ATSNJ Pubalgia workshop 2-27-11

The talk started off with Dr. Andrew Boyarski, a general sugeon from New Brunswick, NJ.  I really enjoyed this one:

http://www.rwjuh.edu/physicians/physician_profile.aspx?physicianid=147

Dr. Boyarski is skeptical of the US trend of using mesh to do these repairs, especially in young athletes.  He put it quite simply, that this technique destroys the continuity of the fascia and may promote nerve entrapments.  He described what he calls the normal "scissor down" effect of the fascia on the inguinal canal, which protects the area from injury.

He says although MRIs are beneficial in the differential diagnosis, they are too uni-dimensional to be of benefit in the diagnosis of an athletic hernia.  He prefers diagnostic ultrasound for this purpose.  He simply asks the athlete to cough, and looks for the "scissor down" effect on the ultrasound.  (Note: on the A.T. side of the evaluation, he says with a little practice this effect is palpable externally.  He says adductor tenderness varies, and is not a good indicator).

 He chooses to a version of the repair technique he learned from Dr. Ulrike Muschaweck, an orthopedist from Germany.  The surgery is done with a local anasthetic.  He asks the athlete to cough while he is staring directly at the canal to be sure the "scissor down" effect has been restored.  In this technique, the floor of the canal is reinforced with sutures and the athlete is usually back to competition in 6 weeks.  He was quick to emphasise the importance of the therapist on the prevention and rehabilitation side of the equation by way of a good "core" strengthening program.

Next up was orthopedist Charles Gatt
http://www.rwjuh.edu/physicians/physician_profile.aspx?physicianid=1668

Dr. Gatt spoke of evaluation & treatment of pelvis/hip injuries in general.  Again the topic of diagnostic ultrasound came up. He uses a portable one to guide cortisone injections in the inflammatory phase, especially in hamstring injuries.  He cites research from Bergfeld to support this (readers take a look at this and let me know what you think) :

http://ajsm.highwire.org/content/28/3/297.abstract

I asked him about FAI, as to whether he felt it was a nature or nurture thing.  He agreed with most researchers, that its the latter.

Russel Steves, PT, ATC spoke on the rehabilitation of athletic hernia:
http://uhs.princeton.edu/staff/detail.php?NetID=rgsteves

Those with Dr. Boyarski's repair are up and doing light walking immediately, doing light stretching and exercise weeks 3 & 4, and are segueing back to competition the 5th & 6th!  While most of he protocol was pretty traditional, it was interesting he proposed the possibility of a functional protocol as being effective also.  He spoke of the need of the "muscles to be powerful in a lengthened position".  Sounds like Dr. Tiberio's "transformational zone" concept, no?  He also mentioned ART and Graston by name as being beneficial.
Finally Jennifer Lister A.T.C. spoke on using a Pilates based approach to pelvis/groin injury rehabilitation and prevention:
http://uhs.princeton.edu/staff/detail.php?NetID=jlister

The Inflence of Children's Shoes on Gait and Running

This is a great article that is free and you may want to save to your hard drive:

http://www.jfootankleres.com/content/pdf/1757-1146-4-3.pdf

Take a look and let me know what you think.

Good Quote from Winston Churchill

"Continuous effort - not strength or intelligence - is the key to unlocking our potential."

The barbell...what a great tool!

Here I am doing a transverse plane power snatch; something you can't do with a olympic bar.  The bar is shorter, thinner, and the plates are welded on.  Of course you could do the same exercise with dumbbells, but the barbell adds a bit of horizontal drag to it that enhances the movement.  Because the hands are fixed, it really challanges the rib cage, scapulae, and core. Instead of just letting the bar drop, I'm pulling it back to the starting position to increase the speed of the bar and get as many reps as possible in 10s.

Your Thoughts

A rotational plank with light force applied downward to the head by a partner.  It's from the neck strengthening video I just did for the ATSNJ.  Of course it's just not about coming up with dopey looking exercises, but I think this could have some value.  It could be done on a field with no special equipment.

Websites

Colleagues contact me all the time and ask me what they think about this or that website.  Don't have an opinion. I'm not really a website kind of guy. It's like a hunter aiming for where the rabbits already been. I read a few blogs by people who inspire me like Vern and Tracy.  My blog is a reflexion of me. The TR is my lab, and I use whats in my toolbox to enhance athletic development from my end as an A.T. I never profess to have all the answers. Things arise that I don't have answers for, and I look to the journals not for answers, but to see if there are others who are seeing the same that I am, and what their approach is.


I will say this- the functional approach does not work with everyone. Those who seem to be the most resistant are those with an external locas of control and don't believe the power to heal is already inside them.

On the Shoulders of Giants!

Spent the weekend with Dr.'s Antonio Stecco & Warren Hammer studying the myofascial system.  The Steccos take a more global, integrated approach to treating the fasica system than I have been exposed to in the past. I'll be hooking up with them again next month after I spend some time on the application side of it with my athletes.  The Steccos are the only fascial practitioners who do their own research, and aren't afraid to stick their neck out in the professional journals.  His father Luigi and his sister Carla's many works can be found in a Medline search.  Carla has the first anatomical book on the myofascial system (not illustrations) due out this fall.


Every ATC should have a copy of Dr. Hammer's text, "Functional Soft-Tissue Examination and Treatment by Manual Methods, Third Edition".  Very detailed, and well illustrated.  It is expensive ($155), but it's the low budget, high tech stuff that works:

http://www.jblearning.com/catalog/9780763752873/

Resisted running- Where does it fit (or does it)?

"THE LONGITUDINAL EFFECTS OF RESISTED SPRINT TRAINING USING WEIGHTED SLEDS vS. WEIGHTED VESTS"- JSCR, 12-10.

Granted it was a small study-only 20 participants, and they were lacrosse-not track athletes, and the study only lasted 7 weeks.

The results showed sprint training with a weighted vest or sled pulls did not improve performance in the short sprints.  Our old track coach, the great Dave Costello claimed all resisted running, including parachute running, had limited value.  He would use it sparingly- only on his regional/national caliber sprinters.  He said while it looked like running, the mechanics were different and had little carry over.

Not to say it doesn't have a benefit.  If you play a sport like football or Rugby where people are hanging on you or pushing you I could see it being purposeful.  Would you use it to compliment shot put, discus, javelin, hammer throw?

Everybody wants a "System"

"Effects of Pilates Based Exercises on Pain & Disability in Individuals with Persistent Non Specific Low Back Pain:  A systematic review with meta analysis" Lim et al, JOSPT 2-11.

I'm glad to see this.  There are P.T. practices popping up all over that use Pilates exclusively as a panacea.  Nothing against Pilates, but it's one of those, "If all you have is a hammer, everything is a nail" things.  The conclusion was, " Existing evidence does not establish superiority of Pilates-based exercise to other forms of exercise to reduce pain and disability for patients with persistent nonspecific low back pain."

Don't feel bad if you don't have thousands of $ of equipment in your A.T. room. You can still get it done.  Successful athletic training is A.T. directed, but athlete- not equipment- centered.

Fascial Stretch Therapy Certification? Fascial Fitness Certification?

Ay carumba.
Don't get confused, stay the course on the functional path.
Doing some course work with the Steccos and Warren Hammer this weekend and I'll report back.

http://www.fasciacongress.org/other-events/Stecco%20Workshop%20Full%20Text.pdf

"Posterior Chain" Weakness? Think again.

"Muscle strength and flexibility characteristics of people displaying excessive medial knee displacement"- Bell et al ', Archives of Physical Medicine and Rehabilitation '07.

Pretty cool.  The authors took subjects who's knees exhibited medial knee displacement during a squat.  They then gave them heel lifts to see if it corrected.  If it did, they studied their lower extremity strength and compared it to those who did not display medial knee displacement.  They had GREATER hip extension and external rotation strength than those with normal squat kinematics!  They went on to make recommendations for ankle strength/ROM.

So much for "training the glutes and hamstrings to fire better".  Just teach them to squat and land better period- don't try to 2nd guess the body as to what muscle is firing how much and when.  And it always amazes me how quickly adolescents adapt with a minimal amount of intervention.  Just take the time.

The Gastocnemius is an upside down hamstring- more evidence.

Ankle Dorsiflexion Range of Motion and Landing Biomechanics- Fong et al, JAT Jan '11.

On page 8 speaks of the importance of the gastroc in force attentuation at the knee during landing.  Greater dorsiflexion was associated with smaller ground reaction forces.

Synesthesia

http://en.wikipedia.org/wiki/Synesthesia

Numbers have specific colors!  Musical notes float through space in specific patterns!  No it's not a psychedelic drug experience.  This is how synesthesiasts perceive the world. Watched the PBS Nova program on the brain last night which had a segment on this neurologic condition.  It's not just limited to music & math, and research is already going on as to how it may be beneficial to non synesthesiasts in learning.

There has to be athletes that experience this on the playing field.

Another good reason to stay active!

http://www.webmd.boots.com/healthy-ageing/news/20110201/exercise-reverses-memory-loss

We can do better.

"Countrywide Campaign to Prevent Soccer Injuries in Swiss Amateur Players"- Junge et all, AJSM '1-11.
In the U.S. we have the "Santa Monica program".  In Europe you have "The "11".

In Switzerland, football (soccer) teams performing ‘‘The 11’’ had an 11.5% lower incidence of match injuries and a 25.3% lower incidence of training injuries than other teams; noncontact injuries in particular were prevented by the program.  In the U.S., the Santa Monica protocol ACL prevention program dropped female collegiate soccer injury rates an overall 41%, and non contact injuries 70%. The program is free online at:
http://www.aclprevent.com/pepprogram.htm

http://www.aclprevent.com/pep_replacement.htm
 
While I admire the effort, and the results, both are really not programs but exercises slapped together.  Why isn't a good lower extremity performance & prevention program weaved seamlessly into the athletic development model, if there is a model at all?!
 
If we have already identified the problem, then why wait till the high school or club years?  Why not begin in elementary school?
 
http://joestrainingroom.blogspot.com/2009/07/from-spark-into-bonfire.html
 
Never forget sports medicine is a discipline that has always been driven by the field practitioners.
 
http://joestrainingroom.blogspot.com/2009/02/kitchen-chemistry.html