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The Hidden Dangers Lurking in Your Knees: Dr. Trent Nessler Reveals How to Prevent ACL Injuries Before It's Too Late

• Dr. Terry Weyman and Dr. Spencer Baron

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On this episode of Crackin' Backs, we welcome Dr. Trent Nessler, one of the top ACL experts in the country, with over 25 years of experience in sports physical therapy and biomechanics. Dr. Nessler’s groundbreaking work has transformed how we understand and treat ACL injuries, using cutting-edge technology like the ViPerform AMI to prevent injuries and enhance performance in athletes across the globe.

In this episode, Dr. Nessler breaks down the critical role of the ACL in knee stability, why it’s so susceptible to injury in sports, and how biomechanics and neurology play a key role in both prevention and rehabilitation. We’ll explore how Achilles tendonitis and glute strains can be red flags for ACL injuries, and the roles the ankle, foot, hips, and glutes play in injury prevention. Dr. Nessler also shares his insights on seasonal exercises and game-time rituals that can drastically reduce ACL injury risks, especially in high-risk sports like soccer, basketball, and football. Whether you're an athlete or a provider, this conversation is packed with valuable takeaways to keep you at the top of your game!

For more information on Dr. Nessler’s work, visit The Athlete Lab

We are two sports chiropractors, seeking knowledge from some of the best resources in the world of health. From our perspective, health is more than just “Crackin Backs” but a deep dive into physical, mental, and nutritional well-being philosophies.

Join us as we talk to some of the greatest minds and discover some of the most incredible gems you can use to maintain a higher level of health. Crackin Backs Podcast

Dr. Spencer Baron:

On this episode of The cracking bags podcast, we're joined by one of the nation's top ACL experts, Dr Trent Nestler, ever wonder why the ACL is so prone to injury in sports? Dr Nestler breaks down the critical role the ACL plays in knee stability, in why biomechanics and neurology are the key in preventing these injuries and and how conditions like Achilles tendinitis and glute strains could be a warning sign, whether you're an athlete, a coach or just curious about your knees, this is an episode you need to protect your joints and keep you and your game strong. Tread. It's great to see you back on again, man. I know that any question we ask you is going to have some very involved and in depth explanation. And so we really wanted to go into the ACL the anterior cruciate ligament of the knee, which is one of the most injured parts of the knee, and we see so many of that. And I know that you have a ton of information, because you're probably one of the top experts in the United States. Man, so when it comes to this joint, we want to know more. So yeah, if you don't mind, let's talk about knee stability and what makes it so susceptible to injury in sports.

Dr. Trent Nessler:

Absolutely, and I. And first of all, thank you guys for having me again, and to be able to share my passion for ACL. ACL prevention is awesome, so I'm excited to talk about this.

Dr. Terry Weyman:

Oh, love it. So I hit it.

Dr. Spencer Baron:

Hit the ground running with okay,

Dr. Trent Nessler:

I apologize. All right. So, so ACL obviously, you know, obviously, there's a lot of ACL injuries in the US. We have over 250,000 ACL injuries every single year. 250,000 you know that the sad, the sad part of that is, is that if you look at the primary injury, and you look at the downstream injuries that result from that. The osteo 79% have osteoarthritis in 12 years. The RE injury rates around 27% if you add up all of that, that's a$5 billion healthcare cost on an annual basis, $5 billion you know. And one of the things that always amazes me about this is that this has not been labeled an epidemic. You know, if this were anything else outside of sports, this would be listed as an epidemic and and sadly, a lot of this is happening in young athletes. You know, when you start to look at the stats around osteoarthritis, for example, 79% have osteoarthritis in 12 years. That's amazing, because if you take a 1015, year old kid, you know, and go out 12 years and they're already starting to develop osteoarthritis, that's, that's a lifelong impacting injury. And so that's part of been, what's been my mission is to really try to impact that in a meaningful way. You know, there's a lot of different reasons for ACL injuries. There's, you know, the majority of ACL injuries, you know, 75 to 80% of those are non contact and orientation, meaning that there is no contact that's actually causing the injury itself. So knowing that, it would make me think that there are ways that we can actually impact that, and that's really what we're trying to do here at the athlete lab, but also across the country, in really trying to impact athletes in a meaningful way that helps them to mitigate their risk. You know, there's certain things that I'm not going to be able to do. For example, you know, females are three to eight times more likely to have an ACL injury than a male athlete. Why is that? Well, number one, their femoral notch is narrower. Their their ACL is smaller, their cue angle from their hips to their femur, the quadriceps angle is is greater. In a female athlete, there's hormonal things that go into that, etc, all of that stuff. I'm not going to be able to change that. Heck, if I could change the hormones. I would have done that my daughter a long time ago. But you can't, right? So, so, so you have to look at the other factors that are impacted. And number one, one of the the main things that we look at is what is called dynamic valgus. And really, we've known about dynamic valgus. You know, it's interesting to me, and I know I'm rambling on here, but one of the things that's interesting to me is that I started studying ACLs in 1997 and I'm dating myself, I know, but I'm starting studying ACL studying ACLs in 1997 and what I found is that the stats have not really changed since 97 despite all the fact of all of the knowledge that we have, all the information that we have, all of the data that we have, there's not really been a whole lot of change in those stats, the number of injuries, the the. The recovery time and the RE injury rate and the osteoarthritis so you know, and sadly, we've continued on this path of doing the same thing that we've always done. And in any other world, we call that insanity, if you're doing something over and over and over again and it's not working, why would you keep on that path? And so that really comes to why we developed the V move plus AMI, which is a biomechanical assessment to capture movement, human movement, within 2% of a viacon or a biomechanics lab, so that we can start to quantify these movements, because when you start to do that, and you start to do that on a large scale, so right now we've got over 90,000 athletes across five different countries, and you start to build this database. So right now we've got over 320 million data points related to human movement, and you start to get all of this data, the data should really start to guide you one on what things you should be looking at, number one and then number two. The really cool part about it is that if you reverse engineer that, and you start going back to origin and insertion, you should be able to identify certain movement patterns and what that leads to for certain weaknesses. I'll give you a perfect example. One of the things that we measure is a side plank. And you know, I don't know about you guys, but what I was taught about a side plank is that it's for the core, right? So what is the core? Right? So first of all, the highest EMG activity in a side plank is actually your glute medius. Glute medius on the downward on the downward side. So we're using that to really kind of the way I use it is, I use that as a measure for stability number one and number two, I use it as a pre fatigue because the rest of the tests that I do in the sequence of tests are going to require your glute med to be very active. So I use the the side plank as a way of kind of pre fatiguing the glute medius. But what I didn't know about the side plank at that time is that if you can actually assess somebody from foot to shoulder in a side plank, simply going down to the foot and the ankle, okay, most people, when they get into a side plank, they're going to keep their ankles in a neutral position. And one of the things that we've seen is that athletes who are at greater risk for ankle sprains, they tend to have what is called a tibial drop. So instead of being in a neutral position, their tibia on the downward, downward leg, their foot kind of rolls in, and their tibia drops down to the ground. So if you reverse engineer that that's more perineals and anterior TIB that keeps you in that neutral position. So what we found is that if someone's demonstrating a a tibial drop, they're three times more likely to have an ankle injury, especially if they're a basketball player, and that can guide us into some specific ankle strengthening that we can do to help stabilize that ankle. Then we move forward, up to the hip, up to the hip. We're looking at your pelvis. Are you able to control lateral side bending? Because that's going to be more glute medius. If your hips raise up, or your hips drop down, that gives us some indication for glute medius. If your pelvis rotates backwards, that's more transverse abdominus. If it rolls forward, that's more quadriceporum. Then we move all to the shoulder. So on the downward arm that you're you're sitting on your serratus anterior, and your rhomboid have to be super strong, if not. What's happening is your shoulder rolls forward because the scapula on the downward arm is not holding up against the rib cage, and you start to gap a little bit, so your shoulders roll forward. So the cool thing is, is that what I never knew is I could take a side plank, simple side plank, and I can know something about the foot in the ankle, I can know something about the hip, and now I can know something about the shoulder. So, so, so there's so much information that we can learn by simply looking at how people move in what we know is that when we make people move more efficiently, is that force attenuation is better, which means simply, your meniscus is stress less, your ACL stress less, your SI joint is stress less, your labrum of your hip is stress less. And Oh, guess what? Power output goes up because power output, because the pelvis is more stable, the quads are able to generate more force, the hamstrings are able to generate more force. That means that you're going to have a much higher power output. So the cool thing about all of this is that, you know what I'm learning from really diving deep on ACLs really led me to a path of diving deep into human movement assessment, which really, quite honestly, guided my my treatment strategy for everything I treat, from the shoulder to the foot, from the neck to the foot, I should say, you know, so you know, to me. Uh, having a good movement assessment, whether it's foot and ankle, whether it's lower kinetic chain, whether it's the shoulder, there's just so much information. So I'll give you a perfect example. You know, one of the things that we're doing here in Franklin, Tennessee, is, I'm working with a large volleyball organization, 3000 athletes, young volleyball players, you know, they're at risk for ACL injuries. So based on all of the information that we have, we actually created a screening tool that I call the athlete performance screen that simply goes through a series of six movements that mom and dad can do with their athlete so mom and dad can take their phone, they can film their athlete doing these movements, and then it says, Do your kids knees go in towards midline? Do they shift their weight over to the side during a squat? Are they able to hold a side plank for one minute? Does their ankle or their tibia drop down to the ground? All of these things that we know about human movement, but it gives mom and dad a way to screen it. They don't have to be experts in it. Just simply says, Do you see this? Yeah, I kind of see that. And more importantly, what it does for me is it helps Mom and Dad go, Holy cow. I never knew my kid moved like that. Like you can look at it and you go, wow, that's not good. Like, I want more information on that. So what we've done is we've created this screen, and then we've created a document that explains, hey, if you see this, do this. If you see this, do that. So we're really trying to guide based on all of the data that we have, using the AMI based on all of the things that we're collecting clinically, to try to create other tools by which mom and dad can do it with their kids, and in have some fair success with that, and have a way to know what actually to do with their athlete. Interesting part of that is, is just a couple of weeks ago, I was presenting at this large fire conference, and so we did the exact same thing. You know, one of the, one of the hard parts in firefighters is a lot of the musculoskeletal injuries come down to very similar movement patterns that we see in athletes. These same movement patterns, they don't they don't stop just because you're a firefighter, they don't stop just because you're a police officer, they don't stop just because you're special forces. These movement patterns really apply to anyone who's, who is, who's doing, especially single limb stuff. So if you're running, you're going up a flight of stairs, you're jumping over a barrier. Whatever that may be is that if your movement patterns are inefficient, then you're going to be more susceptible to injury. So we took that athlete performance screen and made it the Tactical Performance screen. Now firefighters can also go into the firehouse, take a camera, film themselves doing it, and get valuable information about like, Hey, this is how I'm moving. I see it. I can definitely see it on video. And here's three things I need to do to help to address that.

Dr. Spencer Baron:

Hey, Trent, let me ask you real quick, the that side plank, which I am totally using tomorrow when I get into the office, I can't wait because it's so easy, but I don't think about it. Actually, I did do it for tibial, for dipping, but not, not for the other body parts. But was that just a metaphor for how all the biomechanics you can implement, all you know, identify, or was that also for ACL? So

Dr. Trent Nessler:

originally, so funny story about how I came across that. Okay, so number of years ago, I got recruited to Nashville, Tennessee, and I was working on and I was working on this ACL project back then, and I was working with a colleague who is a division one basketball player back in the day, and she offered to take me up to meet her basketball coach. I'm like, Alright, that sounds cool. Let's go meet your basketball coach. So we drive up to Knoxville, Tennessee, having absolutely no clue about female basketball, nor who I was about to meet. So we go in, and I met with Pat Summitt. And so yeah, the Pat Summitt. So I met with Pat Summitt. Tiffany Woosley was the person that I was, was the colleague of mine who happened to be also an NBA or a WNBA player who I didn't, I didn't know at the time. I just, I just knew her as Tiffany. So we go there and we meet with Pat Summitt. And one of the things that she was telling me is that she used planks and side planks as a part of her recruitment tool for her basketball players. Because what she had figured out is that athletes who could not perform a plank and a side plank for one minute period of time as a new recruit, they got injured more as. Basketball player. So here is a a top level coach, and this was back in like 2005 2006 years area. Here's an elite level basketball coach who's figured out something about movement that we still don't really use today. So So do I use it for ACL. Originally, it was designed as a part of my assessment to assess ACL risk. What I found was is that, quite honestly, when you address all of the movement patterns that we see, we reduce all musculoskeletal injuries by over 58% all so so from the foot all the way up to the shoulder. Matter of fact, there's some really good studies by deal American Journal of Sports Medicine that showed that a major league baseball player who performs a single leg squat, who demonstrates a dynamic valgus during a single leg squat, is more likely to tear their labrum in their shoulder than a baseball player who does not so in again, if you think about how, if you think about how the pelvis, specifically the pelvic stability, and the impact pelvic stability has on lumbar spine and thoracic and cervical stability, and how lack of stability there. So you're generating this massive force right from your quads and your hamstrings for a pitch. And if that is lost as it comes across the core, what ends up happening is you make it up at the shoulder, and when you make it up at the shoulder, that means that you're putting more stress on the UCL, on our collateral ligament, as well as the labrum of the shoulder, that's outstanding, right, right? And the sad part of that is, is that that research has been out there for almost 10 years, you know, and still today, we we don't address these things in that way. But you know, again, in thank you guys for having me on, because that's a part of my mission, is to get this information out there, you know, in a part of my, you know, it's, it's part of the reason that I made the athlete performance screen, because not everybody can have an AMI, but everybody can benefit from the information from the EMI. And if you can provide parents with an easy tool, especially for those kids that are going into basketball and volleyball, in those high risk sports, who are going into these massive growth spurts, right? And parents start to see those movement patterns, it's like, wow, I had no idea. Like, who wouldn't if your kid's doing a single leg squat and you see this massive, dynamic values, who and go, Huh, that doesn't look right, like right. And then you're going to want to address it. Hey,

Dr. Terry Weyman:

Trent, have you? Have you made this screen available to everybody? Or is it, I mean, is, how does another practitioner listening going, Well, God, I want to use that screen. How does that work? Yeah,

Dr. Trent Nessler:

what they can do is they can email me at info, at the athlete lab.org, and I'm happy to send it. It's free, you know, my, my, my goal is, is again, you know, it's, I'm a firm believer in that you do good and good will come, you know, and, and I'm not about monetizing everything. What I am about is learning and helping to spread the greater good. So if anybody wants it, just simply email me. You can reach out to me on Instagram. I'm happy to send it to you. It's, it's a simple PDF, just, you know, give me credit. If you go and you post it somewhere or whatever, just tag me on it. Let people know where you got it from, because that's that, to me, is the most important part, in order to address ACLs, 250,000 a year, in order to address ACLs, we got to get it out of the clinic. We cannot simply do this in the clinic, because we will only be addressing those that are injured. So we got to get it out there. We got to get better information out there on a larger scale.

Dr. Spencer Baron:

Thank you. Thank you very much. Do you think there are a lot of unnecessary ACL surgeries done

Dr. Trent Nessler:

unnecessary, you know, I don't, I don't believe that's a major issue, at least the market that I'm in, you know, you know, there's, there is, there are some questionable acil surgeries. I will say that, not that they didn't need to be done, but that they maybe weren't done by the right person. That, that being, that being said, you know, there's, there's a lot of good research coming out of Australia, because, you know, they have socialized medicine there, and they have, they have copers and non copers, right? So they have, they have research that looks at people who've had an ACL reconstruction and those who've not had an ACL reconstruction. And what they found in that environment is that sometimes the ones who don't have ACL surgery actually perform as well as those who. Had ACL surgery. Now the problem with comparing that research to us is that it's a socialized medicine environment. So what people don't understand is that if you tear your ACL, you're not getting an MRI for nine months, yeah, because you're in a socialized medicine environment. So what does that mean? That means you have nine months of PT, yeah, so you're getting a much more aggressive pre operative ACL rehab than we have here in the US. Typically here in the US, you tear your ACL. Matter of fact, I just had somebody tore their ACL. They tore their ACL on Saturday, they saw the doctor on Monday, had an MRI on Monday, and had surgery on Wednesday. So you know, and again, I like, I personally like people to have surgery faster, because it helps to offset a lot of the quadricep deficits that we see, the range of motion deficits that we see. I just see better outcomes that earlier on. Yeah, I'll tell you the other thing that's been eye opening for me. So here at my practice, we do preoperative and post operative nutrition so we give them a preoperative nutrition package and a post operative nutrition package, because I'm a firm believer that, you know, it's biochemistry, and if you optimize someone's internal chemistry before surgery, and you optimize their chemistry right after surgery, is that you end up getting a much better result. In addition to that, I also implement BFR blood flow restriction training very early on in the rehab process, and I don't stop when people get off the table. I continue that out throughout their entire rehab. As a matter of fact, for most of my athletes, they're continuing with BFR as a part of their performance enhancement. So one of the populations, main, main populations I deal with are mixed martial arts. And so, you know, I do it a lot with cardio. So I've got a cardiovascular routine that I do with BFR that helps them maintain their gas tank, pushes their vo two, Max. But the upside of that as well is several fold. Number one is that BFR, when you do BFR, studies show that you get muscle hypertrophy in as little as three weeks, whereas traditional approaches, you're looking at six to eight weeks, so you've literally cut that time in half. And a part of that has to do with the the two effects that you get from BFR. One is you get a localized effect, because you're creating this hypoxic state in the muscle. So what ends up happening is you're doing low loads, but you're creating this hypoxic state, so you end up getting more muscle recruitment. So you get the quad to recruit faster using BFR than if you didn't use BFR. But the second piece of that comes from the biochemistry, because if you do BFR for long enough period of time, you build up lactic acid in the system. What happens is a cascaded chemical reactions resulting in massive release of growth hormone in IGF one. IGF one helps those bony plugs heal faster. Your growth hormone helps you get muscle growth faster. So and again, if you optimize the chemical environment, ie, you have a sufficient amount of protein, you make sure that they're hydrating. Actually add create monohydrate to this, do the equation to help in draw that water into the cell to help that protein synthesis occur at a faster rate. You know, other things I throw at it red light. So we actually have a red light therapy bed here. I throw that at it as well. Why do I throw red light at it? Because red light, what that does is it causes your mitochondria to turn over protein synthesis at a faster pace. So now I'm doing BFR, which causes protein synthesis, which causes the soft tissue repair at a faster pace. I'm increasing the chemical environment, and I'm throwing on another thing that also helps to enhance the recovery process. All of that science has been out there for a long time. The sad part is, it's been out there for a really long time, and we've just not been leveraging it like we should, I think, like we should, to optimize outcomes and to, quite honestly, shorten the episode of care. You know, I firmly believe you do all that, and you get a shorter episode of care. People get back faster. They get back doing life, things that they want to do, and they're moving better.

Dr. Spencer Baron:

You're one of few that understands pre and post op nutrition and how vital it is to healing and reducing the comorbidities that go along with a failed surgery. We interviewed a orthopedic surgeon. Do you remember Terry Jeff Cantor, who was all about pre prehab and nutrition before a major spine surgery. But I want to also ask about the the understand, well, sometimes a good. PT, good. You know, physical therapy. Be for a ACL sprain, or that would have typically gone to surgery. There's some, there's some published research out there that shows a good round of PT can allow for good recovery and yeah and avoid for sure surgery.

Dr. Trent Nessler:

Yeah, for absolutely for sure. In the key, I think there is a strain, you know, if I have a rupture, you know, what I worry about is the long term effects of tibial translation at the knee, and especially if you've got an athlete who is, well, if you look at the research, most athletes who have an ACL reconstruction. Typically only stay in their sport about two years. So they typically only stay in the sport for about two years after that, that injury, that being said, you know, there's, there's also, you know, with that, a big downstream effect on overall health. You know, they, they tend to still eat like an athlete, but not exercise like an athlete. So there's, there's that whole complication. But for me, you know what I what I've seen in the research, and what I've seen clinically, is that if you've got an athlete who's continuing on in their sport, and they have a rupture, I always encourage them to go ahead and have it, because I'm concerned, because cartilage, cartilage is strong in compression, it's very weak and sheer. And when you get that, that anterior translation of the tibia on the femur, you're just sheering away that articular cartilage. And I'm a firm believer that that is part of what adds to the 79% that have osteoarthritis in 12 years because, because we've not addressed in and again, there's, there's really good cert research out there by King in itharm. I want to say it was maybe 2018 American Journal of Sports Medicine. One was in sport health that looked at the biomechanics of an athlete who's had an ACL reconstruction. They've gone to sports physical therapists for their rehab, and at nine months the time of return to play, they still demonstrate a massive lateral shift despite having nine months of PT at 12 or 24 months post. So after already returning to play, when you do single leg activities with them, like a single leg squat, single leg hop, they still demonstrate those biomechanical risk factors that they had at the beginning of the rehab. So, so what it tells me is that we are not good enough at changing human movement, and that's why things like what we're doing with the EMI and the information in the knowledge that we're gaining about how to truly change human movement is extremely useful, because then that athlete who strained their ACL, hopefully we're correcting their movement patterns so that they, number one, don't need surgery and don't ever rupture eventually,

Dr. Terry Weyman:

you know, you brought it. You answered the first part of the question I was going to ask. But it still leads to a second question that we learned on one of the guests I show about the neurology to that the actual lign ACL ligament has neurology. So when you pressure it, you disrupt that neurological pattern. And I have a patient that's been 30 years, and her ortho suggested not having a ACL surgery because her lifestyle didn't dictate that she needed it. Yet, when you think about the disruption in a neurological standpoint, and even though you replace it, you're not replacing that neurological component. You're raising more stability. What's your thoughts on? Because I think a lot of people don't realize when you're rehabbing the knee, and everybody, every football coach wants them back in eight weeks. It takes a long time for that secondary neurology stability factor that come into play. Can you talk a little bit about, yeah, neurological input,

Dr. Trent Nessler:

yeah, yeah. So there's, there's some really good studies with functional MRI that shows that after an ACL, after an ACL injury, that you actually have changes in the higher centers of the brain. And you know, the the the ACL is full of proprioceptors, you remove that, you replace it with a graft, and that that doesn't ever just come back, right? And so what you really have to do is you have to train all of the other structures around there to increase their input, to replace what was lost by the ACL and to make those motor patterns in the higher centers of the brain. And traditional approaches that we do don't do that. You know, some of the traditional training that we do does not do that. And I. I was fortunate enough in some of my previous clinical experience, specifically down in Birmingham with Kevin in the Andrews Institute, is to really get a little bit more engrossed in that. So one of the devices I use is called the Quick board. And the quick board is a it does implicit training. So what it does is, you have a a iPad in front of you, and you're standing on a sensor board, yeah, and you're looking at the iPad, and the iPad will flash a color, okay, so if it's green, you go red, you don't go so you have to first have that interpretation, and then the second thing that it does is that it will light up one of the circles on these on the sensor board that you're standing on, and without looking, that's the key. Is you're not looking, is you reach and you touch. And so what it does is it actually measures your ability to interpret that information. How long does it take you to interpret that information and what is the speed at which you're able to respond, so your reaction time and what is the accuracy of your response? The beauty of that is, is that's a part of like the the return to sport protocol. I do, I do, actually do that neurocognitive test, and from that, I then am able to design an exercise program based off of their results that will train their specific patterns to help to improve that. Because what we see, what I've seen with quickboard, and I was very blessed again early on in the process that when I first launched the EMI, I got introduced to quickboard, and I started using quickboard, and what I was finding is that athletes who improved their performance on the quick board actually improved their performance on our biomechanical assessment. And so what I was seeing is that as they improve their neurological connection, their biomechanics was actually improving. And so that's why it said to me, I'm like, holy cow, I've got to test these two things as a part of my return to play. And so that neurocognitive piece is absolutely essential. And the beauty of it is, is you can train it. There's devices out there to train it. Quickboard is, is one, there's other, there's other devices out there that are more complex. With complexity comes expense. So they they become very cost prohibitive for a lot. Another lesser version of that would be something like the blaze pods. The only difference with the blaze pods is that you look at the pod, and so the difference between quickboard, you're looking at an iPad, and reaching and touching, versus looking and touching, if that makes sense. So those are two different types of motor learning that happen. The first, which is the quick board, is the one that we want the most, because that has the highest carryover to actually changing those those neural patterns in the higher centers of the brain, you know,

Dr. Spencer Baron:

to put it, you know, for the lay people to really deliver the message of what, how important is, what you're saying? Yeah, the MRI studies that were done were also not just post injury, but pre injury, and they found that they just imagine you limping for a couple of months and how the body compensates to be cautious of that pain that you feel when you step a certain way. And athletes are magnificent at compensatory of biomechanics, right? So they think that, okay, I get the surgery and I'm done that. I'm not going to limp anymore. Well, your brain is already mapped that that that gate so you are able to change it. I just got, I think that it is so exquisitely important to understand that

Dr. Trent Nessler:

in two what goes along with as the whole kinesi phobia piece. Yeah, I'm going to give you a perfect example. So in my setting, I get a lot of ACLs that are 678, months post op. And usually there are people who don't feel like they're progressing like they want to, and who are still having limitations. So having quad deficit, etc. I just had one recently. She's seven months post op. And one of the things that I really tried to push with my athletes, matter what level the athlete they are is fatigue, because the other thing that happens is, we know from proprioceptors that as you make someone fatigued, their proprioception is is also gets tired, and they they're they're less, they get less and less aware of body position. And those are the kinds of that's where tragedy occurs, right? So I try to push people into this fatigue state and then really making them move into movement patterns that would historically be a bad movement pattern for them, but it which they need to control, right? So to give you an idea of kinesiophobia, so I had done a. Tsk 11, Tampa scale for kinesiophobia, 11 form with this particular person, and she scored like a 1719. Is like the major cutoff for me. She scored a 17. But I put her into this fatigue state, and we were tired in her workout, and then I had her in a squatting position and just lunging at a diagonal, so down in a squat and lunging in kind of a diagonal, uh, fashion, which tends to make people move into that dynamic valgus position. She broke down crying, and I'm like, I'm like, are you okay? She's like, Yeah. She's like, that's just a move that scares me, like she still had that kinesio phobia. She didn't demonstrate it the entire time until I got her tired, and she was having to control that motion in a very fatigued state. So the beauty of that is, though, is that when you do that and you train that, eventually that goes away, and they and they build the stability. So, you know, it's it to me, the two go hand in hand. You've got to do them together as you go through the process. And you know, again, just staying on top of the research of of we know that that movement patterns change when you're tired. So getting that's why I love BFR, because I use BFR in addition to to quad strength, in addition to the all the hormone things that happen, also use BFR to to really put somebody in a very, very fatigued state, so that I can then make them really, really concentrate on controlling those movement patterns.

Dr. Spencer Baron:

I have a question that is probably one of the biggest challenges that I would be remiss if we didn't address it, and that is, how often we get patients that are post op that do not have full extension because of scar too, tragedy.

Dr. Trent Nessler:

Yeah, that's, you know, that's a that's a tragedy. And in what, what I'll say is that number one is, I'm working on motion day one. Extension is absolutely critical, you know, and, and for those that struggle, especially in initial phases, with getting full extension, I use a lot of the work, original work by a guy by the name of Paul Leo. He's a researcher out of the University of Salt Lake in Paul had done a lot of research with what's called turt Total in range time. And so what he found is that when you take a tissue and you place it in a lengthened state low load over a long period of time is that you get greater plastic changes in that tissue. So Paul happened to be a professor of mine when I was in PT school, and so I was really introduced to this concept of TERT at a very young clinical age. And what I found is that when I apply that, and I apply that throughout the rehab process, knock on wood, I don't ever have a problem with extension. So the first thing is getting that full extension. The second thing is getting that full quad recruitment, because the other piece of that is that the quad deficit that that that is there prevents them from constantly moving their knee into full extension. So once you have the extension, you have to have the strength to get you into that full extension all the time. And that's where BFR comes into play. Because BFR you can do again, low loads. Typically I'm starting BFR. Don't quote me on this, anybody. So I usually start BFR, usually day two or day three post op. And the reason that I do that is that as long as somebody is free for exercise, they're free for BFR. So I will do it with neuromuscular stem. I do quad sets with BFR. I do leg raises with BFR. I do short arc quads with BFR. I do long arc quads with BFR because I really want to push that quad to get full strength through full range of motion, especially that last 30 degrees of extension. Because typically, that's what happens, is a quad shuts down and it's really weak that last 30 degrees of extension. So really pushing that last 30 degrees of extension, again with low loads. So I'm able to do very low load, maybe even body weight, right or limb weight, and do that with a high rep sequence that's with BFR to really get that quad to fire.

Dr. Terry Weyman:

Fantastic. You know, that's fantastic. We're seeing a lot of I know you see it on TV, but you're seeing a lot of Achilles tenditis and glute strains, and it seems like there's just, I'm seeing more of those that I've seen in a lot of stuff. Aren't those also could be underlying issues that will lead to. An ACL absolutely,

Dr. Trent Nessler:

you know. And you know, one of the things, I don't think that we so the movement piece of what I do has taught me a lot. It's taught me a lot about eccentric strength. I don't think we do enough eccentric strengthening. You know, a lot of the Achilles issues, a lot of the hamstring issues that we see could be addressed by incorporating in some good eccentric strengthening. The other piece of that that the movement piece has really shown me is the importance of rotational strength. So rotational strength is really, quite honestly, one of the things that has been an aha moment for me over the last probably, like five or six years, because of what I'm seeing, that when I address rotational strength, that I see that the pelvic stability is much, much better, and especially when it comes to single limb so so there's three movements that I look for at the pelvis. Number one, if this is the stance leg and this pelvis falls down, that's a trend Ellenberg. Number two is when they lean this way, that's a retro trend Ellenberg. So they're they're shortening the glute med over here, here in this condition, the glute med is weak and lengthening. In this condition, the glute med is weak and they're shortening it. And then the third is that they drop and they rotate, because they are failing through the full range of motion of the glute. So so that trendel, or the corkscrew, is what I call it. The corkscrew is, to me, the more severe of the three. And so the in a closed kinetic chain, the glute helps the pelvis stay stable this way, but also in rotation. So when you add rotational strength, especially in single limb, you actually get a lot better glute firing going on in the limb and and more importantly, so. So one of the things that I've seen, so if this is the stance leg again, when the body leans this way, what happens to the center of mass? The center of mass turns this way. So when they land on that limb, and their center of mass is over here, the force vector actually drives their knee into an even greater dynamic valgus. So what I see is that athletes that land like this and that force vector goes that way is their dynamic valgus is greater than their degree. The speed of dynamic valgus is greater.

Dr. Spencer Baron:

I was going to ask you earlier about the mechanics of why you said that earlier. Yeah, and thank you for explaining that. That's fascinating. Go ahead

Dr. Terry Weyman:

when you see that, besides the side plank for the one legged squat, what are some of your favorite exercises to start correcting that?

Dr. Trent Nessler:

You know? So I use a device that I was recently introduced to called the Kaizen vector. It's a it's a portable device. We're actually going to be using it at the pro sport Pyro conference. It's a portable device. It's got a bunch of Thera tubing inside of it goes from 25 pounds up to 110 pounds of resistance. It's mobile. You can use it everywhere. One of the reasons I first started using it is it has a a torso strap. It's a long strap that you basically take your arm through, and you wrap around into it, and then you hook it up to the resistance. And so what the torso strap does is it rotates your body like this. Okay. So the fascinating thing about this device, I could go off for hours on this thing, because I love it. The fascinating thing about it is now I can do rotational strength with single leg squat. I can do it with a single leg lunge. I can do it with a side lunge. All of that because the torso strap is constantly pulling you in this direction. So that's one that I use a lot. Another one that I use is just resisting rotation as you go through these certain things, I like the the rotational strap a little bit better, because it's more dynamic to me, because I can do so much more with it. But the other thing about that, so one of the one of the issues I'm seeing in my mixed martial artists that puts them at greater risk for back pain as well as knee pain is a lack of hip mobility, because we are so many times we're either kicking or we're grappling on the ground and we're trying to create space and things like that. If you don't have good hip mobility, the way you're going to create space is you go into lumbar flexion. So it's obviously, it's going to create a lot of stress on your lumbar spine, right? And so one of the things that is we all do is Mulligan techniques. You put a belt around somebody's thigh, you put it around your waist, you sit back, you distract their hip, and you take them through mobility exercise for the hip. It's one of the things I would always do for. Hip mobility Well, historically, I couldn't do that with patients or have them do that at home. But now with this device, what I actually do is I hook them up to the device, and it's got a strap that goes right around up high on your hip, so it will actually provide about 40 pounds of distraction to the hip while I take them through hip mobility exercises. So I'm basically able to do Mulligan techniques for hip mobility and give them a home exercise program to do it with. The other thing that I like for the rotational strap is, as we know, lot of times I have a stiff shoulder, one of the things I might do is contract relax. So I take them up into some range of motion, I have them contract against me, and then relax, and I'm able to take them into greater range of motion. So with the one of the other things I see in martial artists is a lack of lumbar and thoracic mobility. So one of the things I do is I take that rotational strap, put it around them, and then I have them on all fours, and I have them do a movement where they're on all fours, and they're taking this elbow towards the left knee, so I'm diving down like this. And as I'm doing that, what's happening is the the I'm getting resistance from the band, so I'm I'm contracting into it really hard, and then I relax, and it pulls me into this new range. And then I contract really hard, and then I relax, and it pulls me into this new range. So it's basically contract relax for lumbar and thoracic mobility. So the

Dr. Terry Weyman:

are you sending the patient home with this device? Are they buying it or what I

Dr. Trent Nessler:

sometimes I have them buy it. Sometimes I've got several units here. Sometimes I'll lend it to them. It depends on on the athlete. I've got a lot of athletes that travel, so I usually have them get one. There's one that that's a TSA approved that they can put into their into their bag and travel with them. But I'll have them do their mobility exercises before they actually go into their fight. So you know, if they've, you know, like a lot of our guys, have competitions, and it's two days, they may have five fights in one day, and then another three fights the next day. So I'll have them do all of their mobility work in the morning before they start their their their competition, and they'll have them do it the next day as well. Wow.

Dr. Terry Weyman:

Besides the the martial arts and Jiu Jitsu, which is extremely popular right now, you know, in the football season, which is is and basketball season, which is coming up right now, where are some the preseason is over there in this season, what's some rituals they can do before they practice, before they play to reduce the risk of the ACL

Dr. Trent Nessler:

number one, I think, is mobility doing, doing some mobility work. We don't do enough mobility work. And quite honestly, a lot of the stuff that I see is not really mobility work. There are a lot of teams out there that do some great mobility stuff, but I think having working on good mobility before you go into practice, and then after practice is, is recovery, you know, because, because what I see is that a lot of these athletes in, you know, we've seen it in the numbers, right from the NFL preseason camps, like you get a massive number of ACL injuries every preseason, and a lot of that is because guys are just not conditioned, you know, they don't have the strength, they don't have the mobility, etc. So doing some form of mobility, helping them prepare, and then afterwards is doing some form of recovery, so some form of recovery, so that when they go into that next session, or they go into that next practice, that glued is is rested, that glued is a little bit, has more reserved to it, so that they're not going into this next session at a 25 to 50% deficit. Because it to me, it's the deficits that they keep walking into, especially if they're deconditioned, right? That deficit is going to be even greater. So adding in some form of recovery into that, and most of the teams are figuring that out, like you go into most teams today, they've got normatech recovery rooms in every scenario, right, where they can go and do that, but to me, the recovery piece, and there's so many things on the recovery science, like red light therapy. I mean, I use a lot of red light I actually have my clinic. I've got a cold plunge tank, I've got a hydrotherapy chair, I've got Norma tech systems, and I've got red light therapy. And the reason I do that is because my athletes, my athletes, the majority of the injuries I see are typically because they don't have that reserve their reserve tank is gassed out, and so they're walking into their next session at a 10% deficit, the next session at a 20% the next session at a 30% you know, and it just keeps accumulating until. The point where they actually get an injury.

Dr. Terry Weyman:

So what is we hear mobility a lot. What does mobility look like to you? Mobility, to

Dr. Trent Nessler:

me, is different than flexibility. To me, mobility is really working on getting a joint through its full range of motion, right? So, you know, I use the hip as an example, because I see a lot of athletes who lack hip mobility, and I don't think we work enough on it. And I think hip mobility adds to a lot of knee issues that we see, as well as low back issues. So, you know, you could say, you know, so for flexibility, for me, that's stretching your hamstrings, is stretching your quad, stretching your IT. Band mobility is working on internal and external rotation and hip flexion and extension. And hip mobility is working on flexion on one hip and contralateral extension on the opposite hip. Because one of the biggest problems that I see is that athletes don't have enough hip flexion and extension on the contralateral side running. That's what it is. One hip is inflection, one is an extension. And if you don't have that mobility to get full hip flexion, while at the same time getting full hip extension, what ends up happening one, you're going to rotate in your spine, which is going to cause problems. You're going to get more wear and tear on your SI joint, as well as the rest of the kinetic chain.

Dr. Terry Weyman:

So how do you what exercise is your favorite to do that contralateral.

Dr. Trent Nessler:

So for me, the dynamic lunge is a great one. So the dynamic lunge, for me is a really good one, because in a dynamic lunge, and if anybody's interested in that they can go on my YouTube channel, and I've got the ACL plate, ACL safe and strong program, and there's a pre practice routine on there that goes through a lot of this stuff. So the pre practice routine, one of those, is the dynamic lunge. And I like, really like the dynamic lunge, because it takes one hip into in range of motion, a flexion, and one hip into in range of motion, extension. That, to me is, is one another one that I use is high knees. And when I say high knees, what you're doing is you're pushing off on one leg. So you're pushing that one into extension while taking the opposite one up as high as you can go. So I have them do this exercise where they're doing this in a standing position, where they're taking one hip into extension, one hip into flexion. So they're doing really high knees, but really focusing on pushing off so that you're getting that back leg into extension.

Dr. Spencer Baron:

Yeah, are they suspended or are they? They're on the ground. They're on the ground. Both feet are on the ground. So like a still, like a lunge, but

Dr. Trent Nessler:

it's, it's, it's kind of a, it's kind of a quick paced lunch, but it's fast and it's high. Okay, now and again, there's videos on my YouTube that show that. Oh, good,

Dr. Spencer Baron:

good. We'll direct people to that. Um, we talked about hip mechanics, but, you know, once the foot hits the ground, if the foot is not in good shape, you got ACL, so can we go to the other side of

Dr. Trent Nessler:

the leg? Yeah, absolutely, absolutely, you know. And it's, you know, the real So, the really cool thing is, is, well, I think sometimes we get so micro focused on stuff, right? So I used to have a colleague of mine, I won't say his name, but I had a colleague of mine that, you know, what, dude, if you had a migraine headache, it's because your foot was misaligned. You know, I think sometimes we can get a little bit extreme on these things, but I'll tell you one, one test that I found that really helps to delineate Is this a lower, lower kinetic chain problem? That's what I call Lower, lower kinetic chain problem, or an upper, lower kinetic chain problem. Okay, so a step step up, so a 12 inch step up, simply film them with a frame rate of 90 frames per second or greater, so that you can do it in slow mo. What you want to see is you want to see the person step up onto the step, come all the way up, fully load the limb, tap with the opposite foot, and then step back down. And what you're going to watch for is that as they bring that foot up, and they contact the foot on the step, and they start to load. If it's a low, low kinetic chain problem, what you're going to see is the arch falls immediately as soon as they start to load it. Versus the athlete whose ankle is in a nice and stable position, they start to accept the weight, onto the knee, onto the hip. Now the knee goes into a dynamic valgus position. So it's an easy way. It's it's an easy way for me that I've been able to, like, really, if I'm having a hard time determining, is this, is this a foot and ankle issue? Is it the is it? Is it the hip that's driving the foot, or the foot that's driving the knee? I will use that. But I will tell you what I found is that, using two concepts, number one, it's a weak link, right? Everybody would agree that whatever has happening, the weak link in the system is driving the majority of the problem, right? So the weak link in the system is always the first one to fall. That's why it is the weak link. So when you're assessing human movement, and you're looking for the weak link, it's always the first one to fall second is it's typically the one with the largest deviation. That's why it's the weak link. If it was stable and strong, it wouldn't move right. It wouldn't be the weak link. So using the the the concept or a methodology of the weak link always falls first, and the weak link is typically the one with the largest deviation. Using those two things, it's always helped me gear in towards like, what is it that is driving this mechanics that I'm seeing?

Dr. Spencer Baron:

Love it. I think at this moment we are going to go into the rapid fire questions, our favorite part of the whole program. And I know you're quick on your feet, so if you're ready for number one trend, let's go all right, given your love for Brazilian Jiu Jitsu, what is the most fundamental lesson the Japanese taught you taught the Brazilians when they first introduced the art to them.

Dr. Trent Nessler:

Boy, I don't even know that.

Unknown:

I got you question.

Dr. Trent Nessler:

I know I don't even know that answer. What is it?

Dr. Spencer Baron:

I don't know. Terry,

Dr. Terry Weyman:

so I have a couple sense a COVID to see me, and they're giving me the full background of how Japanese came, brought that the art to Brazil, yeah, and and then the Gracies took over from them. But a lot of it was a lot of was just, just the street and the the culture of Japan, mixing with the culture a little bit of the relaxes of Brazil. And I wanted to get more the fact that the history of Gracie and the history of jiu jitsu is fascinating when you hear because everybody doesn't realize it came from Japan. You know? Yeah, I did from kendo. Yeah,

Dr. Trent Nessler:

I did know it came from Japan and it was a hand to hand combat. If you ever, if any of the listeners, ever want to get into the history of it, Robert Drysdale wrote a fascinating book called The evolution of Brazilian Jiu Jitsu, and it talks about how the Gracies brought it from Japan and then made these circuses, which were basically like fight clubs, where they would bring martial artists from all over the world to compete against jiu jitsu guys, so that they could constantly be upgrading their sport and upgrading their knowledge and upgrading their techniques to defeat whatever it was that defeated them.

Dr. Terry Weyman:

Which was, which is fascinating, but the the what I even learned for is the Japanese guys who taught the Gracies in Brazil. I mean, to even go back further than the Gracies to how they got introduced to it, it's fascinating how they how the Gracies, who were were from Brazil, were they got more information from Japan, and how that mix, because everybody thinks of Japan is the Kendo and those type of arts and jiu jitsu and Brazilian but it's actually a Japanese art. So it was very, it was very fascinating. So sorry for that. I wanted to

Dr. Trent Nessler:

go, you know, you know, is a side note. In most jiu jitsu schools, they have a picture of the Gracies and they have a picture of the original sensei from Japan, wow,

Dr. Terry Weyman:

which in law schools, the sensei I talking about, they just filmed, there's a there's and then a friend of ours who's been on the show is Michael Kroger, and he just filmed a podcast in gracie's original house. Oh, wow. They just, they just, so they just a guy bought it and is turning it back to the original house. It was pretty cool. So anyway,

Dr. Spencer Baron:

sorry, back to the rapid fire questions, and I'm glad that I'm not asking Terry these questions. All right. Number question number two is, you know, based on how we love you, Trent, you're, you're very real, very authentic, very sincere. This is a personal question. It's about your special needs child. Your child sees the world differently, which can bring joys and challenges and all that. But besides patience, what gift have you learned from your child that you may not have learned otherwise?

Dr. Trent Nessler:

Love in all things you know she is you know you might have seen today I posted on Instagram a late post for daughter's day. But she just has such joy for all things, simple things in life, you know, and it's, it's really as challenging as it's been her, her, her mission by God, is to bring joy to people. Yeah. What she does.

Dr. Spencer Baron:

I get so messed up with Father, kid stuff, man, but thank you for sharing that. Oh, all right, I'm moving on to number three. What is your favorite family downtime activity?

Dr. Trent Nessler:

My favorite family downtime activity? Well, we've gotten a new one, but mostly hiking. My wife loves the outdoors. Loves to hike. Love to go out there, just to be out into nature. My wife and I grew up in or lived for a long time in Flagstaff, so we love the outdoors. Our recent one is we're doing Saturday nights with my son and going through all the historic scary movies. Really, it's been awesome. It's fun.

Dr. Spencer Baron:

Scary Movie only. Scary Movie just a time for Halloween.

Dr. Trent Nessler:

My wife is a huge Halloween fan. We have a Halloween tree in my house already?

Dr. Spencer Baron:

No, oh, my god, yeah, there is such a thing. I'll

Unknown:

take a picture of it. Yeah? Love that.

Dr. Spencer Baron:

Yeah, all right. Question number, question number four, what? And again, this is a personal one. I know how authentic you are, and it's, What? What? What do you want to be remembered for?

Dr. Trent Nessler:

What do I want to be remembered for contributing to helping to prevent or mitigate risk for ACL injuries? I want to touch. I want to touch. My goal is always been to touch millions of lives across the world with something that I've learned

Dr. Spencer Baron:

that's great man, great mission. Got it narrowed down, something real laser beam that's beautiful, and I know you'll do it, because that's how you are. So question number five and the last one before we wrap up, what is one exercise every athlete should do every day,

Dr. Trent Nessler:

single leg squat.

Dr. Spencer Baron:

I was afraid you were

Dr. Terry Weyman:

gonna say, I thought I was gonna say side plank,

Dr. Trent Nessler:

single leg squad, because it is, it is the number one, number one movement for prediction of ACL risk, lower kinetic chain risk. So I think doing a good single leg squat with good, good control. You know, squat itself has been shown in the elderly to reduce the risk for falls, yeah, and improve longevity. A single leg squat takes that up a notch. Oh, yeah,

Dr. Spencer Baron:

Trent, you're a rare breed man, really, just such a cool guy with a lot of knowledge up here. And I want to thank you for sharing, and thank you

Dr. Trent Nessler:

guys so much for having really appreciate everything you got going absolutely.

Unknown:

You're the best man, awesome.

Dr. Trent Nessler:

Do I see you guys next week?

Dr. Spencer Baron:

You will see me next week. All right, I'll

Dr. Terry Weyman:

see you guys next week. All right, buddy.

Dr. Spencer Baron:

Thank you for listening to today's episode of The cracking backs podcast. We hope you enjoyed it. Make sure you follow us on Instagram at cracking backs podcast. Catch new episodes every Monday. See you next time you.