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This Notes From article is brought to you by Chris Cothern (@athleteplus1). Dr. Cothern is a physical therapist and founder of AthletePlus Physical Therapy clinics. He is also currently a full-time consultant to a Power 5 basketball team, implementing sports science with athletic monitoring, and is an Australian Catholic University Master of High Performance Sport student.

The first NEXT LEVEL Sports Medicine Conference was presented by Orlando Magic and AdventHealth on July 28-29, 2019, with an outstanding group of presenters at a bargain price of $100. To see the 2019 schedule in detail, click here.  If you are familiar with Orlando Magic High-Performance Director Dave Tenney, you knew this would be a top-notch event that will continue to grow in years to come. I highly recommend it to any athletic trainer, physical therapist, sports scientist, and strength coach. 

I must mention my mentors and true leaders in High-Performance and sports science, who have gone above and beyond to assist my career.  Dave Tenney, representing the servant leadership with accountability and transparency needed in High-Performance, gave me the opportunity to attend an already overbooked Sounders Conference years ago, which was a career changing event [you can read the Notes From that event here].  I met Blake McClean and Jo Clubb who introduced me to the Australian Catholic University and the High-Performance sport program they were offering.  It has been an outstanding experience, and I highly recommend the ACU  Masters in High Performance Sport.  Other mentors who have taken time to assist my sports science endeavors include Jose Fernandez, Jesse Wright, Stuart Cormack, Patrick Ward, Roderick Moore, Mat Young, Skyler Roberts, Mark Simpson, and many more.

Now onto this great conference where the topics included were: Biomechanical Testing, Nutrition, Rest & Recovery, Exercise Physiology, Metabolic/High-Intensity Training, Injury Reduction Methods, and High-Performance Staff Structure Considerations.

Robert Butler PT, PhD, DPT Bolstering Elite Performance with 1’s and 0’s. Director of Performance, St. Louis Cardinals

Dr. Butler began by referencing The Checklist Manifesto: How to Get Things Right by Atul Gawande. Then, discussed a 2019 study by Ekstrand et al. that showed “Communication quality between the medical team and the head coach/manager is associated with injury burden and player availability in elite football clubs.” Dr. Butler states he loves to walk into a room where he can’t tell who the chiro, the PT, the MD or the ATC because everyone is working together for the athlete.  This is the genesis and evolution of staff: get ATC/MD, rehab, and CSCS all under one roof.

The average program works for the average person for the average amount of time. We are not trying to create average. This is about elite. He has 10 teams, ages 16-35 with multiple languages with average career of 3.3 years.

Movement is the common language of performance. There are standard set of movements that we could talk about across all areas. For example, saying a player is strong for a PT is different than for a strength coach at AAA level saying he is strong.

He put a data point on a slide for us and asked what does this data point mean? What is the variability? How do we leverage it? This all helps you understand if it is meaningful change or not meaningful and if we should do something with the athletes. How FAST can we identify the plan is NOT working? It DEPENDS, is about you, not them. PROGRESS OR LEARN.

Words you use to engage the athlete are more important than the data you collect. Optimizing each athlete’s day, considering: Recovery/Hydration/Nutrition/ Physical Preparation/Alertness/Cognitive Skill Work/Physical Skill Work/Schedule.

For recovery monitoring, sleep does not necessarily equal enough recovery.  For a baseball game, most players get to game at 2pm and play at 7pm, so what can we do today and now?
Best recovery monitor? A CONVERSATION
Who are the 3-4 players that we can get more out of if we make an adjustment, not all 25 players.

Fatigue Makes Learning More Difficult (Martin et al., 2016)   
Motor learning requires Brain Power (Whittier et al., In Press)
Baseball Schedule is like a second shift, 2-12 pm and then some play computer games until 5am. Have “Off day awareness”: Mr Mom vs The Hangover – players are often either being a parent or going out.
Dr. Butler ended by showing a slide of this book: Start at the End: How Companies can grow bigger and faster by reversing their business plan by Dave Lavinsky.

Bruce Williams D.P.M., DABPS, FAAPSM, President Breakthrough Sports Performance, Footwear for Athletes: How Shoes Can Increase or Mitigate Risk

Dr. Williams displays why he is the foremost authority on athletic shoes and why NBA teams continuously consult with him regarding foot injuries and athletic shoes. Dr. Williams discussed the shoe components and their effects on enhancement of performance and overall risk to injury in differing professional sports.  He stated it is imperative that you appreciate the workings of athletic shoes if you are doing clinical work with athletes, no matter what their performance level.  Running shoes, court shoes and field shoes all have the potential to enhance or inhibit an athlete’s performance and to increase or mitigate risk of injury.

Dr. Williams gave an in-depth slideshow of:

  • shoe construction
  • shoe cushioning (including studies showing benefits)
  • shoe comfort (associated with injury risk)
  • shoe assessment (heel counter, torsional stiffness and rigidity, shoe flexion)
  • shoe performance (running shoe effects, new foams, Nike sub 2-hour marathon shoe, fifth met risk in football shoes, rigid carbon fiber insert injury risk, cleats and surface interaction, foot pressure analysis, basketball player with fifth met head fracture study).

Comfort as a measure: poor comfort is associated with injury and fit is an issue. Running shoes with greater shoe cushioning, greater longitudinal shoe stiffness and greater shoe comfort were associated with improved running economy. The Effect of Footwear on Running Performance and Running Economy in Distance Runners. Sports Medicine · November 2014.

In conclusion, Dr. Williams states cushioned shoes are not always good for athletes. Shoe comfort is associated with injury and shoe fit plays a big role in comfort. There is no uniform way of assessing the performance of athletic shoes. Bending stiffness matters in shoes for performance, comfort and injury risk. Fine-tuning the stiffness of shoes is the way to go to maximize performance and minimize injury risk!

Sameer Mehta PT, DPT, SCS, CSCS Physical Therapist, Orlando Magic Utilization of Ultrasound in the NBA

Dr. Mehta reviewed use of Musculoskeletal (MSK) Ultrasound (US) as a tool for rehabilitation/biofeedback, diagnostics intervention, research/measurement & evaluation, reviewed case scenarios, and how to improve data-driven clinical decision making. Use ultrasound as a tool for rehabilitation in real time to evaluate muscles (Transverse Abdominus (TA), Multifidus, Pelvic Floor, Gluteus Minimus, Iliacus, and Subscapularis), and soft tissue morphology and function during movement, including measuring muscle morphology (length, thickness, cross-sectional area, fascicle length, etc.).

Dr. Mehta showed a video of the US in use with biofeedback use of TA, which was very interesting because we use the old-fashioned method of stabilizer biofeedback for regular patients with back pain. It is good to know elite athletes have TA disassociation just like our patients. He also showed the US being used for Multifidi and Glut Minimus.

US is most cost-effective, safe and rapid method of obtaining static and real-time images. In PT, diagnostic US can be used to identify tendon abnormalities, assess humeral torsion, acromiohumeral distance w/RC pathology, hemarthrosis within the joints, nerve excursion in entrapment neuropathy, and ligament integrity after injury to inform rehabilitation.

Tissue Monitoring: Bone (Bone callus formation, bridging, delayed/non-union, bone vascularization), Tendon, Achilles (length, cross sectional area), Shear Wave Elastography (mechanical properties not morphology), Muscle acutely→ sub-acutely→ chronic changes.

Advantages: Point-of-Care US (POCUS) – noninvasive, rapid, cost, dynamic images, equal to MRI for most soft tissue pathology, not just morphology but mechanical properties.

Disadvantages: Operator dependent, anisotropy, knobology, cannot evaluate intra-articular pathology well.

  • MSK-US useful tool for Rehabilitation, Diagnostics, Intervention, and Research
  • MSK-US can assess morphology & mechanical properties → biomarker
  • Data driven tool to optimize care & training for athletes
  • Keep scanning, but treat the man, not the scan!

Eric Leidersdorf, Biomechanist, Biomechanics in Basketball: Implications for Performance Development and Assessing Risk of Injury

Eric is a highly intelligent but very humble speaker. In a recent project, I utilized Eric’s P3 research with James Harden rating in the top 99% percentile in deceleration.  P3 was started in 2006 and has trained over 600 athletes with NBA experience with impressive research and results with founder Marcus Elliott MD.

  • One piece of the puzzle
  • Application of engineering concepts to the study of athletic movement
  • Forces/Moments/Torques
  • Acceleration/Velocity/Position

Components of Athletic Testing: Day 1 = 15min to 2hrs. The goal is an in-depth understanding of the athlete’s physical systems for all* tasks demanded by their sport. Eric states in that in three months, the athletes may test three times.

  • Mobility Screen
  • Vertical Plane Movements
  • CMJ, Drop Jump, TBCMJ (trap bar)
  • Lateral Plane Movements
  • 1-Off Skater, 5y Slide (COD)

Assessment Technology - Tri-Axial Dual Force Plates, 3D Motion Capture, 10-Camera video MoCap system, Lower Extremity marker set.

Result: Approximately 500 variables per athlete per assessment
Research Question: Do different mechanical parameters impact performance in different planes?
CMJ  n= 312  vertical displacement  Results Summary: Knee extension kinematics and concentric force output and Jump 1-Off Skater

Case Study: Performance Application
Athlete Profile - Age: 22-24- Position: F- Training Block: 6 weeks
- Injury History: Patella Tendinopathy (in season- Rec. Ankle Sprains)

Interpretation- Athlete’s lateral plane ability lags considerably behind vertical plane. Training program skewed to emphasize PCD and hip-mobility.  Focus on squat and hinge (posterior chain & hip mobility)

Biomechanics for Injury-Risk Stratification
Research Question: Can this same data be used to stratify risk of injury?  Not “injury prediction”, but injury risk stratification.
ML 1.0 – Preliminary Results:  N=481 Injury qualification (n=31) ACL, MCL, meniscus (surgery req). Critical Variables: Rotation through the foot, Deceleration across the hip, Dynamic control of the femur, and Mass (these are potential risk factors)

  • Objective athlete assessment can play an important role in understanding athletic qualities, performance capacity and potential risk of injury.
  • For every “answer” we land on, dozens of questions spring up.

James LaValle Owner of Metabolic Code, Maximizing Performance and Rejuvenation: Key factors and influencers on performance repair and recovery

James gave a very detailed lecture with some interesting tidbits that included he sees lots of NFL guys with low testosterone and rarely finds athletes without a Vitamin D deficiency.  Melatonin extended release is good if they have trouble staying asleep and melatonin chewables if trouble going to sleep.  Adrenal fatigue is not real and is just a marketing term.  If an athlete gets the flu, they can lose up to 7 games of performing at their best. He uses Box Breathing 3-4 times a day with his athletes. 

Cortisol – Stress and the Impact on Performance Recovery and Inflammation
Key Tenants of Aging and Performance including Oxidative Stress/Inflammation, Hormonal Balance, Stress Hormones, Glucose/Insulin Regulation, Immune Balance, Environmental Burden, and Individuality.
Metabolic Effects of Chronic Cortisol Elevation: Increased insulin secretion, Increased fat deposition, Alteration in immune function, Muscle wasting, Hypothyroidism (adrenal exhaustion), Memory loss, Alteration in sex hormones, Mental and Emotional instability, Bone loss/mineral loss, Sodium and water retention, Elevated blood lipids, Loss of REM sleep, Increase plaque formation, Increase in cardiovascular risk factors, and Receptor Site activation on Tumor cells

Exercise and Cortisol
Significant differences in metabolic and hormonal responses to exercise between athletically trained and untrained.  Cortisol levels at increased workloads reported HIGHER in trained athletes than untrained.

Bottom Line: Exercise-induced chronic secretion of cortisol can lead to metabolic imbalances
Cortisol and Sleep

  • Cortisol release is controlled in slow-wave sleep by decreases in corticotropin releasing hormone (CRH) and increases in growth hormone (GH).
  • Exposure to chronic stressors imbalances HPA axis and disrupts normal diurnal pattern of GH, CRH and ACTH release.
  • Results in a paradoxical rise in cortisol in evening hours and initial sleep phases.
  • Nocturnal hypercortisolism can lead to sleep fragmentation, therefore increasing cortisol even more.

Magnesium and Athletic Performance:

Integral in ATP production, Oxygen Uptake, Central Nervous System Function, Electrolyte balance Na/K pump function, Glucose Metabolism, Muscle Function, Heart rate and function, and Bone density

Dietary Supplements that can matter:

  • Magnesium Glycinate 7.5-10mg/kilogram
  • Probiotics
  • Sleep support (Melatonin, Seditol, Theanine)
  • Anxiety (Theanine, Relora, Holy Basil)
  • SNS/PNS (Phospholipids)
  • Blood Sugar (Chromium, Alpha Lipoic Acid, Magnesium, Zinc)
  • Hormones (Eurycoma Longifolia, DIM, Zinc)


  • It is not about the amount of time you train, it is about the effort that is made to recover from intense and regular physical activity.
  • Diet, stress, response adaptation, regular and sound sleep are foundation cornerstones to improved performance

Paul Laursen PhD, Co-Founder or HIIT Science, and Adjunct Professor at AUT in New Zealand.

Session 1:  The Science of High-Intensity Interval Training
What is High-Intensity Interval Training (HIIT)?

“Exercise consisting of repeated bouts of high intensity work performed above the lactate threshold (a perceived effort of ‘hard’ or greater) or critical speed/power, interspersed by periods of low-intensity exercise or complete rest”.

HIIT – Just one piece of the performance puzzle, but often an important one.
Desired physiological objectives: Context is important:
Triathlon 5% skills, tactics 10%, 85% physical. Soccer: 45% skills, 30% tactics, physical 25%

Format of the HIIT session e.g. metabolism involved, amount of neuromuscular load, integration of sport-specific skills, cognitive load, volume and intensity

Fitness: Being fitter/faster can’t guarantee success and not being fit/fast enough can be a problem.

Dr. Jackson Fyfe discussed incorporating HIIT into a concurrent training program but also that considerations must be given for the “Interference Effect” in such a program.

The Physiological Targets of HIIT include Aerobic, Anaerobic, and Neuromuscular with detailed examples given in the HIIT Science book.

Prescribing approaches include RPE-based prescription, HR-based prescription, maximal aerobic speed and power, anaerobic speed reserve, 30-15 Intermittent Fitness Testing, all-out sprint training, track and field approach, and small sided games.


Session 2:  Applying the Science of High-Intensity Interval Training

Discussed Martin Buchheit’s Managing high-speed running load in professional soccer players: The benefit of high-intensity interval training supplementation.

Science and Application of High-Intensity Interval Training in Basketball by Blake McLean and Lorena Torres-Ronda from the HIIT Science book.
Basketball = 33% Physical, 33% Skills, 33% Tactics
Winning Summary: Physical characteristics are clearly important, but some can’t be trained. Basketball is a skill dominant sport. This should always be considered when planning preparation strategies.

Enda King PhD Head of Performance Rehabilitation, SSC Rehab Clinic (Dublin, Ireland) Management of Athlete Hip and Groin - Where is the pain coming from and does it really matter?

Challenges in Athletic Groin Pain

  • Athletes continue to play with symptoms
  • Clarity of diagnosis
  • Is there actually pathology
  • Clarity of management strategy
  • Inconsistent outcomes & high recurrence

Does anatomical diagnosis matter in Rehabilitation? Maybe sometimes…

When Might it Matter?  Stress Fracture Neck of Femur, SUFES, Perthes Disease, Avascular Necrosis, Rheumatological Conditions, and Degenerative Disease

Why so many different diagnoses in same area? Gilmores Groin, Pubic Bone Stress, Sportsman’s Hernia, Osteitis Pubis, Adductor Tendinopathy, Rectus Abdominus Tendinopathy

90% of groin pain issues are in change of direction sports.

Consensus Statement: Doha Agreement meeting on terminology and definitions in groin pain in athletes
helps but problem is pain area starts in certain area and then moves to another area.

Surgery: “How can tensioning then de-tensioning the same structures treat the same condition?” Why do some benefit with surgery?

Inguinal hernia: very hard to miss when see it. Large hernia, but they are asymptomatic. They only come to you because they think they have cancer, etc.

If all you see is adductors, then all you do is squeeze. Squeeze test is sensitive but not ….

Copenhagen 5 second squeeze test (Haroy et al., 2018): lack of adductor strength may not be the main reason.

Rectus abdominis: Planks: overuse when used to brace lower abdominal area and attempts to correct “effects” of anterior pelvic tilt.  Planks can exacerbate groin pain.  Pathology or Overload?
What aggravated them and what are they returning to?

Athletic Groin Pain study in BJSM (Franklyn-Miller et al., 2016): Biomechanical evaluation of change of direction identifies three clusters of movement patterns:

  • 1. Hip flexion, trunk ER, hip IR
  • 2. Trunk forward flexion, trunk side flexion, hip abduction
  • 3. Trunk side flexion, hip abduction

Does the diagnosis matter? No correlation between anatomical diagnosis and RTP time (p=0.56). Also, no correlation between duration of symptoms and RTP time (p=0.17).

Some rehabilitation questions to reflect upon: How do you judge the success of an intervention (rehabilitation) if you did not achieve what you set out to? Has my athlete failed rehabilitation? Has my program failed to change the driving factors? Have I failed to identify all the contributing factors?

Take Home Messages: Source of Symptoms vs Source of Problems
Have we identified all the contributors to the problem?
Has my program addressed all the issues?
Does the diagnosis matter?
Individualized Approach to Rehabilitation
External is Load Key Factor