Veal

A term I borrow from my pal & NJ wrestling legend Gerry Nisivaccia. This describes the high school age athlete who's physical maturation is lagging a bit behind his peers, yet must compete with them. It's a mixed bag. On one hand, this athlete learns to succeed with finesse because the testosterone isn't pumping full blast yet. Once they do fully mature & the strength kicks in, they have the complete package.

However, this does make them more prone to injury. This athlete came to me complaining of a "popping" shoulder. His GH joint is subluxing; not good if you are a wrestler. My plan is to remove him from the sport for two weeks, initiate an aggressive neuromuscular stabilization program. At the point I'm fitting him with a Sully shoulder brace & allowing him to return to the sport while he continues his daily rehab protocol. I've used it before, it is a great pro-active approach. Dislocated shoulders rarely occur as a one shot deal. They nearly all of the time give the athlete that "popping" warning.

Here's a bottom-up scooter exercise. Their body is in a pushup position, while they circumduct the lower extremity clockwise/counter clockwise. It's a cool neuromuscular challenge for the scapular stabilizers. A good rule of thumb is if they can listen to their ipod & talk to their friend while they're doing an exercise; the exercise is probably not neuromuscular.

Which means you are wasting their time.

Any old timers remember this article?

Going back to my student A.T. days at Montclair U. back in the late 70's...there was an article in an old NATA journal called "balance padding for the athlete". It was part of this great lecture series that Schering-Plough used to do. I cut it out and held on to it for decades until it finally got tossed out with an old file cabinet. It was an idea that pre dated orthotics, the concept of placing materials in a shoe to treat various foot conditions. It was a great tool for athletic trainers! A cheap, low tech tool for athletic trainer to treat everything from neuromas to sprained ankles. I forget what material the author suggested, but I used different sizes of felt & it worked just fine. Any suggestions on how I can dig this up?

More good news on IASTM

It is looking more & more like this stuff has a place in the ATC's toolbox. From the APTA combined sections meeting:

Instrument Assisted Cross Fiber Massage Improves Blood Flow Following Knee Ligament Injury Suggesting Enhanced Angiogenesis- Loghmani et al/ Indiana USA

Graston Technique was applied for ONLY 1 MINUTE 3X PER WEEK FOR 3 WEEKS to lab rats surgically transcected MCL's. Showed vasodialation through the ligament beginning 24 hrs post treatment, and lasting 1 week upon it's cessation.

Just finished an email discussion with fellow functional ATC/GAINer Kevin Moody regarding patellar tendinosis etiology & treatment. The effected area is usually at the bone/tendon interface where blood flow is the poorest. I've been using this as an adjunct since the fall with good results.

Of course more good double blind placebo studies are needed in the human population. But sports medicine has always been practitioner driven, and a little kitchen chemistry appears to be safe and in order. This is how we roll at GAIN.

http://www.gambetta.com/Merchant5/merchant.mvc?Screen=CTGY&Store_Code=gambetta&Category_Code=Aprentorship

Elbow Dislocation Rehab

It's wrestling season, & elbow dislocations come with the territory. By the way, I DO NOT reduce these. The risk of neurovascular trauma is too high.

Every A.T. that's work with the posterior elbow dislocation knows what a difficult task it is achieving full ROM, and occasionally you never do. The technique I'm using in the photo is a Mulligan MWM. It's actually designed as a protocol for lateral epicondylitis. I've never had much success with it as a treatment for that injury; I'm wondering what others experience is. However, I've found it to be a terrific mobe for sprained/dislocated elbows.

The mobe belt is placed on the proximal forearm. I've got my left hand positioned inside the belt on the distal humerus, my elbow braced against my abdomen. By gently leaning back I'm producing a lateral glide to the ulna. The athlete is actively flexing/extending the elbow as pain permits. I instruct the the athlete to reverse direction just as they begin to feel the first twinge of pain coming on. Its important to rotate my pelvis clockwise & back as the elbow flex/extends to match the elbow's carrying angle. I can add a little pronation/supination to the elbow as necessary.

The technique is well described in Mulligan's book, "Manual Therapy: Nags, Snags, MWM etc."

Oh yeah, & when coach Fober tells you to watch your snatch grip, well, you better listen.

http://ironmaven.blogspot.com/2009/12/shoulder-position-for-snatch-grip.html

"Functional Balance?"

Coach Jack Martin asks a great question regarding his own experience with balance acquisition following some minor knee surgery.

It's important to set our athlete's up for success. Begin where their strengths are, not their weaknesses. Find that athlete's envelope of function and work at the edges, with the goal of expanding that envelope. Be wary of these guys that insist on standing on unstable surfaces (bosu, tilt boards, dynadisks). It's very rare that in vivo the floor will be moving beneath you, except maybe if you surf or do boating. I'm not saying to avoid it, just saying it should not be the main focus of balance rehab. Teaching yourself to be still on an unstable object has little carryover to function.

If you are confused, take a look at this link to an article on balance by my GAIN buddy Steve Myrland. Steve takes his que on balance training from Bruce Lee's "The Art of Jeet Kune Do". On page 4 Steve gives a great synopsis of what a great balance progression should look like:

http://www.mihisoccer.org/Supplemental%20Material/Forms%20for%20Web%20Page/Steve%20Mryland's%20Condition%20Handout%20-%202002%20Clinic.pdf

Sports Hernia

Garvey et al- Sportsman hernia: what can we do? Hernia. Jan. 12, 2010


The author's state risk factors as reduced hip range of motion and poor muscle balance around the pelvis, limb length discrepancy and pelvic instability.

I think this is all stuff we as A.T.s can be proactive on. Leg length discrepancies can easily be treated with some 1/8, 1/4" felt in the (full length of the) shoe of the shorter leg. Make sure the athlete can functionally 3D load the hips & abs. You would be surprised, for example, how many athletes cannot perform a decent posterior lunge. Traditionally, pelvic stabilization programs are performed in bridging variations. The problem with this approach is you're using the pelvis as a driver, really not getting the athlete into the proper transformational zones. The ab/groin region must be loaded bottom up/top down to be effective.

I'm really surprised the authors never mentioned femoral torsions as an etiology. I think I'll contact them and see what they think.

Rehab it as you see it-ankle taping

Facilitate good joint mechanics, don't inhibit all of them. Traditional American ankle taping inhibits dorsi/plantar flexion quite a bit & is expensive. In addition, it's very generic. This athlete's ankle sprain was to the posterior talofibular ligament (see the edema?), the distal tib-fib ligs (I believe MOST ankle sprains have a "high" ankle sprain component that causes most of the disability), and the medial fibers of the deltoid lig. In other words, there was more internal rotation to this sprain than inversion.

The first strip of tape is a piece of leukotape applied to the lateral malleolus running posterior/superior & anchored to the anterior/distal tibia. This is the traditional Mulligan style taping for a positional fault of the fibula on the talus. This is effective for most ankle sprains, although it may not have anything to do with a positional fault. I think gliding the distal fib back takes some stress off an injured posterior talofibular lig; and the circular pattern approximates the distal tib/fib joint.

The 2nd strip runs underneath the medial calcaneus & anchors just below the medial malleolus, reducing stress on the deltoid lig. I know you are wondering about the varus angle the tape has created, but don't worry. As soon as the athlete ambulates ground reaction force will cancel that out. This athlete was so comfortable after the taping he practiced the following day & played in next day's game.

Taking the time to do a good traditional & functional evaluation of your athlete's sprain creates more effective rehab strategies.

Bookmark This Page:

http://www.biomedcentral.com/bmcmusculoskeletdisord/

A pretty damn good free online journal.

I was just thinking...

In the early '80's arthroscopic synovial plica surgery was all the rage. Everyone had one that had to be removed. What happened?

Does this surprise any A.T.'s out there?

Platelet-Rich Plasma Injection for Chronic Achilles Tendinopathy
A Randomized Controlled Trial

Robert J. de Vos, MD; Adam Weir, MBBS; Hans T. M. van Schie, DVM, PhD; Sita M. A. Bierma-Zeinstra, PhD; Jan A. N. Verhaar, MD, PhD; Harrie Weinans, PhD; Johannes L. Tol, MD, PhD

JAMA. 2010;303(2):144-149.
**********************************************************************************
PRP therapy worked no better than salt water injections in achillis tendonosis in a great double blind study from the Netherlands. I wonder what is so special about the ones Dr. Galea is giving our U.S. athletes in Canada?

Scooter Shoulder: Around the World

Begin on the knees with hands flat on a pair of scooters. Move the hands lateral to medial in a semi circular pattern as the torso is lowered to the floor. As the scooters meet above the head, pull the hands straight back & return the torso back to the starting position. Naturally the lower the torso is to the floor, the more difficult the exercise is. 4 sets of 8 reps is good.

This exercise really challenges glenohumeral stability in an integrated manner. It's appropriate for throwers, swimmers, & wrestlers.

What's your take on this?

Kerrigan, D. C., Franz, J. R., Keenan, G. S., Dicharry, J., Croce, U. D., & Wilder, R. P. (2010). The effect of running shoes on lower extremity joint torques. Physical Medicine and Rehabilitation, 1(12), 1058-1063

This has been all over the media, and I can see where this is going. Instead of a happy medium, a move to track & field type flats across the board. Many athletic injuries to the foot result in permanent mechanical changes that will not like this.

PFPS & Torsions

Thanks Kev for the link to Mike Reinhold's blog. Good synopsis on the foot/hip issue with regards to patellofemoral pain.

But I have to admit there is one thing I have quite not figured out yet- what to do about femoral/tibial torsions. What can you do when the bone itself is torqued? Shirley Sahrmann suggests teaching them to ambulate with a toed out/toed in gait to sync the two bones dynamically, then stop running.

But my soft tissue background tells me I can influence structure through soft tissue. I'm not giving up on this one.

Sorry

Exuse me for my absence. A whole bunch of things going on. Was in the hospital most of the Christmas week with a little health scare, but I'm just fine. Plus I still have that problem with EHS blocking my blog. But on a positive note, I got a brand spankin' new HD video camcorder & camera at an after Christmas sale. Looking forward to the new year!

The Gestalt of the Maven

Let me come clean here.  I am totally intimidated by this girl.  Snatches more than me, educated by Shirly Sahrmann, and for leisure hangs out with Stan Musial and his wife.

Be sure to read this post from last year:
http://ironmaven.blogspot.com/2010/11/nothing-by-slice.html

Yes, I'm guilty of slicing it up but at least it's Jersey style with sausage and anchovies and all that stuff.  The very nature of tweating and blogging is slicing.  But Tracy makes a very good point we can't forget- that the whole is more than just the sum of it's parts. This blog is just dipping your big toe into the lake of function.  Think about joining us at GAIN '11 in Houston this June 17-22.  It doesn't end there-we have a cool forum and library where we exchange videos and documents all year.  Kind of like the NJ mob...once your in you can't get out.  Badabing.