Annoying

Why do the spray buttons on those Cramer Tougskin cans break off so easy? I can't tell you how many full cans I've waisted when they were accidentally dropped on the floor.

The same thing with Cramer Shark tape cutters. One drop on the floor and the tip breaks off and they are finished.

SM,TA,Pelvic Floor-my turn.

I'm going to let JH's comment answer this one for me:

"Working in an industrial setting we see a lot of back issues. Once pain is controlled we find that they are very strong in the movements they perform daily but very weak in any number of given exercises they do not perform on a daily basis. It is really as simple as giving them a variety of movements that are "new" to the body and the appropriate muscles learn how to respond resulting in a more versatile spine."

YES!!!

If you read the studies on this topic, the subjects are almost entirely involved in repetitive tasks, such as factory workers & cricket batsmen. The same movement patterns are performed sometimes hours at a time. My ART recert classes always begin with a lecture on repetitive stress syndrome, and it's effect on the fascial structures of the body. "Grooving movement patterns" is a popular buzz word in sports and physical therapy today. However, remember Wolf's law from your college AT classes- that is, form follows function. That means you are also molding bone, soft tissue, and the nervous system- for a specific task. There are consequences. Vern Gambetta cautions us not to develop "adapted athletes" over "adaptable" athletes.

There is an interesting topic in Dr. McGill's book regarding an athlete doing a deadlift under a fluoroscope. One vertebral segment appeared to buckle under the stress of the load. What caused an abhorrent movement pattern at one particular level, and no where else? Fatigue from a previous workout? Maybe a sore knee that caused the athlete to push harder with one leg than the other? A rib dysfunction that caused an abnormal rotation? An undiagnosed spondylolysis or pars fracture? The reader is left to wonder. However, we must not jump to the conclusion that a weak multifidus at a specific level, on a specific side, or the TA is the culprit, and the solution is to isolate them with biofeedback.

How can we take JH's clinical work in the industrial setting & apply it to athletics? I think the easiest place to get this started is with recovery/restoration. How about some bat swings from the contralateral side...throwing with the contralateral arm...running backwards, sideways, carioca? If your job requires stooping/lifting to the right, how about standing in a stride stance, alternate over-the-shoulder punches to the left...if you are a cyclist, how about lateral lunges with rotational over-the-shoulder-punches?

There are exceptions. Christina Christie, a P.T. from California, works with women who have bladder control issues resulting from child birth. She describes the pelvic floor as a "trampoline". She points out that beginning the rehab process in the vertical overloads this system. Therefore, her protocols are initiated from the floor. Similar concept as to my idea on wall slides for GH instability.

Magic Muscles?

Effect of Stabilization Training on Multifidus Muscle Cross-sectional Area Among Young Elite Cricketers With Low Back Pain- JOSPT: 2008;38(3):101:108
Julie A. Hides, Warren R. Stanton, Shaun McMahon, Kevin Sims, Carolyn A. Richardson

Free magazines such as Biomechanics & Training & Conditioning Magazine are considered "throw aways". However, they are not that at all. They give you a "reader's digest" version of a variety of interesting topics, then give you references at the end so you can dig in further if you wish. I like them because they give me an indication of which way the wind is blowing, sort of speak.

In one of these journals, a physical therapist interpreted the above article as "It would be wise to evaluate & retrain the multifidus in athletes involved in sports requiring repeated trunk rotation, such as baseball, golf, & hockey."

Me, being the skeptic, says:

1. Even the authors admit there was no control group used in this study.

2. These athletes cardiovascular training consisted of "cycle type ergometers".

3. Resistance Training was described as "Weight Training exercise 3x per week.

4. The authors make the statement, "subjects with LBP who received the intervention commented that their ability to squat with weights was improved after intervention, as they could “feel” where their backs were in space as they added load." This kind of gives you the idea of the type of resistance training that was going on. In addition, "Techniques of squatting and lunging were examined, and subjects were instructed to maintain their lumbar lordosis and thoracic kyphosis throughout the movement." Does this really happen in real life?

5. The authors continuously refer to the proprioceptive role of the multifidus, transversus abdominus, and pelvic floor muscles, but yet choose to train them in a "bodybuilding" type isolation style using ultasound to make sure they are isolating enough.

Ok, I buy into the fact that those 3 muscles atrophy after a localized injury to a spinal structure. Paul Hodges has documented that in vitro & vivo extensively. But allow me to refer to the 2nd edition of Dr. Stuart McGill's "Low Back Disorders". On page 110 he makes the statement, "the reason for the clinical emphasis on the multifidus may well be that the bulk of research has been performed on this muscle." He goes on to mention researchers who have found similar unilateral atrophy in other lumbar muscles. On page 120, he makes another key statement, "conceiving spine stabilizers as intrinsic or extrinsic my offer no benefit for clinical decision making. The relative contribution from every muscle source is dynamically changing depending on it's need to contract for other purposes."

Shirley Sahrmann, in her excellent book "Diagnosis & treatment of movement impairment syndromes" says on page 35, "these patients have motor control problems. The lack of extensive discussion reflects the limited information available, NOT the importance of this factor in movement impairment syndromes." In an article in SPINE in '96, Julie Hides herself suggests "impaired reflexes" being responsible for the failure of the multifidus.

What I'm getting at is, don't these muscles get stimulated the same way others do- that is by ground, gravity, and momentum? If that is true, what could be blocking this?

A preamble to my next series of posts.

In my next few posts, I'll be referring to the work of Hodges, Jull, & Richardson on core training & spine stability. If it sounds like I'm being critical, nothing can be further from the truth. I'm not in same league as these people. The truth is I'm a 49 year old man who watches cartoons at night to help him relax before bed time.

However, this blog is dedicated to the high school A.T.; and the care & prevention of injuries to adolescent athletes. So, I must interpret research and apply it in a manner that suits my setting.

I often work with classified athletes. For example, emotionally disturbed, ADHD, neurologically impaired et al. Yes, they are athletes too, and they have spines that get injured. In addition, I work with the "teenage" population. I know what would happen if I left them alone 5 minutes with one of those pressure gauge bags & an ultrasound unit. They would probably be text messaging their boyfriends, while talking to their friends, with an I Pod in their ear. A few would probably be beating each other over the head with the pressure bags.

I don't pretend to have all the answers, but since this is my blog I get to be selfish & tell you how I approach the issue.

High Tech?

I understand this athlete had a CT scan to his brain 3 weeks prior to his death. As with other sports injuries, we cannot rely on technology alone in addressing brain injury issues in sports. Athletic Training is both an art & a science. However, the more an ATC moves away from high tech (head injuries & other wise), the more we are second guessed (I am by no means saying that this went on in the Montclair case). Yeah, it still happens to me three decades into the game-and I'm sure I'm not the only one. If you would like to anonymously share your "MD coach" stories, feel free to do so. Oh, come on, we all them. I've even had coaches who could read X-rays!

Every athletic trainer's heartbreak

http://www.montclairtimes.com/NC/0/813.html

EHS Coaches Comments...

"Muscles" asked what our coaches do differently-

Good question. I spoke with the coaches about this, and they feel it has to do more with the style of play than conditioning. (I find it interesting that they don't think they do much conditioning. I think that's because a lot of what they do involves the ball). They said the South American/European players are trained to avoid direct confrontation, and it is "instinct" to jump out of the way to avoid a slide tackle or collision. My interpretation of this is it is that it involves both outstanding agility, and an intense knowledge of the game. Like Vern always says, personal training is not coaching.

Conversation with Coach Gambetta

Just got off the phone with Vern. He asked, "Hey Joe- great post on the ACL protocol. I'm curious- how many girls soccer ACL injuries have you had in the 26+ years at YOUR school."

Feeling pretty stupid, I said, "0". And only 1 in boys soccer.

In all fairness, I don't think I have very much to do with that though. Our coaches are Portugese & Columbian. Most of our players are Portugese, Columbian, and Brazilian. They bring a lot of their cultural idiology to the sport.

Antonio, Joe, Jack, Gustavo- may you never be brainwashed.

In simplicity there is beauty, redux

A Randomized Controlled Trial to Prevent Noncontact Anterior Cruciate Ligament Injury in Female Collegiate Soccer Players- Am. J. Sports Med. 2008; 36; 1476

Thanks Tracy Fober for bringing this to my attention. 70 hr. work weeks are turning my brain to mush.

This knee ACL prevention program dropped female collegiate soccer injury rates an overall 41%, and non contact injuries 70%. Very impressive. The program is free online at:

http://www.aclprevent.com/pepprogram.htm

http://www.aclprevent.com/pep_replacement.htm

I found it interesting that the study used the replacement exercises to "alleviate boredom". Take a look at both protocols, and see if you came to the same conclusion I did.

Closing the Chain

You don't hear of the term "closed chain" much any more. It was first proposed in Steindler's 1955 text, "Kinesiology of the human body". His definition is, "a condition or environment in which the distal segment meets considerable resistance that restrains free motion". It got too confusing as to what defines "considerable resistance" or "restrains". But, here are two of my favorites. The first is a closed chain "mountain climber". The athlete has a pair of football girdles wrapped around his feet for glide on a painted concrete floor. On a traditional gymnasium floor, a pair of socks will do just fine. The exercise is appropriate for just about any LE rehab. The nature of the injury, and the stage of healing will determine whether the legs move in sync or out of sync, the plane, and the direction. I hate to use the term, but it's a great "core" & cardiovascular exercise.

In the 2nd picture, the athlete is in a narrow stride stance, holding two powerballs over his head and shaking them right to left, in sync, as quickly as possible for 30 seconds. I also have them go sagittal plane hip to overhead, then rotational @ shoulder. Beginning proprioception training for a LE injury from the top down is sometimes a good way to set your athletes up for success.

In simplicity there is beauty

This is a typical afternoon scene at my high school. I set up a rehab circuit on the corner of the field turf. A soccer game is going on in the distance. The athlete pictured is working on a 3 day old grade 1 hyperextended R knee. As you can see, the athlete came in her street clothes, unaware cocktail hour was over. Ay Dios mio! Que gente! She soon regretted it.

-45 second sprint @ 120 RPM's on the stationary bike

-miniband carioca step R/L 30 yards.

-Rockfit, 1 minute

-5" R leg close chain stepup & return (Rockfit upside down), 10 reps each leg

-In R stride stance, BUE rotational reach to R lateral ankle/overhead press with 3lb. dumbbells, 10 reps.

-10 pushups, pivoting off distal thighs.

-3 minute rest

5X around the circuit.

By the way, don't think I'm getting fancy. The stationary bike I found in the trash in back of the junior high. I purchased about 30 bucks worth of parts out of my pocket and moved it over to our field house.

Hip Dislocation!

This past Friday night was a bittersweet victory for Minuteman football. One athlete with a possible medial meniscus tear, and a first for me- a posterior hip dislocation. Special thanks goes to Danielle Coppola, the ATC at Eastside Newark H.S., their team orthopedist, Dr. Robin Gehrmann, the City of Newark ambulance EMT's and the staff at University Hospital. Top notch care through the whole process.

ITBFS

Iliotibial Band Friction Syndrome. A runner that has Genu Varum (bow legged); and who's sport requires them to run in straight lines will be prone to this type of tendinitis. The stretch pictured above should be a regular part of this athlete's program. The athlete stands in a slight stride stance, with the involved leg behind, toes of both feet pointed straight ahead . The back knee is kept in full extension. The foot is supinated by way of a slant board (just prop a T shirt underneath the medial border of the foot if you don't have one). The right arm is relaxed at the side, then does a maximal left lateral overhead reach, then returns to the starting position. 3 sets of 20 reps are performed. Note: Watch for the athlete "bailing out" in the the transverse plane. If this occurs, you may need to place the athlete's lead foot more medially, and/or move closer to the wall.

Performing myofascial release with this stretch is easy!:

1. Position either hand midway down the athlete's lateral thigh, with the heel cephalid & the fingers caudal.

2. Press firmly into the thigh, then direct your tension distally.

3. On subsequent sets, place the hand proximally and distally along the path of the ITB.

4. It may also be helpful to place your hand on the anterior border (VL), or the posterior border (BF).

The athlete is actually doing the release himself, with minimal intervention by the ATC.

Healing Psychology

Marras WS, Davis KG, Heaney CA, Maronitis BS, Allread WG. The influence of psychosocial Stress, gender, and personality on mechanical loading of the lumbar spine. Spine. 2000;25:3045–3054.

It was a coincidence when I had just finished reading this journal article when I received an email from an A.T. student doing a master's thesis on healing psychology. I found it interesting the questions seemed to focus on verbal counseling. That's one way of approaching the problem.

Those of you who read my blog on a regular basis know I believe in empowering the athlete. Tradition tells us to "focus on the weak points, the weak links". Vern Gambetta taught me years ago that this may not be a good strategy for short, or long term success. Rather, teach the athlete to exploit their strengths.

Set the athlete up for success. If you have evaluated the athlete and determined a certain motion or plane is painful, then don't go there. Work around the injury. Find a plane, direction, speed, range etc. that's not painful and let that be your starting point. Think of my previous post with the hamstring strain athlete. Although he had a grade 2 BF strain, he moved very well in the frontal & transverse planes. I put my thinking cap on and came up with as many exercises & drills I could think of that integrated the hamstring in these planes. Forget about endless ice, stim, stretching. Let their own nervous system quiet the pain & muscle spasm. If there are team drills the athlete can safely participate in, let them do it.

In my 26+ years of athletic training, I have never healed anyone. That is a skill I will never have.

Chiropractors

I'm often asked what I think about chiropractors. Well, I definitely don't buy into the Palmer theory (most chiropractors don't either). However, I am a big believer in manual therapy. Although I have certificates in many manual therapy techniques, I am the first to point out that I am not a manual therapist. Meaning, I don't have a traditional degree from an academic institution in manual therapy. A chiropractor does. During my soft tissue courses, I had the pleasure of being instructed by and training with chiropractors. I was amazed at how much better their palpation skills & sense of touch was then my own. They really raised the bar for me, and I am grateful.

Much like athletic training, the chiropractic also suffers from credibility issues. They get paid much less by insurance companies for doing the same thing a P.T. does. The internet is loaded with information accusing them of medical quackery and insurance fraud. To be honest, I started out as a skeptic myself. Then I began to read some of their research in The Journal of Bodywork & movement Therapies. I quickly realized they were on to something and I had better get on board before I got left behind. Ken Cieslack, who works in Teaneck High School here in NJ, is an ATC & chiropractor. I am jealous.

The credibility issue is over, as far as I'm concerned. The efficacy of spinal manipulation has been documented in the research journals ad nauseum. Most of the complaints I've heard from A.T.'s have to do with chiro's being "too pushy", getting involved in gray area's like pre season physicals or nutrition. Stick to the manual therapy you guys. You were the first, as far as I know, to have a degree program in manual therapy & manipulation- and you are the best at it.

Lumbopelvic Manipulation for the Treatment of Patients With Patellofemoral Pain Syndrome: Development of a Clinical Prediction Rule/ JOSPT June '08

Isolated Knee Pain: A case report highlighting regional interdependence/JOSPT Oct. '08

Utility of the frontal plane projection angle in Females with Patellofemoral Pain/JOSPT Oct. '08

Diagnosis & Treatment of Movement Impairment Syndromes, Shirley Sahrmann '02/pp107-108

The physical therapy profession has embraced the Australian school, and manipulation articles are abundant. There is a plethora of research supporting manipulation as a treatment for PFSS. So, I thought I would throw my 2 cents in.

"Global Interdependence"= The kinetic link principle, just like "stretch-shortening cycle training"= plyometrics.

The concept is that the lumbopelvic orientation to the lower extremity is causing abnormal forces at the knee. By correcting it, normal alignment is restored and pain is spontaneously removed.

Me, being the pragmatist, would like to know what caused these dysfunctions in the first place. What came first, the chicken or the egg? Are the lumbopelvic structures simply reacting to abnormal forces coming from the feet, ankles, tibia, femur? I'm not the only one who thinks so. Here's an excerpt from Shirley Sahrmann:

"Extensive information is available from practitioners who ascribe to dysfunction of the SI joint as a common cause of back pain. However, I do not support this premise. Although many individuals have pain in the SI region, I propose that the pain does not arise from the motion of the joint. Rather, pain in the SI region is a result of the tissues that attach to this area (with the exception of pregnancy)."

It is common with athletes who have PFSS to exhibit excessive femoral IR at ground contact. In the 3rd article above, the authors found that as a coping strategy, some of the athletes were subconsciously posteriorly rotating their contralateral pelvis during functional tests to create more external rotation of the ipsilateral femur. Now picture that happening a few million times during running or jumping sports. Would not the pelvis adjust? Maybe an upslip of the R SP? An outflare of the L ilium? A sacral torsion?

As far as I've seen, the longest follow up has been 4 months pain free. What would be the treatment if they returned with pain? More manipulation?...would all that manipulation in the long term create hypermobility? (I've heard this anecdotally, but I've seen no research supporting it).

Anyway, I know some of my fellow ATC's are also chiropractors/manipulative P.T.'s. I would really enjoy your input.

Sandals & Existentialism

Your comments always get me thinking. A reader asked what I thought of the current trend of sandals as everyday footware on foot health.

Sandals are leisure wear, period. It drives me nuts when kids show up for rehab in them. What did they think was going to happen? I would be serving them cocktails on the veranda?

The deeper issue is the external locus of control. The healing is going to come from some pill, or some cream, or some machine, or somebody. A friend of mine used to have a poster hanging in his A.T. room that said, "if you want treatment, talk to an ATC, if you want to heal your injury, talk to God". The religious theme aside, the point is the power to heal is already inside all of us. The creator, or nature-whatever fits, designed our body in a way that requires movement to keep it healthy. The solution to healing lies in that fact.

Sandals belong on the boardwalk, pool or beach. How many of us have seen the idiots who get them stuck in escalators, or who trip over a crack in the sidewalk, or get them stuck in a revolving door etc? I'm not sure of the effect they have on the foot arch or everyday walking mechanics. However, it appears you need more of a shuffling action to walk with them. So, if you have an athlete returning from an ankle sprain, I could see it inhibiting dorsiflexion.

I wish it were that easy too.

Be sure to read Vern Gambetta's blog for today, Oct. 3 '08.

The same could be said about planning a good rehab or remedial exercise program.

Don't cook book your approach.

For instance, let's use my hamstring post as an example. Listen to what the body is showing you. The hamstring has 4 different muscles- which muscles were injured may be significant. Where is the lesion on the muscle? Closer to the hip? The knee? All this gives you clues where to begin your program.

Wall Slides

A Comparison of Serratus Anterior Muscle Activation During a Wall Slide Exercise and Other Traditional Exercises- JOSPT, December '06.

This article documented EMG studies showing serratus anterior activity in the traditional wall slide exercise was not that much different than the traditional push up plus exercise.

The top photo is similar to the exercise version the article spoke of.

The bottom one is my version.

The athlete is a freestyle swimmer of ours with R shoulder MDI. As I alluded to in an earlier post, the worst thing to do with these athletes is put an exercise band or dumbbell in their hand in the early stages of rehab. Think of the arm as a back hoe, with the scapula being the cab. If the cab of the back hoe is not stable, the whole machine becomes unstable, and loses stability.

But, wall slides are boring, and not very functional. In the bottom picture I'm using the opposite arm & hips to create a load/explode to the scapula in the directions I want. The mini band on the ankles enhances the hip load. Meanwhile, the R hand is gliding from the 1 o'clock to 8 o'clock position while it goes from neutral to pronation. I probably have about a hundred versions of this exercise depending on the dysfunction I see. Someday when I have time I should write it down and organize it. Right now I barely have time to take a dump.