Disturbing

The other day a teacher in the high school approached me about their niece. The niece was hampered by chronic bilateral knee pain & she sought my advice. I asked this person about their niece's activities, and they told me the athlete was injured at a very popular strength & conditioning coach's "speed school".

Oh, I forgot to mention the athlete in question is a 9 year old.

I'm sure my European readers are laughing right now. Come on everybody, how did this get stolen from the physical educator? More important, how can we re-claim it? Click on the picture to enlarge it. It is the movement paradigm from a book Vern Gambetta recommended to me years ago, "Physical Education for Children" by Gabbard, LeBlanc et al.

Yeah, I still follow it. As the years go by, the more athletic training has become remedial physical education. Print it out & try it yourself- it works.

642 Wins!

Congratulations to our baseball coach, Ray Korn! Yesterday he became Union County NJ's winningest baseball coach in history. The Minutemen had to come from behind to defeat our next door neighbor & rival Union high school. Coach is retiring this year, but I'm sure he will be involved with the sport one way or the other for a while yet.

One thing I will miss is his quirky comments. Like when when the ball would keep popping out of one of our infielder's mitt before he would recover & throw it. Coach asked him if it was a glove, or a toaster on his hand.

FMR Setup

This is a functional manual reaction setup for left midtarsal joint mobilization. The calcaneus is everted on a BAPS, the forefoot is inverted on a slant board. Here we're over exaggerating the natural motion of the FRONT foot in gait & running. The pelvis is rotated right; the knee is internally rotated; with the left shoulder rotating left. The athlete rhythmically shifts weight from the right foot to the left.

I can use this as a self mobilization, or I can get my hands down on the MTJ for a little over pressure. It's very easy now because I have gravity, momentum, & the ground assisting me in a functionally consistent manner. I'll begin with table mobes/manipulation, but switch over to weight bearing mobes as soon as the athlete can tolerate it. This athlete is doing well. We're now 9 days post gr.2 inv. ankle sprain & I've begun BLE 3D mini jumps.

Obviously as you can see in the picture we've got some regional interdependence issues that probably wouldn't be addressed in traditional physical therapy but that can be easily integrated into an athletic training rehab session.

The enigmatic ankle sprain

I wish more attention was paid to ankle sprains in the professional journals. This is a 4 day old inversion ankle sprain. There was a lot of internal rotation involved, so the deltoid ligament was torn in addition to the posterior talofibular ligament. The “high ankle sprain” is very popular in the media. However, I believe any ankle sprain with a good deal of rotation involves the distal tibiofibular ligaments/interosseous. So, I think it would be safe to say MOST ankle sprains have a high ankle sprain element. A new classification system is seriously in order. So be wary of the cookbook protocol approach. Every ankle sprain is a little different.

Because the sprained ankle is so common, it’s looked at as no big deal. Which makes for a tough sell to coaches when you’re trying to keep this athlete out of competition.

Grade 2 inversion L ankle sprain rehab, day 5:

A.M. session:
3D BLE ankle excursions, 100 each
FMR
Rockfit trainer, 5 minutes

P.M. Session:
3D BLE ankle excursions, 100 each
L stagger squats, 3x12
Squats, hip width apart, heels elevated 1.5”, 3x12
Eccentric heel drops, up on 2 feet, down on L, 3x12
RLE pivot lunge, 3x12
Rockfit Trainer, 5 minutes
HVES(-) c/ RICE, 30m

Gracilis top down

Here's the gracilis integrated core I'm using. I'm staying consistant with gait by having the pelvis rotating R at gound contact, then rotating left at midstance. The idea being the pelvis going too deep into left anterior rotation, R frontal plane rotation, & R transverse plane rotation. Sequencing the core to correct it.

If you chose another sequence, it doesn't mean that you were wrong. Kevin's idea of LLE balance BUE med ball chops is not a bad idea. After all, it's doubtful the pelvis was only unstable in the above mentioned planes.

Gracilis comments

Great job again you guys. Sorry if I come off as a functional exercise freak, but it's important to the high school ATC. If you understand the anatomy & function of a muscle (with the foot on & off the ground) you can inexpensively put together a high tech rehab/conditioning program. In addition, you are preserving function in the gracilis & globally through the entire body. For instance, this athlete, even in the acute phase, was doing cariocas, forward skips, frontal plane double leg mini jumps, throwing - all pain free. I could not have done this if I had generically treated it as your everyday run of the mill hamstring strain.

Moving on, we know the gracilis also influences the pelvis. So, we also need to work top down. What type of core training might provide the gracilis with a better mechanical advantage?

Gracilis strain

One of our baseball players was trying to run out an infield squibbler & came up hobbling. The gracilis is often thought of as a adductor, which is true. But it is the only adductor that crosses the knee joint, which adds knee flexion/internal rotation into the mix. It is often mistaken for a hamstring strain because of it's location to the inside hamstring group. Be sure to differentiate this muscle from the hammies on your evaluation. Rehabilitation is different.

Because of it's origin on the pubis, the gracilis is not a hip extensor. Because of this fact, rehab that involves hip extension is usually tolerated early on. A step up for instance, as long as you begin/end in a narrow stance. So, the step up may be a good early phase way to "tweak out" the gracilis. In other words, it's being minimally recruited in a functionally appropriate manner.

OK, I've "tweaked out" in the sagittal plane. But we know the muscle also decelerates knee/hip abduction in the frontal plane. In the transverse plane, it decelerates knee external rotation. So, how might we functionally tweak out the other 2 planes? On to you guys.

Reductionism

http://www.thetimesonline.com/articles/2009/04/12/sports/top/doc280f2940aa19e13486257595003e125f.txt

What can we learn from this? Certainly not that every high school training room should have a Nintendo Wii. I think the P.T. said it all when she says, "now the patient is excited when they bowl a strike on the Wii, not that they lifted a 3 pound dumbbell." You don't need to tell a suprasinatus or teres minor what to do. Rather, give the body a task that challanges the cuff within the context of their envelope of function.

I just read some dopey article on training the supraspinatus for pitchers. The secret, you see, is only doing the "empty can" exercise to 60 degrees as to not cause subacromial impingement. This gem appeared in a peer reviewed journal. Come on everybody, we can do better than that. The 4 rotator cuff muscles function synergistically to depress the head of the humerus in the glenoid to counteract the elevation effect of the deltoid. THEY ARE NOT PRIMARY MOVERS. Histological studies back that up. I have to dig up a good EMG study done on swimmers a few years back. Motions that you would think would activate one cuff muscle over another did not happen in real life.

Humeral Retrotorsion

Hey Aaron, why do you Aussies always seem to be one step ahead of everyone else?

GIRD in throwers & swimmers has been well documented. Up until the last few years, the consensus was a tightness of the posterior shoulder musculature & joint capsule. As some great research coming out of Australia shows, it's not necessarily the case:

"Sports Participation & Humeral Torsion/Whiteley Ginn et al./JOSPT 4-09.

I realized this occurred in older & professional athletes, but this is the first time (as far as I know), where it's documented in adolescents. The authors say humeral retrotorsion is the norm until about 8 years old. They claim participation in throwing or swimming prior to full skeletal maturity may slow the rate of retrotorsion loss. An interesting finding was in swimmers, the dominant hand side shoulder was more retrotorsioned than the contralateral.

So what does this mean to us down on the hs level? Before making the diagnosis of GIRD, be sure the athletes total arc of rotation is at least equal to the contralateral shoulder. That is, as long as the athlete makes up the active/passive IR they've lost with ER gains, the posterior capsule/musculature may not be hypertonic.

Please Read this article & comment

I just read an article from a very well respected journal by a very well respected pro sports S & C coach. I was very sceptical, to the point I thought the guy was either trying to distract us from his real training program he didn't want published, or someone ghost wrote it for him. After reading this SI article, maybe he was really being genuine, and serious reform is in order.

http://sportsillustrated.cnn.com/2009/writers/ross_tucker/03/18/conditioning/index.html

The neglected hand

One of my favorite comedians of all time, Rodney Dangerfield's signature line was, "I don't get no respect!" The same could be said of the hand. You probably get those brochures for the hand rehab seminars in the mail & you toss them out. From this month's "Archives of Physical Medicine & Rehab"- "Ulnar Nerve Compression Neuropathy at Guyon's Canal Caused by Crutch Walking: Case Report With Ultrasonographic Nerve Imaging Ulnar Nerve Compression Neuropathy at Guyon's Canal Caused by Crutch Walking: Case Report With Ultrasonographic Nerve Imaging".

How often do your American Football lineman come in complaining of wrist pain? Probably all the time, but more than likely you slap some tape on it & send them out. But this type of nerve compression happens, & is re-aggravated by bench pressing ad-nauseum. There are some cool, simple mobilizations for the carpal row & releases for the tunnel ligaments that really feel good on a beat up wrist. I will try to get some up on this blog in August when high school football gets under way again.

Disappointment

I forked over more than 4x the price of my old Rockfit Trainer for the new Firmwave, & I cannot recommend it. As you recall, I purchased the Rockfit many years ago in a closeout sale somewhere. It is a great, cheap sagittal/frontal plane close chain UE/LE exercise device. It even came with this really high quality exercise band that could be attached to incorporate integrated work. I used it so much that I wore out the anti-slip pad on the bottom, which the manufacturer replaced for free.

The firmwave is too small for most athletes, you get the sensation you could fall off the thing. It comes with this crappy workout DVD which went right into the garbage. Don't waste your money.