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Turn, Twist, Triumph: Returning to change of direction & cutting sports with Dr Amy Arundale

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In this episode with Dr Amy Arundale, we covered how we might start some change of direction and cutting with our athletes, what outcome measures to look out for and test and some practical milestones around strength, neuromuscular control and confidence.

Want to learn more about HOW to get your patients back to change of direction and cutting sports? Amy Arundale recently did a brilliant Masterclass with us, called “Return to Play” where she goes into further depth on change of direction and cutting sports. You can watch her whole class now with our 7-day free trial: https://physio.network/masterclass-arundale

Amy Arundale, PT, PhD, DPT, SCS is a physical therapist and researcher originally from Fairbanks, Alaska. She received her Bachelor’s Degree with honors from Haverford College. Amy completed her DPT at Duke University, and throughout gained experience working at multiple soccer clubs including the Carolina Railhawks F.C. (now North Carolina F.C.), S.K. Brann (Norway), and the Atlanta Silverbacks. 

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SPEAKER_02:

Having a plan to say, how do I progressively get myself or get this athlete from that pretty one pace activity to now those higher demands is really important. And that can actually be a hard step, but the more you can break down those demands, the more you can kind of work backwards to say, here's objectively how that buildup might look.

SPEAKER_01:

Returning athletes to cutting and changes of direction can be a challenge. So today we had a We covered things like what we might measure for an athlete before getting into changes of direction, how we might actually do that and how we might program it, as well as looking at strengths, neuromuscular control and confidence. Now, this was a preview to a Physio Network Masterclass. And if you want to learn more about it, more or go deeper, we've got a seven-day free trial attached in the show notes. There were plenty of practical takeaways in this episode. Please enjoy it. My name is Michael Risk, and this is Physio Explained. Welcome, Amy. Thank you for joining us.

SPEAKER_02:

Thanks so much for having me. It's awesome to be back.

SPEAKER_01:

Yes, part two. You've done a masterclass, a physio network masterclass on return to play. So we're going to go a little bit deeper on some of those areas. And we might even focus in on the directional component of return to play today. You'd mentioned it's really important to have a plan and kind of know what you're going to measure. Could you speak a little more to that?

SPEAKER_02:

Sure. If we're taking an athlete at the point, say it's a running-based athlete, we'll take them at the point where they've kind of built back into running. They've been maybe doing some straight line running. Maybe they've been going for some runs, like kind of an easy pace, right? How do we build them from there back into some of those demands of their sport? So if it's a soccer player, right, we need to build them back into having speed. They need to be able to change directions. They need to be able to kind of anticipate or also run. react to an opponent. Those are kind of complicated and higher demand things than just going for a nice, easy, one-page run. So what I mean by building a plan is we've got to understand what are those demands. Kind of gave an example of a soccer player there, but if we've got a basketball player, we know those sprints are going to be short, but really high intensity. They're probably going to come pretty quickly. We know that athletes got to really decelerate quite quickly, and then they've got to accelerate quite quickly to get around an athlete. Those demands are pretty different from that straight line running. So we have to have a plan of how are we going to get them from point A of that straight line to point B, which would be those high demands. So we've got to understand, okay, what are those decelerations? Maybe what's our athlete's top speed? And that's easy if you work in a professional setting. It's a lot harder if you're working in a clinic. So figuring out, okay, how am I going to measure things, right? Am I going to use a GPS watch? Am I going to try and get my hands on a GPS device, like an accelerometer? Or maybe we can have access to some of those higher tech devices. So like, how am I going to measure and quantify knowing what my athlete's going to do? That's important for the first part. The other part of that plan is building out, like, what's that progression? So it's not just running distance, but that's progressive distance is important. Maybe it's it's that volume of what they're doing in a particular session or over the course of a day. It's then the intensity. We know we can build volume, but we can't build volume and intensity at the same time. So having a plan to say, how do I progressively get myself or get this athlete from that pretty one pace activity to now those higher demands is really important. And that can actually be a hard step, but the more you can break down those demands, the more you can kind of work backwards to say, here's objectively how that buildup might look.

SPEAKER_01:

Do you have any tips on how you might do that in a lower tech Would you be measuring time or shuttle length and how many reps and how would you measure intensity? Is that more subjective? Do you have any tips around that?

SPEAKER_02:

Yeah, absolutely. If we start with that end and those demands, if you don't have baseline data for an athlete, there's some pretty good normative data if your athlete plays a team sport. If your athlete plays basketball, especially soccer, going into the literature, there's some pretty decent normative data out there that you can at least roughly base. Now, I say it's decent. It's not amazing. It's not perfect, but it's something. It can give you a starting point for if you've got an under-16 soccer player, how long are they going to run within a game? or what might be their top speed. Now your player's gonna maybe be plus or minus of that, but that at least gives you that end point where we're working towards. Your watches these days, right? So whether it's a GPS watch, which can help you with tracking distance, a stopwatch, like you mentioned, if we're doing some shuttle runs, like we can work backwards to say, all right, this is a five meter, I've marked up off five meters, click, click. It's not perfect, but you can start to calculate what is that sprint speed Or what is that higher intensity speed going to look like?

SPEAKER_01:

Yeah, I think the encouragement is great to measure that. Nice.

SPEAKER_02:

Yeah. And, you know, it's a great actually opportunity to engage the athlete to engage their parents because you may not be on the field as this athlete's doing this session. But if you can say, look, here's a session. I want you to go do this. Maybe that under 16 athlete doesn't necessarily want to hang out with their parents. At 14, 15, that's not the cool thing to do. But if suddenly they need somebody to time them, whether it's a friend or a parent, another teammate, now they've got some engagement in that session. They need to get this session done because they've got accountability to you. And we need to get times. So now you've got a little bit more engagement with that session, which is really valuable as this athlete's like, I'm almost there. I want to be back, but we can help build, engage them in that progression to say, you are almost there, but we still have a ways to go. And we need to check these boxes first. So here's your homework. Here's what I need you to do. When we see you back, here's the numbers I want to see. And then you can engage them too in making those tables, right? Instead of you having to make the Excel sheet and track those numbers.

SPEAKER_01:

I like

SPEAKER_02:

that. At 15, 16 science class, right?

SPEAKER_01:

Yeah.

SPEAKER_02:

They're definitely making tables, making graphs. And suddenly you've got kind of this partnership with your athlete in building some of those progressions. So it looks simple. It doesn't have to be complicated. So time, stopwatch, for doing speed. You mentioned intensity, something like an RPE. So a rating of perceived exertion can be really valuable for an overall session. Or you might even use it on a sprint. Maybe I assign you say, I want this to be a 60% sprint. I want this to be a 70% sprint. As they're coming back, and saying, okay, I might've overshot that a little bit. I might've undercooked that one a little bit. All right, where did that one fall? Do we think that was 60%? And some athletes are really good at that and some are really bad at that. By the point you've gotten to this point with your athlete, you've probably got an understanding of how reflective or how intuitive they are. So giving them some gauges and again, giving them that feedback, an RPE can be really valuable as well.

SPEAKER_00:

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SPEAKER_01:

like the accountability and motivation that would come with them being in charge of some of the measurements and the sheets. That's really cool. You mentioned the prerequisites offered, the strength, neuromuscular control and confidence. I'm interested in that. I'm particularly interested in confidence and how you measure that. Could you take me through each one of those, what you're looking for before you might go into changing direction with an athlete?

SPEAKER_02:

Yeah, sure. So last time we talked, we talked about kind of criteria for return to running. So by the time my athletes are kind of running over ground, ideally I'd love for them to have a baseline strength. I'm looking for the kind of at least 80% limb symmetry, where if we've got a pre-injury value that they're in that 80, 85% of their pre-injury values. As we're starting to build speed, we know the strength demands of those goes higher, especially in your solely especially in your hamstrings, but your quads as well, hip flexors, you're producing a lot more force. You're absorbing a lot more force at that higher speed. And then as you have to slow down from it. So from a strength perspective, I look at all of those lower limb values to be higher than when we started that overground running. If you're in that 90%, 95%, that's awesome for me.

SPEAKER_01:

Yeah. Okay. That's really good. And would you not start direction if you hadn't hit those numbers or are there some times where you're like, I think you're ready, you're confident, you're trialing it?

SPEAKER_02:

Yeah, so there are definitely some times where I'll start before then. Then it's going to be, how do we manage these? So we're still building that strength and getting you up into that range while maybe introducing some of these pieces. So maybe we're introducing change of direction at a lower level, but the focus is still on that building that last little bit of strength. So we've kind of got a partnership. Whereas if they're already at that high strength value, our focus is maybe more higher intensity or more higher volume around those change of direction drills or those changes bead drills.

SPEAKER_01:

That's a nice spectrum to consider. Yeah. How do you measure the neuromuscular component or what are you looking for?

SPEAKER_02:

That one's maybe a little bit harder to objectively measure, but I think there are some pieces. One is the subjective piece to looking at them. How do they move? On a single leg, single leg squat, single leg jumps, how do they move? How do they look? But not just straight playing. How do they look in a side lunge? How do they look if you were to ask them to rotate within the gym? Can they hold a nice alignment if they have to open their hip up? Things like that. So in slower motions, how's their single leg alignment? And then we can also look at other, maybe more complicated or more objectively measured things like jumping. So if you're in a clinic, something like the MyJump2 app can be really helpful to say, looking at a single leg countermovement jump, how does that look side to side? Is your jump height totally different? Jump height doesn't say everything, but if they're totally different, then all right, maybe we need to look a little bit more on what's happening limb to limb. If you've got more tech, maybe you've got force plates. All right. We can get then a bigger range of variables to look at, which sometimes make it sit harder. You got to figure out which variables are important. But maybe something like just jump height or just reactive strength index from my jump to can be a really simple variable to help you compare side to side and say, all right, are they getting up? Yeah. Does that look similar side to side? Some of those factors can be, I think, really valuable in identifying those neuromuscular variables that might be different in areas where we might need to develop a little bit more. So maybe it means we can start some slow change of direction, but in the clinic, we're still working on building some of those maybe more fundamental pieces. We're going to hold off on the higher speed change of direction until we've built that slower piece and that does control or that power or kind of reactive strength that we want

SPEAKER_01:

yeah it's a nice way to think about those two variables i really like that it's a good tip with the app as well i hadn't heard of that app before there's a bit of personal experience in this as a patient and as a physio and i'd love for you to correct me if i'm wrong here something i always remember feeling and seeing was a stiffness particularly around a knee injury, they would land and cut with quite a lot of stiffness and not willing to go into that dynamic flexion. Is that an observation or is that something more objective you've noticed?

SPEAKER_02:

No, so there is actually an objective piece to that. We do know that the injured limb tends to be a lot slower in developing kind of that rate of force development. And also we tend to be focused a lot around concentric strength development, whereas that eccentric strength development may sometimes lag behind So making sure we're looking at eccentric, if we can, looking at eccentric strength, looking at rate of force or rate of torque development can be really valuable. So early on, looking at concentric values can be really valuable. But as we get later stage, trying to get an idea of what those eccentric and those rate of torque development may be really valuable because those may be underlying mechanisms behind why is that athlete not getting up? Why do they just not look like they've got any power on that side? Does it look like that limb's like so much slower or it's just so much stiffer in a landing. Like they absorb on one side through their knee. On the other side, they've got a really big like trunk flexion. Those may kind of be somewhere woven in between. I

SPEAKER_01:

like that. And I wanted to finish on confidence. So what conversations are you having? What are you looking for? And do you have a questionnaire or scale that measures that?

SPEAKER_02:

So questionnaire scale wise, I definitely use the ACL RSI. I also use the knee self-efficacy score because I think those capture slightly different aspects of how does this athlete feel about their knee. But I think also just having those conversations around, do you feel ready for this? How good do you feel? going through slow motions of this. How do you feel overall about where you are in your rehab? And then how do you feel about starting to speed things up? A lot of times you'll get the excitement, but as you start to tease through, what else are they feeling? I think you can really dig into some of that confidence and are they ready?

SPEAKER_01:

Yeah. Could you just repeat the first scale you mentioned today?

SPEAKER_02:

Yeah. So the first was the ACL RSI.

SPEAKER_01:

Thank you for that, Amy. That's a really good review. And just a reminder that you've done a physio in Network Masterclass and we're going to put that in the show notes for all the listeners. So thank you again for your time.

SPEAKER_02:

Yeah, thanks for having me.