Good Quote

"I love the profession, but I hate the lifestyle".

This is from Steve Viana, the ATC at neighboring Linden high school. Another Labor day weekend is upon us, and for 26 years I've spent the entire weekend working football & soccer. You almost dread a holliday coming up in this profession because you realize they will try to squeeze in as many sports as possible in to a small time frame. Is it just me that feels this way?

Ankle Sprains

If there are a few misspelled words in this post, forgive me, the 13 hour days with not even a break for lunch or dinner are warping my brain a little, but here I go...

A very thought provoking study coming out of Japan, published in this month's AJSM.

The authors took a look at 28 athletes with a history of at least one previous ankle sprain & had sensations of instability, even though none were present clinically. They did an arthroscopic study on one ligament, the anterior talofibular.

The results? Ankle sprains are brutal. Get this: 9 had partial lig tears with scarring (ok, to be expected); 3 where the ligament was no longer present at all- it was replaced with scar; 4 cases where the ligament had calcified; 5 cases where it was filleted right off the bone (yet no clinical signs of instability? Eric Naussbaum, care to comment on that?); 2 where it had narrowed, 2 described as having an "abnormal course" at the talus or fibular attachment; & 3 normal cases. AND THIS WAS JUST ONE LIGAMENT! Who knows what the others looked like? Not to mention the osteochondral interface.

For some reason, it's not "sexy" to do research on ankle sprains. The knee ACL gets all the attention. But, it's all the way at the end of the kinetic chain, and boy can it reek havoc on the rest of the body. Instability or loss of motion here usually effects the knee, hip, low back, and if you throw, even the shoulder. As part of your injury history, always enquire about old ankle sprains. Hopefully, this will be my first of hundreds of posts on the ankle joint.

Why Vern Gambetta

One of my goals in starting this blog was to help define the ATC at the high school level. It is important to remember we are not physical therapists. A P.T. gets to spend maybe 3 days a week for a few months with an athlete. We spend 6 days a week with them for 4 years. We see intra & inter injury patterns develop within that time. The athlete is going through physiological changes during that time period that may be insignificant to a P.T. It could be said then that "the P.T. treats injuries, the A.T. treats the athlete". The P.T.'s program would be protocol centered, while ours needs to be athlete centered.

Vern uses the term "athletic development" rather than strength & conditioning. Athleticism is something you can carry with you for the rest of your life, long after your playing days are over. It helps prevent injuries, and just makes life more fun. In Josef Drabek's "Sports Training for Children", he makes a point of discussing important developmental windows of opportunity where athletic skills can be developed. It's not that they can't be developed at a later time, it's that those skills may never get developed to their optimum.

What is unique about Vern is that he has worked on every level, from elementary through elite professional. Not as a consultant either- I mean hands on in the trenches. He understands the needs of the adolescent athlete, and his "Planned Performance Training" concept reflects that. He also understands that we must work with multiple athletes at once, and his training session management techniques come in handy. I will be commenting more on the Gambetta Method & it's application to high school athletic training in future posts. If you want to learn more about him, I have a link to his web site to the right of this page.

Aquatic Therapy

"...for whatever we lose (like a you or a me)it's always ourselves we find in the sea."- e.e. cummings.

I've never had a real athletic training room. But if I had to give up our swimming pool to get one, I'd gladly pass. The athlete in the picture is rehabing a hip flexor strain. He is doing some deep water mountain climbers, then some hurdle walks in the shallow end.

Aquatic therapy has gotten a bad rap. The reason being it is over used, or not used in the context of the big picture. In northern N.J., private clinics sprung up in the 90's that only did aquatic therapy. I imagine to justify the tremendous cost of building the hydrotherapy units, everyone got thrown in the water regardless of injury or stage of healing.

In general, I feel the further you go down the road in the rehabilitation process, the less valuable the aquatic environment becomes. I use it primarily the first few few weeks after an injury to reduce edema and preserve function. It's not the same as just submerging the body part in a whirlpool. It has more to do with the hydrostatic pressure of the water (7 times the resistance of air) pressing on the body combined with the weightless environment. This creates a cardiovascular response that enhances venous return more than any other modality can.

A little further down the road you can use this environment to ease the athlete back into weight bearing activities. At neck height, you are working with approximately 10% body weight; chest- 20%, umbilicus- 50%. With the use of underwater steps, I can begin step ups & single leg squats long before I can begin them on land. The same holds true with proprioceptive exercise. Do you think e.e. cummings had this in mind when he wrote that poem? I'll be posting more on aquatic rehabilitation in the future.

Are you getting the biggest bang for your buck?

We've all seen this. A parent or coach approaches you and says, "I read on the internet or saw on the news that ____is the best treatment for ____". My answer is always...but can you measure that? Does it pass the acid test? Can I pull out my tape measure or goniometer and prove it increased painfree ROM? I could care less that it elevated the temperature of some tendon a half a degree centigrade. Did this athlete walk out better than the day before?

Here is an example. The athlete above had a severe grade 2 inversion ankle sprain right after school got out in June. He spent almost a month non weight bearing on crutches. He came to me because he could not sprint without posteromedial ankle pain. The picture on the right represents his L ankle dorsiflexion. The strip of tape closest to the wall is pre intervention, the second is post. The position he is in now is his new pain free ROM.

The whole thing took me about 12 minutes. The pic on the L is me doing some posterior talar glides, along with some tibia ER mobes. 4 sets of 20 reps. In between sets, I had him doing L SLB RLE anterolateral reaches @ ankle height, 20 reps. While he was doing the exercises, I taped one kids ankle, and took care of a soccer player's nose bleed. I then re-tested him. His sagittal plane knee excursion improved 3.25cm, 1.2cm pain free. I sent him outside to do 6x20 meters each of shuffle steps, galloping with LLE leading, and tapioca stepping to the right.

I'm often asked how I have the time to do manual therapy. The total hands on time of this treatment was about 5 minutes. If you see a dysfunction, then why choose an indirect approach? Why was this technique more effective than the silly one on TV? Because the athlete really corrected it all by himself. All I did was provide the scaffolding.

Don't drink the cool aide

I enjoy the NY Times, but give me a break. Take a look at:

http://well.blogs.nytimes.com/2008/08/19/a-quirky-athletic-tape-gets-its-olympic-moment/?em

"A Quirky Athletic Tape Gets It's Olympic Moment." Tara-Parker Pope quotes the July '08 issue of JOSPT as support for the efficacy of the tape. Here is what the study really says about kinesio taping:

"When applied to a young, active patient population with a clinical diagnosis of rotator cuff tendinitis/impingement, KT may assist clinicians to obtain immediate improvement in pain-free shoulder abduction ROM. However, over time, KT appears to be no more efficacious than sham taping at decreasing shoulder pain intensity or disability."

It also says, "Pain and disability measures, as a result of taping, were not different between groups in our study."

I'm not saying the tape works or it doesn't. But, because of the Olympics, the K-tape website is getting 350,000 hits a day compared with my paltry 80. Everyone is looking for a quick fix for shoulder dysfunction. Didn't Flavor Flav tell us 20 years ago...Don't believe the hype, it's a sequel...BOOOYYYYYEEEE! Some times, you just have to kick it old school.

Anatomical Anomalies

Your comments jog my brain, and this one was brought up by Jon Beyle from the beautiful state of NC. Has a pigeon toed athlete with tight hip flexors and planus feet. By the time the ATC gets to her, she can't squat or lunge without pain.

Usually (not always) this scenario is a result of some combination of femoral or tibia anteversion. It's frustrating for the ATC & athlete alike. Naturally, there is nothing you can do about the skeletal configuration. However, you can address the soft tissue issues that go along with it. The femoral rotation creates what Janda called "pronator distortion syndrome" (you should be able to find some references to it on the net). Lots of passive ROM & myofascial work, especially about the hips, is in order; as well as remedial PRE for the abductors, external rotators, and extensors. The athlete must understand that these exercises must ALWAYS be included in their warmup/conditioning. An orthotic can be useful here.

If lunging & squatting hurts, then don't do it. Mini-band work may be a better option. But usually, you can play around with squat depth & foot placement/angle/rotation so you get a pain free squat or lunge. A lot of cooperation on behalf of the coach is also needed; reducing the amount of sagittally oriented running activities.

2 years ago I had an athlete with a similar problem. He did football & track. Chronic knee/low back pain. FB was manageable, since most running is multi-directional. However, once he got to track & field it was another story. It took a lot of ART & passive ROM work on my part to keep him pain free. We also did 2 workouts per week in the pool. He's in college now, just doing football, and for the most part is well. As successful as he was at it, I doubt he could have continued his track career.

Orthotics

Whenever an athlete presents symptoms of plantar fasciitis, medial tibia stress syndrome, PFSS etc., our first instinct is foot posting. However, it may not be a good place to start. Always look globally at what is going on with the rest of the body. Let's take achilles tendinitis as an example. Many proximal postural asymmetries can contribute. A kyphotic running posture can move the athlete's center of gravity forward as to pre load the tendon. The arms crossing the mid line of the body can create excessive long axis rotation, creating a "wringing out" effect at the tendon.

Never forget the body is a linked system. So, you have to keep in mind that an orthotic may help out the foot, but screw up the body somewhere else. Tim Sensor, head ATC at Kean University in N.J., makes these accommodating molds that are not as rigid as a traditional orthotic and usually does the trick. 1/8-1/4" felt comes in handy too.

Of course an orthotic can be a valuable modality, provided it is used in the context of the big picture.

Running Without arms

Jonathon Hewitt brought up a good question- what about sports where you can't use your arms to assist your running, like carrying a football or a lacrosse stick?

Jonathon, you have stumbled upon one of the greatest core exercises- running with your arms crossed across your chest! Never forget, when we run force is not only generated from the ground up, but also from the top down. Arm action:

- blocks over rotation of the torso & pelvis in the long axis so the rear leg can swing forward.

-helps lift the body off the ground.

-increases horizontal thrust in the sagittal plane.

-helps maintain balance.

-Mechanically "dampens" abnormal body postures created by distal postural asymmetries.

I look pretty silly when I run with my arms crossed across my chest. The osteochondritis dissecans in my left ankle from an old sprain is transmitted up through the torso causing me to weeble-wobble down the track. Yet, it is an important conditioning activity for me.

Without using the arms, the torso's lever arm advantage is removed. The core of the body must compensate for extraneous body movement in all planes- reactively, subconsciously. Watching someone run without the arms can be a useful evaluation tool.

Great Questions!

The questions asked in response to my last post were so good I think they deserve separate posts to answer them. Please comment often! They keep the mental wheels spinning. Feel free to ask questions. If you are embarrassed, post them anonymously. However, there are probably many others out in blogland who have the same questions you do. Remember, this blog is all about learning through sharing, and it will stay simple & unpretentious.

Reactive Abs

Here is an example of a functional abdominal exercise that would be consistent with running mechanics.

Starting Position, standing approximately 12" from a wall:

-R SLB

-RUE abducted to 90 degrees with elbow flexed

-LLE flexed @ knee 90 degrees

Action:

Simultaneous

-RUE R rotational reach @ head height to wall

-LLE posterior reach @ knee height to wall.

Repeat 20X.

You can make it harder by placing a dumbell or exercise band in your hand, an exercise band or weight cuff on your ankle. You can increase the tempo etc.

Try this yourself. Do you feel the tightness around your belly button? That is the abs reacting to your extremity movements subconsciously. The way they work when you are running. You can use this as a movement screen too. Can you keep your eyes fixed straight ahead as you move, or do you fell that your head is rotating/side bending? Do you have trouble keeping your balance? Does your hand & foot touch the wall at the same time?

Any movement glitches occurring during this exercise are probably also happening during running. Can you see now that stiffness in the right shoulder could possibly delay the foot locking up (supinating) at the right moment... delaying adduction/external rotation at the knee...causing abnormal patellar mechanics? Kind of like that old "leg bone's connected to the hip bone" song my dad used to sing to us with his ukulele.

Amen

"Concussions are brain injuries and among the most difficult of sports injuries, starting with even identifying who's had one."

Good article from AP medical news that suggests cognitive deficits from a mild concussion may interfere with learning for over a month post injury.

http://apnews.excite.com/article/20080811/D92GCEUO0.html

McConnell Taping

About a dozen years ago evidence began to appear that patellofemoral taping had no effect on alignment. However, most evidence still supports an analgesic effect. I still use it, because it allows the athlete to get back on their feet & exercising sooner. With the careful use of a slant board & a bungee cord I can usually create a pain free environment. This is important in keeping the linkage system going and maintaining fitness.

It is tempting to place the athlete in a supine or side lying position & try to isolate out those panacea "magic muscles". Keep in mind the injury did not occur in isolation, and every muscle has a 3D function.

Abs

Part of the answer to my last post on PFSS lies in the abdominal muscle structure & function. Here are some good excerpts from pages 40-41 of "Running- Biomechanics & Exercise Physiology Applied in Practice", Bosch & Klomp 2005.

- During functional movement, the abdominal muscles ALWAYS work together with other muscles.

- isolating the abdominal muscles during training (certainly for well trained athletes) is of limited use.

- Being able to handle a REACTIVE load is more important for abdominal muscles during running than being able to contract forcefully.

- the abdominal muscles absorb forces in repeatedly alternating diagonal lines.

Great runners need to have what Dr. Stuart McGill calls "super stiffness". Strong abs seem to have the ability to block extraneous motion in the coordination of the upper & lower extremities.

Good PFSS (patellofemoral stress syndrome) study

Pretty interesting article from the Aug 08 issue of JOSPT- "Proximal and Distal influences on Hip and Knee Kinematics in Runners With Patellofemoral Pain During a Prolonged Run". Goes something like this:

Recreational runners with & without patellofemoral stress sydrome were evaluated isometrically for hip abductor and external rotator strength. Next arch height was measured, and anatomical markers were placed on the hips and legs for 3D motion analysis. They then ran on a treadmill until they reached 85% max heart rate. Hip abductor/external rotation was re-tested.

The findings?

1. The PFSS group had weaker abdcutors, before & after the run.

2. External rotation strength was the similar in both groups, before & after.

3. PFSS group exhibited greater hip adduction at stance phase.

4. Arch height was similar in both groups.

5. In 80% of the males, 27% of the females, the hip remained in an abducted position for the 1st half of the stance phase. The researchers reported this was created by leaning the trunk towards the affected side.

A few questions:

1. The findings of similar ER strength between groups is inconsistant with previous PFSS studies. Why do you think?

2. Why didn't greater hip adduction in the PFSS group have any effect on arch height?

3. Why the gender difference in the compensation pattern for the increased hip adduction?

4. Only 2 muscle groups were tested, in one plane each. What other muscles may have turned up weak had they been tested?

I have my own ideas, but I do not want to pollute the waters with my bias- yet.

The Young, the innocent, & the functional movement screen comments...

Thanks for the comments on the hip's relationship to PFSS. Comments help jog my brain, so do so frequently. SPG made a comment about placing the heels of the squatter on a barbell plate as a diagnostic tool. You would think that it would exacerbate symptoms, but not necessarily. If there is a deficit in dorsiflexion, the foot will bail out in the frontal or transverse plane, or both. Elevating the rear foot creates pseudo dorsiflexion during the squat, and will alleviate PF pain, if the TP or FP is creating the dysfunction. Of course, it is not a fix.

Oh, and thank you JH for mentioning the contribution of the contralateral hip to PFSS, and using a leg driver to sniff it out.

If you get a chance, take a look at the August issue of JOSPT. I will be commenting on the PFSS article.

The Young, the innocent, & the functional movement screen

If you take the train (patella), Elizabeth is the 3rd stop on the northeast corrirodor railroad (trochlear groove) between New York & Trenton. But if the train is late getting to a stop, who's to blame? Do we blame NY? Trenton? Somewhere in between?

...every ATC has this annoying scenario. You're busy taping before a game and at the last minute, " my (fill in the blank) hurts!"

How long has it been bothering you?

About 2 weeks.

So now my hands are tied up, up I want to help this kid.

In this case, it's a knee. He points to his left patella, along the inferior medial border. No time, or room, to evaluate them on the table. "When do you do that irritates it the most?".

When I get into my 3 point stance.

I ask him to show me his stance, and I notice he goes into an unusually wide stance. Next, I go to my fuctional movement screen. I ask to see his squat. Same thing. He goes into an unusually wide, toed out stance. I ask him to narrow it, point his toes forward, and squat again. The foot abducts, the heel comes off the floor, and the knee internally rotates and abducts. I ask him to go into a R, then L, SLB. I get a pronated L foot. I ask my student AT to check the computer for this athlete's injury history. Bingo. An unresolved ankle sprain 2 years ago. Came in for first aid, then I never saw him again.

How can I help him? Next, I give him a sheet of 1/4" felt, and ask him to place it logitudinally on the medial border of his left foot. I instruct him to go into a hip width stance, and squat again. He says it is about 90 percent better. Now, I ask my student AT to give him the slant board, and while I'm taping, show him how to do self ankle mobes. I make him a felt insert for his shoe to control his pronation. I ask him to repeat the squat.

Pain free!

Of course, we have a lot more work to do. What would be the next step? The young one is the athlete, of course. But who is the innocent? The train (weak VMO? Tight lateral retinaculum?), or the track? Where on the track would you look? I chose Trenton (the foot), but where would you look next?

Support for the kinetic link principle.

Techniques are worthless unless they are grounded in sound principle and driven by strategy. Remember, I’m not some internet guru trying to sell you his junk. I’m a real life ATC who works at the largest high school in N.J. I’m accountable to athletes, parents, coaches, athletic directors, and principals. I get evaluated on the job I do. And usually (not always) chain reaction biomechanics is the most time efficient, and provides the best results. But that’s just me yapping. What does the evidence say?

Last March, an article appeared in JOSPT entitled, “Regional interdependence- a musculoskeletal examination model whose time has come.” There are many practitioners out there who are taking credit for discovering it. However, it’s nothing new. The earliest scientific dissertation on the subject came way back in 1875. German engineer Hans Reuleaux described how movement at one joint produced movement at another mechanical link elsewhere in the chain.

Kinesiologist Alex Steindler, in 1955, was the first to apply it to the human body. I believe he was the first to use the terms, “open & closed chain”. Finally, in 1964, EP Hanavan put together a working computerized mathematical model of the human body that substantiated the process did indeed occur in vivo. Humm. Maybe my critics are right- I really am old school!

The idea took off in the ‘60’s thanks to kenesiologists Logan & McKinney, who were the first to describe the concept of the “serape effect” (I’ll get into that in a future post). In the mid 70’s sports scientists seem to focus their attention on technology, and the machine era was born. Hence Cybex, KinCom, the isokinetic movement.

Thankfully, in the 90’s the kinetic link concept was revived by physical therapists Gary Gray & UConn’s Dave Tiberio. Chicago White Sox strength coach Vern Gambetta was the first to give the concept practical athletic applications. On the orthopedic front, Ben Kibler has also done great research to validate the superiority of the kinetic link concept over others. Today, functional training & rehabilitation is the term used to describe the kinetic link system applied to sports therapy.

A word of caution: many practitioners will represent themselves as functional therapists, especially on the internet. They have mis-interpreted the research and therefore mis-apply the concepts. Stick to the names mentioned above if you care to research the subject further. I’ve worked personally with several of them, and I can tell you they are the real deal. Well OK, not the guys from the 1800’s :)