"The Goal Posts move as your playing the game"

"The race in science is not for a predetermined end, and once you're there the story's over, the curtain comes down. That's not at all what it's like. Rather, it turns out, you find things you didn't expect."- Simon Schaffer, physicist.

These are quotes from the Nova special "Absolute Zero".

It documents the story of three scientists attempting to achieve the lowest theoretical temperature, -273 degrees C. Scientists Michael Faraday, James Dewar, & Kamerlingh Onnes all in competition in the late 1800's. Dewar insisted his experiments be conducted in absolute secrecy. The other two freely exchanged information, even published their results in scientific journals. By isolating himself, Dewar had boxed himself into a corner in an attempt to eliminate his competition. Onnes had one the race.

I couldn't help but compare Schaffer's quote to this blog's "learning through sharing" theme. I've gone to workshops given by a few of our own gurus. I'm always amazed at how the faithful mechanically blurt out the mantras that are the jargon of their particular "system". Multi level marketing schemes that are reminiscent of Scientology. The thought process being once you've achieved all the certifications with this particular individual you have reached the pinnical of your art. Practitioners who believe that if what they're doing is not working it is because they are performing it incorrectly, & they need to go to a refresher course. They are boxed into a corner.

A true professional will tell you right off the bat that some of their athlete's injuries do not get better. But they will never stop trying.

Puerco Asado!

Tracy, I'm sorry- just don't look.

Christmas dinner, in the Cuban tradition. I have to admit, for a gringo I am pretty good at it. I begin with a prayer thanking God for the lechon, then quickly summon the ancient Cuban spirit Chango & ask him to oversee this gringo's sazon de puerco. I prepare my own mojo dressing, then carefully massage it into the pig with my own hands. Then it's into the caja china for 5 hours of roasting. Finally, my father in law Maximo & I proudly flash the #1 sign.

Somos un buen equipo.

The path of least resistance

Being on the spot when injuries happen expedites healing time and is cost effective. This is one of our football lineman who, in the transition to indoor shot put, developed achilles tendinitis. The etiology is a planus foot structure aggravated by some lower extremity force reduction issues.

ATC's love to tape, and I'm no exception. With some Coverroll & Leukotape, simply pull the calcaneus firmly in a varus direction with the tape beginning & ending with the lateral & medial malleoli respectively. Then, another strip directly across the achillis tendon pulling medial to lateral in the same fashion. The subtalar joint will have a medial bias when you are done, but this will self correct when the foot hits the floor.

This is not a wait and see procedure. It should bring immediate relief of symptoms. I will repeat it for about 2 weeks. This is without any modalities or remedial exercise or any further intervention. The trick is catching the injury in it's infancy, with a few pennies worth of tape.

THIS IS WRONG!

...but funny. Sorry, I had to throw the yellow flag & delete this comment from one of my "friends".

"Joe P. is a great athletic trainer, but when he stands behind one of those orange cones, you can't see him".

When will they give me peace.

Rotation Part 3

Thank you all for your comments, you guys are right on. Jeramiah brings up a good point, that is the importance of "stiffness" in the transmission of force from one link to another. Porterfield, McGill & Sahrmann always allude to the importance of this in the prevention/rehab of back pain. In this vein, Vern always mentions the importance of throwing med balls, but also catching them. It's important to remember that one segment is slowing down as another is speeding up, and that requires proper stiffness about a joint(s). Vern also makes the statement that no more than 15% of your core training should be on the floor, and I think that is accurate and is consistent with the Japanese research. I agree with the group, that even if the rotation is taking place air born like a volleyball strike or a dive, the momentum is still initiated off the ground.

Many of the injuries attributed to rotation (disk injury, pars fx, et al) have a multifactoral etiology beyond the scope of this blog. It doesn't change the formula for a healthy back: Push, pull, squat, rotate, reach in a sound progression.

Rotation Part 2

Excellent research from last year's American Society of Biomechanics meeting from a few Japanese researchers, "A MECHANICAL CAUSE OF BODY ROTATION ABOUT THE VERTICAL AXIS IN BASEBALL BATTING". The authors concluding, "Such a rotation of the entire body could only be generated by the external forces acting eccentric to the center of mass and by the free moments acting on the body. The results clearly indicate that the rotation of the body during baseball batting is generated primarily by the moment of the ground reaction forces acting on the legs around the center of mass".

This drives home what we high school A.T.'s have always known, that is the transverse plane (rotation) is primarily driven by momentum, whether it's swinging a bat or throwing a baseball.

Yet, at last year's combined sections meeting of the APTA, a statement was made that "what is causing the torso to rotate is the muscles, so we have to work on the obliques, the core itself, and hip stability".

Now go back & read Vern's "Rotation is bad?" post from December 13 and decide for yourself who is right.

Rotation, part 1

It's amazing how people could read the same books & come to different conclusions. A lot of this anti-rotation stuff is extrapolated from Shirley Sahrmann's & Porterfield/DeRosa's work. I have much respect for these researchers/practitioners. In fact, P&D were pioneers in the role of fascia in the kinetic link principal.

OK, the reasoning goes something like this: The average range of motion of any one lumbar functional spinal unit is around 10 degrees flexion and 5 degrees extension, 5 degrees lateral bending and around 3 degrees rotation. Total rotation is approx. 13 degrees more or less. True Dat, as the kids say.

The T-spine, having 12 segments as opposed to 5, theoretically has a lot more rotation, approx. 35 degrees total. Word up on that too.

So, based on these anatomical configurations, exercises that are designed to ask more than 13 degrees from the lumbar spine bad. Isolating rotation in the T-spine good. Get it?

Well, that's an over simplification. Pure motion in any one cardinal plane doesn't really exist in the spine. Motions are coupled, or even troupled depending on how you look at it. If motion is not available in one plane, the spine will borrow it from another. Osteopaths, chiropractors, and P.T.'s use this concept all the time when they do their manipulations. No damage is done. In fact, these rotary manipulations that gap the facets have been proven clinically efficacious in reducing pain & muscle spasm after an injury.

A good illustration is a test John Perry, PT did at GAIN '08. He did a ROM test on Vern's feet by using upper extremity drivers! When Vern did a right trunk rotation for instance, his left foot pronated & his right foot supinated. He didn't ask Vern to do that-chain reaction biomechanics did it subconsciously. Once ROM was used up in the shoulders, the body transferred it to the ribs, T-spine, lumbar spine, hips, knees, then finally foot & ankle.

If this phenomenon does not take place, go be a detective Columbo & find out why. A particular segment could be mechanically stuck or out of sequence. Or, remember muscles are highly adaptable. They can be trained to do just about anything. Like the "proper form" enthusiasts who micro manage movement and inhibit this chain reaction.

Now, lets get to the exercises they say are absolutely contraindicated-certified back wreckers. Scorpians, seated trunk rotations et al. The proponents claim, "significant decrease in the complaints of low back pain since eliminating these exercises".

Jeez, how often were they doing these exercises? Why were they a staple of their repertoire to the point that they were causing back ache? The only application I can see to the scorpion or lying trunk rotations is maybe a wrestler. I'm not a big fan of the contraindicated exercises either, but not for the reasons they give. I'm not done yet. Stay tuned for part 2. Your input please, pro or con.

Rotation is Bad?

Be sure to read Vern Gambetta's post for December 13. I will expand on this.

NJ High School Soccer Coach of the Year!

http://blog.nj.com/hssportshonors/2008/12/boys_soccer_coach_of_the_year.html

Congratulations to Elizabeth High Soccer Coach Joe Cortico. This was no easy task-3 of the top ten teams in the state are in our conference. Joe created a battle hardened team that physically & mentally wore even the best teams down. If you have never coached in an urban environment like this, it's difficult to understand the unique challenges that it presents.

One side note that I can't understand. In an obvious attempt to bore us to death, our impromptu "soccer band" was squelched by the grinch who stole soccer. I'm not sure who was responsible. What a show! High school students singing & playing Spanish tunes & dancing salsa in the stands waving the EHS banner. It definitely added to the experience.

Aquatic Therapy 2

Vern's post today, "the evidence gap" got me thinking. If it walks & quacks like a duck...

This athlete is doing a single leg water dumbbell high pull in chest deep water. He is a middle distance runner of ours I suspect has a stress fracture. I chose this exercise in an attempt to preserve power output without gravity beating up on the injury. He has no MRI, no x-ray, no bone scan to confirm my suspicions. 3X per week are aquatic workouts, 2 days on land with 1 competition day. He is improving. I've used this protocol probably a hundred times in my career, with athletes even winning county championships in the process.

The hardest part is getting the cooperation from coaches & parents. It requires patience & trust. It helps that I've been around here 27 years and many of these athlete's parents have been my students.

Muscle Energy Technique

M.E.T. is an osteopathic joint mobilization technique developed by Fred Mitchell & Phillip Greenman from Michigan U.S.A. It is a gentle, safe technique that uses a series of muscle contractions/relaxations to restore motion & reduce pain/spasticity. Most techniques are designed for the spine.

As the years go by, I find myself using it less & less. Not because it's ineffective. It's just that the more I understand function, the more I see the lumbar & cervical spines being hit takers for some other joint(s). I mainly use it for sprains directly to the spine from a sports injury. It's particularly soothing to cervical sprains from wrestling & football. MET fits in well with the functional approach. With manipulation, the practitioner is driving through a dysfunction. MET is a triplanar approach. That is, when resistance is felt in one plane, the A.T. backs off & goes to another plane.

I'm not sure if M.E.T. has any advantage over manipulation. I don't do manipulation- it's rare that I have roentenograms/bone scans to rule out a fx. One thing the A.T. must always be cautious of is being hell bent on increasing passive ROM. Measurable improvements do not always coincide with measurable pain improvements. I am always more concerned with the pain free ROM I have assisted the athlete with.

My suggestion to A.T.'s is to be a good detective & look for the trouble makers. Jimmy Cyriax told us decades ago that the cause of a dysfunction can be 1" or 1 yard away from the pain. We have the advantage of sitting and watching the athlete compete- other health care practitioners don't get that, and that is a HUGE advantage. Joint dysfunction magnifies itself under fatigue, making the compensations more visible.

"Hit takers & trouble makers"- a good topic for GAIN '09?

The sacrum is the lower extremity scapula

What do you think of this idea? It came to mind as I was working with my hip impingement/lumbar spine pain athlete. He has iliosacral/sacroiliac issues. I'm doing MET to correct them, but knowing damn well it is only temporary.

Ben Kibler MD came up with the "scapular funnel" concept of the upper extemity. That is, the scapula transmits forces coming through the lower extremity & torso to the ipsilateral arm. But, it's reactions are only as good as the information coming in. In the computer industry they call it "garbage in/garbage out".

I think the same might be said of the sacrum. As in the scapula, dysfunctions in the IS/SI joint doesn't always manifest itself in pain directly on the joint. I've seen in the literature stress fx's of the sacrum in distance runners, which might back up my hypothesis.

The big researchers on this joint are Kaltenborn, Vleeming, and Schneiders. It's interesting stuff.

10,000 hits!

Thanks to all my readers, especially Tracy, Pat, Juan, Jonathon, the two Kevins, and all of my international enthusiasts. I hope I'm keeping to the spirit of this blog- applying the scientific to the practical to address injuries the high school ATC sees every day. With a diversion now & then.

Don't be afraid to ask questions, or to disagree with me when you see fit. I'm approaching 50 & my cerebral cortex needs plenty of stimulation.

I found it amusing when a university clinical director depicted me on their web site as the Will Farell character in "old school". They have since removed it. I don't know if this person still follows my blog, but I hope they do. I thought the premise was pretty funny.

Anyway, thanks for stopping in my A.T. room- even it's just to take a peek at what the old man is up to. I am truly humbled.

All your problems behind you

All right, stop giggling. So you opened up my blog today and got a backside in your face. BUTT, this is serious stuff. OK, no more jokes, I promise. This is what Shirley Sahrmann describes as the "Muslim prayer position". We see the hips have translated to the left, and (is a little less obvious in the pic) rotated to the right.

The athlete suffers from chronic L lower lumbar back pain; and bilateral anterior hip impingement. We're looking at bilateral posterior iliofemoral joint capsule tightness. He got through football ok, but running indoors on a hard dusty floor is unbearable. Fortunately, his P.E. period is kind of slow so I'll have plenty of 1 on 1 manual therapy time.

In the past, these type of dysfunctions were seen in more sedentary peeps 40+. They have entered the high school A.T. realm. Why do you think? Are we getting better at diagnosis? Too much sports specialization? Are computers & video games creating too much sitting time?

My home state

Every day driving home from work I have to go over the Victory Bridge. It is a nice looking bridge as bridges go, dedicated to our WW2 vets. The problem is it has become a hot spot for suicide attempts. Occasionally I am stuck in traffic jams while police try to coax someone off the railing. In this down economy, putting up a barb wire fence to prevent jumping was deemed too expensive. Plus, I guess it would interfere with the aesthetics. As an alternative, signs were put up every 100 feet persuading potential leapers not to jump.

http://www.1010wins.com/Signs-Aim-to-Deter-Suicides-on-New-Jersey-Bridge/3426615

Nordic Hamstring Curl question

Rob asks:
"I am strength coach who uses this exercises, and dont fully understand why you are saying this is not a good exercise.
Also, what do you use/recommend to use instead of this exercise?
Are you also against Glute/Ham Raises, Physioball Leg Curls, and Slide Board Leg Curls."

******************************************************************************
- Thanks for the great question Rob. In upright function, the hamstrings work as the reins on a horse. With assistance from the soleus, they EXTEND the knee, not flex it; they work DYNAMICALLY at the hip, not isometically; they accelerate or decelerate rotation about the knee (depending on what phase of gait you are in). In the nordic leg curl, half the knee (tibia) is fixed to the ground.

No, I don't use the other exercises very much either. Maybe after an ART session. Remember, the hamstrings- like other muscles, are stimulated by ground, gravity, and momentum. You don't get that with those exercises.
Not to say YOU are wrong. As a matter of fact, Bosch & Klomp use the nordic leg curl in their running book. I don't get it though, I don't feel it fits in with their model of running physiology. One thing I was critical of in the book was the disconnect between theory & conditioning.

Nordic Hamstring Curls: Not a Fan

I can't believe P.T.'s/A.T.'s working with elite teams are still prescribing this exercise as a method of reducing hamstring strains & preventing ACL trauma. It's tunnel vision focusing on the sarcomeres of the four muscles themselves. What about improving neural drive? Isn't that part of strength & power output too? Who ever strained one with the leg posterior to the torso? There is no carry over what so ever of this exercise to upright function.

My opinion is the resurgance of this exercise has something to do with the resurgance of isokinetics in the literature. Trying to find an "on field" way to replicate it. I'm seeing a lot of "quad-to-hamstring strength ratio" and "bilateral discrepency" terminology that I heard back in the early 80's.

There's some talk of the pelvis' role in the injury process, but they feel the the hamstrings are influencing the pelvis, rather than the other way around, as I see it on the high school level.