A few PFSS ideas

I'm going to jump out a window if I hear more quad settings stuff from MD's. They don't work. It's like walking around in your old 70's leisure suit (yeah, I had a few).

Get these athletes step-uping, squatting, and lunging as soon as possible. It's easy if you understand TWEAKOLOGY. That is, using UE or LE drivers to help the knees out. Where they have the pain (ie medially, laterally, inferiorly) will guide you on where to go. Here are some good places to start.

1. RLE stagger squat. You might think this is more difficult than a traditional squat. However, there is practically 0 knee excursion going on and is usually more comfortable. In addition, you are recruiting more hamstring, which in this position is a knee extensor, assisting the quads.

2. SLS c/ BUE same side rotation @ shoulder height. Recruiting more glute in the TP- again assisting the quads.

3. SLS c/ BUE @ shoulder height anterior reach to max; this time recruiting more glute & erector spinae in the SP, again assisting the quads.

Of course as the athlete gets stronger, you will need to tweak the quads back in. Topic for a future post.

Less is more

A.T.'s love to tape and I am no exception. This is an unloading technique for lateral epicondylitis, tennis elbow if you will. We know tennis players rarely get it. In fact, I don't believe I've ever seen it in a high school athlete. But this blog is dedicated to the h.s. A.T., & we all have a lot of middle age coaches, grounds keepers etc that stop in with this problem. The tape job is easy:

1. First, have the athlete place their arm at the side in the anatomical position. The elbow is flexed about 30 degrees, the hand must be maximally supinated during the entire process. Apply two strips of coverroll stretch. The frist is placed on the proximal ventral forearm moving diagonally to the lateral distal humerus. The second is place on the extensor belly moving proximally to the lateral distal humerus. Now place the leukotape-P on the diagonal piece, pulling firmly from distal to proximal. Do the same on the extensor belly strip. Wrinkling of the skin is a sign that your tape was applied correctly. The athlete should get the sensation that the elbow is "floating".

2. The tape should stay on two or three days. Give them an old roll of flexiwrap to cover it in the shower. On the 3rd or 4th day, give the skin a day's rest to recover. On that day you can apply your modalities. Plenty of cold packs during the whole process.

I know there are mobilizations/manipulations for this condition. I have rarely found them helpful. It seems the less you fuss with it, the better. Now on to what causes it- in my experience lateral epicondylitis goes hand-in-hand with a loss of wrist extension, usually contributed to OA. I believe wrist extension is one of those "use it before you lose it" phenomenons. The humble old push up, bear crawls & crab walks are great ways to develop good wrist mobility & maintain it. Hell, I'm 49 & still do them. Now I wouldn't have a 50 year old custodian who hasn't done a pushup in 30 years drop down and give me 20. But, wall slides are a good integrative alternative. I still wish I had time to organize all my patterns and for what conditions and write them down. But this blog isn't about me, it's about you guys. So what do you think?

Busy

Sorry I haven't been posting much lately. We are reaching critical mass here at EHS, hosting our county tournaments & even some state tournaments at our place. On top of that, helping to get our baseball team ready for the spring. Plus a lot of social stuff, christenings, weddings etc. I will get back to posting on a steady basis as soon as things calm down a little. Plenty of topics to get to.

Any way, keep asking questions! JH came up with a good one. He had the opportunity to hear Dr. Stuart McGill speak. JH mentioned Dr. McGill speaks of the importance of "bracing" in back health. Here's my take on it, and I would like the opinion of others if I am on the right track with this:

A lot of McGills work is in the industrial settings, with industrial "athletes" who have to do heavy lifting repetitively for hours at a time. Compounding this is equipment that often constrains these workers to lift in certain patterns. A good example is my brother, who is a pipe fitter. His job often requires him to lift unbalanced loads on a scaffold in tight quarters. He's closing in on 50 now, and has never hurt his back. It's also interesting that his abs are ripped, and the guy hasn't done a situp since high school.

When I asked him his secret, he explained to me how his work often requires his torso to be in one spot while his arms are stretched somewhere else lifting pipe with one hand, and maybe holding a bracket in another. His (unconscious) strategy is to splint his body rigidly in order to hold his balance to accomplish the task without something falling on someone 100 feet below. There is no space to "load" and "explode" as you would on an athletic field.

McGill also makes an interesting point that once a structure is permanently compromised mechanically from an injury, bracing may be a skill that needs to be encouraged & taught. Porterfield & DeRosa agree.

I think this is where Tracy Fober's olympic lifting hybrids could come in handy. A mixture of bracing & ballistic movements occur, and quite subconsciously. It all comes down to chapter 3 in "Athletic Development- The art & science of functional sports conditioning".

1. Analyse the demands of the sport
2. Analyse the qualities of the athlete
3. Understand the common injuries in the sport

All Training is Core Training

When I first heard this from Vern Gambetta I didn't know what the hell he was talking about. "The Core" is a very vague term to begin with. So I always find it surprising to find it in many scientific journals. This time in this month's JOSPT- "Shoulder Injuries in the Overhead Athlete". Don't get me wrong, there's lots of good stuff here by top notch researchers/practitioners Wilk, Andrews et al. It was a combination of this article, plus seeing the "tea cup" exercise on the Iron Maven's website that got my wheels spinning. As you watch Steve Cotter go through the exercise, it is interesting to watch his torso adapt to the various shoulder positions. Not something you would think of as core training, but it definitely fits.

I found it well, kind of annoying that the importance of "lumbopelvic" & "core" training was only given lip service. What did they mean by "core stabilization training"? Does this mean they choose to train this region isolated from the rest of the body? After all, the isolated, uniplanar, unidirectional stuff had lots of pictures- even online videos. Upon watching them it is obvious the core is used isometrically to splint the body's extraneous motions. But is this what happens in vivo?

My buddy Pat Donahue & I prefer, and have had good success with an integrated approach using specific combos of lunges with arm drivers. I think some of the new myofascial research backs up the efficacy of this approach. So, I really don't see this as "outside the box"thinking at all. Baseball season is coming up, so you will see me posting on more shoulder/elbow stuff in the coming months.

New JH Blog

Jonathon Hewitt, a frequent contributor to this blog has left to start his own. Kind of like when Scott Weiland left Velvet Revolver to go with Stone Temple Pilots. Without the sex, drugs, and rock & roll. Auditions for a new lead commenter begin today.
http://hewdogg.blogspot.com/

More anti-clam

From the APTA combined sections meeting '09: Does Isometric Gluteus Medius Torque Affect Frontal Plane Pelvic Drop While Running? In a nutshell, no.

I hate to beat this topic to death, but here is more efficacy to keep your athletes weight bearing. Researchers Burnet and Pidcoe measured side lying gluteus medius strength with a hand held dynamometer to see how well "on the floor" strength translated to running. With a 3D kinematic device they measured frontal plane pelvic drop, and found a poor correlation between the two.

Go with step downs, mini band walks, hip hikes & remember- no load means no explode.

To wiggle or not to wiggle

or, a conversation with Dr. Tim Hewett; director of the Sports Medicine Biodynamics Center at Cincinnati Children's Hospiatal. Tim has some cool unpublished research going on involving ACL injuries. It goes like this:

Normal & ACL deficient athletes are placed in front of a biofeedback screen, hands folded across chest, SLB, contralateral leg 90/90. A square on the screen moves in different directions, and they have to move their head with the square. The preliminary results look like this:

The uninjured athletes, at lower speeds, performed the task with little variability which increased as the speeds did. This was just the opposite in the injured athletes. They had a tendency to "lock down" the lower extremity as speeds increased.

My question to Dr. Hewett was why this was in opposition to perturbation training concepts, where "stillness" is desirable. His answer was, " in an unstabilized situation locking down is good. In a normally stable position, locking down is probably bad". My response was, "but your bio feedback screen was causing head movement, which created instability, no? His answer was, "humm, that does give me something to think about". I then asked him if perhaps when the instability is driven bottom up, "locking down" is good, and bad when it is driven top down. He said he wasn't ready to come to that conclusion.

Another statement he made was the time from when the foot hits the ground till the ACL lig tears is from 50-70 mlliseconds. Spinal level reflexes occur at 80-150; too slow to prevent an ACL tear. He feels the benefit of neuromuscular training to be preparatory rather than reactive.

Talk at the Berra Center

Paul Reddick & Frank C. started it off with a demo of their 3D video analysis program for pitchers. Pretty cool stuff, picture if you had about 20 hands that were fast enough to follow the athlete's body around with a goniometer while they throw.

I began with a brief history of the kinetic chain concept (as seen previously on this blog). I then went on to back it up with some up to date fascial sling stuff to back it up. Next a demo of a few movement screens I typically use. I finished with an FMR technique to mobilize the L hip for throwers, and the warmup our pitchers at EHS use.

I explained to the group that I don't use the thrower's 10 program all that much. Only as a "milk-down" to relieve soreness the day after pitching. I was surprised I didn't get any flak. Either everyone was sleepwalking (it is the beginning of a new NATA CEU period, so that is possible); or maybe some just aren't satisfied with the results either and are looking for something new.

It was great to catch up with my old pals Al Errico, Carl Hensal, and John DiAndrea- some of the only guys left from when I first got into the profession in 1982. Thank you John Davis for giving me the opportunity to speak, and all your student A.T.'s that helped out.

"Kitchen Chemistry"

...this was a derogatory term Dr. Albert Sabin used to describe Jonas Salk's brand of medicine. Jonas Salk felt most laboratories were more interested in expanding scientific perspective and not necessarily goal driven. The two were in a race to come up with a vaccine to eradicate polio in the U.S. in the 1950's. Of course Salk won (and so did Sabin in a way- he developed a cheaper oral vaccine of his own in the early 60's).

I couldn't help applying the term to sports medicine. It is a discipline that has always been driven by the practitioners. Being a kitchen chemist is not a bad thing, as long as what you are doing is based on sound scientific principle. Innovation by way of strategy & technique is impossible without it.

Tomorrow is my talk at the Yogi Berra center. Definitely kitchen chemistry stuff. I'll let you know how it goes.

More TFL

Great job everyone on your comments. You understood what I was getting at. We often get treatment orders from orthopedists restricting this or that, but it doesn't mean we can't stay functional & weight bearing. Rehab the athlete, not the injury.

By creating inversion in the ipsilateral foot, either by UE or LE drivers, we would be following the tx orders of "tweaking out" the TFL. However, getting creative gave us many more options than the unidirectional, uniplanar, proprioceptively impotent, gravity confused "clam".

Now we can even go aerobic here! We'll use my idea of placing the foot in inversion by propping up the medial foot with a towel; JH & Brian's idea of shoulder height BUE arm drivers toward the affected side; now combining this with SP contralateral single leg ant./post. lunges. Maybe add a 5lb. dumbbell to the mix.

OK, I know there are those of you who are saying, "by blocking that femoral IR, aren't you also inhibiting the TP load to the glutes too?" One way around this I can think of- same exercise, an exercise band around the ankles.

Limit activation of the TFL?

From the platform presentations of the APA combined sections meeting:

"Which exercises target the gluteal muscles while limiting activation of the TFL? EMG assessment using fine wire electrodes".

The authors point out is important to limit the action of the TFL in PF rehab because it "internally rotates the hip & exerts a lateral force on the patella". I'm not sure the TFL actually does this once the foot is on the ground, but let's assume it does for the sake of argument.

The authors immediately go horizontal/floor to the CLAM exercise, as it gives the best EMG results.

Well, you know how I feel about lying on the floor. What are some ways we could quiet the TFL during glut. strengthening in an upright functional position?