Professional Podiatrists Members' Day 2nd of October 2011 "Kinetic chain" approach in the rehabilitation of an athlete: increasing and decreasing chains -- Mrs. Fabienne Vandesteene --

1. Kineticchainapproach in the rehabilitation of anathlete: increasing and decreasingchains Fabienne Van De Steene Sportkine UZ Gent RevakiUGent

2. Let us look together… 2 podo congres - 2 okt 11

3. contents Kineticchain Principle Condition Disadvantage Most common adaptation Hip Trunk Shoulder Crosschains 3 podo congres - 2 okt 11

4. Kineticchain: principle podo congres - 2 okt 11 4 Human body = series of interrelated links orsegments Coordinatedaction of body segments Strength & power are generatedfromgroundreactionforces and transferredinto the final link of the chain (hand – foot)

5. Kineticchain: principle podo congres - 2 okt 11 5 Open kineticchain Closedkineticchain

6. Kinetic Chain Wrist F O R C E Elbow Shoulder Trunk and Back Legs 0 TIME (Kibler, Gent 2003) 6 podo congres - 2 okt 11

7. Kineticchain: principle podo congres - 2 okt 11 7 Each link is necessaryformovement Injurycandevelop in the weakest link Knowledge of link important forinvestigation and treatment Groppel, 1992

8. Kineticchain: principle podo congres - 2 okt 11 8 Each sport has hisspecificdemands Each sport has hisspecificadaptations Each sport has hisspecificenergyproduction in the body

9. podo congres - 2 okt 11 9 Energy production in the kinetic chain Hip/trunk-energy 51% Shoulder-energy 13 % Elbow-energy 21% Wrist-energy 15% (Kibler et al. 1996)

10. podo congres - 2 okt 11 10 Correlation Strength – Ball velocity Upper extremity strength .46 Lower extremity strength .89 (Kraemer et al. J Sport Rehab 1995)

11. Kineticchain: principle podo congres - 2 okt 11 11 Proximal stability necessary for distal mobility Trunk, shoulders and upper limb are links in the increasing chain Trunk, hips and lower limb are links in the decreasing chain They cannot work independently from each other, however “dependent-compensatory”

12. Large versus small knee flexion during tennis serve (Olympic Games Sydney) FleisigGS et al 1996 Elliot et al 2003 *Significant difference (p<0.05) 12 podo congres - 2 okt 11

13. Kineticchain: principle podo congres - 2 okt 11 13 Legs/hip/trunk Stable basis Build up strengththrough the chain Shouldergirdle Move composedstrength Shoulder to hand – hip to foot Crossedchains!!!! Groppel, 1992

14. Kineticchain: condition podo congres - 2 okt 11 14 Conditionforoptimalkineticchainfunctioning Joint needs to be in optimalposition to pass on the energy Muscleactivityneeds to beon time And in the proper sequence (exc-conc)

15. Notonlyamount of muscleactivity is important,also proper timing and sequencing! Elite versus beginner tennis player – sequence in muscleactivity (Girard et al. Med Sci Sports Exc 2005, Lintner et al. 2008) 15 podo congres - 2 okt 11

16. Kineticchain: disadvantage podo congres - 2 okt 11 16 Consequencesof optimalkineticchainfunctioning “mal”adaptations (Wolff’s low) Strengthimbalance Muscleweakness Joint stiffness …

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18. PITFALLS KINETIC CHAIN Wrist Wrist F O R C E Elbow Elbow F O R C E Shoulder Shoulder Trunk and Back Trunk and Back Legs Legs 0 0 TIME TIME (Kibler, Gent 2003, adapted from Groppel) "catch up" 18 podo congres - 2 okt 11

19. KineticChain “Breakage” Usually acquired: Remote injury Incomplete healing after injury Muscle weakness or imbalance Muscle inflexibility or joint stiffness Improper mechanics (Lintner 2008) 19 podo congres - 2 okt 11

20. Mathematical model kineticchain in tennis (Kibler et al. 1995) 20% reduction in kineticenergyfrom the trunk 34% increase in velocity 70% increase in mass To achievesamekineticenergy of the hand "catch up" 20 podo congres - 2 okt 11

21. KineticChain podo congres - 2 okt 11 21 Conclusion Chain is necessitybut… Chain is difficult to evaluate No “gold standard” Less “evidencebased” Trial and error…

22. contents Kineticchain Principle Condition Disadvantage Most common adaptation Hip Trunk Shoulder Crosschains 22 podo congres - 2 okt 11

23. hip podo congres - 2 okt 11 23 Commonadaptations Decreasedflexibility (rotation-extension) Decreasedabductionstrength (endurance) Muscleimbalance (abductors-adductors) Insufficientcontrol of localstabilizers How do we test? ROM (exo-endo-flexion-extension) / musclelength !!clinicalinvestigation!! Muscletesting (trendelenburg) Isokinetic-MMT Functional tests: squat-lounge Cools & Walravens 2007, Ellenbecker 2007, Vad 2003, Johansson & Cools 2010

24. HIP podo congres - 2 okt 11 24

25. hip podo congres - 2 okt 11 25

26. hip podo congres - 2 okt 11 26 Commonadaptations Decreasedflexibility (rotation-extension) Decreasedabductionstrength (endurance) Muscleimbalance (abductors-adductors) Insufficientcontrol of localstabilizers How do we treat??? Mobilising-stretching in the chain Restoremusclefunction Muscle training Analytical Functional Neuromuscularcoordination

27. hip (mob/stretchingexc) podo congres - 2 okt 11 27

28. hip 28 podo congres - 2 okt 11

29. Hip (neuromusccoord) 29 podo congres - 2 okt 11

30. Hip (strength) 30 podo congres - 2 okt 11

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32. Hip podo congres - 2 okt 11 32 Commonadaptations Decreasedflexibility (rotation-extension) Decreasedabductionstrength (endurance) Muscleimbalance (abductors-adductors) Insufficientcontrol of localstabilizers Influenceonother joints Decreasing – increasingchain Ankle Foot …

33. Ankledistorsion Evidencebased risk factors: Posturalcontrol Proprioception General prevention Stability training Local General 33 podo congres - 2 okt 11

34. podo congres - 2 okt 11 34 Preventief effect “stability training” “core stabilitymeasures” are predictivforlowerlimbinjuries Leeton et al. 2004

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37. Ankledistorsion Most important risk factor (prospectiveinvestigation): 144 youthsoccerplayer U11-U17  playerswith a lateralfootunroll: significant greaterchance (Witvrouw, Thijs, Van Ginckel, De Bo) 37 podo congres - 2 okt 11

38. trunk podo congres - 2 okt 11 38 Commonadaptations Decreasedflexibilitydorsalstructures Decreased ROM extensionthoracicspine Hypermobilitycervicalspine (compensatory) Decreasedextensionstrength (endurance) Muscleimbalanceabdominals-back Decreased core stability How do we test? Sit and reach ROM investigation (functional) Muscletesting Isokinetic test Normalfysiological lordoses Cools & Walravens 2007, Ellenbecker 2007, Vad 2003, Johansson & Cools 2010

39. trunk podo congres - 2 okt 11 39

40. trunk podo congres - 2 okt 11 40 Commonadaptations Decreasedflexibilitydorsalstructures Decreased ROM extensionthoracicspine Hypermobilitycervicalspine (compensatory) Decreasedextensionstrength (endurance) Muscleimbalanceabdominals-back Decreased core stability How do we test? Sit and reach ROM investigation (functional) Muscletesting Isokinetic test Normalfysiological lordoses Cools & Walravens 2007, Ellenbecker 2007, Vad 2003, Johansson & Cools 2010

41. trunk podo congres - 2 okt 11 41

42. trunk podo congres - 2 okt 11 42 Commonadaptations Decreasedflexibilitydorsalstructures Decreased ROM extensionthoracicspine Hypermobilitycervicalspine (compensatory) Decreasedextensionstrength (endurance) Muscleimbalanceabdominals-back Decreased core stability How do we test? Sit and reach ROM investigation (functional) Muscletesting Isokinetic test Normalfysiological lordoses Cools & Walravens 2007, Ellenbecker 2007, Vad 2003, Johansson & Cools 2010

43. trunk podo congres - 2 okt 11 43 Commonadaptations Decreasedflexibilitydorsalstructures Decreased ROM extensionthoracicspine Hypermobilitycervicalspine (compensatory) Decreasedextensionstrength (endurance) Muscleimbalanceabdominals-back Decreased core stability How do we treat??? Mobilising-stretching in the chain Restoremusclefunction Muscle training Analytical Functional Neuromuscularcoordinationstrenght crosschain

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50. Shouldergirdle podo congres - 2 okt 11 50 Commonadaptations GIRD idshoulder: decreasedflexibility Muscleimbalance (IR>ER) Protractionscapula Alteredmusclerecruitmentscapula How do we test? GIRD- endorotation/ROM clinicalinvestigation Muscletesting Musclelength Scapular setting Trakis 2008, Dines 2009, Cools & Johansson 2010, Kibler 1996, Laudner 2007, Oyama 2008)

51. podo congres - 2 okt 11 51 GIRD in the shoulder

52. Shouldergirdle podo congres - 2 okt 11 52 Commonadaptations GIRD idshoulder: decreasedflexibility Muscleimbalance (IR>ER) Protractionscapula Alteredmusclerecruitmentscapula How do we test? GIRD- endorotation/ROM clinicalinvestigation Muscletesting Musclelength Scapular setting Trakis 2008, Dines 2009, Cools & Johansson 2010, Kibler 1996, Laudner 2007, Oyama 2008)

53. podo congres - 2 okt 11 53 Scapular setting

54. Shouldergirdle podo congres - 2 okt 11 54 Commonadaptations GIRD idshoulder: decreasedflexibility Muscleimbalance (IR>ER) Protractionscapula Alteredmusclerecruitmentscapula How to treat Mobilising/stretching Strength training Scapular setting Integrationchain!!!!

55. Shouldergirdle podo congres - 2 okt 11 55 Muscularshortening

56. Shouldergirdle podo congres - 2 okt 11 56 Commonadaptations GIRD idshoulder: decreasedflexibility Muscleimbalance (IR>ER) Protractionscapula Alteredmusclerecruitmentscapula How to treat Mobilising/stretching Strength training Scapular setting Integrationchain!!!!

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58. Cross chain 58 podo congres - 2 okt 11 A lot of sports movement have a cross chain pattern!!!! With influence from the decreasing and increasing chain...

59. Cross chain mov 59 podo congres - 2 okt 11 Compensations ... unavoidable???!!! All tissues are ... involved in the chain and in the adaptations from the chain

60. podo congres - 2 okt 11 60 Compensation

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62. Integration chain 62 podo congres - 2 okt 11

63. CONCLUSION podo congres - 2 okt 11 63 Knowledge and assessment of sportspecificadaptationson ALL levels of the kineticchain !!! Flexibility + strength + motor control... Investigate/Treatadaptationson ALL levels of the kineticchain Integratekineticchainintoexercises - advice

64. Questions?????????? 64 podo congres - 2 okt 11 Thank you!!!!!!!