Does 'proximal control' need a new definition or a paradigm shift in exercise prescription? A clinical commentary.

WhAt constitutes proximAl control? There is level 1 evidence that ‘proximal control’ exercises are effective in the management of common musculoskeletal injuries of the lower extremity. 2 However, there is little agreement on what ‘proximal control’ entails. A meta-analysis by Sugimoto et al examined neuromuscular training for ACL injury prevention and found that exercises incorporating a ‘proximal control’ component (OR 0.33, 95% CI 0.23 to 0.47) were comparable to strength-based exercise or ‘multiple exercise’ interventions. Sugimoto et al chose a global definition of proximal control (any exercise involving segments proximal to the knee joint) which included full-body dynamic warm-up programmes with plyometrics, jumps/hops, bounding, and various running and agility movements. One might argue that while these full-body interventions represent an integrated holistic approach, calling them ‘proximal control’ is inaccurate, as they fail to incorporate hip-specific exercises as the next ‘proximal’ link in the kinetic chain. In comparison, a review by Lack et al reported on the benefits of proximal control interventions for patellofemoral pain syndrome defining ‘proximal control’ as ‘exercises directed at the hip or lumbopelvic musculature or both.’ Consequently, Lack et al’s review was limited to more traditional static, hip-focused movements, such as side-lying or standing hip abduction and seated external rotation strengthening exercises. These hip-focused exercises are certainly ‘proximal’ in relation to the knee, but one might question whether such a reductionist approach translates into upright, complex, sport-related movements.