Envelope of Load Acceptance

This is a term used by Scott Dye, MD used to describe the etiology behind patellofemoral pain/injury. It describes why the same load may lead to patellofemoral pain in one person and not in another, or even lead to pain in the same person at one time but not at another. A loss of patellar and peripatellar tissue homeostasis if you will.

This concept can be applied to any joint in the body, no? Every athlete begins a sports season with a personal envelope due to their anatomy, level of sport specific fitness, previous injury, and what Janda described as "pattern overload". In other words, too much of the same thing; whether it be running in straight lines, or playing video games.

With all the scientific stuff I talk about, the manual therapy, functional exercise et al, never forget program design. In my opinion, I've never met anyone better at it than Vern Gambetta. I think all A.T.'s should own his book, "Athletic Development: The art & science of functional Sports Conditioning". I really think this is the scaffolding that builds a great rehab program. Without it, all you are doing is throwing pancake batter at a wall and hoping it sticks. I'm trying to convince him to get a weekend course going that will focus on just this.

I believe there is too much cook booking going on with strength coaches, and with athletic trainers (by way of treatment protocols). Working with a team or teams is a lot tougher than working in a private clinic. We deal with multiple athletes all at once in the concept of a team or teams- all with different envelopes of function. If we are not expanding those envelopes, we may be heaving pancake batter.

FMR Certification

This past weekend I was in Chicago as part of the Functional Manual Reaction certification process. It is a mobilization with movement approach similar to Mulligan, but is consistent with chain reaction biomechanics. It was good to see and work with Pat Donovan, an ATC at U. Illinois @ Chicago. Like myself, he is a "traditional" ATC. I was constantly running back to him asking, "hey Pat, what do you think of this", or "hey Pat, do you think that would work with this?" I must have sounded like Louie the lizard from the old budwiser commercials. It becomes clear that the ATC has a window of opportunity to prevent future movement dysfunction that other professions are not privy to. While the two professions are similar, they are definately not redundent.

Tina

A few readers asked me how to get in touch with Christina Christie, P.T. Christina specializes in the functional approach to female issues resulting from child birth. You can contact her at:

http://www.pelvicsolutions.com/

Her Clinic is:

Accelerated rehabilitaiton Center

6759 Dempster Street

Morton Grove, Il.60053

Ph# 847-470-9995

Grade 2 R ACL sprain c/ 2 degree knee ext. deficit

Here is a functional alternative to your posterior tibia glides on the plynth. This athlete cannot walk without an antalgic gait. The athlete performs a LLE pivot lunge while partial weight bearing with the crutches. The R heel must remain on the ground at all times. Frequently check to make sure the R foot does not externally rotate. If it does, it means the athlete is stepping too far. You can easy get down on one knee and use your hands to slow the tibia down/speed up the femur as the L leg comes forward. It is also a great way to re-train gait. Another example of the athlete correcting his own dysfunction using proper appliction of ground, gravity, and momentum.

The Agony of Defeat

The Minutemen lost in overtime yesterday to defending state champs Clifton, 2-1. This athlete got elbowed in the opening minutes of the game. It was a 1mm laceration that required 17 sutures. It was fun trying to clean & dress it in a 29 degree, 15 mph wind. He did return to play.

Proximal Acceleration thoughts

JH picked up on the segweigh from "proximal acceleration" to "anyspacewhatever", and asked why I chose that particular foot/hand movement. The rotational step cause the L shoulder to go through something that looked like flexion, horizontal abduction, then maybe abduction (sagittal, transverse, frontal). "Troupling" if you will. What I was going after was the pelvis & shoulder moving out of sync. If you remember, I used a similar movement in the "reactive abs" post last August. I could also choose to have the pelvis/shoulder moving in sync, with the shoulder moving a little faster (kind of what goes on in the cocking phase of throwing, or swimming).

From the AP news wire:

http://apnews.excite.com/article/20081117/D94GTED80.html
As you read on, will see yet another nod for "regional interdependance" (the kinetic link principle). High school A.T.'s- this is something we can help prevent. Repeat the mantra here: there is no such thing as "just a sprained ankle". Resist the urge to slap some tape on them and send them back to the field.

I just had a former athlete visit me last night with chronic knee pain. I worked with him early last year for a wicked deltoid/spring ligament tear on the opposite ankle. I had to give myself a pat on the back when I saw how good that ankle looked. His history revealed an injury to the ipsilateral ankle this past August. His rehab consisted of ice, seated band exercises, and tape. Upon evaluation, his mid tarsal joint was all locked up. The ankle was not painful however. It simply borrowed transverse & frontal plane motion from the knee.

Protocols are helpful, but rehab it as you see it. Every ankle sprain is a little different.

Anyspacewhatever

This past Sunday my wife & I took a ride across the bridge to NYC to see an exhibition at the Guggenheim museum. The building itself is cool, designed by Frank Lloyd Wright. Besides the timeless paintings by Picasso, Degas, and Van Gough etc, the entire building was transformed into an exhibit:

http://www.guggenheim.org/exhibitions/exhibition_pages/anyspace/index.html

The exhibit was inspired by French philosopher Gilles Deleuze's concept of "anyspacewhatever- a cinematic moment linking one scene to another...which in isolation makes no sense...free from constraints...a free floating moment of pure possibility."

In other words, every wall, floor, ceiling, railing etc. was transformed. All flowed together. I couldn't help but comparing it to the wall-less training room concept and the kinetic link principle. After all, athletic training is both science & art, is it not? One of my favorite parts of the exhibit (if there were parts at all) was "cinema liberte". It involved a banned film from the 1930's. Why? "Circus freaks" were part of the cast. It re-enforced what I have always believed- that your plan must be adaptable to include everyone from the elite athlete, to the kid in the wheel chair with muscular dystrophy...at the same point in time. In a P.E. class a few years back, in the same class I had the high school football offensive player of the year & classified students at the same time.

Life imitates art, art imitates life, and oh yeah, the apple doesn't fall far from the tree...Vern Gambetta's son is an architect.

When you need some inspiration, check out Stacy Smith ATC's art:

http://stacy-art.com/

(p.s.- in the spirit of anyspacewhatever, the run on sentences in this post were deliberate).

Whoohoo!

Congratulations to EHS Boys Varsity Soccer- State Sectional Champs! Two more games to go!

http://www.nj.com/hssports/results/boyssoccer/index.ssf/2008/11/elizabeth_1_columbia_0_high_sc.html

Proximal Acceleration

In Vern's recent post on working with his volleyball players, he mentioned exercises designed to "emphasise shoulder lag & hip lead".

Good.

There's too much of this "keeping the humerus in the scapular plane" stuff going on. In certain shoulder conditions it may be helpful to start there, I understand. However, the shoulder capsule is not a passive structure. It is rich in proprioceptors- Pacinian Corpuscles, Golgi-Mazzoni Corpuscles, Ruffini Endings, Golgi Endings- to name a few. They communicate by way of fascia with the rest of the body.

Dave Tiberio of UConn coined the term "proximal acceleration" to describe the phenomenon that feeds these proprioceptors. That is, the proximal segment moving faster than the distal. This places a specific stress on the capsule that lets it know what it needs to tell the shoulder musculature. Which muscles to contract, when to contract, at what speed, in what sequence.

In my work with my dislocated shoulder athlete, I'm using this concept. And I can do it safely, provided I sequence it properly. The picture shows me with a 3lb. implement with wheels on it so it can roll on the wall. I begin with the implement in my left hand at shoulder height, feet shoulder width apart, L foot forward, R externally rotated. I am leaning onto my left foot. Then I take a R rotational step with my L foot to meet my R. My LUE is rolling straight up the wall. I quickly return to the starting position.

This exercise looks like it may be containdicated for this shoulder condition, but look closer. Although the shoulder is abducted, it is also internally rotated. In addition, stability is afforded to the shoulder in the sagittal & frontal planes by way of the wall. I can increase or decrease the athlete's threshold by controlling how far he moves the hand up the wall in relation to the quantity & amplitude of foot movement. Heck, I can even do my posterior GH glides as he's exercising. It's all in the sequencing.

I'm feeding the core, I feeding the capsule, I'm feeding the shoulder- I'm getting hip to shoulder.

Good functional listening

Tracy Fober's Ironmaven post for today was a good example of when a kinetic link does the unexpected and zigs instead of zags. A lateral lunge caused right knee pain. Sometimes hip or ankle stiffness or a genu varum or valgum gives unexpected results. It doesn't mean you give up doing lateral lunges. Tracy's solution was to put him in a stride stance and use pelvic drivers to get from point A to B. In other words, she set her athlete up for success. Simply put, she saw the frontal plane was gunked up, so she used the sagittal & transverse planes to get to the frontal. It would be interesting to see what would happen if the athlete went back to lateral lunges after Tracy's intervention. I'm sure that knee would feel a little better.

A-C Joint Unloading

A.T.'s love to tape, & I'm no exception. This athlete has a grade 1 acromioclavicular sprain. The technique often provides pain relief in the acute stages of the injury. In addition, an athlete with this injury finds it difficult to run because of the bouncing that goes along with it. With this technique, conditioning can usually be continued while the shoulder is healing. It also provides some resistance to horizontal adduction, the most painful arm movement with this injury.

It's easy:

1. Liberally spray the area with an adherent.

2. Apply 2" wide coverroll stretch tape (or similar) (9" is usually good) from the mid lateral delt to just higher than mid trap.

3. Apply a second piece (8" is usually good) bisecting the joint anterior to posterior.

4. Have the athlete bend the elbow of the affected side 90 degrees, and get an assistant to hold it so the arm is weightless.

5. Apply leukotape (or similar) caudal to cephalad, firmly pulling so that the skin wrinkles.

6. Apply a second piece to directly over the AC joint, depressing the distal clavicle.

The tape will usually stay on 2 days, as long as they don't spend too long in the shower. Instruct them to blot it with some paper towel or toilet paper after they get get out.

Veteran's Day 2008- Luigi

The horrors of war have always been close to home for me. In my home town of Rahway, N.J., nearly every street is named after a fallen WW2 vet. My dad was a D-Day vet himself. As an 8 year old boy I remember my neighbor across the street crying when his 18 year old friend was KIA in Vietnam.

This past spring, Elizabeth NJ had to rename another street. On September 20 2007, we lost one of our former football players-Luigi Marciante. He was KIA in Iraq. He left a wife and a newborn son. If it never happened to you, you will never understand how you can never let this go. Luigi was not some gung-ho wannabe bad ass. He wanted to be a cop like his dad, but figured some military experience as an MP would also serve his country. A true citizen soldier.

I am very proud of his sister Enza, a former student athletic trainer of mine. She has turned this in to something positive- raising funds for the thousands of Vets who will return from Iraq & Afganistan disabled. Whether you are for or against the war, we have to support these men & women all we can. I will do future posts on this topic at a later date.

Dislocated Shoulder comments

JH asks, "I would be curious to see how his dislocations have effected his scapular positioning and movement. Speaking of which, have you developed or seen a post op principle based shoulder program that starts at the scapula and thoracic spine instead of at the glenohumerous?"

JH, your questions are always more than meets the eye. He does have scapular mal-position (depressed), but it doesn't seem to transfer over to dyskinesis. The long thoracic nerve seems to have been spared in the injury.

I'm sure one can find protocols on the internet that meet those requirements. However, I feel you should treat it like you see it. With my swimmer with instability, I'm doing more "peltrunkula" work. But in this case it will not be my primary focus. I will aggressively go after his GH capsule, as it is biting down already. A tight capsule sounds like it might add stability to the joint, but nothing can be further from the truth. Usually (not always) a GH positional fault occurs, where the humeral head sits anterior in glenoid. This sets you up for your next dislocation or labrum tear. Will I use traditional mobes? Mulligans? FMR? ART? Not sure yet.

Simultaneously, I'll work on restoring his neuromuscular control. Stay tuned. This is a challange.

My work is cut out for me.

When Vern said we all would have to work harder, & transferring dreams into reality, he wasn't kidding. Here is my latest challange. This athlete had 2 traumatic left shoulder dislocations last month that required closed reductions. Take a look. Brachial plexus injury is obvious. He has active & passive IR/EX ROM deficits. Oh yeah- he is a wrestler.

No outside help here. Typical, the only P.T. who accepts his health inurance is too far away to be logistically practical for him or his parents. This is the trenches. But I wouldn't have it any other way.

Getting Political

No matter how you feel about the latest U.S. election, there is one thing you can't deny: The high school athletic trainer as part of the solution to the health care crisis. If my Sportsware injury tracking query is correct, last year I treated over 700 injuries myself. Not to mention the thousands of rehab sessions, or the injuries that I helped to prevent. I encourage every high school A.T. to do an end of the year report and present it to your school A.D., principal, and school board. The tax payers need to be aware of the quality, low cost health care we provide to our athletes every day. Whether you voted for McCain or Obama, you have to appreciate that.

Range Tweaks

If an exercise causes pain, it doesn't mean you need to abandon that exercise. In this month's JOSPT, researcher's measured patellofemoral joint forces in short vs. long lunges. In this case, more WAS better- if you have PFSS that is. The longer lunge reduced knee flexion, therefore reduced retro patellar stress. You could use the same stategy for your step ups & squats. However, it is only one strategy. If you understand the kinetic link concept, there are ways to INCREASE joint flexion while DECREASING retro patellar stress. Stay tuned...

Speed & the Brain

Here is some interesting research explaining why reaction time & speed declines as we age, especially after the magic age of 40.

http://apnews.excite.com/article/20081103/D947M52G0.html

County Champs!

Congratulations to Coaches Joe Cortico & Jack Gonzalez for a tough victory in chilly 38 degree weather last night. What a great bunch of kids- I really feel happy for them. We have 3 of the top 20 teams in the state in our conference- and you have to play each team twice, so it was no easy task. On to the state tournament!

http://www.nj.com/hssports/results/boyssoccer/index.ssf/2008/11/elizabeth_1_summit_0_high_scho.html