My last post of the year.

Great comment on Fascia from British Osteopath Leon Chaitow:

"in therapeutic terms, as well as anatomically, there is little logic in trying to consider muscles and
joints as separate structures from fascia, because they are so intimately related. Remove connective tissue from the scene and any muscle left would be a jelly-like structure without form or functional ability, and joints would quite simply fall apart.  We also now know that there exists a tensegrity-like state of structural and functional continuity between all of the body’s hard and soft tissues, with fascia being the ubiquitous elastic- plastic, gluey, component that invests, supports and separates, connects and divides, wraps and gives cohesion, to the rest of the body- the fascial, connective tissue network.

 Any tendency to think of a local dysfunction, as existing in isolation should be discouraged as we try to visualize a complex, interrelated, symbiotically functioning assortment of tissues, comprising skin, muscles, ligaments, tendons and bone, as well as the neural structures, blood and lymph channels, and vessels that bisect and invest these tissues e all given shape, form and functional ability by the fascia."-  JBMT 1-11 (pre-print)

As the pelvis goes so goes the rest of the body

"Pelvic Control Of Professional Baseball Pitchers And Its Correlation To Pitching Performance"- McKenzie, ACSM '09 annual meeting.

"Pelvis & Torso Kinematics & Their Relationship to Shoulder Kinematics in High School Baseball Pitchers"- Oliver et al JSCR 12-10.

The first showed pitchers who tilted seven degrees or fewer during their stance transition had lower opponent batting averages (.244 vs. .290) and fewer walks and hits allowed per inning.  Interesting, they did not have fewer injuries.

In the 2nd, the authors found a correlation between torso axial rotation speed and shoulder elevation angle (in other words, shoulder drag) in high school baseball pitchers.

Interesting, both recommended "core" training in the same or subsequent articles or lectures.

Couldn't this same concept of pelvic control be applied to other activities like running & jumping; or low back pain?  The question is, is core training and pelvis stability exercise the answer.  Or, is the unstable pelvis a manifestation of a generalized lack of strength & power in body?  What would their PCA look like?

Did I pervert the research here?

"Scapular Muscle Recruitment Patterns: Trapezius Muscle Latency with and without Impingement Syndrome- Cools et al, AJSM '03".

Last month I got hammered pretty good on a discussion thread on the GAIN forum on this topic.  The topic had to do with the use of traditional olympic bar pulling movements (shrugs, high pulls et al) in the training of throwing athletes.  I made the point that these types of pulling movements create upper trapezius hypertrophy which can cause impingement syndromes in throwers and swimmers. This is one study, of several, which shows trap shrugging preceding middle/lower trap activity in subjects with impingement syndrome.  Of course one could say this is an adaptive pattern that people with impingement syndrome take on subconsciously to avoid the portion of the arc that is painful. 

My take on the matter is that this muscle firing sequence CREATES impingement syndromes/tendinitis.  I first came up with the idea years ago when I was fortunate enough to take a course with Australia's Lyn Watson, a manual P.T. who specializes in shoulders.  Lyn felt it had to do with the traditional shrug being more levator scapulae dominant than trapezius.  The upper trapezius came more into play when the arms were pushing overhead.

I don't want anyone to be afraid to shrug or pull!  In sports like volleyball, the shrug is an important part of the jumping/striking sequence.  The same could be said for the javelin thrower, where the implement creates a long lever arm that the shoulder must contend with.  But I still think they must be applied prudently in swimmers, baseball players and cricket bowlers. 

These pictures are of one of my favorite thrower/swimmer exercises, the see-saw.  It can be done with the bands attached to a fixed object, or better yet in opposition with a partner.  It creates joint stability/power where you need it the most- where the arms are at the extremes of motion and switching directions.  The "transformational zone" as Gary Gray calls it.  The goal is to get straight arms behind the ears without arching the back.  Many of your atheltes won't be able to do this with moderate resistance.  And if they can't, they're really not getting hip to shoulder.

My point is that it's not only about hip to shoulder; but rather how you get hip to shoulder.  My example has resistance applied with a horizontal vector bias.  The middle/lower traps are integrated quite nicely.  And so are the upper traps, but as opposed to a shrug, through a long lever arm.  As the arms would during swimming and throwing, no?  Think about it a bit, and let me know if I'm on target or just making some wild metaphysical leap with the research.

New Jersey: The Soprano State

Corruption at every level:

http://www.nj.com/news/index.ssf/2010/12/nj_taxpayers_fund_millions_in.html

Poor, good for nothing quads

I was just reading Vern's leg circuit post, followed by an article by a noted ACL injury researcher.  The ACL article spoke of girls using a faulty quadricep dominent movement pattern, with the need to "teach them to activate their glutes & hamstrings more.  Interesting, the recent strength coach roundtable I recently mentioned pointed to the same, but in all athletes.  I wonder what running, cutting, and landing mechanics would like if the researchers injected a nerve block into the femoral nerve?  Do these athletes need to be taught to fire their "posterior chain" better, or is this pattern a result of a poor leg strength foundation/progression?

Listen, do yourself a favor and save Vern's post to your hard drive:

http://www.functionalpathtrainingblog.com/2010/12/the-gambetta-leg-circuit.html

Can we have our food now?

At 51 years old I still relax the same way I did as a kid, watching cartoons before I go to bed.  There is a new episode of South Park where one of the parents decides to become a gourmet chef, quits his job as a geologist, and begins preparing his neuvo cuisine in the school cafeteria.  The students are left standing there with their empty trays saying, "can we have our food now?" as the dad becomes totally immersed in his culinary skills and totally forgets he has hundreds of mouths to feed.

I had an email discussion with my buddy Pat Donahue, ATC at U.Illinois @ Chicago.  I was inquiring about a new school of rehab he had experience with, and I asked him how it was working out.  He brought up a very good point- that while its practitioners were claiming outstanding results, it just didn't fit into the A.T. concept.   Very practitioner driven, one-on-one protocols.  In the A.T. environment, our time is very precious to us.  When we tie up our hands with manual techniques we must be sure we are getting the most bang for our buck.  For instance, I do myofascial release.  I choose ART and Graston because I feel they are very effective and extremely time efficient.  However, it appears the Italian School of MF release (Carla Stecco) is really showing an edge.  But it's just too time intensive for the typical A.T. setting.

I feel this philosophy goes well beyond the A.T. room as the health care dollar shrinks.  We don't want to feed our athletes fish sticks and pizza, but we don't want them standing there with empty trays either.

Good question from Kev...

"Could you define pelvic drop since I am unable to view the article please? Is it in the frontal plane? Would farmer and waiter carries be an appropriate exercise to address the QL and GM in order to encourage stabilization of the pelvis and reduce lumbar shear?"

pelvic drop=non weight bearing pelvis dropping in frontal plane= Trendelenburg sign.

In these subjects, in was occurring in Treadmill walking.
The point I'm getting out of this article, and others like it, is don't piece meal muscles (of course occasionally you need to, but not in this case).  If we look at this issue from that point of individual muscle then we would also have to look at the same side erector spinae, the same side internal oblique, opposite ext. oblique- the list goes on and on.
As far as remedial exercise, Frans has a few that address the issue.
Others I can think of are SLS on the leg opposite the drop, while keeping the non weight bearing illum as high as possible...double time skips doing the same...extended walking/running in other planes & retro sagittal.

However, in my opinion it may be more of a physical competency thing.  Not enough of a lower extremity strength & power base.  Pelvic drop means the body is lollygagging in the force reduction phase, maybe as a protective measure.  Opinions?

No Magic Muscles

"The Relationship Between Hip-Abductor Strength and the Magnitude of Pelvic Drop in Patients With Low Back Pain- Kendall et al, JSR 12-10."


Pelvic drop in walking or running is not a good thing. It creates shear at the lumbar spine, is implicated in patellofemoral stress syndrome & medial tibial stress syndrome ("shin splints") et al.

These researchers wanted to know if strengthening the glut medius/minimus would improve the Trendelenburg sign (pelvic drop) during treadmill walking. This type of study has already been done studying floor exercise, but this one used, well, somewhat functional exercises. Interesting that while these two muscles did get stronger, it did not carry over to functional pelvic stability- the same result as the floor based strengthening exercises. But if you are a regular reader of my blog you'll understand why it didn't work. Remember Bosch's definition of strength training, "Coordination Training with resistance" and the outcome is no surprise.

GIRD of the hip?

"Velocity in Professional Baseball Pitchers Passive Ranges of Motion of the Hips and Their Relationship With Pitching Biomechanics and Ball- Robb et al, AJSM 12-`10."

Not me saying that, it's the authors!  Femoroacetabular dysfunction of the lead hip in baseball pitchers; causing loss of ball velocity and shoulder injury.  And, it was the first article that I've seen that suggested a correlation between GIRD and hip dysfunction.  The authors used fluid goniometry to assess passive AB/ADD, IR/ER of both hips (in prone by the way).  Interesting they didn't assess Flex/Ext; it would have been interesting to see how they influenced the previous.  A similar test was done recently by Todd Ellenbecker involving active ROM that didn't show as much of a deviation between R/L hips as passive ROM did.  The authors chose passive because they felt it also measured accessory motion.

Be sure to evaluate lead hip active/passive IR on the whenever you see GIRD of the shoulder and/or elbow injury in throwers. 

This is definately a case of "pattern overload" that could benefit from retro training, like doing some throwing with the opposite arm.

After Sid Viscious, the Ebonettes

After coming to my neck of the woods we can see why Malcolm Mclaren got bored with the Sex Pistols.  I always liked the Ramones better anyway. 

Just think of the ACL injuries we could prevent Tracy!

High Ankle Sprain-Day 3

Do your athletes still get advice to soak a sprained ankle in a bucket of hot water and epsom salts?
That's what happened here, but we survived it.  If you can exudate the substrate out of the ankle mortise with good acute care and early minimal weight bearing exercise, the injury should look something like this.  Aquatic therapy is particularly useful because of the hydrostatic pressure and weightless environment, so if you have access to a pool use it!  With the tape job described in a previous post, this athlete is already ambulating without an antalgic gait!  Ahhhh youth.

Functional Training= Purposeful training

This is part of the on ground sequence I used today for my  left "high" ankle sprain re-abilitation program.  Whenever you choose to go to the ground you have to keep in mind you are in a gravity confused environment.  So, the therapist needs to be certain they are getting something from the ground they can't get from upright function.  In this case I'm using contralateral lower extremity drivers to mobilize the affected ankle; because the athlete is not ready for full weight bearing.  I'm doing something that will enhance upright function and prevent soft tissue dysfunction.

Be wary of the mindless application of on ground function- it is rampant.

High Ankle Sprain

I took a snapshot of this because you don't see this too often.  An "isolated" high ankle sprain of the distal anterior tibiofibular joint.  The deltoid, ATF, CF, and PTF ligs, and posterior tibiofibular ligs were spared.  The transverse draw tests were negative for aberrant motion, but were minimally painful.

In this scenario the traditional Mulligan style taping for a positional fault of the distal fibula will give you good results; because it also provides good stabilization to the distal anterior tibiofibular joint.  I'm expecting this athlete to make a fairly quick recovery.

This is the future

Vern spoke at this conference at the UKSEM's invitation.  It's a quick read that will keep your compasses adjusted to true north.  It's not just track, it's going on in other sports also.  We A.T.'s; especially us old schoolers with a physical ed-motor learning background have an edge here.  Get over this blog being called Joe's "training room" and REALLY start defining yourself from other health care professionals.  At 51 I've never been more excited to be an athletic trainer.

http://www.guardian.co.uk/sport/blog/2010/nov/21/athletics-world-records

Goin' retro

I've previously posted on the value of retro training as an important part of the recovery/restoration process, but a recent conversation with fellow GAINer Chris Webb got me thinking.  I did some research into lower back pain in swimmers.  Apparently the stroke doesn't have too much to do with it.  The consensus seems to be the hyperlordosis created by the aquatic environment.  As a result, most of the treatments I've read involve pelvic stability stuff.  Consider a few other things.

The T-Spine:  This section of the spine is susceptible to Fryett's type 3 motion...that is, if one or more joints are locked up in one plane, that dysfunction will also carry over to the other two planes.  Most "movement screens" involve the transverse plane.  In my clinical experience, this is the "go-to" plane.  In other words, this is the plane that has the most range of motion in the T-spine.  So it can trick you. The frontal plane in both directions, and the sagittal plane in the posterior direction are the most affected in T-spine dysfunction.

The T-spine is a trouble maker; the lumbar spine a hit taker.  Since swimming is primarily driven by the hands top down, it might be possible that the T-spine is stealing the motion it doesn't have from the lumbar spine.

Retro-Training:  Janda coined the term "pattern overload", meaning sports that require repetitive motion in one plane in one direction (ie cricket bowling, pitching, swimming, running) may result in muscle & joint imbalances.  Simply doing some training in the opposite direction, or with the opposite hand my be beneficial in ameliorating this.

I'm suggesting two more variations- environment & orientation to gravity.  Using swimming as an example, simply switching from the Australian crawl (yeah, that's right, the Aussies invented the freestyle stroke) to the backstroke is probably not effective.  The reason being the body is essentially weightless.  To produce the retro effect I'm thinking you would need to go dryland/horizontal supine or full weight bearing.  Adding exercises to the athlete's repertoire like jackknifes, pencil rolls, reverse crunches (horizontal); posterior lunge-overhead medball combos, dropstep- overhead exercise band combos (FWB).

Please chime in, even if you think I'm full of it- especially if you think I'm full of it!

Yeah, but who has this kind of time?

"Negative effect of static stretching restored when combined with a sport specific warm-up component"- Taylor et al, Journal of Science & Medicine in Sport '09.

Static stretch, then negate the neural inhibition caused by the static stretch with a dynamic warmup.

Save the static stretching for the recovery/restoration phase; you'll get more out of it.  I know the so called "science" behind the "stretching a cold muscle is better" movement.  They are treating muscle and fascia as it is a plastic or metal, and not the living biologic tissue that is.

Taping for MTSS- The modified Hossler Technique

Learned this technique years ago from Phil Hossler, the great ATC at East Brunswick NJ, USA high school; and took some artistic license with it.  It's important to remember it's not a substitute for a good athletic development program that encourages lower extremity osteogenesis.  But used prudently, it does provide excellent results.

DiveBomb Pushup

This is a sports specific variation of the traditional pushup that places more of an emphasis on the lats.  Its an appropriate exercise for throwers, swimmers, and latter phases of shoulder rehabilitation.  Thanks to Adam Moss for naming it after the famous WW2 P-38 war plane- I am honored.

This 'n that 'n muscle slack

Muscle slack is a term I picked up from Frans Bosch this past summer at GAIN. Quite simply, it means the interval between initial muscle stimulation and contraction is too long. Don't confuse it with Coach Wilt's "amortization" term as it is applied to plyometrics. While Amortization is a proprioceptive term; muscle slack is more of a coordination term. Improper joint angles or posture at any given point in a skill results in a lack, or excessive pre stretch in any one given muscle.

I decided to do a post on it because it seems it is being misapplied on many internet sites. Exercises are singled out because the practitioners feel they contribute to muscle slack and should be avoided. I think the mistake they are making is applying it specifically to straight ahead running on a relatively flat surface. Once you get away from that, you need allot of tools in the toolbox. Please be prudent when applying sports specificity- you could be creating new problems.

So far I've only seen muscle slack applied to sprinting. It also happens in batting, tackling etc. I'll address it later posts.

I love "The Onion"!

Oprah Invites Hundreds Of Lucky Fans To Be Buried With Her In Massive Tomb

You can't afford NOT to have an A.T. on staff!

Potential Savings of a Program to Prevent Ankle Sprain Recurrence:  Economic Evaluation of a Randomized Controlled Trial- Maarten et al, AJSM 11-10.

A great, simple study with a large group of subjects comparing 2 groups of ankle sprain patients.  One with just initial acute intervention, the other with some proprioceptive training added in (common place in the high school setting).  The authors computed the cost of medical care/ lost productivity among the two groups.  The  mean costs per athlete in the intervention group was 81 euros ($112); and in the control group 149euros ($205).  This is the kind of data we should be presenting when we make the case for a full time A.T. on staff in this economy.  Overall it is just plain more cost effective.

Serious Computer Crash

Dropped my laptop on a concrete floor from a 1m height.  The weird thing is the diagostics are showing the hardware to be functioning normal; but the hard drive seems to be corrupted.  So, a clean install which wipes out everything.  I have everything backed up, but will probably take me a week or so to re install all the programs and what not.  I may be away a bit.

BTW- Anyone who wishes to contact me personally may do so through my Linkedin profile.  I think you have to establish a Linkedin account youself first.

The state of the art of Strength and Condtioning

Reading a round table discussion last night from a group of U.S. strength coaches.  Let me summarize  what I learned.

1.  Barbell squats of ANY type are BAD and should NEVER be done.
2.  There is an ANTERIOR and POSTERIOR chain that are separate entities, and need to be trained that way.
3.  The glutes are not activated by ground, gravity, and momentum like the other muscles of the body.  They need plenty of supine sagittal plane bridge work to fire properly.
4. Athletes must be trained on how to properly activate the lower extremity.
5.  Every athlete must static stretch/self myofascial release before every workout.
6.  Glutes and hamstrings MUST be emphasized over the quads.  Machines that isolate the "posterior chain" help.
7.  Use the FMS to evaluate physical competency to do a sport.

One of the things I love about the GAIN network is the diverse background of the group- geographically, culturally, and knowledge base.  While it's the Gambetta method that unites us, we definitely have a wide variety of opinions on how to get from point A to point B.  And understand there are many ways to get to Rome sort of speak.

At least in the U.S., I see a lot of intellectual isolationism going on in this profession.  You could easily be led to believe for instance that,
1.  Tom Myers fascial work from 10 years ago has never been expanded upon.
2.  The efficacy of the FMS has never been studied.
3.  Muscles function independently of modern motor control theory.
4.  Human tissue has the same mechanical properties as plastics and metals.

I know sometimes I come across as just saying things for the sake of being different.  And, I also understand that sports medicine is a discipline that has always been driven by the practitioner first.  But always remember I'm not just some internet guy- I make no money with this blog.  I earn my living being a real life ATC in the biggest high school in NJ.  The time I get to spend with each athlete is limited, and very precious to me.  Everything I do has to give me the "biggest bang for my buck". 

I can't afford to take wrong turns.

Good Question

Kevin Moody asked a good question in response to my "Taking advantage of the topography" post I thought deserved a separate post:

"Just tried some retro & side walking on the treadmill with an incline pitch. Had to slow the speed down for the side walking. Could definitely feel the quads working on the retro walking but wasn't getting much on the side walking. However, I was only experimenting and did not have a lot of time play with it.

Any thoughts?"

That would make sense Kevin.  If you were walking down the hill, the lead (lower) leg would be resisting momentum and abduction.  On the treadmill, there is neither.  In order to get the same effect on  treadmill, I'm thinking you would need to do a tapioca with the affected leg to the rear.  Safety would become an issue; be sure you have a bar to hold onto.  Try it and give me your thoughts.

Meanwhile, I'm stilllllll thinkin'......

This is one of our athletes scoring what would be a 1 on the ankle dorsiflexion PCA test- the toes only 2cm from the wall and the heel already coming off the floor.  It is fortunate she is not a rock & roller back in the 50's because she would never be able to do the famous Chuck Berry duckwalk.  Back then we didn't worry about the knees going past the toes when we squatted.  We were too busy ducking under our desks training for when the Russians would drop the big one on us.

Think I'll keep a Fender Telecaster handy in my AT room and use the duckwalk as a remedial exercise:

"OOOOHHHH Carol don't let him steal your heart away, I'm gonna get that ankle ROM back if it takes me all night and day"

The rest that's best- the shoulder

Subacromial pressures vary with simulated sleep positions: Journal of Shoulder & Elbow Surgery, 10-10; Werner et al..

The researchers studied subacromial pressure in subjects side lying, prone, and supine.  Both the side lying & prone positions place at least one arm in an abducted and/or internally rotated positions for 8 hours at a clip.  Not suprising they increase subacromial pressures greater than the supine posture.  The authors were studying this in the context of the post surgery environment, but I think it's safe to assume the same happens in the throwing athlete recovering from a tough day of practice. 

It's interesting when 2 years ago researchers were studying sleeping posture relationship to kidney stones, the side lying position was again implicated in 88.2% of patients.

But yet the side lying position is often advocated in patients with low back pain, and the back to nature primal enhusiasts.

I don't know, when I sleep I'm flopping all over the place like a fish.  Does anyone know if a sleeping position can be taught?

Veteran's day 2010: Corporal Francisco Jackson

I wish a year could go by without me posting about one of our ex athletes dying in battle.  For many of us these faces are strangers & its easy to forget the U.S. is still very much involved in a war.  I have my own feelings about it, but this blog is not the place for such a discussion.  Francisco was a wrestler of ours. 

Domination!

Congratulations to Coach Jack Martin and the Westfield Blue Devils for once again wiping up the competition at the Union County NJ Cross Country Championships.  5 of the top ten finishers were from Westfield!

The rest that's best

Treatment of chronic radiculopathy of the first sacral nerve root using neuromobilization techniques: A case study -Journal of Back & Musculoskeletal Rehab 9-10, Talebi et al.

A good book for every A.T.'s personal library should be Australian David Butler's "The Sensitive Nervous System".  It's full of great, safe, easy to learn neuromobilization techniques.

This is the kind of stuff I think belongs in the recovery/restoration phase of training.

Where did that day after the high school football game lifting/running deal begin?  All you see is a bunch of sore, tired kids using bad technique and slogging.  After a collison sport like football or rugby, why not an extended dyamic flexibility routine; something that looks like yoga or thai chi?  It's a great way to get some neural mobilization going before the fibrin and elastin from the inflammatory injury response bites down on the axons.

Taking advantage of the topography.

We have a  40 degree hill outside the front of our gym that I'll frequently use when treating patellofemoral issues.  The two exercises pictured are backward walking up the hill, then frontal plane walking down the hill with the affected leg on the down side.  The exercise creates a great  "integrated isolation" in the lower quad/VMO muscles.  The movement naturally creates a slight backward lean of the torso which tweaks out the glutes and erector spinae.  I like the athlete to do enough reps that it creates a good burn in the lower thigh; about a 2 minute rest, then 10 sets.

For some reason, running the movements doesn't work as well; not even as a progression.  A good progression is weighting them (pictured), or resisting them with a belt & bungee cord.  Sometimes athletes ask me what the difference would be walking backwards up a stairway.  My simple answer is it hurts and it doesn't work.

It's great for any patellofemoral issues, i.e. "jumpers knee", patellofemoral stress syndrome.

Finesse!

This is Pat Fisher, an NFL hall of fame defensive  back for the Washington Redskins back in the '70s.  He is 5'8" tall, and 170 lbs was the most he ever weighed.  The greatest tackler I've ever seen; had no problem bringing down the biggest guys in the league and I don't recall him ever being injured.  Sure there were guys who hit harder.  They are either dead or seriously incapacitated.

Someone who new I was a big fan sent me a recent picture of him surrounded by Hooters girls signing autographs.  You go Pat.

Make failing to tackle without "wrapping up" a 15 yard penalty.

Transitioning/Sequencing

Come on, its happened to the best of us.  An athlete has a muscle injury, you tested them well, you thought they were ready to return to play and they wind up with a re-injury.  It could mean you didn't transition them well and sequence their return to the activity.  The example here is a grade 2 rectus femoris strain of the right leg.  The plane here is to transition to straight ahead running by sequencing what movements we do in what planes, in what directions, in what tempo, in what speed, at what amplitude, and at what degree of fatigue environment is appropriate for that degree of healing. On ground, the athlete is doing frontal/T-plane with a sagittal plan bias.  That include activities like lateral lunges, slide board, and icky shuffle in the agility ladder.  I'm using the accomodating resistance of aquatic therapy for my sagittal plane work.  The exercises pictured here are deep water pikes/rotational pikes, and B-skips in the low end of the pool.  With the help of the water, you can get pretty agressive without concern of re-injury.

Don't throw like a girl! Don't land like a girl either?

With all the great ACL prevention programs out there, why are these injuries not going away?  Kinesiologist Scott McLean is going to make you think:

http://journals.lww.com/acsm-essr/Fulltext/2010/10000/Complex_Integrative_Morphological_and_Mechanical.7.aspx

Biomechanics and Motor Control come together

This article reminded me of that old peanut butter cup commercial where the peanut butter truck and the chocolate truck run into each other and make a delicious treat.

Great article in this months Journal of Sport Science Research by Natalia Dounskaia, a kinesiologist from Arizona State U.

"Control of Human Limb Movements: The Leading Joint Hypothesis and Its Practical Applications".

Ever since I read Dr. Lederman's book and heard Frans Bosch speak and do in Florida this past June I realized I was behind the 8 ball a little.  They drove the point home that not all movement is driven by the proprioceptive system.  Rather it's the muscles communicating with each other; much of it independent of the CNS.

"The LJH is based on the idea that the CNS exploits the biomechanical properties of the limbs for movement organization.  One of the most influential biomechanical properties of human limbs is that they are linkages of several segments.  This multijoint structure causes motion-dependent mechanical interactions among the segments represented by passive ‘‘interaction’’ torque (INT) exerted at each joint. INT has a complex, highly nonlinear nature, making motions at all joints of the limb interdependent."

"An advantage of the LJH is that it makes organization of joint control during each movement transparent. Revealing the leading and subordinate joints clarifies both the control strategy applied to the entire limb and to each participating joint."

Funny...its getting simpler and more complex at the same time.  Stay tuned.

Applied Osteopathics

Here is an actual exercise I used to follow up my on table manual muscle energy technique for an injured athlete.  The athlete had hurt his back doing a maximal deadlift while I was down in Florida with GAIN this past June.  By the time I got to him a few weeks later he had no lordosis in his spine and a left lateral shift.  My evaluation revealed a type 2 dysfunction of his lumbar spine.  Nomenclature it L3 ESRL.  That is, lumbar vertebrae 3 was stuck extended, sidebent, and rotated left.

The exercise is a right side lying modified (bottom knee bent to shorten the lever arm) rotational plank.  We're using gravity to gently mobilize the spine through muscle contraction, yet  prevent the trunk from going through the interbarrier zone of the injured joints; in all three planes.  In other words, the body position, ground, and gravity are blocking the body from where it can't go yet.  The starting position takes us deeper into the dysfunction so we can use the explode out of it to assist the correcton.

Don't Inhibit...Facilitate!

I am so sorry about my lack of posting this fall.  Tons of stuff to get to, just haven't had the spare time to sit down and put any coherent thoughts together.

I probably use the least amount of athletic tape of any ATC here in northeastern N.J.- about 25 cases of 1.5" Zonas Speedpack per school year.  In comparison, some of my colleagues go through 60-80 cases- all that wind up in the garbage and finally in that landfill in Staten Island that is large enough to be seen from outer space now.  But my athletes are no different, they want to look like the kids from the other schools and the guys on TV.  So they sneak in and steal some tape to spat their shoes because I refuse to do it.  I feel bad- most of the teams we play even have fashion team color spatting!  Of course I tell them there is no evidence what so ever that spatting is effective and it's a waste of money and time.

Why would you want to inhibit ankle motion- especially dorsiflexion?  How can you play low and get underneath your opponent and knock them off their feet if the knees can't translate over the toes?  Yet many of my American footballers would have a tough time passing the PCA test for ankle dorsiflexion.

Natrally the healing ankle requires support.  Most ankle braces do their job, but aren't of a low enough profile to fit inside the shoe without distorting it or causing blisters (the ASO comes close).  I've been experimenting with a technique that uses 4-5 strips (specific to the injury) of Coverroll Stretch and Leukotape P.  If you cut the strips ahead of time, with a little practice you can apply it just as fast as a traditional Gibney Basket Weave.  If the ankle is shaven, all lotions removed from the skin and pre-treated with Cramer Tough Skin, the tape will usually stay on 2-3 days.  As long as they don't go swimming or sit in a bath, I instruct them to blot it dry with some paper towel after they towel off from the shower.

Go ahead and give it a try and let me know what you think!

No Short Cuts

Injury Reduction Effectiveness of Assigning Running Shoes Based on Plantar Shape in Marine Corps Basic Training -Knapik et al; Am J Sports Med September 2010.

Here there was no difference between the control group and the experimental in preventing injury.  It all starts with physical competency and good planned performance training by the coach. 

Sub-Concussive Brain Injury

This U. Penn FB player was never diagnosed with a concussion:

http://www.nytimes.com/2010/09/14/sports/14football.html?partner=rss&emc=rss&src=ig

Long days

Sorry-  I'll get back to posting soon.  This should be my last 70hr week for a while.  Lot's of interesting stuff going on, just too hectic to get the digital camera out and edit.

Any Bryan Ferry fans?

New album out this October

Lou Gehrig's disease or cumulative brain injury?

I had no idea Lou Gehrig was a running back at Columbia.

http://www.nytimes.com/2010/08/18/sports/18gehrig.html?_r=1&partner=rss&emc=rss&src=ig

Thought provoking cognitive research:

http://www.nytimes.com/2010/08/16/technology/16brain.html?_r=1&partner=rss&emc=rss&src=ig

"Negatives"

This was a recent topic of discussion on the GAIN forum:
http://news.medinfo.ufl.edu/articles/top-stories/the-negator-muscle-building-science/

I'm not sure why this is rearing it's head again.  The concept of eccentric resistance training was popular in the 80s. If I'm not mistaken, at the end of the decade there were even companies that were iimplementing it in isokinetic machines. 

In my mind, strength training is more than just sarcomeres.  There's a motor control element to it.  On page 28 of Richard Magill's new edition of his "Motor learning and Control" book, he says, "..researchers interested.in understanding the action preparation process are able to to obtain more specific insights into what occurs as a person prepares to move.  Most reseachers agree that the premotor time is a measure of of the receipt and transmission of information from the environment, through the nervous system, to the muscle itself.  The time interval seems to be an indicator of perceptual and cognitive decision making activity in which the person engages while preparing an action."

The machine scenario seems not to be concerned with any of this, only overloading the eccentric phase of a specific unidirectional, uni plane movement.

Eccentric overload requires a good amount of isometric stabilization to handle the extra load.  Let's take a squat.  If we use a weight beyond our 3R maximum we need to lower the weight very slowly and use spotters for the concentric portion to avoid injury.  However, in my scenario, we can use a weight well below our 3R max, but instead actually "pull" the weight down to increase the eccentric momentum; then abruptly stop it at the bottom and concentrically return it under our own power.  The neural component of the squat can be ehanced even further with a command by the coach to abruptly freeze and hold any position for a given amount of time.  It also creates a great anaerobic effect.

Comments?

Wait and see?

Sorry I haven't been posting.  Pre season football is at critical mass.  Enjoy this article brought to my attention by fellow GAINer Sal Marinello.  It concerns delayed ACL reconstruction.

http://www.nejm.org/doi/full/10.1056/NEJMoa0907797

Good Book

In my very limited spare time this August I'm reading the 9th edition of Dr. Richard Magill's, "Motor learning and Control- concepts and applications.  I actually already own the original editon of the book, but Magill updates his reasearch every few years to stay up to date with current research.  Remember function is not just biomechanical! This is the kind of stuff that seperates athletic training from the other healing arts.   A thought in the back of my head- if movement is goal/task oriented...then does a one size fits all movement screen make sense?

Soft Tissue Influences Structure

As I've posted before, the Italian Spine Institute (http://www.isico.it/ukcosa.htm) is doing some very cool work with scoliosis.

Here's some new research from Italy's neighbors the Swiss published in the August issue of the "Journal of Sport Rehabilitation"- Paraspinal Muscle Activity During Symmetrical and Asymmetrical Weight Training in Idiopathic Scoliosis.  What was special about this study was the simplicity of the application of exercises.  They chose 4 common weight room exercises:  front press, lat pull-down, roman chair,and bent-over barbell row to influence the muscles on the concave sides of the curves.  By altering the sequence of the exercises they successfully targeted the traditionally flaccid muscles on the concave sides of the S-curve in the T-spine and L-spine.  The lesson to be learned here it's more than just the exercise itself.  Simple variations like using different size dumbbells, changing your vector, the speed, the range etc. can all have a profound effect on your results.  There is no one size fits all; the ATC needs to think on their feet.

ATSNJ Concussion Summit

Kudos once again to Eric Nussbaum ATC for once again putting together a great seminar.  These are notes from Dr. Rober Cantu's presentation, and the roundtable discussion which followed:

-VERY important the athlete is permitted appropriate time for healing to take place.
-There is no set number of concussions that is a disqualification for further participation in contact sports.
-2 man wedge tackling, blindside hits rule changes in American football are in order.
-No way to predict CTE in a live person; lawyers should not be driving decision making.
-Concussion accounts for 6-10% of all athletic injuries.  The reported ones are just the tip of the iceberg.  Subconcussive blows and their effect is an unknown factor.
-Loss of consciousness is not a good indicator of degree of brain injury.
-You don't need to grade a concussion to manage them efficiently.
-Time to recovery is a good indicator for risk in subsequent concussions.
-When a player shows any symptoms of concussion, they should discontinue participation at least for that day.
-The cornerstone of concussion management is physical and cognitive rest until symptoms resolve.
-Prolonged post concussion syndrome (1m+) is usually associated with playing with a pevious head injury prior to the concussion.
-Concussion Research- Journal of Neural Trauma:  http://www.liebertonline.com/toc/neu/27/7
-Many concussions occur at lower force, 60G's and below.  The new NFL helmet recommendations are suspect because they involved testing at higher G's.  Head and spine biomechanist specialists were not used in the study.
-Since every concussion is different, is legislating concussion guidelines a good idea?

Something to Ponder...

In my last post I mentioned that strength training has changed a lot in the past 15 years.  I should say, what we know about it.  Because if you look around, especially in football strength and conditioning, it's the same ole same ole with some tire and rope flipping tossed in.  Bosch's definition of strength training is, "Coordination training with resistance".

THAT is where we should be headed.

Reducing ground contact time in runners

Coach Martin brought up a good topic; both for A.T.'s and coaches alike.  The longer the foot remains on the ground, the more things can go wrong.  I believe there are 2 components to getting off the ground faster.  The first is strength, the second is neuromuscular coordination.  Whenever I talk about strength training for runners, I always go back to an old NSCA article from August of '95 (can't seem to locate it through the NSCA article search, sorry):


The coach put his girl's cross country team through a dumbbell weight training routine. Nothing fancy,  Some of the exercises were specific to running, others were not.  They had maintanance workouts two days per week in season.  The results:  The times of every athlete on the team improved.  Of course a lot has changed in the past 15 years, but the point remains the same.  That is, the right kind of strength training helps bone density and resists gravity from smashing the body like an accordion with every step.  Every (high school) athlete should be able to do a single leg squat to at least 90 degrees without the torso leaning forward and hold it for at least 30 seconds without motion.  Every athlete should be able to give you at least 15 good pushups (girls included) without technique breaking down.  Every athlete should be able to jump out at least a meter and stick their landing without any wiggling.  Every athlete should be able to lunge 3/4 their height for 30s with the knee remaining over the ankle.

Frans Bosch turned me on the neuromuscular component of running.  At ground contact, the knee of the trail leg should be passing the weightbearing leg.  This is important in locking up the front side and propelling it off the ground; minimizing ground contact.  At GAIN this year we had the opportunity to have him put us though many of the drills in his book/DVD.  Running with a jump rope is one of the best drills you can do to help clear out mechanical issues that contribute to a long ground contact.  If you paw the ground, if your trail leg is lollygagging behind you; the rope will stop you.

Joe's Training Room, 2 years out

...and I'm still struggling with the same issues from last year.  Mainly trying to get more high school A.T's involved here.  The blog is not growing, still staying steady at about 65 hits a day.  Hey, I know part of it is my own fault, like not having a Youtube channel.  I was even considering dropping the blog and moving over to the NATA Think Tanks.  However, I followed it for a while and found the participation was even worse.  It has not been a good year for me; an '11 NATA presentation on function is not going to happen.  I don't really understand whats not to like about the approach- it's inexpensive, it adapts and changes to the latest research, and it works.  In addition, after hundreds of hours of work on the ankle book, it is probably not going to happen.

But hey, for those willing to listen there's still plenty of stuff to get to here.  Loads of great ideas and research to digest and apply.  Hope you enjoyed the last year, and as Jay-Z says, on to the next one!

Lateral Epichondylitis (Tennis Elbow)- Less is More, Redux

Thanks fellow GAINer Randy Ballard to this link on an exercise for tennis elbow rehab:
http://well.blogs.nytimes.com/2009/08/25/phys-ed-an-easy-fix-for-tennis-elbow/

I think it complements my post from about a year and a half ago on the topic:

http://well.blogs.nytimes.com/2009/08/25/phys-ed-an-easy-fix-for-tennis-elbow/

Mi Muchacha's Birthday!

Great seats behind home plate at Yankee stadium; then onto the best soul food in the U.S. at Sylvias on Lenox Street in Harlem.

Great Overveiw

Femoralacetabular Impingement in Athletes, Part 1: Cause and Assessment- Byrd, Sports Health 7-10.

If an athlete complains of chronic iliopsoas soreness and/or low back pain that doesn't seem to clear up; be sure to screen for FAI.  I'll post myself doing some tests at a later date.

Occlusion Training in ACL Rehab

I've commented on this issue in the past:

http://joestrainingroom.blogspot.com/2009/06/blog-post.html

I didn't realize it had crept into ACL reconstruction rehab.  I'm going on record here as saying don't do it.

I understand arthrogenic muscle inhibition (AMI) is an issue in knee injury; it's well documented in vitro and vivo.  However, neuromuscular facilitation is a lot more complex and time consuming than increasing the size of a sarcomere.  Unless I'm wrong, all of the research on the topic has been at the myofibril level.

Don't be a reductionist; think global, think functionally.  Think about what is taking place here.  You are applying a tourniquet to a limb.  You have have no doppler studies.  The risk here is deep vein thrombosis.  If you think I'm being reactionary here, that DVT following ACL surgery is a rare occurance, take a look at this study-

http://www.orthosupersite.com/view.aspx?rid=22838

If your goal is to hypertrophy the quads, there are safer, more tried and true ways to do it.  We did it in the past with our old NK tables, leg extension machines, orthotrons, KinComs etc.  Those quads came back fast!  Obviously it wasn't the answer.  I know it's frustrating when an orthopedist judges return to play by plopping your kid on the table and putting a tape measure across their thighs.  Stay focused.

E-Stim to the quads & ACL Rehab

"Effects of NMES after ACL Reconstruction on Quad Strength, Function, & Patient Oriented Outcomes:  A systematic review"- Kim et al, JOSPT 7-10.

"There is no evidence to conclude that NMES has an effect on functional performance when measured by anterior reach, lateral step up, and unilateral squat tests..."

"The best evidence suggests that 4 weeks of NMES using a clinical stimulator in conjunction with exercise therapy can result in a moderate effect in self reported patient outcomes at 12 and 16 weeks post operatively..."

"The effect of NMES upon functional performance is unconvincing, and the imprecision in the limited reported results suggest that a clinically meaningful benefit may or may not exist..."

From what I understand from the research, the clinical grade NMES units seemed to improve isometric knee extension strength better than exercise alone.  But...is isometric strength really "NEURO-muscular", and isn't our goal squelching NEUROmuscular arthrogenic inhibition?

Post pitching arm icing?

http://www.boston.com/sports/baseball/articles/2010/07/11/arroyo_has_dealt_well_with_life_in_cincinnati/

Thanks for fellow GAINer Mark Day for the heads up on this article on Cincinnati Reds pitcher Bronson Arroyo.  Scroll down a bit and read his comments concerning post game arm icing.  It's a bad habit to get your players into.

Bookmark this website

http://strengthplusmagazine.com/

Thanks to Tracy Fober, P.T. for the heads up on this.  I've long been a fan of weightlifting derivatives for athletic development.  I think this website could help bridge the gap.  They have a free online PDF magazine, at least for this month.  Worth a look.

Physical Literacy...Do your athletes have it?

I describe a lot of different exercises in this blog that are all appropriate in the right place and time.  However, they are no substitute for physical competancy.  You can pass someone's movement screen and not be physically literate, that's why I don't care for movement screens.  I doesn't make a difference what sport you do, it's universal to all.  I have always admired the Australians.  I always thought they do the best with the small population they have.  Yes, I know it is the size of the U.S., but the central part of the country is mainly uninhabitable.

Coach Kelvin Giles is the CEO of Movement Dynamics (http://www.movementdynamics.com/).  He has quite an international resume.  Educated in the U.S.; then on to the U.K. to coach track and field; back to Australia to become Performance Director for the Brisbane Broncos; and a lot in between.  His broad background led to to develop a set of tests that are universal to all sports.  Pushing, pulling, squatting, rotating, the ability to hop and stick a landing.  Then the ability to measure it and use it to put together a picture a that athlete's level of physical literacy- independant of their skill in a particular sport.

It's the lack of physical litercy that will ultimately limit the athlete's ability to reach their potential.  It's not designed to be an injury predictor, but from the experience I've had with it, it does indeed.  It involves a series of tests and specialized instruments which all gets plugged into a software program that Coach Giles developed.  The PCA (Physical Competancy Assessment) is all ready to be rolled out in the U.S. If you are interested, you may contact him at his website.

Hip to Shoulder Lats

What do you think?  If you were developing a performance/prevention program for a thrower, might these be more appropriate exercises for the lats than a lat pull down or a pull up?

1. Reverse pyramid pushup

2. Windmill lunge

3. Drop step lunge with R/L hand 120 reaches @ overhead.

  Notice I've got the pelvis moving in synchronization with the shoulder, with the hands moving a bit faster by way of the momentum in the 2nd and 3rd pics .  Neither the pelvis or shoulder are fixed.

Great Overview

" Extensor Coxae Brevis: Treatment Strategies for the Deep Lateral Rotators in Pelvic Tilt"- Thomas Myers (of Anatomy Trains fame), Journal of Bodywork and Movement Therapies- July '10.

If we look at the inominate (ilia) bones as the pelvis as the lower extremity scapulae, and the femur as the LE humerus, these muscles would make up the LE rotator cuff. Like the scapulae, the ilia are only dumb bones, and do what the muscles tell them to do. If they are given erroneous information the deep hip rotators, like the rotator cuff of the shoulder they will become stiff and painful.  It's nearly impossible to treat them by traditional methods like ultrasound, electrical stimulation, and therapeutic heat and cold.  They are too deep.

It's common for these muscles to become stiff and fibrotic in any lower extremity injury. In the case of the ankle sprain, it can even set you up for another injury, as lack of hip internal rotation has been indicated as a causative factor in inversion ankle sprains.  Myers also makes the comment that when these muscles are hypertonic, the adductor magnus is should also be suspected (he is correct).   Remember any injury is an opportunity for the athlete to do remedial work on things they didn't have time to focus on before.

While well intended, traditional exercises prescribed for lower extremity injuries, such as a stationary bike, may exacerbate this problem.  Many common Yoga exercises address this area.  Non weight bearing hurdle steps are also a good alternative.

Torn Lat- your opinion please

If you are not familiar with Jake Peavy's pitching mechanics, here is the link with commentary:

http://www.chrisoleary.com/projects/Baseball/Pitching/ProfessionalPitcherAnalyses/JakePeavy.html
OK, I know he was a Cy Young award winner. But as I have said in the past, those pitchers who push off the rubber do not have long careers. Jake tore the insertion of his right latissimus dorsi off the intertubercular groove of the humerus. Take a look at the videos and give me your opinion as to what about his mechanics could have caused the injury.

Your hip bone connected to your back bone.

The old "Dem dry bones" song.

"The Association Between Low Back Pain and Osteoarthritis of the Hip and Knee: A Population-Based Cohort Study"- Stupar et al; Journal of Manipulative and Physiological Therapeutics 6-10.

The authors studied the relationship of hip & knee osteoarthritis to low back pain. There was a strong correlation between hip OA & low back pain. The lumbar spine is stuck between two trouble makers- the hips and the T-Spine. If the pain is lower lumbar, always take a look at that those hips. The modified Thomas test is a good, quick screen.

Inner Core? Outer Core? Time to move on

This is one of the ground based exercises from my upcoming ankle book. Look A.T.'s, we've got to move past this inner core/outer core stuff- and all the testing and corrective exercises that go along with it. If you have no idea what I'm talking about, good for you. The model that validates it is 35 years old now, and the newest motor control research does not support it.

The core already knows what to do and when to do it and how strong to do it and in what direction to do it and in what plane to do it and at what velocity to do it; kind of like Beetlejuice from the Howard Stern show. Give the body a movement task. If it zigs when you expected it to zag it is outside the zone of function. Shorten one or more lever arms and try it again.

What's old is new. Unfortunately, what's new is old.

A great Question

As usual, JH asks a great question from my last post that requires further elucidation:

"Since the idaea of function is many muscles, joints, systems, etc, how then does the knee, hip, sacrum, spine have the ability to respond at ground contact when so little time is spent there? Wouldn't the information recieved in the sacrum for example take too long to get there as well as the response to that stimulus?"


The proprioceptors are very much there Jonathon, but according to Lederman act in concert to "fine tune" movement rather than act in a reflex manner, say like when you touch a hot stove. I thought Oschman was nuts when he first proposed the idea of fascia having it's own nervous system; but damn, the research seems to be headed in that direction. Remember when we use the term "functional" it is not the same as biomechanical. Biomechanics are integrated in with function, but it is the neuromuscular system that drives it. I don't see the neuromuscular approach and the functional approach as a one or the other thing; but that's my personal opinion.

Bosch 101

Vern used the analogy of a caterpillar. How does it know which leg to move and when? It has a very primitive nervous system, with no brain to speak of to organize these movements. In my ankle book due out this fall, I mention the fact that in sprinting, ground contact time is too short for proprioceptors to have any input. In sprinting, foot ground impact force takes less than 50ms to reach its peak magnitude and ankle inversion can reach 17 degrees in as little as 40ms. Under these conditions the spinal reflex is too slow to initiate a corrective response.

Frans Bosch believes that, rather than reflexive, this type of neurological input is contained in the muscles themselves. The latest research coming out of last year's fascia congress seem to support this. The "cross talk" that EMG techs see on their monitors might just be a way that muscles communicate with one another. What implications does this have for injury prevention and rehabilitation? For starters, if you are doing proprioceptive training on wobble boards or something similar, you may just be training the athlete to be successful on a wobble board. It may have implications for those who need to perform on unstable surfaces (like surfers), but questionable for others.

The other points I get out of it is time and repetition. The way I see it, it's doubtful this type of motor re-organization can take place in the typical 12 week institutional rehabilitation scenario. The athlete must take an pro-active role in this process (A.T./coach directed; athlete centered). Even in Frans' world, laziness is a hinderance to performance and getting well.