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

FAKTR, spelled F-A-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 6 continents. Serving as a framework that guides clinical decision-making in 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 in healthcare in a short format that is easy to consume. 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 Dr. 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 9-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, But 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 100% prevention rate. But what we can do is better prepare our athletic patients for competition by implementing 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 40% 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 Medicine and Public Health where they implemented a prehabilitation program with the study participants. This program resulted in a 50% reduction in the risk of lower extremity injuries among collegiate athletes. And Dr. McAllister will hit on that some when it comes to ACL tears. This is a, 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 29% decrease in non-contact lower limb injuries, emphasizing the preventative 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 reduce the overall risk of sports injuries by approximately 30%. 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 2-episode series is Dr. Davis McAllister. He's a clinic faculty doctor for the Parker University Dallas Wellness Clinic. Dr. McAllister earned his Doctorate of Chiropractic from Parker University in 2003 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, Dr. McAllister served in military intelligence for the U.S. Army from 1991 to 1999. 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. Dr. McAllister also has a bachelor's degree in anatomy from Parker University, a master's degree in educational leadership from Sul Ross State University, and he has certifications in adaptive rehabilitation, acupuncture, concussion, and kettlebell. 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 18 years. Prior to that, 8 years in the military. During that time, while I've been in practice, I have also been a strength and conditioning coach and a high school coach here in the state of Texas for the past 15 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 WNBA 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 with the PBR, several semi-pro 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 work with had a problem in their basketball program, the girls basketball program, where they had 3 ACL tears in the same school year. Basically, it devastated— all 3 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 ACL rehabilitation. Of course, the angle that we're going with this is non-contact ACL. Obviously, there's not a whole lot you can do if somebody comes crashing through somebody's knee and you get your triad there. But So this, we're trying to minimize the possibility of risk for an ACL tear just by poor mechanics and, 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 ACL ligament. It's the anterior cruciate ligament. It extends from the lateral femoral condyle to the anteromedial aspect of the tibial crest. It assists with knee 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, 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 knee. And then to achieve knee 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 ACL that's right here. The PCL is behind it alternating going the other way. Here's the PCL on the backside as well. And then just a quick review of the musculature. You have a lot of, 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 flexion-extension with very, very minimal internal and external rotation as a 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 incidence of injury. So you have 15 to 25-year-old competitive and recreational athletes are at the greatest risk of 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 revolving knees when kids are in middle school to early high school. You'll start to see things like patellar tendonitis show up because they're getting into that stage where the muscular development will start to increase and typically will increase rapidly and the tendons don't necessarily have time to adjust. And so— We've got to allow those, the musculature to properly develop with the tendons around the knee 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 25 and then all of a sudden life kicks in and you have kids and a job and everything else and activity level typically will go down for most people. 80% of your ACL injuries are non-contact. And then overall, female athletes are at risk 4 to 6 times greater than male athletes. And there's a lot of speculation, and most people attribute it to just one thing, but there's some other factors that we're going to go into. Female high school athletes are 9 times greater at risk of injury. Female college athletes are 5 times greater. Professional female athletes have 5 times greater risk. And sports that have reported the highest incidence of injury due to high dynamic loading I thought these were pretty interesting. Most of them made sense to me because they were ones that I've seen with high school students pretty consistently, except for the handball. I didn't even know people still played handball anymore, but that was still listed on fairly recent research. So, and so females in the military are found to not be more susceptible to ACL 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 refer to as in the rear with the gear. But 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 you guys are going to be able to speak to this pretty effectively. So for athletes, time on the disabled list, increased risk of further injuries and development of osteoarthritis in the knee. For military personnel, that's loss of duty time, same consequences as athletes. Prior 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, they've 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 going 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 250 pounds up on the squat. Well, if 3/4 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 take into consideration when you're looking at this. ACL reinjury occurs in 1 out of every for youths. There was no distinction of age on that study. Male athletes are more likely to rupture an ACL 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 patellar versus the cadaver tendon. The cadaver tendon 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 incidence of the patellar tendon graft versus the cadaver graft, but that would be some interesting information to be able to find out. There was a 12-year study of 221 post-ACL, found that 64% had chondral defects. You'll get that plaque that starts to develop in the joint. And then 26% had patellofemoral 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.

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All right, so some features that contribute to ACL injury. So you have structural features. Intercondylar notch size. All right, if the notch is too narrow, especially in females due to a predisposition of smaller bone structure, the space may become compromised during rotation. The shortened distance as well as shorter fibers of the ACL may result in decreased elastic stretch distance. One of the studies that I read showed that if you have somebody that suffers an ACL injury, they recover, they go through the surgery, they repair, and then shortly thereafter they end up tearing the other ACL injury, the other ACL on the other knee, More than likely, it contributed to the smaller intercondylar notch size. Now, one of the high schools that I 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 ACL injury that they had was a female that had torn her ACL the previous year. And this tear, 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 a possibility of a familial 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 2 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 measured between the intercondylar notch and there is research and some statistics out there that, 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. The other things structurally that we need to look at, integrity of the meniscus. So, during loaded motions such as flexion and rotation, femur remains in contact with the tibial plateau. While the meniscus functions to assist condylar motion. The depth and integrity of the meniscus affects the efficiency of that motion. So, you have to pay attention. The meniscus is meant to act as a pad and as a gliding mechanism within, and so that can be disrupted if there's damage to the meniscus. A tear of the meniscus will alter the translational motion of the condyles resulting in added stress to the ACL during cutting and jumping motions. The joint capsule and ligamentous structures, those have to be stable as well. So, you have the joint capsule and the collateral ligaments provide passive restraint. 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 knee stability. Damage to any passive restraint to the knee will have a compromising effect of the biomechanical function and increase the risk for ACL injury. An increased tibial 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 an ACL non-contact injury. Dynamic and modifiable biomechanical features. You have movements that contribute to ACL stress. Hyperextension, excessive valgus, and abduction are the most common. Greatest 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 10 to 30 degrees of the knee flexion. So you think about your athletic stance, athletic stance, the knees should be bent about 10 to 30 degrees. And as it goes down, goes beyond that 30-degree mark, now you've increased the possibility of overextending and putting tension on that ACL. That if they were to take a cut step, overextend, do anything like that, and it goes into an internal rotation with that, then you're looking at the possibility of tearing that ACL. Quad dominance. So during sustained flexion action, the quadricep contraction unbalanced by sufficient hamstring contraction results in anterior translation of the femur on the tibia, creating predisposed stress on the ACL. Now I'm going to throw something out here that kind of figured this out after working with athletes for 15 years and being in a training room. Pretty much everybody's got quad dominance. I'd love for somebody to tell me, oh, I'm hamstring dominant, and I said, no, you're not. And so you have that quad dominance. So if you think about certain mechanisms, the quads come up, they attach to the ASIS on the front, and that can create a great amount of tension. A lot of people put a lot of focus on the psoas because it is the primary hip flexor, but they tend to neglect the dominance of the quad as it comes up and attaches to that point on the anterior 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— is always going to tend to be stronger or tighter than the other. So now you've got that anterior tilt with torsion to that side. Well, if that anterior tilts to that side with torsion, that the ischial tube raises. So if the ischial tube raises, we now have a stretched hamstring. Here's the problem. Most of the time when somebody complains about tight hamstrings, what's the first thing they do? They tell them to go stretch their hamstrings. So if they stretch the hamstring, what they've actually done is compounded, made the problem worse by allowing that quad more room to be able to pull that SI anterior on that, the ilium anterior on that side. And then the next approach that I've started to see that's becoming more prominent is, well, we'll strengthen the hamstring. That's great. You can strengthen the hamstring, but the hamstring is still exposed to injury because it's being pulled taut. Now you're asking a taut 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. Some other dynamic and modifiable biomechanical features. So, greatest force on the ACL generated in the knee during a double limb or single limb landing. With the knee extended and abducted. Just as the knee accelerates to a valgus position, stress on the ACL increases. So what they're basically referring to is somebody jumps up, comes down, lands, you see the knees go in, whether it's on a single limb or double limb. My favorite thing to see is you watch NBA players, both in the WNBA and the men's NBA, and You see them up there just doing free throws 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 bad mechanics as it is. And then those guys get out there and have to get out and jump. And if 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 end up tearing their ACLs and in the process. So, poor muscular control affects knee alignment and can increase anterior-posterior translation with rotary shear forces of the knee stressing the ACL. This can cause an excessive rotary laxity that results in ACL injury and tearing of the meniscus. So, as far as risk of reinjury post-surgery, prior knee injuries contribute to the risk of recurring knee injuries. Prior hip injuries will significantly increase the risk of ACL injury. ACL reinjury occurs in 1 out of every 4 youths. And then male athletes more likely to rupture an ACL graft. So we went into a little bit of that already, but there was a 12-year study that we talked about earlier, and I just wanted to add the reference in here to that. On that 221 people that had the 64% chondral defects and the 21%, the 26% developed OA in 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 ACL during excessive adduction of the knee. Increased knee adduction are correlated with drop jump landing, single or double leg, and cutting maneuvers. So what you'll see is as they plant, you'll see that knee overextend. They plant, they drop, and you'll see that knee kind of cave in a little bit. I saw, we had 2 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, overextended, 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 sidestep cutting with poor mechanics generates 6 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, 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 different things that are at 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 arch support and proper support of the ankle, 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, 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 set in. The more fatigue sets in, the sloppier they will get, the less focused 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 in sagittal and frontal planes, In conjunction with increased ground reaction forces. So hip and knee internal rotation increases, resulting in increased valgus. Increased ground reaction forces are going to increase the single leg— will show being increased on a single leg hop. So you think about your volleyball players, think about 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 leg. So now you've increased the possibility of— Exaggerating that valgus and putting them at risk of an ACL tear. So the increased valgus force and increased ground reaction force predispose for an ACL injury. So core and trunk stability. This is one of the things that I spend a lot of time focusing on. Even within the clinic that I'm working in right now, we have 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 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 of mass displacement and frontal plane motion of the knee. So if you think about it, if you watch somebody, they're going into a lateral 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 of their body shift. We'll talk about some of the other things that you can look for on a court, 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, that's a problem. So that's something that needs to be addressed, 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 inherent glute 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 lateral 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 is going up and down in a squat motion, how are they shifting? Is the weight distribution— are they shifting to the left? Do they shift to the right? You may see it break down because there are different stages within the squat 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 2/3 of the way down. And when they get down to the bottom, they may shift one way or the other again. And so there's 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 3 to 6 times their body weight, will alter the distribution of force loads throughout the lower extremity ligaments and lumbar spine, increasing the risk of soft tissue and ligament injury. So you can get— also develop low back issues as well. You think about what we talked 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 360 core engagement. Well, if the erectors are constantly overactivated, then what's going to eventually happen is, is both your internal and your anterior external core are going to Start to weaken over time. And one of the classic things that you'll see is people that they refer to as swaybacks, 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 that correcting 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 58, where we wrap up part 2 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 wanna miss it. Episode 58 drops in 2 weeks. Before we end today's episode, I have a quick favor to ask. We're working on some exciting new things at Factor, and while I can't yet announce everything, what I can say for certain is that our team is continually seeking new and innovative ways to serve you, our global network of healthcare providers and students. After working with providers across the globe for the past decade, I feel like I have a pretty good pulse on the biggest needs of our community, but I never want to make assumptions and miss the mark. So in the spirit of making sure we're heading in the right direction, head to the show notes and click the link on the Factor survey. It contains just 5 simple questions to help us zero in on exactly what you need most from our team, and it'll take less than a minute to complete, and I will be ever so grateful to have your feedback. And as a thank you gift, We will send you a cultivated playlist of our top 10 Factor podcast episodes, the most popular ones from the past 2 years. So go to the show notes, click the link on the Factor survey, or you can visit the link in our bio on Instagram. If you're not following us on Instagram, definitely head over there and do so. Our handle is Factor Education. That's F-A-K-T-R Education, all one word. I have to tell you guys, I've been getting these responses in for the past couple of weeks. I read each and every one of them personally, and I am so excited about what I'm hearing back from you guys and from our global community. We're so excited to be working on some exciting new offerings for you. So that's all for today. We'll see you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R hyphen store dot com to find out more information about all that we have to offer. We have a variety of online offerings as well as our hands-on Factor Rehab System course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us. spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.