#57 - Creating a Pre-habilitation Program with Dr. Davis McAlister, Part 1

Factor spelled FA k t R stands for Functional and Kinetic Treatment with Rehabilitation. Over the past decade, this unique approach to treating pain and dysfunction has been utilized by healthcare providers on six continents, serving as a framework that guides clinical decision making and patient visits around the globe on a daily basis. With this podcast, our goal is simple to bring the best and brightest in clinical education to the forefront and empower practitioners with cutting edge, evidence based content that improves patient outcomes and inspires healthcare providers to continually evolve their approach to treatment. In each episode, we will feature a training or interview with some of the top minds and healthcare in a short format that is easy to digest, with actionable information that you can implement into practice right away. Let's get started. Welcome to a new episode of The Factor podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome and thank you for listening. In today's episode, we're going to explore a fascinating topic that has gained significant attention in recent years. Today's training is titled creating a Prehabilitation program with doctor Davis McAllister. Whether you're an athlete, a fitness enthusiast, or someone preparing to go under the knife, prehabilitation is a proactive approach that can help optimize your physical and mental well being before an event or a sport. This subject is one that really hits home for me as I sit here today prepping to leave for a World Series Baseball tournament with my nine year old and his baseball team. Even at such a young age, we are constantly monitoring our kids to make sure they're getting proper rest, nutrition, hydration so that they can perform at their best and of course, reach their full potential as an athlete at every stage as they grow. Now, I am fortunate enough to have a husband that's very well versed in athletic performance and recovery, and I consider myself a little bit smarter than most when it comes to that subject. But for most parents that's simply not the case. So what do they do? Who do they look to to help guide them on making sure their athlete is well taken care of and not leaving themselves open for injury. In the world of sports medicine, we talk so much about how to treat injuries after they occur, but you don't hear a lot about how to prevent them in the first place. And of course we can't prevent every injury all of the time. With athletes, there's never going to be a one hundred percent prevention rate. But what we can do is better prepare our athletic patients for competition by implement menting a prehabilitation program that is customized to the unique needs of their sport and current level of fitness. And this isn't only for athletes. This can also be for your weekend warriors or those that enjoy running regularly, cycling regularly. This doesn't necessarily have to be only when there's a major competition or a sporting event a game of some sort. This could be for your patients at all levels. So you might be asking, well, what does the research say about this topic. Lucky for you, I have a few quick excerpts I'm going to share here before we get into today's training because I think these are relevant and they were certainly eye opening for me. So a study published in the American Journal of Sports Medicine found that athletes who participated in prehabilitation programs experienced a forty percent decrease in the incidence of sports related injuries compared to those who didn't. There was also another study by the University of Wisconsin School of medic in Public Health where they implemented a prehabilitation program with the study participants. This program resulted in a fifty percent reduction in the risk of lower extremity injuries among collegiate athletes, and doctor McAllister will hit on that sum when it comes to acl tayers. This is a very important study. There's also one from the National Athletic Trainers Association that reported that athletes who engage in prehabilitation activities specific to their sport had a twenty nine percent decrease in non contact lower limb injuries, emphasizing the profinitive benefits of both of these programs. And then, of course, finally, a systematic review published in the British Journal of Sports Medicine analyzed various studies and concluded that prehab programs reduced the overall risk of sports injuries by approximately thirty percent. So if you aren't currently doing any prehabilitation programs with your patients, listen closely and take notes. I can guarantee this training will teach you strategies you can implement in practice right away. Our instructor today for this two episode series is doctor Davis McAllister. He's a clinic faculty doctor for the Parker University Dallas Wellness Clinic. Doctor McAllister earned his doctorate of Chiropractic from Parker University in two thousand and three and has been a team doctor for various high school sports teams and both pro and semi pro sports teams. Prior to his career in chiropractic, doctor McAllister served in military intelligence for the US Army from nineteen ninety one to nineteen ninety nine and as a human intelligence specialist and linguist. After his military service, he attended Mississippi State University, where he earned his bachelor's degree in science. Doctor McAllister also has a bachelor's degree in anatomy from Parker University, a master's degree in Educational Leadership from soeul Ross State University, and he has sifications and Adaptive Rehabilitation, occupunctions and cushion and kettaball. He specializes in chiropractic treatments for sports related injuries, rehabilitation, taping, and soft tissue. Let's cue the intro music and dive in. Just a little bit of background where kind of where I'm coming from. I've been a chiropractor for eighteen years, prior that of eight years in the military. During that time while I've been in practice, have also been a strength and conditioning coach and a high school coach here in the state of Texas for the past fifteen years. I'm a powerlifting coach both for USA Powerlifting and for a Texas high school team, and I'm also the team chiropractor for the w NBA Dallas Wings currently, but I have also worked with the XFL Dallas Renegades before COVID shut everything down last year. I've also done work the PBR, several semipro baseball teams and so forth. So give you a little bit of background as to where this presentation came from. One of the high schools that I worked with had a problem in their basketball program, the girls basketball program, where they had three ACL tears in the same school year. Basically it devastated the whole Three of them are varsity players, starters, and it just basically decimated their program. And so they asked me to come in evaluate assess what was going on. Functionally with their players and then be able to offer some advice and out of that, I felt that there was a need to be able to put together a program to be able to share some information some of the evidence and research that's out there on ACO prehabilitation. Of course, the angle that we're going with this is non contact a CEO. Obviously, there's not a whole lot you can do. Somebody comes crashing through somebody's knee and you get your triad there. But this we're trying to minimize the possibility of risk for an ACO terror just by poor mechanics and some of the other factors. And we'll get into a little bit of that. So just a little bit of a refresher on the acel ligaments. The anterior cruciate ligament extends from the lateral from oral condyle to the anti medial aspect of the tibial crest. It assists with need stability by providing passive biomechanical restraint for rotation and limiting anterior translation of the tibia in relation to the femur. And as we get into some of the mechanisms and mechanics of it, I want you to bear that in mind as far as the function, we're going to get into different aspects of function, as far as passive restraint versus active restraint, when we talk about structure of the need, and then to achieve need stability while running, jumping, or cutting, there has to be a combination of active muscle contractions in conjunction with precise neuromuscular timing. So those are some of the things that we're going to talk about. So you can see we have the acel that's right here, a PCL is behind it, alternating in the other way. Here's the PCL on the backside as well. And then just a quick review of the muscular chure. You have a lot of musculature that goes around and crosses the knee. I mean, if you think about most of your dynamic joints, I mean, obviously with the knee being a hinge type joint, you're looking at primarily flection extension with very very minimal internal external rotation. It's possibility at the knee. So you have to pay attention to the muscular balance and especially when you're doing your functional assessments, and we'll talk about some of the different things that you should look for during your functional assessment that may relate to muscular imbalances, especially when you're dealing with lateral stability versus medial stability with the adductors, quad dominance versus hamstring weakness, and those types of things. So some of the contributing factors that you're going to deal with, let's talk about some of the incidents of injury. So you have fifteen to twenty five year old competitive or recreational athletes are at the greatest risk of injury. You start to see, especially if you're dealing with high school, you'll start to see a little bit of issues that can creep up for evolving knees. When kids are in middle school to early high school, you'll start to see things like teller tendonitis show up because they're getting into that stage where the muscular development will start to increase, and it typically will increase rapidly and the tendons don't necessarily have time to adjust, and so we've got to allow those the muscular truth to properly develop, with the tendons around the need to properly develop so that we can get that active restraint around the knee. So that's you think about. Most of your people are most active up until they hit about twenty five, and then all of a sudden life kicks in and then you have kids and job and everything else, and activity level typically will go down. For most people, eighty percent of your ACO injuries are non contact and then overall, female athletes are at risk four to six times greater than male athletes, And there's a lot of speculation and that most people attribute it to jo one thing, but there's some other factors that we're going to go into. Female high school athletes are nine times greater and risk of injury female college athletes or five times greater. Professional female athletes have five times greater risk, and sports that have reported the highest incidents of injury due to high dynamic loading. Thought these were pretty interesting. Most of them made sense to me because there were the ones that I've seen with high school students pretty consistently. Except for the handball. I didn't even know if people still played handball anymore, but that was still listed on fairly recent research. And so females in the military are found to not be more susceptible to ACO injury compared to males. Now that's based on statistical information of incidents within the military. Part of the reason for that, though, is because traditionally the role of females in the military have been more support oriented. They tend to be kind of what we've referred to as in the rear with the gear. As women start to progress more and become more active participants in combat roles, I would be confident in saying that that dynamic will change and that number will change. So some of the consequences that you deal with with ACL injury, and so we have a lot of athletic trainers on here so that you guys are going to be able to speak to this pretty effectively. So for athletes, time on the disabled list increase risk of further injuries and development of osteoarthritis in the knee. For military personnel, that's loss of duty time, same consequences as athletes. Knee injuries contribute to further knee injury, and prior hip injuries will increase the risk of specifically ACL injury. So when we see people that have been injured that got to go through a proper neurological rehab, not just rehab the muscle, not just provide some passive stability to the joint. We actually have to go through neurological rehab to make sure that we're having proper weight distribution and symmetry from one side to the other, because if you think about it, if somebody's constantly loading to one side because of a dynamic shift that occurs when they're doing through movement patterns, you're constantly loading one side more than the other. And so if you're asking somebody to load up on a squat, you're asking them to put two hundred and fifty pounds up on the squat. Well, if three quarters of the weight is being shifted over to the right hand side, that's going to have a greater capacity for injury to that side as well in the long run. So those are things that you need to also thick into consideration when you're looking at this aco re injury occurs in one out of every four use. There was no distinction of age on that study. Male athletes are more likely to rupture an aco graft after repair than a female is just because they tend to be you're dealing with greater forces, greater dynamics, And then it also depends on if they're using the proteller versus the candaver tending the candaver tendant tends to be a lot tighter. I have not been able to go back and really get some good information on if there's a greater incidence if anybody's actually done any studies on the greater incidents of the patellar tending graph versus the cadaver graph, but that would be some interesting information to be able to find out. There's a twelve year study of two hundred and twenty one post acl found that sixty four percent head condural defects. You'll get that plaque that starts to developing the joint, and then twenty six percent head from all osteoarthritis. So once you do damage to that knee, the symptoms and the progression continues on from there. So those are things that you need to be able to advise your athletes on as they continue to progress and go through their rehab. If you're listening to this podcast and you've yet to attend a Factor Rehab live course, I have a special offer just for you. See, I realize that sometimes you need to kick the tires a bit to learn more about a course before you register, especially one that offers a certification track. So I've developed a special offer just for those of you who are interested in learning what this Factor thing is all about. See, We've put together a free one hour webinar to introduce the concept of having a systematic approach to rehab. In this one hour online course, our director of Education, doctor Todd Riddle, will show you how implementing a system for patient treatment can improve patient outcomes, streamline your operations, grow your profitability, and help you to build a practice that you absolutely love. You'll also hear from doctor Riddle's personal experience in using the Factor Rehab system, both with elite athletes as well as the everyday patient just looking to move and feel their best. It's a great first step to learn more about FACTOR certification and how Factor could impact your patient care. And to sweeten the deal, we're offering CE credit for completing this online training absolutely free. Yeah so you heard that correctly. Free ce so CE credit is available in a number of US states for chiropractors, as well as for massage therapists, athletic trainers, and physical therapists. To learn more and get your free CE while learning more about how Factor can impact your patient care, visit the free Factor webinar link in our show notes. Now back to the show. All right, so some features that contribute to ACL injury. So you have structural features enter condular not size. All right. If the notch is too narrow, especially in females due to a predisposition a smaller bone structure, the space may become compromised during rotation. The shortened distance as well as shorter fibers of ACO may result in decreased elastic stretched distance. One of the studies that I read showed that if you have somebody that suffers an ACO injury, they recover, they go through the surgery, they repair, and then shortly thereafter they end up tearing the other ACO injury, the other ACO on their knee. More than likely it was contributed to the smaller interconto their knock size. That was one of the high school that our referenced that we worked with the next year, after we came in and did our changes with them, and after our assessment, we went through, we redid their warm up protocol. We actually went through and looked how they were training and working out with their athletes and wrote a whole new program for them. The next year, they went from being last in district to district champs the next year and made a pretty good run in the playoffs. They only had one ACL injury during that next year, and the one a CL injury that they had was a female that had torn her ACO the previous year, and this terror, the second tear was on the opposite knee. That was interesting enough. Not too long ago, that same coach called me and asked me, is there possibility of a familiar relationship with ACL tears? And I said, well, I said, given the athlete that we were talking about, that is very well possible. I said, because anatomic development genetics do play a part. And I asked him, I said, why do you ask? And apparently this same athlete has two younger siblings that are all going through the exact same thing, and I told him, I said, the best thing that those athletes can do is they need to go get an X ray, get the distance measure between the intercondular notch. And there is research and that some statistics out there that will tell you what the greater disposition is for somebody to be at risk for an ACL tear based on the size of that notch. So I thought that was interesting. Are the things structurally that we need to look at integrity of the meniscus. So during loaded motions such as flexion and rotation, female remains in contact with the tibio plateau. While the meniscus functions to assist condular motion. The death and integrity of the meniscus affects the efficiency of that motion, so you have to pay attention. The meniscus is meant to add as a pad and as a gliding mechanism within and so that can be disrupted if there's damage to the meniscus. That tear the meniscus will alter the translational motion of the condyles, resulting in addage stress to the acl During cutting and jumping motions, the joint capsule and ligament the structures those have to be stable as well. So you have the joint capsule and the collateral ligaments provide passive restraints. So we talked about the difference between active and passive restraint around the knee. So your joint capsule and collateral ligaments that provide passive restraint for the knee by controlling dynamic motion, assisting with the stability damaged to any passive restraint to the ning will have a compromising effect of the biomechanical function and increase the risk for ACL injury. And the increase tibual slope can have a potential risk for ACL injury as well. So if somebody's already had an MCL injury and they don't have it properly rehabbed and properly healed up, and they continue to go out and continue to try to cut, then they are now at greater risk of ACL non contact injury noamic a modifiable mechanical biomechanical features. You have movements that contribute to ACL stress. Hyper extension, excessive valgus, and abduction are the most common. Great stress on the ACL is during internal tibial torsion at or near full extension. So the ACL has the greatest resistance to rotational forces between ten to thirty degrees of then flection. So you think about your athletic stance, athletic stance and needs should be been about ten to thirty degrees and as it goes down goes beyond that thirty degree mark. Now you've increased the possibility of over extending and putting tension on that ACL. That if they were to take a cut, step over extend, do anything like that and it goes into an internal rotation. With that, then you're looking at the possibility of tearing that actl quad dominance. So during sustained flection action, the quadricep contraction unbalanced by sufficient hamstring contraction results and and t your translation of the femur on the tibia, creating predisposed stress on ACL. Now, but I'll throw something out here that kind of figure this out. After working with athletes for fifteen years and being in a training room, pretty much everybody's got a quad dominance. I'd love for somebody to tell me I'm hamstring dominant and I said, no, you're not, And so you have that quad dominant. So if you think about certain mechanisms, the quads come up, they attached to the asis on the front and that can create a great amount of tention. A lot of people put a lot of focus on the so ass because it is the primary hip flexer, but they tend to neglect the dominance of the quad as it comes up and attaches to that point on the antier aspect of the hip. Well, if that's tight, you can have bilateral where you get a bilateral anterior tilt, or you get one side that has always been a tend to be stronger or tiger than the other. So now you've got that antier tilt with torsion to that side. Well, if that anterior tilts to that side with torsion, that the issue two braises. So if the issue two braises, we now have a stretched hamstring. There's a problem. Most of the time when somebody complains about tight hamstrings. What's the first thing they do? They tell them go stretch their hamstrings. So if they stretch the hamstring, what they've actually done is compound and made the problem worse by allowing that quad more room to be able to pull that si anterior on the ilium anterior on that side. And then the next approach that I've started to see that's becoming more prominent as well, with strengthen the hamstring. That's great, you can strengthen the hamstring, but the hamstring is still exposed to injury because it's being pulled taught. Now you're asking a taught muscle to try to contract and shorten when you haven't addressed the initial problem to begin with, which is the tight quad. You loosen up the quad, release the ilium, get the ilium to retract and then then you can start focusing on getting the hamstring tighter after that. So another dynamic immdifiable biomechanical features, so great and greatest force of the aco generated and the knee during a double limb or single limb landing with the knee extended and abducted, just as the knee accelerates to a bogus position, stress on the acel increases. So what they're basically it's referred to somebody jumps up, comes down lands you see the knees go in, or whether it's on a single limb or double limb. My favorite thing of the seeds. You watch NBA players, both in the w NBA and the men's NBA, and you see them up there just doing free throbs and they drop down into their stance. Instead of their knees pushing out, they push their knees in and allow their knees to touch just to come up and do a free throw shot. That's already a predisposition to a bad mechanics as it is. And then those guys get out there and have to get out and jump, and they're going to do that just on something as simple as a free throw. You really need to pay attention because they're probably going to do it on their landing and then they're going to turn their acls and the process. So poe musk of the control affects neil linement and can increase antier post tier translation, but rotary sheer forces of the knee stressing the ACL that can cause an excessive roto relaxity that results in a cl injury and tearing of the monescus. So as far as risk of re injury post surgery, knee injuries contribute to the risk of recurring knee injuries. Prior hip injuries will significantly increase the risk of a co injury. ACO re injury occurs in one out of every four utes, and then male athletes more likely to rupture an ACO graph. So we went into a little bit of that already, but there was a twelve years study that we talked about earlier, and I just wanted to add the reference in here to that. All that two hundred and twenty one people that had the sixty four percent condural defects in the twenty one the twenty six percent developed the OA and the knee after that. So performance impacting movement and factors, So you have frontal plane motion. In the frontal plane you have an increased risk of a cl during an excessive adduction of the knee. Increased knee adduction or correlated with drop, jump landing, single or double ag and cutting maneuvers. So what you'll see is as they plant, you'll see that knee over extent. They plant, they drop, and you'll see that knee kind of cave in a little bit us all we had to two years ago one of the players on another team. I was at the game and I was able to go back and look at it, and she planted over extended and then when she tried to cut and redirect, that knee dropped into a valgus or adducted and snapped her ACL right there just on the push off. So those are things that you have to work on. Comparatively, the single leg technique of side step cutting with poor mechanics generate six times more adduction than the drop landing. All right, The single leg motion analysis should be assessed prior to training program initiation to assess mechanics. So you need to go through and do a proper functional assessment to see what the predisposition of the athlete is in order to be able to determine their level of risk frontal plane motion. This is what I was referring to. Now, there's a couple of different things that are play here. So if you look at the knee, you can see everybody pays attention to the Q angle. The other thing that needs to be paid attention to is what's going on right here. If they've got fallen arches, flat feet, those types of things without proper art support and proper support of the angle, you've now increased the risk of this becoming a problem with that angle. So we've got to make sure that these are properly supported down here in order to be able to make sure that we can minimize this. Then it's also a matter of focusing on lateral stability development on the quad to be able to help push those knees out and get them focused and retrained on pushing those knees out when they land. And again Q angle differences so another contributing factor. So as an athlete goes out, they may be paying particular attention to the techniques and things that you go over and that you coach them on. But then as time goes on during the game or even during the course of practice, fatigue will start. To that end. The more fatigue sets in, the sloppy or they will get, the less focus they become they get on technique. So it's something that has to be consistently reinforced both in practice and throughout the course of the game. So during the onset of fatigue, athletes will demonstrate increased motion and sagittal in frontal planes in conjunction with increased ground reaction forces, so hip and the internal rotation increases, resulting in increased valgus. Increased ground reaction forces are going to increase. The single leg show being increased on a single leg hop. So you think about your volleyball players, think butch your basketball players. Those that have to jump, and a lot of the times they don't always come down on both feet like they should. They're coming down single legs. So now you've increased the possibility of exaggerating that valgus and fitting them at risk of an ACL tare. So they increased valgus force and increase ground reaction force predisposed for an ACL entry sore and trunk stability. This is one of the things that spend a lot of time focusing on even within the clinic that I'm working in right now, we've developed a program working with veterans that have TBI and I handle the physical portion of their therapy in conjunction with a neurologist and trying to get them to regain their balance and start being able to do proper weight distribution. And one of the first things that I look at is their core stability, so knee control during single limb and cutting motions that are directly influenced by the position of the trunk and hip motion. Weak trunk and hip strength will result in a much greater center of mass displacement. Strengthening these components will cut down on your center mass displacement and frontal plane motion of the kneed. So if you think about if you watch somebody they're going into a loudal motion, or you ask them to they're in a straight line motion, ask them to cut and redirect, you'll see that upper body if they if their core is weak and they're not properly engaging their core during active movement, you'll see that top other body shift. And we'll talk about some of the other things that you can look for on a core on a functional assessment, but that's a huge indicator. If somebody's trying to redirect and you see the upper body still moving with the lower body not, that's a problem. So that's something that needs to be addressed and working with that athlete on active core engagement when they're doing movement patterns. So specific training of the trunk and hips will result in more control of the frontal plane motion and the athletic performance overall. Again with the core and then glute engagement, you'll see a lot of athletes that because of the quad dominance and those things, you'll see it inherent and blute weakness start to develop on that side and they don't know how to engage their glutes anymore to be able to help maintain control. So those are things that need to be looked at. So hip displacement while in the squat position, so a weight variation of this motion can impact ligament and joint loading, soft tissue strain and ligament sprain, and the asymmetry of strength development. So the lateral displacement can alter force distribution of the hips and lower extremity and joint forces. This is what I was talking about, is that when somebody's going up in in a squat motion. How are they shifting as the weight distribution or they shifting to the left or they shift to the right. You may see it breakdown because there are different stages within the squad that if you see them shift to the right on the initial they may go all the way to the left or back to midline half about two thirds of the way down, and when they get down to the bottom they may shift one way or the other again. And so there are different muscles that are engaging through that. So you need to be able to make sure that you're paying close attention through that process so that you can see that you get proper muscle engagement throughout the course of the entire motion, because as they go down and come back up, certain muscles are activating and deactivating as they go through that process. So combining lateral displacement with increased ground reaction forces which has been calculated to be three, three to six times their body weight, will all through the distribution of force flows throughout the lower extremity ligaments and Lombar's mind increasing the risk of soft tissue of ligament injury. So you can get also developed low back issues as well. You think about what we talk about with the quad dominance and how that affects the pelvis, Well, that stress has got to go somewhere, So then that stress is typically going to go right into the low back. Now you've got overactivation of the erectors in the back, and inherently what happens is is that they should have three sixty core engagement. Well, if the erectors are constantly overactivated, then what's going to eventually happen is is both your internal and your ant your external core going to start to weakend over time. And one of the classic things that you'll see there's people that they refer to as sway backs, but if you watch them run, you'll see their stomach start to come forward and their hips start to drift back while they're running. And that's a lack of core engagement and lack of glute activation that's going to put greater stress on that low back as well. So these are all just kind of things to look for and watch for. So studies have shown the correcting and the lateral displacement will improve vertical jump height and sprint speed. That's it for today's episode. Be sure to tune in for episode fifty eight, where we wrap up part two of this series. We'll discuss the evidence based components that every prehab program should have. Dive into the research surrounding ACL injury, as well as the application of force and movement as it relates to injury prevention. You won't want to miss it. Episode fifty eight drops in two weeks before we end today's episode, I have a quick favor to ask. 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