Still Doing SLR's?

The Effects of Quadriceps Contraction on Different Patellofemoral Alignment Subtypes: An Axial Computed Tomography Study- JOSPT April '09

I know, sometimes the athlete is in so much pain & you have no choice. But if you think you're improving PF kinematics, think again. This study took a look at various types of patellofemoral alignment types & how quadricep contractions influenced them. The study comes to the conclusion that we functional A.T.'s knew all along...that it's the track, not the train.

There's a lot of cool stuff you can do with on ground function if you just can't get the athlete pain free weight bearing. I'll be giving some examples in future posts.

Great Book!

It's 18+ years old now, but I still find myself dragging it out for rehab ideas.

"Childrean & Sports Training" by Jozef Drabik, PHD, 1991.

Doc Drabik is a Polish P.E. professor who spent plenty of time in the trenches. From page 1 you can tell he knows what he's talking about. A lot of times now I find myself scratching my head & wonder if some of these academicians ever spent one day in a gym or classroom.

This is a cheap book that will give you tons of ideas.

half way to summer!

Two N.J. Legends

Took a professional day this Friday to attend the MF Track & Field Clinic in Atlantic City, N.J.

I drove down with my friend Gerry Nisivaccia. Gerry holds a high school record for being the only NJ wrestler to win 3 consecutive state championships. He missed winning a forth when he dislocated an elbow during a match. Stuck his arm between his two legs, snapped it back into place, then finished the match with one arm. His opponent was so grossed out he couldn't concentrate and lost the match. However, the tournament officials would't let Gerry continue in the tournament. Coach Nisivaccia went on to be one of the most winningest high school wrestling coaches in NJ history.

http://www.mycentraljersey.com/article/20090309/SPORTS14/903090404/-1/PIX02

The reason we drove down was to hear our friend Dave Costello speak. Dave is the boys/girls track coach at Viera high school, Fla. Retired, Dave moved down there about 5 years ago with every intention of playing golf & watching his son play baseball. When his son registered for school, his guidance counselor happened to be familiar with high school track. He asked, "Your dad wouldn't happen be the former track coach at Elizabeth high would he? And your uncle Frank coached at Maryland? Well, go home & tell your dad he is no longer retired". Dave is in his early 60's now, and I've never seen him more enthusiastic. He's already won two regional champioships.

I am proud to call these two guys my friends.

AAAAAHHHHH-TWEAK OUT! (LLE MCL), Bottom up, Top down

forward/back hurdle steps

R rotational L stagger squat

SLS to 45deg. c/ foot everted

Santa, will you please bring me a new HD digital video camera? Mine really sucks.

The Canine Training Partner

Who's the better training partner?:

http://well.blogs.nytimes.com/2009/12/14/the-best-walking-partner-man-vs-dog/?em

Agree 100%. When my alarm went off at 4am my dog would start pulling the covers off me. Could care less if it was raining or snowing. Never complained about aches or pains. Ran with me step for step without a leash, just happy to be out there.

The researchers in this study were amazed how canes & walkers disappeared. Dogs get us back in touch with our primal side.

The Lower Extremity Sling Shot

Effect of Medial Arch Support on Displacement of the Myotendinous Junction of the Gastrocnemius During Standing Wall Stretching, Jung, Koh et al; JOSPT 12-09.

John Madden was in the Oakland Raiders locker room back in the 70's giving his pregame speech, when the players started asking too many questions. He blurted out, "Don't worry about the horses, just load the wagon!"

That's a good analogy for function. Don't get tied down in what individual muscles are doing. DO make sure the athlete can load the wagon. If the athlete cannot sufficiently dorsiflex, one of the most powerful musculotendinous units in the body is not getting loaded. It can contribute to everything from tibial stress fractures to glenohumeral impingement.

This study found that in athletes with a pes planus foot, dorsiflexion improved an average of 6.4 degrees by supporting the longitudinal arch. A little adhesive felt in this population goes a long way.

DNS

Thanks to my GAIN buddy Steve Myrland for this link:

http://www.rehabps.com/REHABILITATION/PS_in_Quotes.html

If you have never heard of Vladimir Janda, well, you probably do and don't know it. He is a Chek neurologist who invented a system of therapy to ameliorate his symptoms of polio. His theories form the basis of NASM. "Upper Crossed Syndrome", "Lower Crossed Syndrome", and "Pronator Distortion Syndrome" are all his terminology. The idea that certain muscles are inhibited & weak & need to be strengthened, and others are hypertonic & tight and need to be stretched.

The Australian method is openly dissed here.

Does anyone know if this DNS stuff has ever been put through the scientific method in the journals?

We won't get fooled again!

Great tune by The Who.

Jack Blatherwick, strength coach of the famous '80 miracle on ice U.S. hockey team, reminds us to not just read the abstracts in these professional journals. Read the whole thing and dissect it. A good case in point:

"The effects of taping on scapular kinematics and muscle performance in baseball players with shoulder impingement syndrome" Yin-Hsin Hsu a, et al-
Journal of Electromyography and Kinesiology 12/09.

The reseacher came to the conclusion, "elastic taping (Kinesiotape) significantly increased the scapular posterior tilt at 30 and 60 during arm raising and increased the lower trapezius muscle activity in the 60–30 arm lowering phase (p <>

I believe it. An inhibited lower trap, and the tight pec minor that goes hand in hand contributes to external impingement syndrome. I'm all for anything that facilitates correction.

The problem is the sham taping they used- 3M micropore tape applied in the same manner, but without any stretch force.

What if they had used Leukotape with a pull instead? What if they had preceeded the test with my pec minor stretch?...with scapular FMR?...the tape & all of the above? What would that scapular tilt & EMG look like?

ACL Tears & the Brain

"Anterior Cruciate Ligament Deficiency Causes Brain Plasticity, Kapreli et al."
AJSM, 12-09

In the April 2005 "Journal of Orthopedic Research", the ACL in mice was found to have a direct connection with the spinal cord, brain stem, & cerebellum.

This research inspired some Greek researchers to investigate this phenomenon in humans. Some key brain MRI findings in ACL deficient athletes:

-visual information contributes more to the configuration of movement.
-these athletes unconsciously "plan" their movement.

Is it safe to assume this phenomenon goes on with other joint instabilities? Let the others argue about what squat is good or bad or whether to suck your belly button in or not. We'll stay on the functional path.

Lunch with Sal

http://www.healthandfitnessadvice.com/

Showed me some video of stuff he has going on in his gym, the Millburn-Short Hills Athletic Club. Like Tracy Fober, he also uses olympic lifting hybrids to enhance athleticism. He's got alot of female clients, and I like the way he goes buck wild on laying down that bone mass in this population.

He's also working on his own hybrid of an old Romanian core training gadget that is pretty cool.

It's Tricky

...an old Run DMC Song, and my theme for today's blog.
Both Tracy Fober and Vern Gambetta recently made references to this article in the NY Times a few days ago:

http://www.nytimes.com/2009/11/25/arts/dance/25palsy.html?_r=1&em=&pagewanted=all

It brings up an interesting point that Vern always drives home regarding function:

ITS MORE THAN JUST AN EXERCISE!

Of course I always give examples of remedial exercises to address specific issues, like my recent one on the pec minor stretch. However, it would be silly to believe that repeating any one stretch (even my own) would be a panacea. Rather than master the stretch its more important to understand the steps that came before it. Where were the hips in relation to the shoulder, what were my drivers? The article brought me back to my days when I worked with physically disabled students; where neuro pathways were destroyed & you needed to create new ones.

If the pec minor is ornery, there are also other issues going on. Inability to load the front side & some weak anti gravity muscles always go hand in hand. If you understand this, you can integrate this theme into the athlete's repertoire, rather than just coming up with a few ancillary exercises.

GAIN '10 Dates Released!

http://www.thegainnetwork.com/

Dive into the stuff we talk about on this blog. Don't worry, we'll all be in the deep end over our heads! Believe me when I tell you not a minute of the 6 days from the 18th to the 23rd of June is wasted. Our Australian mate Kelvin Giles makes sure of that- "if you're on time you're 5 minutes late!" No passive learning here; we're all learning, working out, eating, and just hanging out together.

Besides all the great presenters from last year, Frans Bosch will be joining us. If you haven't read his running biomechanics book you are really missing out.

In addition to the meeting, you join our community of learning & sharing. We've got a website where we continuously send documents & videos back & forth to re-enforce & apply what we've learned in Florida. We hope you can join the revolution.

Pec Minor Stretch, Joey Style.

This is my idea of a pec minor stretch. In front of the edge of a wall, in a right stride stance, do a RUE L45 reach @ thigh height. From there do a thumb down R120 reach @ shoulder height. As you do the reach, attempt to tap the R AC joint to the wall the best you can. Hold for 2 seconds @ return to the starting position for 3 sets of 10.

The right stride stance will block rib rotation so that the origin of the pec minor is being lengthened in all 3 planes. The AC joint tap on the wall requires the lower traps to glide the scap caudally. The pronated hand reach shortens the pec major, lengthening the insertion of the pec minor in all 3 planes.

Any thoughts?

Traditional Pec Minor Stretch

A hypertonic pec minor muscle was identified as a big trouble maker at this years Scapular Summit in Kentucky. This is the recommended stretch for the muscle, the "doorway" method.

Here's the problem the way I see it. We're assuming the scap is staying put while the ribcage rotates away. We're also assuming we're stretching the pec minor & not the major. We're assuming the athlete has no anterior GH laxity. My thought is if the pec minor is tight, what's to stop it from dragging the scap with it? In this scenario all you would be stretching are the muscles that insert on the proximal humerus (pec major, ant. deltoid, biceps etc), no?

The Elizabeth Lambert Saga

I usually don't comment on this stuff, but the hair pulling incident brought up some issues I am seeing in high school girl's sports. I do see officials making calls they would NEVER make in a boy's game. And it seems parents, coaches, and athletes are OK with that for the most part. But there is the occasional official who works both girls & boys games and doesn't differentiate between the two genders.

We had girl's rugby game this past spring where a lot of player's from the other team were getting hurt. Some of our girl's tackles looked like NFL highlight films. They're really I nice bunch of kids- they just like to hit and they're good at it. The best is this little Puerto Rican girl, all 5'2" of her! The coach came out onto the field and admonished the ref for "letting the game get out of control" and threatened to pull his team off the field. To keep the game going our coach actually had to tell our players to bring them down a little easier, and took our 5'2" assassin off the field. It was a playoff game to boot.

Kibler's '09 Scapular Summit

Dr. Ben Kibler is an orthopedist from Lexington Kentucky USA. Would love to meet him someday. There are not many orthopedists who understand function more than him. This is his third international summit on the scapulothoracic joint.

In the coming weeks I'll be commenting on some of the highlights. Several of the presentations focused on the neuromuscular issue of the upper trap overpowering the mid/lower & the scapular dyskinesis that goes with it. I was a little disappointed all the solutions appeared to be isolated ones. Most of the exercises look like manual muscle testing positions.

I'm not sure what percentage of my functional approach has been scientifically driven, and how much comes from the population I work with. Remember I work with the adolescent population who by nature just cannot sit still; with a wide variety of learning disabilities mixed in. Getting them to lie down, put their elbow here, shoulder over there etc is just not going to happen.

At GAIN '10 I presented some of my ideas of how I approach the trap issue. It sure looked a lot different than what was presented at the scap summit. It's kind of paradoxical how my almost 30 years of experience in one job has enriched me in so many ways, yet boxed me in so many others.

Be careful with this stuff

I know quad atrophy following acl tears is frustrating, but don't rob Peter to pay Paul:

Patellofemoral joint force and stress during the wall squat and one-leg squat.
Escamilla RF, Fleisig GS, Wilk KE, Andrews et al, Med Sci Sport.EX 4/09

Doesn't make a difference how close you position the feet to the wall, they beat up the osteochondral surface of the patella.

Rachel's question

"I am an HS in So. IL and just getting into the S&C scene and just wanted to make sure I am understanding you correctly w/ how I approach this:Most HS athletes don't even know what core is and have done nothing to address it - so I look at doing the neutral positions first then adding movement when they are able to perform w/o help and w/ little-no difficulty."

First of all, welcome to the blog Rachel- Glad you found us!
2nd- Your athletes don't even know what the core is? GREAT!!! You are one step ahead of the game because they haven't been corrupted yet!

When you get a chance, be sure to visit my archives. YOU will be corrupted (in a good way) to my version of "the reactive core". A core that can brace the body to take a punch or handle a collision with another athlete; as well as blasting a soccer ball into a net. Like any other muscles of the body, the core is loaded by ground, gravity, and momentum. The core muscles are loaded with proprioceptors; and fascia which links it with the rest of the body. It loves when the hips are moving one way & the shoulders another; or in the same direction but different speeds.

There are some exercises which I consider core-ready, give your athletes a good dose of this stuff Rachel:

-3D jumping jacks
-3D skipping
-3D mountain climbers
-3D "burpees"
-3D pushups

Got to go. A weekend off, the first since July!

Neuromuscular vs. Muscular

This month's Journal of Strength & Conditoning research:

Relationship Between Hip and Knee Kinematics in Athletic Women During Cutting Maneuvers: A Possible Link to Noncontact Anterior Cruciate Ligament Injury and Prevention
Imwalle, Lauren E; Myer, Gregory D; Ford, Kevin R; Hewett, Timothy E

Journal of Strength and Conditioning Research:
November 2009 - Volume 23 - Issue 8 - pp 2223-2230

placed biomechanical markers liberally on the upper & lower extremities & had them do 45 & 90 degree cutting maneuvers. At least in this study, frontal plane adduction moments at the hip were the biggest predictors of how much the knees abducted. They site Brent's research from a study published 3 years ago in "medicine & science in sport & exercise" that showed steady increases in hip abduction strength in adolescent boys; with no such similarity in girls. The authors recommend strategies that increase hip abduction control, & include protocols that include plyometrics, dynamic stabilization, & trunk neuromuscular training.


Much like in Hodge's work on spine stability, we have to be careful on the application side of this. Resist the temptation to run to those 4 way hip machines. Neuromuscular is a lot different & complicated than muscular. Neuromuscular adaptation takes longer. Neuromuscular integrates myofascial slings throughout the body that contribute to hip & knee stability. Neuromuscular understands the foot is on the ground dealing with artificial turf, or wet grass, or improper footwear; that the eyes are driving movement from above with the head & shoulders reacting.

Dave Tiberio, P.T. uses the term "resonent frequency" to describe tendon & ligaments (that includes the ACL) ability to react to changes in load intensity & velocity. Re-setting that resonent frequency is the key. We forget the ACL is living tissue & loaded with proprioceptors! It will tell the rest of the body what to do, provided the body has been trained to work in what G2 calls, "the transformational zone".

Neuromuscular takes planned performance training-muscular does not.

More Squatology

Thought I would give an A.T. perspective on Vern's post for today:

http://www.functionalpathtrainingblog.com/2009/11/more-than-an-exercise.html

Vern states he would not use the Bulgarian squat for football, soccer, or hockey. He is correct, groin strains & athletic hernia are prevelent in these sports, and alludes to this squat contributing to it.

While it might be appropriate as a lead up to a SLS (single leg squat), it's important to move on. The problem begins when you load the movement. The trail leg is used to stabilize, creating isometric contractions about the hips & pelvis that are not conducive to rythmic, flowing movement. Of course you can argue that isometric contraction happens naturally in a traditional SLS, and you would be correct. But, in the Bulgarian Squat, that stabilization is initiated top down since it is traveling through the pelvis first- "neural confusion" if you will.

IASTM

Acronym for Instrument Assisted Soft Tissue Mobilization. Here I am doing Graston Technique (only one type of IASTM) with the #3 tool ("tongue depressor") on this athlete's patellar tendon. Sort of like an instrument assisted deep transverse friction massage. Only it's a lot easier on the hands & treatment times are a lot shorter; about 2 minutes max. It is immediately followed by active ROM, then functional exercise. Dr. Warren Hammer introduced Graston at this year's Fascial Congress last month in Belgium. There are several types, including SASTM & ASTYM. They definitely have a place in the A.T.'s toolbox.

Graston is an NATA sponsor. However, we don't get a price break on learning the technique or purchasing the tools. Again, this keeps a valuable modality out of the hands of a typical high school ATC. I have seen collegiate programs send out entire A.T. staffs to be certified in Graston or ART at premium $$$. ALL of my continuing ed (almost 30 years worth now) has come out of my own pocket. Not fair NATA- help us.

Mi Muchacha Y Yo!

Intellectual Isolation

Trying to push my way through the last few weeks of the fall season. 6, occasionally 7 day-70hr weeks for the last 3 months have taken their toll. Not getting enough sleep or exercise, eating crappy food. But I'm certain I'm in good company! This months "Strength & Conditioning" mag had a good Q&A with a high school ATC from Pa., USA.

I am jealous of the fact he is able to get away & work with the Pittsburgh Steelers (american football), and travel to the U.K. to work with Welsh Rugby. I doubt I would be able to swing that here at EHS. This past weekend was typical for me, flying out on a Sunday morning to recert a soft tissue technique, flying back that same night to be back at EHS monday morning.

It made me cognisant of the intellectual isolation we high school A.T.'s experience. School funding for our continuing ed is slim or none, plus we deal with more teams than a typical collegiate A.T. does. The annual GAIN meeting means a lot to me. It takes place just as school gets out in June and gives me a chance to recharge my batteries. SHARING (actively) with professionals from all over the globe. Much smarter, & just as passionate as I am about the profession. Guys just as nuts as I am- Jim Radcliffe from Oregon flying in on the AM to give a workshop, then flying back that afternoon to work with his volleyball team.

I hope you guys enjoy my posts as much as I enjoy your comments. Although I don't always respond, I read every one of them. I hope it helps bridge the intellectual isolation gap.

Boyle on Squats

I’ve received a lot of questions on Mike Boyle’s recent statements condemning “traditional squats”, and promoting the single leg squat.

There are hundreds of ways to squat, both good or bad depending on the context in which they are used. If you are working with a football lineman , there are situations where a traditional squat could be a good thing. On the other hand, single leg squats may be contraindicated for an athlete with a patellar osteochondral defect. Once you consider foot placement & angle, what the opposite leg is doing, what the arms are doing, the implements you are using to load (or unload), the combinations are endless. If you’re looking for a great, inexpensive video on the subject, consider Vern Gambetta’s, “Legs, Legs, Legs”. It will not only demonstrate 3D squats, but as with all Vern’s stuff will provide you with great ideas to build on.

Enough already!

Look, I don't want to beat this core stabilizaton thing to death, but Hodges work in 90's was misinterpreted! Thats not me saying it- it's Doctor Hodges himself!!:

The lumbar multifidus: Does the evidence support clinical beliefs? Manual Therapy, Volume 11, Issue 4, Pages 254-263D. MacDonald, G. Lorimer Moseley, P. Hodges 2007

“Although there is support for the importance of the lumbar multifidus and the specific contribution of this muscle to intervertebral control, several of the clinical beliefs have little or no support “.

Feedforward Responses of Transversus Abdominis Are Directionally Specific
and Act Asymmetrically: Implications for Core Stability Theories, JOSPT 5/08

"bilateral activation of the TrA in isolation does not reflect the normal
motor pattern for rapid unilateral ballistic patterns of movement and, therefore, future research may examine if such training may detrain individuals who require such fast actions (eg, elite athletes).”

There is an article in the NSCA's "journal of strength & conditioning" this month that makes the statement, "development of the core is accomplished first through ISOMETRIC STABILITY with progression to multi joint movements involving the hip, torso, and scapular region". Readers of my blog know I believe in the concept of a "reactive core". One that emphasises training in the "zones of transformation"; that is when the body is switching directions and injuries occur. There is nothing wrong with doing isometric bracing movements (planks et al). As long as it is understood they occur in a neutral zone. A truly strong core is one that can take a direct blow, protect us from falls, as well as coordiate the upper & lower extremities in a fluid, coordinated manner.

The article makes references to Hodges original work in the 90's. I think that's where this "rigid pillar" isometric-style core gets it's origin. I know Doctor Eyal Lederman of London's Center for Professional Development in Osteopathy (www.cpdo.net/myth_of_core_stability.doc) occasionally tunes into this blog. If you're out there doctor, I'd really appreciate your opinion on this.

Doctor Coughlan's comment

Hey Garrett-never connected the dots that it was you! But I know great research when I see it. Thanks for attacking a complex issue the way only a Celt can. You say:

"we need to focus not only on the ankle but also huge emphasis on the proximal musculature/joints and the coordination of movement between the shank and rearfoot."

Which was what I was getting at with rotational squat/glute inhibition question. That squat would unlock the foot & load the soft tissue. If it was compromised by trauma, then I think it's safe to conclude we're not getting the proprioceptive input up the chain. The answer lies somewhere in a combination of both- restoring soft tissue integrity/mobility at the ankle, and addressing the proximal issues.

I think what you're alluding to suggests a shift to the more functional styles of joint mobes that integrate U-LE, ie Mulligan & FMR. Then the next step; what do we do about the soft tissue integrity? I've just begun using Graston. I know Stacy Walker, A.T. professor at Ball State is a reader of my blog. They do a lot of Graston research. If you're out there Stacy I would really appreciate your comments.

A little comic relief

I thought Sal Marinello (http://www.healthandfitnessadvice.com/)
was playing a practical joke when he sent me this until my step son said he had seen the infomercial on TV the night before. Use your imagination on this one.

https://www.shakeweight.com/ver5/index.asp

Training around the injury

Much thanks to Dr. Phillip Gribble, PHD-ATC from U. Toledo for sharing some of his unpublished manuscript that was presented at the International ankle symposium in Australia this past summer.

"A COMPARISON OF 2 REHABILITATION PROTOCOLS ON STAR EXCURSION BALANCE TEST PERFORMANCE IN SUBJECTS WITH CHRONIC ANKLE INSTABILITY"

He compared a "traditional" ankle rehab program (that focused in on the ankle) with one that focused on the hip & knee. The hip/knee program contained half functional (SLS variations) & half open chain supine (SLR's et al). His conclusion was:

"Proximal joint rehabilitation may be as effective, or more effective
than traditional ankle rehabilitation, for improving dynamic postural
control in subjects with CAI."

Along the same lines, some researchers from Ireland (Coughlan et al) in their study came to the conclusion,

"that a 4-week dynamic lower limb training program resulted in no significant changes in the ankle position or velocity during treadmill walking, jogging, and running. This study raises issues regarding the methods of ankle sprain rehabilitation and the measurement of their effectiveness in improving functional activities. "

Kind of sounds like when I say "rehab the athlete, not the injury", no?

Now I need you opinion. In other research, Dr. Gribble found that CAI subjects had less glute max activity in a same side rotational SLS at the point of maximal excursion than the control group. Any ideas why?

Respect articular cartilage

From this quarter's "Sports Health"-

"The Basic Science of Articular Cartilage: Structure, Composition, and Function"- Fox, Bedi, Rodeo; p. 461.

"Articular cartilage is devoid of blood vessels, lymphatics, and nerves & is subject to a harsh biomechanical environment. Most important, it has a limited capacity for intrinsic healing & repair...injury to articular cartilage is recognized as a cause of significant musculoskeletal morbidity...it's unique & complex structure makes treatment, repair, or restoration challenging for all."

Always keep articular cartilage on your mind when rehabing weight bearing joints. It's my opininion that this stuff lags behind other connective tissue in the healing process. I know I always preach getting the athlete weight bearing as safely possible, and I stick to that. However, a good eval will clue you in on what joint surfaces may have gotten beat up and need to be protected. Prudent use of chain reaction biomechanics by way of a slant board, U/LE drivers can help you stear away from grinding that articular cartilage early on. Spin bikes & aquatic therapy come in handy.

Crawl Sequences

Whenever you go to on ground function, be sure there's something you can't get upright. This is Steve Myrland demonstrating his "frog". It is one in a series of crawls, each with an animal name, and each creating a movement puzzle for the body to solve. They really integrate & challange core/glenohumeral stability.

You may contact Steve @ Myrland Sports Training, (608) 836-4701.

The best pal a guy ever had

One of the worst days of my life; put my buddy down yesterday. 14+ years old, out living his breed by about a year and a half. A testament to his healthy lifestyle. This picture was taken a few years back on one of our typical winter Sunday mornings. A nice 3 mile run around Sandy Hook NJ, followed by a little stick fetching in the icy north Atlantic.

But it was much more than that. I first met him while running in the park when he was just a puppy. A beautiful woman was taking him for a stroll, and I used the excuse of petting him to say hello to her. She's now my wife.

Adios perro, ti amo.

Dissociation?

Journal of Bodywork & Movement Therapies, Oct. 09:

"The neutral spine principle, M. Wallden DO".
"The migratory fascia hypothesis, P. Lelean."

From page 351, "being able to dissociate the spine from the hips is a foundational movement skill".

?

First of all, Dr. Wallden did a great job of articulating his view on the topic. However, I'm still not buying into this. Yes, the neutral spine is something to be desired, but is it something that needs to be taught? Or, is the neutral spine a chain reaction of everything that went before it? On page 358 he gives a chart of pathological findings, and corrective exercises to ameliorate them. The problem is every one of the exercises focuses in on the spine itself.

At GAIN '09 I spent about 3 hours going over 2 case studies of athletes I worked with personally with low back back pain. In both cases, there were upper & lower extremity reasons why the athletes could not maintain a neutral spine. Not one isolated "spine" exercise was performed.

I think the second article I referenced kind of backs me up. The author discovered abnormal fascial folds throughout the pelvis & hips in patients , which produced facial strain patterns , which could contribute to iliolumbar strain patterns. The concept of rather than a weak spine, a spine that is biomechanically fed erroneous neural input.

I'm not sure if there is one size fits all here. I'll continue to rehab it as I see it.

Your opinion please

Occasionally I get snail mail, email looking for A.T.'s for clinical work. Not that I'm looking to leave my job, but I notice they all say, "clinical experience necessary". What are we traditional A.T.'s, chopped liver!? Don't we attack difficult issues week after week on this blog? We work with a challenging population, large volumes of patients, with limited resources, under difficult circumstances. Who wouldn't want a traditional A.T. on their staff?

JH and others who work in the clinic please give us your input of the mind set. If any readers have made the switch over, or switched over & come back to traditional, I would really enjoy your input.

On Ground Function: Hip to Shoulder

This is an exercise I'm using for an athlete rehabbing a L GH joint dislocation.

Pretty simple, it's I guess what you would call a modified scorpion.

Lying prone, shoulders & elbows @ 90-90.

The athlete reaches posterior left with their RLE & returns. This creates a chain reaction through the shoulder that challenges GH stability safely in what we used to call "closed chain". You may increase/decrease difficulty by raising/lowering the arm/elbow angle. You may also choose to do some self mobilization to the GH joint by placing a rolled up face towel beneath the proximal humerus. This provides a gentle posterior glide to the humerus in the glenoid as the leg comes around.

Ankle Sprains & Footware

Some great stuff out of the '09 International Ankle Symposium from this past summer:

"CLAIM AND COUNTERCLAIM: FOOTWEAR AND FOOT AND ANKLE MECHANICS DURING PHYSICAL ACTIVITY"
RICHARD SMITH, Discipline of Exercise and Sport Science, University of Sydney, Sydney, Australia.

Compared lower leg & foot mechanics during barefoot running to running with so called "neutral" & "dual-density" shoes. Their conclusion was, "The change is not always that which was intended by the shoe maker. The ground/shoe/rearfoot interface with the shank can be the
promoter or recipient of the motion drivers." Across the board there was more ankle motion/less mid-tarsal joint motion with the shoes. In the "stability" shoes, they noted tibial external rotation began much earlier than in barefoot-even while the knee was still flexing at ground contact. What do you think? Can this make one more susceptible to ankle sprains?

More on Concussions

High School ATC's who work with collision sports stay vigilant. Remember we get paid to watch the athletes, not the game. Athletes (some coaches too) think it's macho to ignore head injuries & will hide it from you. Here is an interview from the NY Times with an ex-Gators linebacker. He's only a year older than me yet has paid all his life from injuries 30+ years ago. He talks about how much has changed from those days, but has it really?

http://www.nytimes.com/2009/10/09/sports/ncaafootball/09concussions.html

Pete/Sarah Comments

Pete and Sarah had some great comments asking why I choose to not reduce GH dislocations on the football (American) field, which I thought deserved a post.

1. It's difficult to overcome heavily developed biceps/pecs/subscapularis without a forceful technique.
2. Even if you un-hook the shoulder pads, you still have the tight jersey to contend with.
3. Considering #2, it's very difficult to get enough ROM to do a Milch.
4. Along with Sarah's comment about the "audience", I've seen practitioners (including orthopedists), fail to reduce, get frustrated & embarrased, and use more & more forceful techniques.
5. The extra 1 minute walk or so to your A.T. table behind the bench is worth it compared to an ambulance ride & ER wait (remember I'm a hs ATC, no team orthopedist!)
6. Finally, in the spirit of this blog, it's only my opinion on what works best for me.

More on NDT's

My blog compadre Juan Luis Tagle (www.backtofunction.blogspot.com) is a big fan of neurodynamic, aka "nerve flossing" techniques. The evidence is building to back him up.

"A Randomized Sham Controlled Trial of a Neurodynamic Technique in the Treatment of Carpal Tunnel Syndrome", Bialosky et al JOSPT 20-09.

NDT reduced temporal summation in this population. I believe these techniques have a place in the recovery/restoration phase of conditioning. It should be noted that the sham NDT also provided a therapeutic effect. This drives the point home that as A.T.'s we shouldn't be afraid to use our hands. Have the technique manual nearby so the athlete understands what you're doing.

I've used NDT in American football brachial plexus (aka "stinger") injuries, hamstring strains, shoulder dislocations, and other injuries that create neural stretching. Any comments Juan?

New Blog

You will enjoy Will Stewart's soft tissue twist on function. Great functional anatomy tutorials-
www.3doptimalperformance.blogspot.com

CRB's, left scapula

Clarification

Ron expressed concerns about A.T.'s reducing shoulders. It all depends on your school M.D.'s standing treatment orders & your state's A.T. practice act & the need to weigh long term damage (axonotmesis etc) caused by delay in treatment. I'm not instructing here, just giving some advice based on my experience (as in all of my posts). I've heard the screams of athletes needlessly suffering from a practitioner trying to reduce a shoulder with levering/traction/thrust techniques on the field, and in the E.R. The Milch technique is the safest, gentleist of all shoulder reduction techniques. No external force by the practitioner is required. If anyone else out there is familiar with it, your comments please.

football glenohumeral anterior dislocation tips

1. NEVER attempt to reduce the shoulder on the field.

2. NEVER attempt to reduce the shoulder with shoulder pads on.

3. A hospital gurney or other mushy surface makes reduction more difficult. A typical A.T. table is perfect.

4. Avoid reducing the shoulder in the seated position, fainting is possible & would complicate the matter.

5. Use the Mich technique. It is gentle, painless & effective. No thrusting or torquing is involved.

Plinth? We don't need no stinking plinth!

Back in the early 80's there was a song by George Thorogood called, 1 bourbon, 1 scotch, 1 beer. I'm not really a drinker so my woos version is 1 squat, 1 step up, 1 lunge.

This athlete is day 3 of a grade 2+ left knee MCL tear. Walking non-weight bearing with crutches, yet full weight bearing in rehab with proper use of chain reaction biomechanics. I am convinced if you want range of motion back/edema reduction as quickly/safely as possible, this is the way to go.

Give me a triple shot of that juice.

Where/how does the exercise fit?

Good to have JH back into the discussion. Asked in what context the core exercise I described was being used.
It is part of the rehab circuit for an athlete with a complete ACL tear. In this athlete's sport the ground is a dangerous place to be and needs to get up and back onto his feet quickly after a fall.

Coach Martin

Talk about sustained excellence- Coach Jack Martin from Westfield High School NJ has been producing championship runners for 4 decades now. He doesn't need my help, but he asked for something to help him with his conditioning video, so here it is:

"Running: Biomechanics & Exercise Physiology Applied in Practice"

a book that came out in '05 by Frans Bosch & Ronald Klomp. They nail running biomechanics. Oh, by the way- we're keeping our fingers crossed but we may get Frans Bosch at GAIN '10!

Be sure to give us a shout out coach when you release the video.

Inspiring

http://www.pbs.org/wgbh/nova/allfours/

A rare gene mutation caused a family in Turkey to walk like our ancestors. A physical therapist got tired of all the scientists coming over to study them & applied some kitchen chemistry. Function can change structure and give DNA a run for it's money.

Good Core Exercise

The athlete's arms & legs cannot touch the ground.
They do a jack knife, then follow it with a barrel roll to another jack knife & repeat. I'm allowing this athlete to cheat a bit, the elbows should be straight & the feet together.

FMR Left Shoulder

Sorry I haven't been posting. The hours & work load have been brutal, plus the school system blocking all blogs.

Out on the field there is a soccer game going on; I have a rehab circuit going on with 7 kids in the corner by the high jump, and I'm doing some manual therapy against the nearby fieldhouse. The athlete has an anteriorly subluxing shoulder. The itiology is scapular dyskinesis, primarly due to some muscle imbalances between the rhomboids & serratus anterior. You will see this quite a bit with athletes that do a lot of bench press. Yes I'm doing quite a bit of neuromuscular work. However, a positional fault of the humeral head in the glenoid fossa has been created. It requires direct & indirect work on the capsule itself.

The athlete is doing what I call a "windshield wiper" wallslide. He begins facing the wall, then takes a cross step with his left foot. The hips & shoulder are moving out of sync. The technique is FMR-to be specific I'm doing an posterior/inferior glide to this athlete's L GH joint. If you are familiar with a Mulligan N.A.G., it is very similar. The motion of the body enhances it.

Positional Faults

When you're evaluating an ankle sprain, always look for positional faults of the distal fibula (as described by Brian Mulligan) on the talus.

The athlete will typically present a pinching sensation in the vacinity of the anterior talofibular ligament with weight bearing dorsiflexion. A few mobes combined with the recommended taping procedure usually brings a pretty significant relief. It's not a wait & see thing-either it works or it doesn't.

The theory is when the ankle inverts it gets locked against the ground; but gravity continues to drive the fibula down & forward onto the talus. It's not hocus pocus- it has been documented in the literature. I just don't think it's as common as they say it is; but when it works it works. The problem is coming up with a exercise protocol to keep the correction. Haven't found one yet.

Gym Scooters for Rehab

They kick butt! You can use them partial weight bearing open-bottom up- kinetic chain (involved extremity on scooter), or closed-top down- kinetic chain (involved extremity on the ground). Of course you can do the same thing with towel slides, but the scooter adds a little instability to create a proprioceptive effect. I like the ones that have holes in the middle so I can attach elastic bands for more resistance. Give it a try!

Problem

As I have said before, I am a real high school ATC with a hectic schedule just like everyone else. I usually do my posts while the kids are changing classes & I have a few minutes to spare. Unfortunately, the school has blocked all blog sites, mine included. Also any web site that has the word "sports" in it, including "American journal of sports medicine" & "medicine and science in sport and exercise". It makes it very difficult to get any work done. When I stroll into my house at 10pm and my dog misses me and I have family matters to attend to the last thing on my mind is blogging. I'm working with our tech dept. to see if we can get this problem solved.

Exercise or Angioplasty for Cardiac Artery Occlusion?

"World in motion - speed your changes,
Close your distances,
drive your angels,
Lose your fears and meet your dangers"

-Jackson Browne

The European Society of Cardiology says, "Get the world on it's feet!"
(p.s.- that means we ATC's too. Get your athletes off the plynth):

http://www.escardio.org/about/press/press-releases/esc09-barcelona/Pages/esc-2009-Hambrecht-role-exercise-training.aspx

Mouthguards

"Protective Athletic Mouthguards: Do they Cause Harm?- Glass, Conrad et al ; Sports Health, 09-10; 09.

Soft tissue lesions about the mouth increased more than threefold during a D1 (American)football season. The authors concluded over the counter mouth guards "may have a significant influence in producing oral disease". When cultured, the mouth pieces themselves "yielded 339 bacterial isolates, 20 yeast isolates, & 108 fungal/mold isolates".

The authors recommend replacing a mouth piece every 14 days, and daily cleaning with a denture cleansing solution.

I'm not going to get mad at the kids for losing them any more.

Partial Weight Bearing Squat+

I took a pair of adult medium crutches & drilled two extra sets of holes to make the handles 1.5 & 3" higher. The athlete places as much pressure on the hands as is needed and works as much range of motion as is comfortable & appropriate. They may also be done in a stride stance.

R Medial Meniscus Tear Pre-Hab, Day 5

Circuit:

10 pushups

10 side bridges, 5 each side

20 R leg kneel BUE 7lb. medball rotations @ shoulder height.

10 yard forward/back bear crawl

20 Mountain Sliders

20X Partial weight bearing L leg pivot lunge on 6" box (R foot in slight varus)

20X Partial weight bearing L leg lateral pivot lunge on 6" box

20X Partial weight bearing squat+

stationary bike

Repeat 3X.

Busy

Sorry I'm behind in my posting. Things will be crazy here at EHS for the next few weeks. 12-15 hour days, 6 days per week for about the next 3 weeks. I don't pretend to like this time of the year, I swear I can feel my brain rotting from the long hours combined with the assembly line nature of it all. Got to dig in & get by these next few weeks. I'll need you guys to get me back in the groove.

Down to the wire

This is the last week before football camp officially begins. I have been scrambling to clear out some nagging injuries from the month I had been away from EHS. Some PFSS, a possible athletic hernia, a few groin & ham strains, and an ankle sprain.

I am beginning my 3rd week of working on the sprain. Not that bad of a sprain, I would say a mild grade 2. But it had been neglected a full month before I got my hands on it. The athlete still has about a 3cm functional dorsiflexion deficit. I will keep you posted.

Ankle Sprains & the Core

Impaired Trunk and Ankle Stability in Subjects with Functional Ankle Instability
PAUL W. M. MARSHALL1, AMANDA D. MCKEE1, and BERNADETTE A. MURPHY2- Medicine & Science in Sport/Exercise; August 09.

My blog readers know ankle injuries are "my bag" as Austin Powers said.

The authors found TTS (time to stabilization) delays in the trunk musculature of athletes with FAI (functional ankle instability). They are cautious of prescribing traditional "core training" to ameliorate this. In other words, they are unsure as to who is zooming who- is the trunk assisting proprioception deficits in the lower extremity, or is the ankle sending erroneous neural drive to the trunk? Either way, you see what a pain in the ass a sprained ankle is? They provide reference to an '08 Clinical Biomechanics article that showed improvements in whole body postural stability as well as localized ankle stability by way of ankle rehab alone.

At GAIN '09 I presented several recent real life cases I had with athletes with chronic back pain that I helped resolve by never even touching the back, or administering traditional back pain exercises. Rather I chose to attack the trouble makers that were directly or indirectly overloading the lumbar spine.

So take your time when you evaluate those ankle sprains. There is no such thing as just an ATF tear, or a just a high ankle sprain. They are all a little different, and a good eval will tell you which way to go first. Stop protocol cookbooking.

Curves & Korn

A Biomechanical Comparison of the Fastball and Curveball in Adolescent Baseball Pitchers
Carl W. Nissen, MD†*, Melany Westwell, MS, PT‡, Sylvia Õunpuu, MSc‡, Mausam Patel, MS‡,
Matthew Solomito, BSBE‡ and Janet Tate, PhD§; AJSM, August '09

The researchers came to the conclusion based on the kinematic and kinetic data that the rising incidence of shoulder and elbow injuries in pitchers may not be caused by the curveball mechanics. The fastball actually produced higher shoulder & elbow moments.

Coach Korn told me this decades ago. The way he teaches it, you use the whole body to throw it, not just just the wrist & elbow. However, he chooses not to teach it until the high school years because he feels developing sound throwing mechanics comes first. He is officially retired as of last month. What will we do without him?

P.E. Class Injuries

http://apnews.excite.com/article/20090803/D99R9MI00.html

A 10 year study showed a 150% jump in P.E. class injuries over a 10 year period. I think the conclusions the authors come to are right on the money for the most part. By the way, are "heart palpitations" & "fainting" considered bonified injuries now?

Rehab it as you see it

If this stuff doesn't get you psyched up...

Thanks to Dr. Dave Tiberio for the heads up on this article from the June '08 "European Journal of Physical Rehabilitation Medicine". "Rehabilitation of Adolescent Idiopathic scoliosis: results of exercises and bracing from a series of clinical studies".

The SEAS (scientific exercise approach to scoliosis) was shown to be an effective alternative to bracing. These exercises are isometric in nature, & not the ones I would necessarily choose, but exciting none the less. The concept that soft tissue can ideed influence structure. They actually reduced the Cobb angle. The important concept of SEAS is that there is no one size fits all protocol. It is individualized to the patient.

I think this concept can be generalized to incude athletic injuries. We are on the right track here. Rehabilitation should be athlete driven, not protocol driven. Like Bob Dylan sings, "you better start swimmin', Or you'll sink like a stone, For the times they are a-changin'."

Promenades sous la peau

Or, "Strolling beneath the Skin". I would like my readers to google image "biotensegrity" & "tensegrity" and look at the structures. Then go to Dr. Stephen Levin's (Ezekiel Biomechanics Group) biotensegrity blog. If you you scroll to the bottom of the page, he gives a preview of French hand surgeon J.C. Guimberteau's fascia DVD.

http://web.mac.com/stephenlevin1/_StephenLevins_Biotensegrity/Shear_or_Not.html

You really begin to appreciate the similarities, & how fascia links the body together as system. Manual therapists bring up an interesting point- that the human body's center of gravity doesn't really pass through the spine, but rather through the gut. We begin to see how soft tissue can influence structure. It creates new possibilities for us. For instance, we can understand how we need the entire body working correctly to prevent lower leg stress fx, not just strong legs.



It is the essense of what "core" is all about.

Joe's Training Room, 1 year out

My goal was to get a grass roots movement going at the high school level. Mobilize the foot soldiers into tackling problem areas in the care & prevention of adolescent athletic injuries.

I've failed.

I've gotten over 25,000 hits in the past year. Don't get me wrong, I am grateful to all my blog readers. I'm not just blowing smoke when I say you guys keep me on the ball. It's humbling when I check my hit tracker & see readers coming from almost every continent around the world to read what some high school guy from New Jersey USA has to say.

Unfortunately, barely any are from my home state. And almost none from the high school level. I would really appreciate everyone's opinion as to what I'm doing wrong, and where to go from here. I realize it's not just me. The ATSNJ has had a decline in enrollment in the past 2 years. The new ATC's coming out of college have figured out you can join the NATA BOC without actually joining the NATA. And I hate to sound sarcastic, but we're getting what we deserve. The ATC certification is not carrying much weight any more. I would like to give you specific examples, but I can't without using names.

I'm going to end this post with a quote from Bob Wiersma's "performance builders" blog, referring to the fact that more & more U.S. citizens are going uninsured each year.

"This is about real people in your community in crisis - they have real problems that they can not afford to address in the current health care system. Their solution is not in "the box" of traditional providers and services. What is need is a solution that is out of the box... There is something you can do about it!"

Guys, this is the environment I've worked in for almost 30 years. Most of you have been insulated against it. Get ready because it's coming.

Milestones in Biotensegrity

1948, artist Kenneth Snelson’s “floating compression” principle.
1949, Architect Buckminster Fuller develops 1st working model
1970’s, Orthopedist Stephen Leven applies tensegrity principles to human gross anatomy (biotensegrity)
2004, French orthopedist J.C. Guimberteau publishes “Promenades sous la peau”.
2007, Tom Flemons publishes, “The Geometry of Anatomy – the Bones of Tensegrity”

Biotensegrity as a Core Stability Model

“Tensegrities are self–contained non–redundant whole systems. All components are dynamically linked such that forces are translated instantly everywhere; a change in one part is reflected throughout. These features distinguish tensegrities from all other tension structures, e.g. a sailboat’s mast is fixed at the base and needs that fixed point to keep it upright. The boat does not need the mast for it’s integrity but the reverse is not true.”
- A Biotensegrity Explanation for Structural Dysfunction in the Human Torso, Flemons ‘07

Now we need not be concerned how are bodies are oriented to gravity. Many core training enthusiasts use the term, "you can't fire a cannon from a canoe!" But what if you must? Volleyball players do it all the time. As do divers & swimmers.

Biotensegrity is no new-age thing. It has sound engineering roots going back to the 40's and makes perfect sense. And, it fits in perfectly with the new fascia research that has come out in the past few years. I will elaborate more on this in the coming weeks.

Are there any honest politicians left in NJ?

Black market kidney trafficking, bootleg designer handbags, money laundering; it all goes on here. 3 mayors, a governor's cabinet official & 40 other government officials go down:

http://apnews.excite.com/article/20090724/D99KQQT80.html

Go Roberto!

Former Elizabeth High School N.J. short stop Roberto Ramos tore through the Gulf Coast league last week, posting a .526/.545/.632 line with 2 doubles, scoring 5 runs while batting in four, taking 2 walks and stealing 4 bases in 23 plate appearances over 8 games, for which feats he was recognized by the voters as SoxProspects.com Player of the Week of July 6-12. Ramos, 20, is hitting .448/.485/.517 with five stolen bases on the young GCL season. This is Ramos's second go-around with the GCL Red Sox after having hit .261/.306/.348 in 18 games in 2008. He was signed as an undrafted free agent by Boston in June 2008.

Greg's 5in5 Response:

The following is Greg Thompson's response to my post:

http://joestrainingroom.blogspot.com/2009/07/from-spark-into-bonfire.html

"I will look into posting something. I would love to do it with video for you Joe. Our plan is to have 24 modules with video clips for sale in the fall through Beacon Athletics. As Joe said, the program is designed to be used in concert between the PE teacher and classroom teacher. The exercises are taught in PE class then led by students in the classroom. Our push up numbers were excellent this spring and we hadn't done a regular push up in 5 months or so. Feel free to contact me with questions:
gregory.thompson@farmington.k12.mi.us

Windin' up da butt

I'm suprised no one called me out on a good exercise for training the glutes in gait/running. Here is a good exercise to train the posterior oblique sling system in a manner that is functionally consistent with running.

R SLB, LLE anterior/posterior pivot reach @ankle height c/ toe touch;

BUE anterior @shoulder height R/L rotational reaches out-of-sync c/ pelvis.

The R knee flexion/extension are a chain reaction from the LLE motion, NOT a single leg squat. Yeah, some balance is involved so there is a learning curve here. However, once you get the hang of it try to go as quickly as possible with good form.

The Muscle that Screams the Loudest Please Stand Up

"Gluteal Muscle Activation During Common Therapeutic Exercises"-JOSPT 7-09

Be careful about choosing exercises for conditioning or rehab based on EMG studies. The authors conclude their study by dividing the exercises into "tiers" based on the level of muscle activation. It would not be surprising then that a sagittal plane exercise like a SLB & reach to the toes would be the nominated as best exercise for activating the glute max. The same for frontal plane side lying adduction & the glute medius.

Every muscle has a 3D function, and the most obvious one may not be the most important with regards to joint function. For instance, let's say our athlete has patellofemoral dysfunction with running. While the SLB c/ toe reach may indeed create MVIC >60, the exercise is not consistent with gait, and may not be useful in this case.

Don't Miss Pat Donovan @ NATA '10 in Philly

Dr. Ken Cieslak asks:

"I would like to get a better understanding of the approaches Gary Gray uses in his assessment and rehab. I know you are well versed in this area. I noted on his website that they sell educational materials. Which ones would you suggest (tape titles, etc) I get to obtain a basic grasp of his approaches and methods (kind of like a Cliffs Notes summary of his approach). Any suggestions is greatly appreciated."
*******************************
I've gotten the thumbs up from Gary & Dave T to do a presentation at the nationals on just that subject. Been turned down about 5 years in a row. As a high school ATC I am a non person as far as the NATA is concerned . But, I believe they did approve Pat Donovan (U.Ill@Chicago) for 0-10 in Philly. I believe they are giving him several hours, and he plans to go through the whole spectrum. Be there. I know Pat will do a great job.

Now this is great research

Instrument Assisted Cross Fiber Massage Accelerates Knee Ligament Healing- JOSPT 7-09.

The researchers did Graston Technique on 51 rats who's MCL's were surgically injured. 3X a week for 1 minute; 31 received 9 treatments, 20 received 30.

At the end of the treatments, the rats were sacrificed, and the MCL's were placed under an electron microscope for study. Then, mechanically strain tested also.

At 4 weeks out, the treated ligs were 43% stronger, 40% stiffer, and able to absorb 57% more energy. At 12 weeks out, both treated & untreated ligs were similar, with the exception of the treated ligs being 15% stiffer.

The authors hypothesize that the Graston Technique has an underlying effect on collagen, influencing the fibroblastic cells.

How do my blog readers feel about this? It was fast, and a hell of a lot cheaper than other popular tendon therapies (platelet rich plasma, stem cells etc). Would ASTYM work just as well? Or, how about good 'ole deep transverse friction massage, which doesn't cost a dime to learn (it is well described in Warren Hammer's book).

From a Spark into a Bonfire

Sorry I've been neglecting my P.E. peeps somewhat.

Greg Thompson, an elementary P.E. teacher from Wisconsin, did a presentation at this year's GAIN on his 5-in-5 concept. It is based on Dr. John Ratey's SPARK concept:

http://johnratey.typepad.com/

Dr. Ratey's concept is that daily vigorous exercise improves cognitive function. My only issue is that is very technology dependent, narrow scoped, & difficult to implement in most typical school settings.

Greg amped it up by developing a series of exercises that can be done in limited space- even in a classroom, with no equipment, and is easy to administrate. It is a series of 5 exercises performed in 5 minutes, repeated at regular intervals throughout the day. It involves squatting, pushing, pulling, rotating, balancing, reaching, hopping/jumping. There's no reason to stare into some heart rate monitor, it's very clear you are above 120 beats per minute.

We'll Never Know

"Does Core Strength Training Influence Running Kinetics, LE Stability, and 5000M Performance in Runners?"- JSCR Jan. 2009 p. 133

Jack Blatherwick at GAIN 09 explained to us why you shouldn't just read the abstracts.

In this study, 28 subjects in their late 20's to late 30's were quantified for core stability weakness by way of the Sahrmann Core Stability Test. 12 received core stability training by way of 5 physioball exercises. 8 "were instructed to maintain their training routines". 8 dropped out, not sure why. After 6 weeks, the core training group showed faster times, even though there were no improvements in ground reaction force.

The problem is there was no "plecebo" generalized strength training group. After all, they were not college aged athletes, and may very well not been inolved in any strength & conditioning program. Therefore, any intervention would have seen an improvement.

The other problem is the assessment tool- Sahrmann's core stability test. It is a series of leg lifts done in the supine hook lying position. Does it fit here?

So, we'll never know if the author's protocol was effective or not.

Why

You can lead a horse to water, but don't drown them! This was the workout that caused rhabdomyolysis in a D-1 college American football player. It was prescribed by the school's S&C coach. It could have killed him. Keep in mind this was the day before a game.

1. 10x30 squats c/ resistance bands, 1m rest in between each set.

2. 30 consecutive Romanian dead lifts with 2 40lb. dumbbells.

3. 30 consecutive "shoulder shrug bicep curls" with 2 80lb. dumbbells.

Room temp 84 degrees.

The patient, including several other members of the team, were vomiting during & after the workout.

One workout can't make you, but it can break you.

Pushing off the rubber?

Sports Health July/August '09: Baseball Pitching Biomechanics in Relation to Injury Risk & Performace- Fleisig et al.

Unless I am reading the article wrong, the authors are advocating propelling yourself off the rubber during the stride phase. Those of you who heard me speak in the past know I oppose this for a whole slew of reasons. It sets up a cascade of poor mechanics.

However, these authors are no slouches. And, the pitcher in this pic is literally bounding off the rubber. Remember, the mound's decline would magnify this even further. But, unless I'm reading it incorrectly, not pushing off the rubber is in the "pathomechanics" category.

Propriability

Thanks for all the great comments. Marshall gave us a great insight with his own experience with back pain; that he has what would be traditionally considered a strong core, yet he still experiences pain 4 years out despite numerous bouts of p.t.

Porterfield & DeRosa discuss this phenomenon in their excellent book, "Mechanical Low Back Pain"- "Tissue that is significantly injured or degenerated cannot attenuate stresses with the same efficiency as normal, uninjured tissue", and go on to say, "to assume that 3- 45m sessions 3X per week alone will significantly impact long range outcome is unrealistic." (p.226)

This is part of the problem when discussing core. We typically think of core training as strengthening the muscles.

Never forget that ligaments are part of the core system. They don't just connect bone-to-bone. They are rich in Pacinian Corpuscles & Ruffini endings. They are an important part of the core. If we are doing "stiffness" or "bracing" training in the neutral zone, are we stimulating these proprioceptors??? Do most injuries happen in the neutral zone, or rather in the "transformational zone"-where the body is changing directions?

Remember proprioceptors are the spirit of function. When we speak of neuromuscular training, or re-education, this is where it's at. If there is no proprioceptive stimulation, there is no load, therefore no explode. However, as Juan said so well, we need to work at the edge of their envelope of function if they are to improve, and not be injured. We need to safely take the back patient, or healthy athlete into-and out of the transformational zones. On to you guys- by the way, where have all the ladies been???

Reactive Core-Theory 101

I spent quite a bit of time at GAIN 09 examining the currently accepted model of core stability. ALL of the big core guys use it. It appears in Andry Vleeming's books from the late 90s.

It is the "pirate ship" concept. That is, a ship mast (spine) with a skull on top (head), with 2 sets of guy wires attached. An "inner unit" (multifidus, TA, Ext. Oblique et al), and an "outer unit" (erector spinae, rectus ab. et al). The inner unit providing inter segmental stability, with the outer unit in control of column movement in general.

My question was, what would happen if you took this model and tossed it in the air (gymnastics, platform diving etc)?...or tossed it in a swimming pool upside down or on it's side (swimming)? Is not core stability required in these environments?

I believe the problem is spine stability is interchangeably used with core stability. That's where we get the concept of the core as a "rigid pillar". Core strength expressed as "stiffness", connotating something isometric in nature. It's very rare someone injures their spine lying down, so this makes sense.

But when we think of core, we're not only thinking the external's influence on the internal, we are also thinking vise versa. That is, the role of the core in ACL prevention, or hustling up off the ground after a fall. I've seen McGill's bracing exercises used in ACL prevention programs. Is this the proper application of a bracing exercise?

Juan & other physios & A.T.'s that treat backs, I would really enjoy your input on this. Did Vleeming intend this to be a core stability model?

Getting back to work

Spent the weekend chill-axing in my backyard barbequing & swimming. I ended it with a half hour trip down to the Jersey shore to hang out with our buddy Lou Argondizza- EHS JV soccer coach & part time bartender at Sunsets, a restaurant in Point Pleasant.

http://www.sunsetsnj.com/

The following link from THE ONION is a great satire of what goes on at the Jersey shore in the summer, and is not too far from the truth. BadaBing indeed.

http://www.theonion.com/content/news/massive_tag_body_spray_slick

Well, I'm refreshed from the long school year & ready to get the blog rolling again.

This is more like it

It's fresh in my mind because Kelvin Giles spoke at GAIN 09. OK, I know Gray Cook's FMS is the most popular one. It just isn't my favorite:

www.movementdynamics.com

Great Experience

Just returned from GAIN '09 with my head swimming full of new ideas. My contribution was "reactive core". My goal was to scientifically challenge traditionally accepted models of core stability & simplify core training. I will clarify this in a series of upcoming posts.

I also led a heavily Mabel Todd ("the thinking body") influenced Smorgy workout; & finally applied reactive core to thrower/swimmer rehab.

I don't think Vern planned it that way (or maybe he did...), but all the presentations seemed to mesh into one another & build upon one another. Biomechanics professor Dan Cipriani started us off with his functional anatomy lecture, leading into John Perry's "propriability" lecture & workout. By the time it got to me I was worried there wasn't going to be anything to talk about!

I picked up some great shoulder rehab tips from Steve Myrland, LE tidbits from Bill Knowles. Jack Blatherwick got our BS detectors fine tuned regarding research interpretation. Ed Ryan updated us on some cool new products for edema reduction. Jim Radcliffe, strength coach at Oregon, is in a class all by himself.

It was great to see Kevin Moody again; I haven't seen him since my days at the Lake Placid OTC 12 years ago! I finally got to meet Tracy Fober, the Iron Maven herself. Oh yeah- she has this incredible secret she cannot share with anyone!

There is a LOT more, I will get to it in coming posts.

Phew!

Exhausted, & exhilarated at the same time. It's 5am, I'm brushing up on my last lecture for GAIN '09, which begins at 7:30am.

p.s.- the Aussies are incredible. They are dedicated, passionate, & are driven by sound research & methodology. They could make a big difference in American football, I'm certain.

GAIN '09

I'm really getting psyched- this time next week I'll be down in Fla knee deep in function with G-Unit. No, not the 50-cent one; but Vern & his crew.

I'll be leading the group in a smorgy workout, then giving a long talk on core training. Preparing for this has been an interesting experience. In attendance will be Dr. Dan Cipriani, biomechanics professor at San Diego State. He is the acid test as to whether I'm track or not. But I've really done my homework and certain I'm solid ground. I'll be looking forward to sharing my ideas with my blog readers in the coming weeks to get your input.

I finish at the end of the week with injury prevention concepts for the throwing athlete. Wish me luck.

Kevin Moody's Flexibility Question

Kev asked for a good substitute test for the standard sit & reach test.

I like Steve Myrland's smart-test.

It is described on the web site, but there is also a hand out you can get if you call or email them.

http://beaconathletics.com/store/products/Smart_Hurdle_Smart_Tests-502-28.html

However, remember it's all about mostibility- the ability to take advantage of just the right motion, at just the right time, at just the right speed, in just the right plane in just the right direction, not flexibility.

For rehab documentation of functional ROM, I use Gary Gray's 3D testing pole.

?

"The Use of Occlusion Training to Produce Muscle Hypertrophy"-Strength & Conditioning Journal June '09

you tie a giant rubber band around your leg & do leg extensions.

page 81- "patients who are injured, specifically ACL injuries, have been shown to benefit from an occlusive stimulus".

page 82- "even recommended for astronauts!"

A. The S&C Journal is running out of things to write about.

B. These guys pulled off a great practical joke.

C. Like many orthopedic surgeons I have worked with, their's are also hell bent on quad hypertrophy and, well, it's the end of the school year, and these poor guys just lost it.

Juan Ruiz- Tagle asked a couple good questions I thought deserved a post:

1. In a team of a very competitive athlete, what percentage of those athlete would you expect that would get permanent injuries (labral tears, meniscus tears, rotator cuff tears, spinal dysfunctions, etc.) and in your opinion what is acceptable part of the sports and what is just poor coaching?

*In 27 years of baseball I've never had a labral tear (shoulder) or a rotator cuff tear. Maybe 5 ACL constructions from soccer/football in that time frame. About the same for meniscus tears. However, probably hundreds of aching backs. None serious, all got better with some rest, massage, rehab etc.

I'm sure that is way below the norm for a high school program as huge as ours. I can only take a small part of the credit for that. I have been privileged to work with some great coaches.

I'm not sure Juan what is avoidable & what isn't. I do know that many take certain injuries for granted, that are definitely preventable. "Shin splints" are preventable. (most) Hypermobile shoulders in swimmers & throwers are preventable. (most) non contact ACL tares. (most) hamstring strains. Athletic hernias.

Hip labrum tares? That is a matter of opinion, I say probably.

2. Do you stop the athlete from playing for a while and rehabilitate or do you rehabilitate without taking time off ?

*it depends. But, if there is any possible way I can keep an athlete in competition, I'll do it. In the inner city, there is the risk of an athlete with an injury "disappearing" from you & the team. It is not physically, nor psychologically good for the athlete to be separated from his team. If I can reasonably tape, brace, or softcast something, I'll do it. Ultimately, it depends on what they look like functionally by way of objective testing. I think that is one of the things that separates athletic training from physical therapy.

Bueno topic Juan- I'll comment on your last few blog posts in the coming weeks.