There is no such thing as shin splints

I had an incident occur at my school recently that is all too common. A visiting team coach calls me over to look at an athlete with "shin splints". The athlete was wearing two ankle stirrups to help alleviate bilateral medial tibia pain. I watched the player jump and land a few times, and it became obvious there were serious force reduction issues going on. It was particularly troubling because the fall season has just begun.

I wonder if that coach ever saw an athlete land from a routine jump and completely shatter their entire lower leg?

I have.

If you are a coach, don't think it can't happen to you. Get the blinders off- a shin splint is a stress reaction in the tibia. In other words, either a precursor to a stress fx, or a stress fx itself. Asking your ATC to tape the shin is a waste of time. If the athlete has a planus or cavus foot structure, an orthotic may help. But more often than not, it's a training progression issue. Don't think this is the A.T.'s responsibility alone. Sport appropriate axial loading exercises that increase bone density must be integrated into your workouts. If you're working with female athletes, it's even more important.

If your athlete presents with these symptoms, listen to your ATC. Rest accompanied by non weight bearing exercise (ie stationary bike, pool) is crucial to prevent further damage. Just because these symptoms appear does not mean the end of the season. Manipulation of work/rest and weight bearing/non weight bearing exercise can allow bone remodeling to take place. I will post more on this topic in the future.

Hamstring Rehab

This is an athlete with a grade 2 strain of the L bicep femoris muscle. Although the injury is only a few days old, I'm already doing agility work in the transverse & frontal planes. The ahthlete cannot jog without limping, but looks sound in these two planes. I will avoid going directly into the sagittal plane at this time, understanding it's beyond this athlete's threshold. This way I am producing neural drive to the muscle in an integrated manner, meaning there are plenty of other muscles around to assist the BF. In addition, I'm minimizing scar formation. An article in the March '04 JOSPT by Sherry & Best supports this approach.

Mike Mussina on pitching

Ray Korn, our baseball coach sent me this link. In an era of anabolic steroid/GH abuse, this erudite approach to pitching is refreshing:

http://www.nytimes.com/interactive/2007/08/17/sports/playmagazine/20070817_MUSSINA_GRAPHIC.html#

HexLite

Occasionally I'll give my opinion on a product, although I accept no monetary compensation for it. This one is for Tracie Fober's HexLite bars. It's fresh on my mind because I used it for the first time for ACL rehab.

If you've been reading my blog, you know I like to keep learning movement on an subconscious level when ever possible. If you're trying to teach an athlete to squat properly, this is a great tool. Because of the way the weight is distributed, the body has no choice but to do it by driving though the hips & legs. Even if you consciously attempt a torso dominant strategy, the body will self correct.

The HexLite is small & convenient enough that you're not married to the anterior sagittal plane. I included it in my rehab circuit and had the athlete monster walking forward, back, laterally, etc. It can handle over 200 lbs of plates and stores easily in the corner of your A.T. room. Even if you're like me and don't have one. The website is http://www.ironmaven.net/hexlite.html

This is what it's all about

The Minutemen won big Friday night, shutting out it's opponent once again. Even more special to me was my ACL reconstruction player cementing his starting job. He was 2nd string JV last year when he suffered the injury. It is particularly rewarding to see the physical transformation that took place with his whole body during the rehab process. He is leaner, stronger, & faster. We played the game in the rain on a wet, slippery field. I knew this situation would arise, so I tried to design a drill in rehab that would safely proprioceptively prepare him for this. What I came up with was walking, then agility drills on a grass hill in front of our gym with his sneakers on. There was plenty of slipping & sliding, but not so much that he couldn't regain his balance.

It's important to remember that proprioception deficits after ACL reconstruction have been documented up to 2 years post surgery (Corrigan, '92). This drives home the need for a remedial component in every strength & conditioning regimen.

Don't be passive

A reader comments, "at $14400 for the GIFT program and $3600 for the GAIN program I think I'll have to rely on Joe to educate me!".

This blog is not an infomercial for any program. Don't imitate-innovate! I'm not smart enough to be Vern or Gary. Early in my career, I made the mistake of monkey-see-monkey -do. Athletic development should be athlete centered, not protocol centered.

What I'm getting at is it's not about money. Ask your school librarian if she could get Athletic Therapy Today or the Journal of the American College of Sports Medicine etc. added to the periodical list. But never stop learning. Don't become one of those people Tracie Fober spoke of in her blog. The type that like to place the name of their school that they graduated from 30 years ago after their signature. In the real world, nobody cares. It's "what have you done for me lately"- the quality of your work. If college & professional athletes that you had in high school are coming back to you for something their ATC or P.T. can't do for them, you know you are on to something.

Don't be passive- life is competitive and the stakes are too high.

A quick, great read...

Below is a link to an article in this month's Biomechanics magazine. While you are reading it, keep in the back of your mind my "Who's zooming who?" post. Is it a compensation, or a bonafide dysfunction?

http://www.biomech.com/current_full_article/?ArticleID=157

The myofascial puzzle

This is me working on our ex baseball short stop, Roberto Ramos. He was drafted by the Boston Red Sox this past summer. I'm doing ART (active release technique) on his cervical muscles.

Fascia is the framework that connects all soft tissue and organs continuously throughout the human body. Muscle, tendon, and fascia are anatomically inseparable. A good book on the subject is Schultz's "The Endless Web". In the past, we have looked at it as a passive structure, but recent studies have proved it has contractile properties of it's own. In 2006 a group of German researchers presented research documenting this phenomenon at the World Congress of Biomechanics.

Thomas Myer's book "Anatomy Trains" describes the functional links between the upper and lower extremities by way of fascia. Take a look at it, and you will understand how a myofascial dysfunction in the neck can cause a plantar fasciitis.

There are many types of myofasical release. My favorite happens to be ART because it is fast, and there are no gadgets to loose. I didn't do MF release for a long time because some of the other techniques required you to hold static positions for up to 10 minutes! It killed my wrists and hands, & the time requirement was totally inappropriate for my setting. In addition, ART involves active movement by the athlete. I believe rehab modalities that involve the athlete fixing his own dysfunction are the best. By the way, the new neural flossing protocols are really cool!

However, learning ART is very expensive, and requires a yearly re-credentialing process. That being said, I am seeing more & more collegiate ATC's when I re-cert. Many chiropractors & some P.T.'s are certified, and the ART website has a provider locator's service. It's not a bad idea to develop a relationship with a practitioner.

Lenny Paraccino, a soft tissue therapist out in California, is working on some real exciting stuff. He is using MF release in a more global, integrated way. I think he is really on to something. Check out his website at http://www.kineticconditioning.net/

Iron Maven's last blog

Be sure to check out Tracy Fober's blog for Sunday, Sept. 21, '08. Coach Fober had the pleasure of speaking to Paul Hodges and Shirley Sahrmann! Add that to the fact that she snatches more than me and is just plain smarter than me, and I am thoroughly intimidated. She is a P.T. with an olympic lifting background, and applies hybrids of weight lifting movements to athletic development and rehab. Take note of her comments on the hubris of some of the faculty and students. It's funny because I see it in the A.T. profession too, and experienced it when I was first starting this blog.

Who's Zoomin' who?

A great old song from Aretha Franklin.

The feet pictured above belong to one of our cross country runners. This athlete approached me complaining of an annoying chronic right knee pain along the inferolateral patella. The past few years, when ever she gets to a certain point in her training volume/intensity it flairs up.

Looking at the overpronation in the left foot, you would think it was zoomin' the LEFT patellafemoral joint. Not the case here.

What is going on is the foot compensating for a leg length discrepancy- in this case, the left leg longer than the right. The calcaneus everting, the talus following to make the leg shorter.

I placed a full length 1/4" felt insert in her right shoe and within days the R knee pain/edema were significantly reduced. Of course more more needs to be done, ie some myofascial work on the R lateral knee structures.

Correcting the left foot overpronation could have made the pain worse.

So, be careful when deciding what to do with what you find on a movement screen. Decide what is a bonafide dysfunction, & what is a compensation.

In other words, do what Aretha does and ask, "Who's zoomin' who?

A little more about me.

A reader comments: "I would love to join the GAIN network and I would also love to join Gary Gray's GIFT program but it takes money and I ain't got it."

I want you to never forget that I am a real life high school ATC, just like you guys. And, I will never try to sell you something on this blog. As the title states, it is dedicated to you guys.

A little more about me. I have been fired from my position here at Elizabeth High School twice in the past 23 years. In both cases, combinations of a coach and administrator who had it in for me. I'm not sure what ever happened to the ATC who replaced me, or the coach & administrator. They're probably selling insurance or real estate some where.

The point is, the only reason I was asked to come back is because I produce. I produce because I am competitive, and want to do a better job then the next guy. Had I not met Vern Gambetta some 15 years ago, I'm not sure I wouldn't be selling insurance too. He introduced me to Gary's concepts, the kinetic link principal, and I still believe it's the fastest & most effective way to get the job done.

Elizabeth High School has not paid for a single continuing education credit. All of it has been out of pocket for me. This stuff is not only my profession, but also my hobby. Sorry, but the idea of spending thousands to hit a little white ball over a green doesn't excite me. But this stuff inspires me. If you think I'm a dope for doing it, fine. But, the little 60 minute bites I was getting at conferences was not enough in this era of competitive health care. Who says a chiropractor or P.T. can't learn how to tape and do what we do?

Look, I'm not suggesting YOU pay out of pocket for anything. But, many wouldn't think twice about asking their board of ed or booster club to purchase an electrotherapy unit for thousands of dollars. And like I asked in a previous post, are you getting the biggest bang for your buck? Can you take out your stop watch or goniometer and measure the improvement? If you can't, maybe think twice about how you budget your money. The kinetic link principal is the best modality I own.
I hope you'll continue to let me share it with you.

Recovery & Restoration

Make sure you read Vern Gambetta's blog today. He discusses the trend of using corrective exercise in place of performance training. Every sport has it's injury patterns, and an appropriate remedial program should be built into every athletic development program. My Mulligan Technique instructor used the phrase, "asymmetry is the norm". Attempting to correct it may have undesirable effects.

For instance, I recently had an ex basketball player of mine, who is training for in the police academy come to me complaining about lateral knee pain on his distance runs. He has has genu varum that is contributing to ITBFS. Basically, the same anthropometric makeup that made him great at jumping and lateral movements make him a lousy distance runner. Running long and slow will not be required once he graduates the academy (especially with the action he'll be seeing in this part of NJ!). So, a little ART with some active/passive stretching thrown in and he's doing just fine. If you body mapped him, I sure you could find plenty of stuff to work on. Orthotics and all that.

I think the muscle imbalances that may come up with non-cyclical sports such as baseball or tennis can be addressed as part of the recovery process. Why does recovery need to be passive? Why can't the athlete do some throwing or hitting or racket swinging with the opposite arm? How about the cross country runner running backwards or laterally?

Econcentrics

This term refers to the concept that muscles may be acting concentrically, eccentrically, & isometrically all at the same time, at different joints, and/or in different planes of motion. JH asked me to give an example of where this occurs in the human body, and the answer is everywhere. If you are going to buy into the concepts put forth in my blog, you have to re-examine the idea of agonists, antagonists, synergists, and stabilizers. In function, all muscle are synergists. I am not an expert in this area, and if you need more info, Gary Gray goes in depth on the concept in one of his functional video digests. If you really want to dive into this stuff, apply for next year's GAIN APPRENTORSHIP and learn hands on. Dr. Dan Cipriani, biomechanics professor at San Diego State will go over the theory, while Vern & Steve put it into practice.

Ay Dios Mio, here come the rotten tomatoes again, but here is an example:

The gastrocnemius at late mid stance: Proximally is isometrically contracting to prevent hyperextension at the knee, distally eccentrically decelerating dorsiflexion at the ankle, while concentrically inverting the calcaneus.

Why ask Why Comments

Kevin Moody says:

"I see quite a few high school runners with MTSS. When I ask them to squat they usually internally rotate at the hips, adduct at the knees and pronate at the foot/ankle."

There is a reason Kevin is the head ATC at the Lake Placid OTC. He is a great "functional listener". Right on Kevin- MTSS, stress fx are force reduction problems. Films on lower leg stress fx commonly show spiral or frontal plane patterns:

External Frontal Plane Loads May Be Associated with Tibial Stress Fracture/
Medicine & Science in Sports & Exercise. 40(9):1669-1674, September 2008.CREABY, MARK W. 1,2; DIXON, SHARON J. 2

Free moment as a predictor of tibial stress fracture in distance runners/
Journal of Biomechanics , Volume 39 , Issue 15 , Pages 2819 - 2825
C . Milner , I . Davis , J . Hamill

So, what I'm after here is moving the center of gravity to the inferomedial tibia & use contralateral LE drive to add a FP, TP force.

Why the arms up over behind my head? Right again Kevin, I'm influencing the core. In this case, I'm taking my glutes, lats, & erector spinae out of the picture as to make the leg itself work a little harder (integrated isolation, as G2 calls it).

JH, great comment about the pronation lengthening the tibialis anterior!! A very underrated force reducer. Dr. Dan Cipriani, biomechanist & GAIN faculty member makes a good point that every muscle has a triplane function, & contracts ECONCENTRICALLY. In other words, it may be working isometrically in one plane, eccentrically in another, and concentrically in third. I've seen some practitioners use variations of toe raises to strengthen it. A waste of time, I think.

Thanks again Kevin & JH...you guys keep me psyched up.

Why ask why?

These are two exercises I include in prevention/rehab for medial tibial stress syndrome. They are a RLB, LLE L lateral reach; & RLB, LLE L rotational reach- both c/ a BUE posterior overhead reach. OK, now put your thinking caps on, as Sister Vincent Marie, my first grade teacher told us.

Why these two exercises?

Why am I lifting my hands behind my head?

FMR

the acronym for functional manual reaction. The brain child of Gary Gray & Dave Tiberio, it's a type of joint mobilization done in functional positions, using authentic drivers , based on chain reaction biomechanics. It's a great time saver for the ATC because proprioception is built into the process. If you haven't done so yet, go the the Gray Institute's link on the right & sign up for their free internet news letter. FMR is featured in this month's installment. Pat Donahue, if you're out there, feel free to add in anything I missed.

Over the Hills & Far Away

Not just a great Led Zep tune, but a great training modality.

Way to go, BK! I love the way you guys (and women, you know what I mean) think! I have a slope right in front of the gym entrance to our high school, and yes I use it for ankle mostability. Forward, backward, sideways walking and jogging. Movement is driven not only from the ground up, but also from the top down because the arms are chugging along. You may find that the ankle sprain athlete can walk backwards up the hill long before they can walk normally on flat ground, because of the absence of dorsiflexion- therefore preserving function. I also use slopes for knee rehab, and have my baseball guys crawling up & down them for shoulder mostability.

Comments on my "Hit Takers " " post

Don't worry Kev if you never heard of Freyette's law of coupled motions. Not everyone buys into it (Does the Evidence Support the Existence of Lumbar Spine Coupled Motion? A Critical Review of the Literature- JOSPT April '07). I just find it a convenient way of describing and documenting spinal dysfunction. So much for that.

Brian asked why I chose a right stride stance. Good question. In this case, if I started with the head in neutral, I would have used up most of my left cervical rotation. In osteopathic terminology, I would have already been into the interbarrier zone. Going through it would have been painful, and forced the motion to other cervical segments that had more motion.

Extension was the most painful motion for this athlete, so I chose to address the other two planes first. I do believe in Freyette's 3rd law-that if motion in one plane is restricted, it will influence the other two. So, I can improve extension ROM indirectly by going after frontal & transverse planes first (and it worked, by the way).

In summary, the point of the post was influencing the cervical spine indirectly by way of the T-Spine. It's completely safe, because unlike a manipulation, the athlete is doing the correction, is in complete control, and can stop it any time he wants.

My Buddy

What a beautiful Sunday morning I had. My first day off in 15 straight days. I jumped in my pool with my training partner, my springer spaniel Dallas. He will be 91 dog years old next month. Arthritis prevents him from running with me any more, but he still loves long walks and his favorite sports-swimming & diving. Dara Torres has a long way to go.

Hit Takers & Trouble Makers, Part 1

The manual therapy journals keep coming to the same conclusion, that thoracic spine manipulations are useful to increase range of motion & decrease pain in athletes with neck pain. Once again, this is support for the kinetic link principal. However, you are probably asking what this has to do with the high school athletic trainer.

Martin Lambert, a physical therapist in Hamburg, New York invented the idea of "hit takers 'n trouble makers" in the human musculoskeletal system. C2-C7 are stuck between two trouble makers: the O/A joint and the T-Spine. The lower T-spine has mostly sagittal plane motion, the upper mainly rotation, with frontal plane motion pretty evenly distributed. However, if motion in any one plane is inhibited, it will reduce motion in the other two. So, when it runs out of motion, it will quite often go up or downstairs to steal more...because it can. So, that sprained neck may have been set up for failure by a hypomobile T-Spine.

The photos above illustrate an exercise I am using now on a football player who sprained his neck. Diagnostic films have ruled out serious injury, but the athlete was left with a type 2 dysfunction of C3-4. It is stuck FSR, that is flexed, side bent & rotated right. Simply put, the kid has pain/stiffness extending & rotating/sidebending his head left.

I'm using my RLE & arms to create relative left rotation & left side bending in my neck. I choose a right stride stance as not to place my neck at end range left rotation. I begin with eyes fixed forward, BUE extended at shoulder height, left hand supinated, right rotation, then go to BUE right lateral reach toward the floor in one smooth motion. Kind of like a oarsman rowing. I'll repeat it 4x20 reps.

What I've done is used my arms to drive my T-spine in the direction I want as to mobilize my neck. I'll avoid using my head as a driver for the time being, as it will be too painful. I'll use massage & other modalities to relax the muscle spasm & work around the injury for the time being.

In conclusion, we're applying the new evidence based practice stuff coming out of the research journals, and giving it the good old fashioned ATC twist.

My take on Hip Hinging

I can see the rotten tomatoes being flung at me now, but just read this entire post before you begin your wind up.

Hip hinging is the process of disassociating iliofemoral flexion/extension from lumbopelvic flexion/extension. It is learned through exercises such as "the waiter's bow". I realize Shirley Sahrmann & Stuart McGill are proponents. But-you need to remember I work with the adolescent population and I'm not sure this is a skill that requires specialized training.

To me, hip hinging is a natural process. I can recall watching my 2 year old nephew and niece attempting to lift up my 7lb. med balls. They lifted it with body mechanics that a weight lifting coach would be proud of- and they were never taught of course. The body subconsciously chose a hip/knee dominant strategy. Hip hinging to me is a natural phenomenon. When you see otherwise, go look for the link that's out of sync. Think...what would make the body choose an erector spinae dominant strategy? For starters, lack of dorsiflexion at the ankle. Yes, even with straight legs, the talus must glide posteriorly for a hip hinge to take place. How about a sore knee from Osgood-Schlatter's disease? How about a tight posterior hip capsule & a weak butt (you'll see this a lot).

I realize in certain weight room tasks, the hip hinge must be taught. Learning a Romanian Dead Lift comes to mind. I also understand in certain populations, this strategy might be used to protect a prolapsed disk. Or, used in the situation where a LE joint is severely arthritic as a technique to protect the lumbar spine.

Finally, let me end with this study from '99 by Granata et al. They studied a group of veteran city sanitation workers and compared their lifting techniques with inexperienced lifters. The conclusion? The experienced lifters chose a multitude of lifting strategies to get from point A to B. There was no one right way. The inexperienced lifters however, showed very little variability in their technique. The authors concluded the experienced lifters demonstrated "motor control flexibility". Bingo.

Let me go change my shirt.

3D Ankle self mobes

If you see me doing my pre game taping before a football game, you will see the "on deck tapee" in the corner doing the exercise above. The slant board will be placed about 18" from a wall or fence, in three different positions: frontal plane neutral, " " everted, " " inverted; at 20 degree angles. The athlete does this by turning the board sideways, then placing a few rolls of tape or weight plates on the wall side to get the sagittal plane angle. The athlete will stand on the board with his foot/knee/hip in 0 rotation. The contralateral LE will be flexed to maximum, hands as high as you can reach on the wall, hip pushed toward the wall as ROM permits. From there, the TP element is added in by horizontally abducting/adducting the thigh as ROM permits. 1 set of 20 reps, each foot, in each position. Or as long as it takes you to tape a set of ankles!

Not only is this a terrific three dimensional mobilization for the ankle, but also for the hip! They are functionally & anatomically linked together by the way- a topic for another blog.

If you are trained in joint mobilization, it's easy to squat down & use your hands to accelerate or decelerate one segment on another as you see fit. Again we see the athlete is correcting his own dysfunction, with the ATC in the secondary role as a scaffold to healing.

Cuttin' -n Pastin' all da live long day.

The theme of this web site will always be the application of the scientific to the practical by way of learning through sharing, so feel free to share my stuff. None of it is copyrighted, unless otherwise noted. However, I have seen my stuff copied verbatim on other's web sites, and professional presentations as if it were their own. That is perfectly legal. However, it is in violation with the spirit of this blog. So, if I catch you doing that without giving me my props, I will call you out on that in this blog, because embarrassment will be in order.

So, just a reference to me in a footnote would go a long way.