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 Phillip Gribble, PHD-ATC from U. Toledo for sharing some of his unpublished manuscript that was presented at the International ankle symposium in Australia this past summer.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