Neuromuscular exercise for Patellofemoral Stress Syndrome- Bosch Overhead Reach Drill

The boys like to watch the pelvis wiggle, but the knees don't like it very much.  Upon foot contact in running/jumping, the pelvis goes too deep into the frontal plane, presenting in contralateral rotation.  Ideally, the ilia should be at least level, or optimally the fee pelvis a bit higher.  When the ipsilateral ilium is higher, it contributes to excessive knee abduction/internal rotation at ground contact.

This is one of the exercises I use to enhance pelvic stiffness in athletes presenting with patellofemoral stress syndrome.  I do it a bit different than Frans does. BTW, Frans does not use this as a rehabilitation exercise, he uses it as a neuromuscular drill to enhance sprint mechanics.  I'll have the athlete take a big step forward onto the affected leg, punch the non weight bearing ilium and hand to the ceiling, then step backwards with that same leg and return to the starting position for 3 sets of 10 reps.  I begin with the athlete holding a crutch overhead, then build up to a weighted bar.

I know horizontal training ("clam shell" exercise etc) is popular for developing pelvic & core stability, but as I've articulated many times on this blog, it has little carryover to upright function.

Sahrmann vs. Lederman

I listened to a recent webcast from Dr. Shirley Sahrmann in which she says a if you can't recruit a specific muscle under a controlled condition, there is little chance it will be beneficial in an integrated manner.  If you read her "movement impairment syndromes" book, a lot of open chain strengthening done on-table with alot of grooving movement patterns to get that muscle working in the real world sort of speak.
Dr. Eyal Lederman, on page 10 of his "Neuromuscular Rehabilitation in Manual & Physical Therapies" he says, "There are several misconceptions about motor control which are likely to make rehabilitation unnecessarily long and complex.  They all originate from the principle of "isolate in order to integrate".  The muscle is NEVER the goal of the movement.  Focusing on tensing, clenching, bracing, or holding specific muscles during movement turns them into the goal of the movement.  Muscles work in complex synergies- they never work alone.  All muscles are equally important, even muscles that are silent.  Muscles which are slow or at low EMG activity are part of the whole control pattern."

Sahrmann's approach is very much, "isolate to integrate".

In her excellent text, "Diagnosis & Treatment of Movement Impairment Syndromes", for the most part she uses very isolated corrective muscle work. On page 32 she says, "the desired muscle action should be practiced under the specific conditions in which it is to be used."

Comments?

3 weeks out, from 1 to 5

Not a single ROM exercise.  I focused in where the PCA led me.  Its interesting how symptoms resolve before the the SICK scapula totally corrects.

PFSS Rehab





Hip hikes, stagger squats with double arm reaches at ankle height, and lateral mini band walks.  Here I'm unloading the quads a bit to minimize patellofemoral compression.  Focusing on the pelvic engine. 

Fire Puxatony Phil

              Ahhhh, springtime in New Jersey.



On ground function carryover to upright

Don't be afraid to go to the ground if you think you can get something out of it that can facilitate upright function.  This athlete is using a traditional bridge with a L/R bilateral upper extremity, in sync (arms moving in the same direction) rotational reach.  Real important to keep the elbows locked straight and hands together.  He's using it as a remedial exercise to improve his ability to rack the olympic bar to his shoulders (ie front squat position).  His glenohumeral flexibility is actually not bad, its his thoracic spine and rib cage that have the motion restrictions.  Restrictions of the costovertebral/costosternal joints are commonly created when heavy bench press exercise is overused.  These restrictions are often overlooked as a culprit in shoulder dysfunction.

It has nothing to do with lactic acid

"Unraveling the neurophysiology of muscle fatigue", Enoka et al; JEK 3-11.

The authors don't have all the answers, but basically fatigue is the brain's way of protecting the body from injury.

Hodge's new Pain & Motor Control Theory

He's not ready to give up his abdominal hollowing and multifidus exercises yet, but I think its a bold step for him pointing more to what we talk about it this blog.  A few excerpts:

"One example is work in low back pain that has investigated temporal and spatial aspects of activation of the deep abdominal muscle, transversus abdominis, in trials of motor rehabilitation. The implication is not that this change constitutes the entirety of the adaptation, but that it is a common component that can be used as a ‘‘marker’’ of adaptation."

"each individual develops a protective strategy (from injury) that is unique based on experience, anthropometrics, posture, task, etc."

"it would seem reasonable to conclude that it is necessary find the right balance between restoration of control to some baseline and the maintenance or retention of elements of the adaptation in order to meet the demands of function."

There are VERY popular fee based sports medicine websites out there that flop from one idea to the other with no rhyme or reason looking for the latest panacea.  I would like to think I've stayed pretty consistent here with my approach, and not because of stubborness...I hope.

The body is self organizing-get used to it- part deux

If this doesn't stop all the BS I don't know what will.
http://aol.sportingnews.com/sport/story/2011-03-20/one-legged-wrestler-anthony-robles-wins-collegiate-championship

Books/Journals vs. the Web

Thanks Vern for this-Seth Godin sums it up just perfectly:


"Books, used properly, immerse us in a single idea. Books bring a voice into our head, create a different brain chemistry, open doors to a more powerful lever, a learning that can yes, change us. Dozens (perhaps hundreds) of times in my life, a book has changed my mind. So have some powerful lectures or direct engagements with teachers or mentors. These are the moments of true change, times when we are entrained with the message, when we feel the learning happening in real time.  Yes, tweet. Yes, stay in sync. Yes, absorb the lessons that come from many inputs, over time.  The quiet enjoyment that books (and great teachers) bring, the uncomfortable place they bring us when we’re open enough to let them in and to be honest with ourselves… this is precious."

The "N" Word

"Neuromuscular Training Improves Knee Kinematics, in Particular in Valgus Aligned Adolescent Team Handball Players of Both Sexes- Barendrecht et al, JSCR 3-11."


I am guilty of using it. No I'm not speaking of the term that you hear rappers use. I talking about the word, "neuromuscular". It has become as ambiguous as the word "core". Nordic hamstring curls are considered neuromuscular in this study. The authors achieved their goals of improving knee valgus on a drop jump test...but the control group was "usual handball training", whatever that was. Was it no strength training at all? It wasn't clear. And that's the problem with these ACL prevention protocols- they always compare to no intervention at all.

Is this the way the A.T. would do it? Would we take athletes which we had no idea of their conditioning history and have them bounding? Triple jumping? ...As part of a 10 week ACL prevention protocol? I doubt it because we know what would happen. Patellar tendinosis, patellafemoral syndrome up the wazoo. If not in 10 weeks, soon after. Since we spend years, and not weeks with our athletes (as opposed to other practitioners) we know there is no such thing as a quick fix. We think LTAD= long term athletic development= functional leg progressions. Rather than a 2X per week, it would be interwoven seamlessly into the daily warmup and conditioning modules. No P90X, no "Instanity workout"- no guru, no method, no teacher.

Wisdom from Brian Green

"10 years years from now we might find out that leaving it alone is the best treatment".

Absolutely Brian, and you have Dr. Lederman to back you up!  Page 170 of "Neuromuscular Rehabilitation in Manual & Physical Therapies,( 2010)":

"The injury response is a positive healty response and not a motor dysfunction or pathology.  Acute musculoskeletal injuries should be left alone- the body knows best.  The patient should be encouraged to keep active".

That sounds a lot like when I speak of "training around the injury", or "training at the periphery of function", no?  That does NOT mean throw out all your manual therapies, but it does mean keep it puroposeful and functional and keep the athlete actively involved whenever possible (e.g. FMR, Mulligans).  That was the basis of my (now defunct) ankle rehab book.  But a simple example- let's say an athlete sprained their ankle and dorsiflexion is painful.  But you want to preserve function.  You ask them to squat and they lean to the contralateral side because it hurts.  Simply move the involved foot forward and have them stagger squat, as it requires less dorsiflexion.

Joe's A.T. room gets legitimized

Thank you Paul Grace A.T.C., NATA hall of famer  for your kudos!:

"I think you've got something going on  that is worth reading and helping get people talking  about athletic training".

Go to resources for the functional ATC

Shame on me if I make this stuff seem more complex than it is, because its not my intention.  Please call me out on it when I do, so thank you for your comment SLS.  I want to keep things simple, inexpensive, and EFFECTIVE as possible for the high school ATC.  After I punish myself in the time out corner for 5 minutes.

1.  Pedagogical resources (Free).  These guys have marketing in mind, but after you read you'll see what I mean:

http://sethgodin.typepad.com/
http://bobsutton.typepad.com/

2.  Books:
about $20 bucks a piece:
A.  Athletic Development: the Art & Science of Functional Sports Conditioning- Gambetta
This is the scaffolding for your rehab programs.

B.  Functional Training for Athletes at all levels- Radcliffe.
Provides a great menu to plug into the scaffolding.

Now a little more expensive:

Books:

1. Physical Education for Children: Building the Foundation- Gabbard, LeBlanc, Lowy
I would have placed this book at #1, but its out of print and can only be purchased from re-sellers for top $.  The authors never intended it for rehab purposes, but it is one of my favorites.

2.  Functional soft tissue examination and treatment by manual methods, 3rd edition- Hammer.  Expensive, about $150.  But, an extremely valuable resource that should be in every A.T. room.


DVD:  Ankle Sprain, Chain Reaction Rehab- FVD 2.10, Gary Gray.
It is selling for $80 on Perform Better, but you might be able to find it cheaper.  You'll see Gary's functional approach in action and get an idea what it looks like.

...and think about joining us at the Gambetta Athletic Improvement Network (GAIN).  Yeah its expensive, but once your in your in.

http://www.thegainnetwork.com/Merchant2/4.12/merchant.mv?Screen=CTGY&Store_Code=Gain&Category_Code=Apprentorship
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Remember, SLS and others, that functional training=purposeful training. Otherwise you are just wasting the precious little time that you have to work with your athletes.  Did I articulate myself better here?  Let me know.

Great question from JM

"Joe, what are your thoughts on this recent shift focused on the respirtory/neurological system by regulating breathing? System integration makes sense rehabbing the athlete and not just an injury. Keep up your great thought provoking posts! We are all thankful."
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Excellent question JM that lets me get up on my soapbox & bore with my pontification. The local hip hop stations all seem to have the "old school" at noon where they play music from the 80s. Most just change the station. So you can too but it goes like this...


Back in the day, A.T. education was unique, because we all graduated with a dual A.T./P.E./Health certification. There was no such thing as an A.T. degree. Because of that, those of us coming out of that era had a strong base in motor control/learning. That was something that separated us from other professions like the physical therapy and chiropractic. This whole "functional" movement evolved from US, not the before metioned. They just re-named what we did (e.g. plyometics became "stretch cycle shortening training"). Somewhere around the time actual A.T. degree programs were created, we lost that background in pedagogy, motor control, and movement education. We seemed to borrow from physical therapy, causing the lines between the two professions to blur, leading to unnecessary conflict between the two.
In the last 5 years, the plethora of information supporting complex systems & motor control theory have exploded! And, they are pointing to the "old school" way WE used to do it. Yet we are mindlessly led from one marketing innovation to another rather than taking the lead.
So finally, to answer your question...to us old schoolers this breathing movement is not "system integration" at all. In function, you can do the same task a thousand times, breathing differently each time, using different muscle firing patterns each time... and be doing it absolutely correct. If a breathing pattern does appear aberrant, that particular task is simply outside the athlete's envelope of function. Modify it until you get the results you desire. The catch 22 is, you would have no idea how to do that without a strong background in pedagogy, motor learning/control, and movement education.  Running out and getting some personal trainer certification won't fix it.

Brilliant!!!

Does anyone know who Jason Silvernail D.P.T. is?

http://www.somasimple.com/forums/showthread.php?p=95314&posted=1#post95314

http://www.somasimple.com/forums/showpost.php?p=96406&postcount=7

Training Stages (Gambetta, Giles)

1.  Fundamentals (age 6-9) focus on physical literacy, gross motor skills
2.  Learn to Train (age8-12) learn overall sport skills
3.  Train to Train (age 11-16) consolidate sport skills + tactics with physical abilities
4.  Train to Compete (age 15-23) sport specialization, increase training intensity
5.  Train to Win (age 18+) focused, dedicated, competitive

If you really want to reduce ACL injuries, "Tommy John" surgeries et al follow these guidelines. Quick fix protocols later on only have limited success.

Youth + the right kind of remedial work

10 days out...from a "1" on both tests; to a 4 on the shoulder internal rotation test & a 3 on the shoulder lift off.  12 minutes out of his lunch period 5 days per week + some work on his own.  The shoulder throwing pain he was having is already gone, but I explained to him that is only because volume is very low right now.  Once the season moves on to back-to-back games his remedial work will take on an even greater roll.

Exercise is GOOD for your knees!

These Australian researchers see knee osteophytes as a protective mechanism, not part of the degenerative process:
http://journals.lww.com/acsm-msse/Fulltext/2011/03000/What_Is_the_Effect_of_Physical_Activity_on_the.8.aspx

The human body is self organizing-get used to it.

"Individuals With Low Back Pain Breathe Differently Than Healthy Individuals During a Lifting Task"- Hagins et al  JOSPT 3-11.

This teaching proper breathing stuff has taken on a life of its own.  These authors demonstrate breathing patterns could be a subconscious stabilizing strategy.

Using the PCA to save time

This athlete is a pitcher who came to me complaining of posterior shoulder pain during the early acceleration phase of his delivery.  Evaluation revealed a forwardly rotated scapula, a tender coracoid process, and GIRD.  I used the gauge to This scapular malposition is usually associated with weak same side lower trapezius muscles and a tight pec. minor; the GIRD a tight posterior shoulder capsule.

The tests I used were:

1.  Shoulder Liftoff
2.  Shoulder IR (note:  NOT an official PCA test)
3.  Standing shoulder ER
4.  Thomas Test 1.

The whole process only took me less than 5 minutes and gave me good information.  The shoulder liftoff was expected- the athlete scored a "1", which would be consistent with weak lower traps.  This is problematic, indicating this athlete cannot really get "hip to shoulder".  What I didn't expect was the good performance on the standing shoulder ER, meaning the pec. minor was probably not a culprit.  The Thomas Test 1 revealed a slightly tight same side iliopsoas (this would grade a "3", which normally isn't bad, but in throwers your really want a "5", meaning the thigh should drop below the table) which could theoretically prevent a good low trap load via poor torso extension.  The internal rotation shoulder test will provide the athlete with a visible indication of their progress.  This would grade a "1", which is undesirable for a thrower.  This score indicates the possibility of shoulder & elbow injuries as per Donnelly.

My next step was to confirm my suspicions further by inspecting some of the myofascial centers of coordination about the scapula.  Interesting the pec minor myofascial cc was indeed negative.

http://www.amazon.com/Fascial-Manipulation-Practical-Luigi-Stecco/dp/8829919780

I'll only get to see this athlete a half of his lunch period 5 days a week.  But with the help of a streamlined remedial program he should have a great season.

Good article from the NY Times on Tendinosis

http://www.nytimes.com/2011/03/01/health/01brody.html?_r=1&src=me&ref=health

Interesting the thing that gave the author his greatest pain relief was his change in swimming mechanics.  Frans Bosch believes if you fix mechanics, the body will fix itself.  Much of GAIN is spent in this realm.

"If they give you ruled paper, write the other way"-Juan Ramon Jiminez

The epigraph on the first page of one of my favorite books of all time, Farenheit 451 by Ray Bradbury.

How does it pertain to athletic training?
Never be afraid to question what you have learned...even if it is coming out of a prestigious university.  As the health care dollar shrinks, marketing becomes more intense & protocols which have very little merit are presented as the next best thing.  You can be fooled into thinking you are falling behind if you don't jump on the bandwagon.  Remember that's just part of the marketing strategy.  Do your research-and don't just read the abstracts and make up your own mind.

I heard others refer to this blog site as "outside the box" thinking.  Its really not at all.  It's about the high school A.Ts lack of time and needing to get the most bang for your buck.  Getting it right the first time so the athlete isn't returning time and time again for that chronic ankle soreness or concussion.  Or better yet, preventing it in the first place.