So we look into self reported outcome measures such as the P D I K DC and the AC L RSI in order to assess the patient's perspective. And then we also want to take into account again that fear of movement and their psychological well-being, we assess, we assess the muscle strength via isokinetic testing and quad hamstring strength, looking at limb symmetry inrix and quad to hamstring ratios. And then we have our functional testing which involves hop testing um being the most common like the single leg hop for distance, triple crossover and the six m time top. And then we also have our movement mechanics. And this is what we focus primarily on in the motion analysis lab where we assess a battery of tests that I will be mentioning in the remaining slides. So all of these tools put together is help, what helps us take our athletes to the next level and have them go through the right trajectory to return a sport. So here's the big question, why motion analysis. So as I had mentioned and reviewed all those statistics, um there is a huge risk of injury if we don't look at movement, it is a big piece of the puzzle, right? Um Our, all of our injuries are multifaceted and there should be um multiple components for us to look at and um and trying to get them to return a sport. So remember that the first, it's only takes the 1st 40 milliseconds for them to obtain a noncontact AC L tear. And this is something that you can't really see in a physical exam or in an M R I or even through special testing, we need to understand that what an athlete's mechanics looks like in this particular time frame in order to assess their return to sport readiness. And this is something that we do on a frame by frame basis at our motion analysis lab and then you're successful. So you may wonder where we might influence, implement this motion analysis into our rehab time frame. So as physical therapists, we like to consider two different timelines. We have one that's provided by the surgeon or the MD. And we follow along those postoperative guidelines in order to ensure that there's proper healing of the AC L graft. And then we also want to consider a criteria based timeline. And we, what we do is we use specific movement checkpoints in order to clear our patients to move on to that next phase of rehab. And so based on this timeline I've created uh the motion analysis lies roughly here. And so, um we want to evaluate their strength and jumping mechanics at a mid point of their rehab, which is around 6 to 7 months. And this is when they're first starting to be um introduced to those sports specific movements. And then as they um we have their video and then we have them go through it with their physical therapist. We um reevaluate them around 12, 10 to 12 months as they um are getting prepared to actually return to sport. And so one of the many perks of actually having a emotion analysis lab in our clinic is that it's a very standardized testing environment and that allows us to assess how much our athletes have actually learned in the clinic and see if they're able to recreate some of these commonly performed movements without any feedback from their therapist. And so we utilize a two D motion analysis and focus on these specific movements. We look at drop, jump testing, we also look at triple hop and then we do a series of change of direction tests which involve the lateral shuffle, deceleration and cutting. And I will be showing you more of those examples in the upcoming slides. So in the research, the use of Molson analysis has actually shown to have pretty good in inter and intra radar reliability specifically from the frontal plane kinematics. In addition, um well, 3D analysis is the gold standard. Um It has demonstrated that there's moderate to strong validity in the sale plane but poor validity in the frontal plane. And uh currently, there's no data for two D and transverse plane. So in our lab, we like to use sample markers on our patients and we place them on these specific landmarks, so we can track movement and visualize specific joint angles and kinematics. Um The markers that we use are located here, we have the greater counter the center of the patella, the lateral knee joint and then the lateral malleoli, we wanna make sure that when our patients come into the clinic and that, that, that they're ready to go, they are not coming in in Crocs, they're not coming in in flip flops, they have appropriate shoes to wear. So then that way they can perform these movements safely. And then we wanna also make sure that they're wearing um shorts that are short enough to see their knees and tuck in their shirts to be able to evaluate the trunk appropriately. Oops, sorry. Ok. So finally, um we've been waiting for this moment right to actually watch some video and see um some examples of our athletes performing some of the return to sport testing. So in this particular example, the athlete is performing a drop jump test. And so what um the athlete is going to be doing is she's going to be jumping off from a 12 inch box directly onto the first force plates and then jumping straight back up. So, a common cue that we like to use in the motion analysis is we're gonna have you jump onto the force plate and then jump up as if you're going to grab a rebound in basketball. Oh, sorry about that. And so, um, I'm gonna go ahead and just play the video and I want you all to just take, take a look at her mechanics. So we can clearly see that at the lowest part of her squaw. And right before she takes off that she, her knees have actually been, they're significantly closer than what they originally started with. So her knee separation is roughly around 65% compared to her hips. And according to a study done by Cincinnati Sports Med group, having a knee separation of less than 80% actually corresponds with higher AC L re injury rates. So, um with videos like this one, we want to make sure that our athletes are observing their movement as well. Um So then that way they can see their own movement faults and then also be able to um work on them with their therapist throughout their continued rehab. So now we're gonna show a comparison again, this is the same exact movement we're taking our at the um there and then let me just go ahead and show you the video. So here you can notice that she is landing um with her knee operation at about 95%. And so remember that the cut off is around 80%. So she's definitely better in terms of that. In her case, if we were to actually um have the force plates turned on, we would also be able to know that she's slightly leaning towards that right leg and her operative leg is the left one, in fact. So, um we definitely want to not only take into account what her knee separation looks like, but what is her weight distribution? Right. So, um, even though she is meaning that cut off for that knee separation, we wanna make sure that we're addressing all aspects of this motion analysis. So then that way, um we minimize the risk as much as possible. One other thing to keep in mind, um is that uh performing these type of movements in a lab setting is one thing, right? But it's very, very different when you have them do it in a competitive sport type environment. So even though there are people that are coming in with these cut off scores and they look great in um in clinic or in lab, we want to take into account that they may still not be ready for competitive sport. Um, when you are going into a game or at least when an athlete is going into a game, they're not really thinking about what their squatting mechanics look like or even what their landing looks like, what they're paying attention to is going to be their opponent. How are they going to react in the game? What is the next play and so on? And so, um hopefully, what we hope for is that when we have this information, we can continue to work on it, provide that constant feedback to our athletes and have them repeat and repeat and repeat. So then that way it ends up becoming a very natural, automatic way for them to do these things and they don't really have to think about it while they're playing in their sport. So now, um this athlete is going to be performing a deceleration drill where she runs towards the fourth plate and then makes a sudden stop and then does a back pedal. And so, um this is also another very common change of direction drill that is done and you see it a lot in soccer, basketball and football. So I'm gonna go ahead and play the video. So this athlete has significant dynamic knee valgus as you can see. And this is another risk factor that has been mentioned in the previous slides, if this athlete, let's say we were to discharge her at this point. Um This athlete is very, very likely to sustain a major non contact knee injury. And so we just wanna, I just wanna reiterate the importance of being able to watch an athlete move because, um, a string test or a special test is not gonna give you the answers, right. You wanna be able to see exactly what they're doing before they actually go out and do it themselves. So now let's watch this out, perform the same exact movement. So when we look at this athlete, um, she is demonstrating some dynamic valgus, but it's to a lesser degree than the previous, um, person. And again, um she does have some room for improvement. But as we identify these things, we're gonna have her practice as much as possible. Um If we were to have our athlete retest, uh a good way to do it would be to simulate a real world scenario as best as possible, right? We can't really bring in a bunch, a squad of like five or 10 kids to play with her, but we can um try to simulate it by and sporting equipment that she may be using, having her, her shoes on and that she uses in a game. And then in fact, just try to have her react as more uh more as possible. So then that way it brings her to that next level of learning and promote that actual carryover. So in this view, we have um this athlete performing a cutting motion where the athlete is gonna be running directly straight to that force plate and then planting her left foot and cutting to the right side at a 45 degree angle. So let's watch her knee and her pelvis as she plants and cuts. So here we see that at that very instance, she cuts to her right side and there is an increased knee abduction moment. And so we saw that that's also uh a great risk of ac L tear. And we wanna take into account that contralateral pelvic drop as well, um which may indicate a poor core musculature as well as hip muscle strength that can be retrained in the clinic. So there isn't much evidence or strong evidence really to support that hip musculature weakness in relation to AC L Taro Taro is um um there isn't much evidence on that and it's a little conflicting, but unfortunately, I didn't find a good one. Um that suggests a strong prediction, but it's still important to take note of um as we want to address that. So this athlete is gonna be doing the same cutting motion. So let's go ahead and watch. So her mechanics are significantly better. She might have a slight knee abduction moment, but it's very minimal and her pelvis is a lot more level than the previous slide. So that would put her at a lower risk of injury. So in this video, we're going to be looking at the cutting motion as well, but now it's in a lateral view. So in this particular view, we like to take into account the knee and the hip kinematics or the joint angles. So, um I did want to mention that those that demonstrate a higher hip and knee flexion do have a more protective mechanism to minimize the risk of recurrent ac L injury. And that's because the hamstring is now being um able to activate a little bit better. Um But with her, um we can see that as she plants to her right plants and cuts to her right, that her knee flexion angle is roughly around 50 or 63 degrees. And then we have her hip flexion angle being a 55 degree. So, um what we really want is for her to actually get a lot lower. Uh And so as clinicians, we wanna look roughly for 75 degrees of knee flexion, but there isn't necessarily good data out there to define that in general, we really just want the athlete to get lower and just because we want our athlete to be lower doesn't mean that we want them to be running in a low and crotch position. There is many of our athletes that get confused of this and when we describe the mechanism, we want them to run as normally as possible, but we also want them to lower themselves once they actually perform that cutting movement instead of having that stiffer upright posture. And so this is our last slide. Um This athlete is not performing the cutting motion. Um She is doing a lateral shuffle but I wanted to show you this video. So then um it can show you exactly uh a good representation of that knee and joint knee and hip angle. So in her case, her hip flexion is much higher at around 90 degrees and her knee flexion is around 70. So again, she is providing that protective effect to her knee by doing this and thus is reducing her chances of a noncontact AC L injury. So that is all I have for you today. Um The next presentation by Brent and Jamie are going to address these deficits in the clinics clinical scenario and these are the references and thank you so much.