Do I Need a Brace After ACL Surgery?

By Ziad Dahdul, DPT

To say that bracing after an anterior cruciate ligament (ACL) reconstruction is controversial is an understatement. You ask any physical therapist their opinion on the effectiveness of bracing and you’re likely to get dozens upon dozens of different answers. Our experiences with this injury will 100% guide our opinions as any sports physical therapist has seen this injury way too many times to count.

But what does the literature actually say? That’s what I set out to find out when asking two questions:

• Should the athlete be braced ealry on following ACL reconstruction?
• Should athletes be braced as they near return to sport (RTS)?

Post-op

First, let’s look at bracing in the acute and sub-acute stages post surgery. Many studies examined the effects of bra cing on joint effusion and knee stability in the early stages of rehabilitation post ACLR. One study found that when bracing was randomized in patients during the first three weeks post-ACLR, there were no differences in joint effusion at the 3- or 12-month marks after surgery (1).

In regards to knee stability, another study showed that acute bracing is used in the initial week or two of recovery in order to protect the quadriceps inhibited knee from sudden flexion under weight bearing loads (2). This can provide both an external support in addition to peace of mind to the athlete knowing that they are supported during a vulnerable period of the rehab process.

Although these are just two examples, we haven’t seen enough research in support or against the use of bracing in the early stages of the rehab process to conclusively lean in one direction or the other. In the absence of conclusive evidence, this is where we lean on surgeon preference/outcomes, the clinician’s experience, and the confidence level of the athlete when making a decision like this.

Return to Sport

When taking a look at functional bracing on athletes upon return to sport, we find evidence both in favor of bracing and against its use;  however, the majority of the research lean against its use long term. One study found that functional bracing does not protect the reconstructed ACL nor improve long-term patient outcomes when compared to non-braced participants. (2). Also, another systematic review showed that post operative bracing does not help with pain, function, rehabilitation, or stability. (3)

The two studies above are just the tip of the iceberg as the majority of studies I came across showed no clinically significant differences when bracing versus not. Many will argue that the use of bracing plays a large role in the athlete’s confidence in their reconstructed knee as they initially return to their respective sport. I do agree that knowing your athlete and their mental state goes a long way in the decision making process and should be a factor in the decision making process.

At the end of the day, clinical experience and research are two pillars of evidence based practice. We must use both as a means of guiding how we practice and how we help our athletes return to sport. While the literature is by no means conclusive in one direction or the other, we have to take into account the mental component as athletes near clearance to return to their respective sports. And that includes the confidence that wearing a brace affords certain athletes.

In the absence of conclusive, high level evidence (as is the case here), making decisions for that individual patient is crucial and must take into account the evidence, clinical experience, surgeon expertise, and patient preference. As clinicians, it is in our athlete’s best interest to do everything we can to help guide them through this arduous process so long as we don’t create dependency and give them a “crutch”. It’s a fine line, but it’s something that we grapple with in the clinic on a day to day basis.

 Blog post written by Ziad Dahdul, PT, DPT, OCS, is the owner of Ignite Phyzio & Sports Performance, a concierge physical therapy practice in Southern California specializing in one-on-one care. Connect with him on Instagram (@ignitephyzio and @zeeadd)

 

References

1. Lindstrom M, Wredmark T, Wretling ML, Henriksson M, Fellander-Tsai L. Post-operative bracing after ACL reconstruction has no effect on knee joint effusion. A prospective, randomized study. The Knee Journal. 2015;22(6):559-564.
2. Smith SD, Laprade RF, Jansson KS, Arøen A, Wijdicks CA. Knee Surg Sports Traumatol Arthrosc. 2014 May; 22(5):1131-41
3. Rodriguez EC. Knee bracing after anterior cruciate ligament reconstruction. Orthopedics. 2016;39(4);602-609.

 

 

Plyometric Shoulder Training

By Kathleen Hank, DPT

Both upper extremity and lower extremity plyometric exercises are used for rehabilitation or performance enhancement. The concept of plyometrics is used as part of functional movement patterns when performing a sport.  Plyometric training uses the physiological phenomenon of a stretch-shortening cycle to enhance the ability of the neuromuscular system to produce maximal force in the shortest amount of time possible. (1)

Plyometric exercises are high-velocity movements that pre-stretch muscles through eccentric contractions, briefly store elastic energy, and then release kinetic energy to produce a powerful concentric contraction.(2)  During overhead sports, the shoulder must accept high joint loads generated by the lower extremity and trunk and efficiently transfer that energy to the upper extremity.(2)  

The term amortization is used to describe the time from the end of the eccentric pre-stretch to the onset of the concentric action.(3) This phase is key to the performance of plyometrics. Plyometric movement is more effective and powerful with a shorter amortization time because the stored energy is used efficiently during transition.(3)

Potential Training Benefits of Plyometric Exercises:

-increased average power and velocity

-increased peak force and velocity of acceleration

-increased time for force development

-increased levels of muscle activation

-evokes stretch reflexes

-improved neural efficiency

-improved proprioception

-increased neuromuscular performance

Training programs should be individualized to each athlete and his or her sport to develop the best motor performance pattern through neuromuscular dynamic stability.(3) Plyometric training for the upper extremity should coincide with other resistance and flexibility training. Plyometric exercises can be performed in both closed and open kinetic chain positions of the upper extremity.

Examples of plyometric exercises for the shoulder complex:

-two hand chest pass

-two hand rotations from side

-two hand overhead throw

-one hand side arm throw

-90°/90° baseball throw

-eccentric deceleration followed by trunk rotation and concentric tosses

Blog Post written by Kathleen Hank, DPT.  At the time of publishing Kathleen was in her Sports Ortho Clinical with me at Catz Physical Therapy.

References:

1. Gjinovci B, Idrizovic K, Uljevic O, Sekulic D. Plyometric training improves sprinting, jumping and throwing capacities of high level female volleyball players better than skill-based conditioning. J Sports Sci Med. 2017;16:527-535.
2. Swanik KA, Thomas SJ, Struminger AH, Bliven KCH, Kelly JD, Swanik CB. The effect of shoulder plyometric training on amortization time and upper-extremity kinematics. J Sport Rehabil. 2016;25(4):315-323. doi:10.1123/jsr.2015-0005
3. Davies G, Riemann BL, Manske R. Current concepts of plyometric exercise. Int J Sports Phys Ther. 2015;10(6):760-786.

Lisfranc Injuries

Lisfranc joint injuries are the second most common foot injury in athletes, yet are often missed or misdiagnosed.¹ Lisfranc (midfoot) injuries refer to bony or ligamentous compromise of the tarsometatarsal and intercuneiform joint complex. The Lisfranc ligament connects the plantar portion of the medial cuneiform to the base of the second metatarsal.² Without proper treatment, a chronic Lisfranc injury may lead to longitudinal arch collapse, abduction of the forefoot, and midfoot arthritis.³ Physical therapy can help individuals regain functional mobility and return to sport or activities.

Mechanism of Injury

High-energy: Forced hyper-plantarflexion with a valgus/varus component. Example: Car accident, crush injury or fall from a height.

Low-energy: Forced hyper-plantarflexion of the midfoot with an axial load through the foot.  Example: Competitive sports or a ground level fall.

The midfoot injury may involve the ligament, bone, or a combination of both.

Signs and Symptoms

Bruising and swelling over the plantar surface of the midfoot, pain with palpation over the midfoot for up to five days after injury, pain with weight-bearing that is typically exacerbated with heel raises.¹

Non-operative Treatment

Stable injuries (partial sprains and extra-articular fractures) are treated non-operatively. Typically an immobilization boot is worn for up to 6 weeks, gentle range of motion exercises are performed, and weight-bearing is progressed as tolerated.² Treatment focuses on restoration of a normal gait pattern and proprioceptive training.¹

Operative Technique

Unstable or displaced injuries of the midfoot require surgical management. Open reduction and internal fixation (ORIF) with transarticular screw fixation has been the gold standard. Traditional screws are typically removed at 4 months.³ However, ORIF with primary arthrodesis has become more popular as it’s been associated with a lower reoperation rate for hardware removal compared to ORIF alone.²

Post-operative management

Post-operative patients are initially placed in a non-weight bearing cast and progress to a walking boot. Full weight bearing is initiated by the 8th week postoperatively.¹ Athletes may transition from a walking boot into a stiff-soled athletic shoe with a semirigid orthotic device or an athletic shoe with a graphite insole added for stiffness.³

 Blog Post written by Kathleen Hank, DPT.  At the time of publishing Kathleen was in her Sports Ortho Clinical with me at Catz Physical Therapy.

References:

1. Lorenz DS, Beauchamp C. Functional progression and return to sport criteria for a high school football player following surgery for a Lisfranc injury. Int J Sports Phys Ther. 2013;8(2):162-171.
2. Clare MP. Lisfranc injuries. Curr Rev Musculoskelet Med. 2017;10(1):81-85. doi:10.1007/s12178-017-9387-6.
3. Haytmanek Jr. CT, Clanton TO. Ligamentous Lisfranc injuries in the athlete. Oper Tech Sports Med. 2014;22(4):313-320.

 

ACL Rehab – Finding The Right Physical Therapist Matters

By Wesley Wang, DPT

In my opinion, not every physical therapist is qualified to treat ACLs from start to finish. While this statement may ruffle some feathers, let me present you with an analogy that may help put things in perspective. If your car starts having issues, do you take it to just any average mechanic or try to find the best one for your specific type of car? If you’re looking to improve your skills in a specific sport, do you hire an average coach or try to find a specific one for your specific sport? While these examples aren’t perfect, recovering from ACL surgery is a lengthy process and finding the right therapist can significantly improve outcomes.

There are many components that need to be addressed in physical therapy to ensure full recovery.  Research provides detailed guidelines on specific factors including range of motion, strength, movement assessments and return-to-sport testing which should all consistently be addressed to ensure athletes are safe to go back to sports. These seemingly minor details can significantly decrease second ACL injuries which are reported to be approximately 1 in every 4 to 5 patients. (1,3)  Coming back to the mechanic example, would you want a mechanic who wasn’t detail oriented examining your car? Would you want a coach who didn’t use the latest methods to optimize your training sessions?

The entire ACL recovery process takes approximately 9-12 months and sometimes even longer. Research tells us that nine months is the minimum recovery time after surgery and returning too early increases the risk of a second ACL injury. (2) There is simply too much to address in ACL rehabilitation and returning to sports too early is just not worth the risk.

There are two major components of ACL rehabilitation, strength and neuromuscular control. Limb asymmetries which includes range of motion and strength are pivotal for optimal recovery. One of the primary foundations of ACL rehabilitation is achieving full range of motion. For example, if the knee can’t fully extend (straighten), it makes it extremely difficult for the quadriceps to regain full strength. Obtaining greater than 90% quadricep strength and a hamstring-to-quad ratio of at least 85% (compared to the non-operated knee) have been shown to significantly decrease second ACL injuries. (1,2)

Dynamic neuromuscular control involves how the athlete is able to control their body when performing tasks such as balancing, jumping and landing. When performing these tasks, the athlete should be able to demonstrate proper control of their trunk, hips, and knee. For example, when landing on the surgical knee (once it’s safe to do so of course), there should be minimal upper body movement such as the trunk swaying from side to side or the hips twisting and minimal knee movement particularly into valgus (inward). (1,3) Return-to-sport tests identify deficiencies and one study found that successfully completing return-to-sport criteria reduces re-injuries by 32.5%. (2)

Additionally, physical therapists should have knowledge of various exercises to consistently challenge patients in their recovery process which includes both strength and dynamic control. This is a big issue in rehab as I’ve heard from many patients that they weren’t challenged in their previous physical therapy facilities and instead repetitively performed simple exercises. Athletes should be challenged in every physical therapy session or we are doing our athletes a disservice.

Finding the right physical therapist for ACL recovery is absolutely necessary to safely return to sports. The physical therapist should utilize up-to-date research and be able to properly progress and challenge patients to significantly improve outcomes following ACL surgery.

 Blog post written by Wesley Wang, DPT.  Wesley practices in Rockville MD at Healthy Baller Sports Medicine.  He is a go-to resource for ACL & sports rehab info, find him on Instagram @wesleywang.dpt

References

1. Hewitt T, Di Stasi S, Myer G. Current Concepts for Injury Prevention in Athletes After Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2013 Jan: 41(1): 216-224
2. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg M. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Deleware-Oslo ACL cohort study. British Journal of Sports Medicine. 2016 May.
3. Wiggins AJ,Grandhi RK, Schneider DK, Stanfiel D, Webster KE, Myer GD. Risk of Secondary Injury in Younger Athletes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med. 2016 Jul:44(7):1861-76.

The Influence of Hormone Levels on ACL Laxity: Are We Missing a Piece of the Puzzle?

By Steph Allen, DPT, OCS

How many of you out there have torn or know someone who has torn their ACL? How many of you, or the ones you know, are female? Have you/they injured the ACL multiple times? How many have injured BOTH knees one or more times?

If we go with what research statistics have shown, there are likely a large number of you that answered “yes,” “two or more times,” “most are female,” or “both right and left knees.” These are common responses we hear. Not super promising.

The thing is, we seem to know so much about the anatomy of the ACL, injury mechanisms, risk factors, and potential prevention. However, injury rates are not improving, and females remain [continue to be] at a much higher risk of both initial injury and of reinjury.

Frankly, I think we are missing something here, people!

Let’s first take a look at what we DO know, based on years of scientific research:

1. ACL injuries are often non-contact in nature
2. ACL injuries are 2-6 times more likely in females than in males
3. Re-injury and injury to the opposite side are all too common
4. Rates of return to high level/previous levels of sport are low
5. Injury prevention programs are starting to take better shape, and it is more widely accepted that a focus on jump/land technique and neuromuscular control is essential
6. Around puberty, females tend to show a decrease in strength and power and generally poorer LE control and mechanics with jump and land, as well as cutting tasks, as compared to their male peers

This is all extremely helpful, and should be taken into account with all athletes and patients. BUT, I’d like to hop outside of the box for a sec (with pristine control, of course) and explore a possible “X” factor in this conundrum…

I want to look more closely at the impact that hormones have on the ligament complex and how this differs in males vs. females. We have done a great job with researching risk factors, and developing solid injury prevention/risk reduction programs for athletes. However, the sex disparity in ACL injury is still significant.

So let’s dive in a bit with the sparknotes of the research that has been done regarding hormonal influences on ligament laxity…

WHAT THEY DID: They took ACL’s, exposed them to the various hormones present during different phases of the menstrual cycle and measured “laxity” via tensile strength (resistance to pull).

WHAT THEY FOUND: Greatest laxity resulted when the ACL was exposed to Estradiol, which is at its peak in ovulatory phase (10-14 day mark). They also noted increased laxity when it was exposed to relaxin (another hormone floating around during the cycle). AND… they found these exposures to have profound effects on tissue remodeling. [NOTE: due to variability between individuals, it is difficult to assign highest risk to one phase].

Alright, that’s cool. But, how does this work? How can these hormones actually make the ligament more lax?

Here is the mind blow…There are hormone RECEPTORS ON THE ACL!!

When the hormones bind to the ligament, this can affect gene expression and collagen metabolism in a way that can influence the characteristics of the ACL and other soft tissues around it. (*This is key- it is not just the ACL that is affected- it is ALL the soft tissues).

A bit more about why collagen matters: In tendon tissue; collagen accounts for approximately 60–85% of the dry mass of the extracellular matrix (mostly type I collagen). Tiny collagen fibrils group together within the tendon and form “functional fibers”, whose purpose is the transmission of force between muscle and bone. This is HUGE! If the metabolism/cellular turnover and production of the tissue that is largely involved in force transmission at a joint is being affected, this could be a big contributor to the problem of overall joint stability and injury risk.

 

Okay so enough of the cell and biology stuff, let’s take a step back and look at the bigger picture. Let’s take into account movement patterns and neuromuscular control, which we all know is MAJORLY important, both in risk reduction and post-injury rehab/return to sport.

Park et al. found increased loads during cutting tasks in females during their cycle. The most common non contact MOI is deceleration with a quick change in direction, such as a plant and twist that occurs with cutting in sport. In biomechanical terms,  this is combined valgus with tibial IR, putting the ACL on high tension (great explanation in the @cvasps podcast with Tim Hewitt- click here or see references below). These two things, combined with the fact that we now have reason to believe that hormones can increase ligament laxity, may just be what is creating the perfect storm for ACL injury in females…

Lower tissue tolerance/greater tissue laxity + Game type speed and force on ligament with cut/jump/land + physical/mental fatigue and poor mechanics = Tissue failure

Oh man, so what in the world can we do about this? You might argue, hey, we can’t control something such as the menstrual cycle; it’s part of every healthy female’s life. And I can’t disagree with that. However, I cannot, and WILL NOT believe that there are not some actions we can take to combat these biological constants.

First and foremost, let’s make risk reduction/injury prevention programs more of the norm in youth athletics and let’s start these programs EARLY. Thompson-Kolesar et al. found that pre-adolescent female soccer players demonstrated greater improvement in double leg jump tasks after participating in an injury prevention warm up program than did older adolescent females. So if we can reach these kids before skeletal maturity and while they are still learning motor patterns for the first time, we can be more confident that they are able to control their sports specific movements even when they are fatigued or the movements are unplanned.

Second, let’s keep encouraging females to get really strong for their sport, thereby making it “cool” and more socially accepted during teenage years when being cool is as important as breathing oxygen. Thompson-Kolesar et al. also found that the rapid bone growth that occurs in adolescence correlates with an increase in muscle power and strength in males, but corresponds with a decrease in strength and dynamic knee stability in females. So now we have a larger human and larger bones to support, coupled with less of an ability to produce force and decreased neuromuscular control. Yuck. Let’s get ahead of this and address BOTH the strength and motor control deficits that seem to poke their heads out during puberty and adolescence.

Third, let’s stop burning the candle at both ends. This part may be a bit on the opinion end of the spectrum, but I think many would agree. So many young athletes, especially elites, are training SO much and training a single sport. Under-recovery and repeated motor patterns without exposure to movement variability is also a piece of the problem puzzle, if you ask me. I am an advocate of proper recovery and promoting multi-sport participation, regardless of age.

Lastly, let’s please make the conversation surrounding the menstrual cycle as it pertains to training less taboo, more the norm, and a bit more influential. Sex differences in injury cannot be fully explained by strength or motor control alone. There is something else to this! If there is a way we can combat the influence of hormones on ligament laxity and overall injury risk, ultimately leveling the playing field (literally and figuratively), then let’s do it! I think this warrants a deeper dive into research and investigating longer term data so that we can actually solve this puzzle and get these injury and reinjury rates under control.

I hope this piece sparks some interest and discussion, and results in more people asking outside of the box questions. Our athletes, patients, and clients deserve it. Let’s go!

 Blog Post written by Steph Allen, DPT, OCS. Steph has a particular passion for ACL research and rehabilitation and hopes to be instrumental in making positive changes, both in in post op rehab and risk reduction programs.

I asked Steph to write on this topic after hearing her Interview on the CVASPS Podcast, click here to listen. This is an important topic if you have daughters involved in sports, or if you coach, train & rehab female athletes.

Steph is on staff at Boston PT & Wellness in Medford MA. You can find her on Instagram @stephallen.dpt

 Resources:

CVASPS Podcast with Tim Hewitt: https://www.youtube.com/watch?v=dC7zU0fvhnI

Thompson-Kolesar JA, Gatewood CT, Tran AA, Silder A, Shultz R, Delp SL, Dragoo JL. Age Influences Biomechanical Changes After Participation in an Anterior Cruciate Ligament Injury Prevention Program. Am J Sports Med. 2018 Mar;46(3):598-606. Doi: 10.1177/0363546517744313. Epub 2017 Dec 27. PubMed PMID: 29281799.

Von Rosen P, Kottorp A, Fridén C, Frohm A, Heijne A. Young, talented and injured: Injury perceptions, experiences and consequences in adolescent elite athletes. Eur J Sport Sci. 2018 Mar 3:1-10. Doi: 10.1080/17461391.2018.1440009. [Epub ahead of print] PubMed PMID: 29504456.

Leblanc DR, Schneider M, Angele P, Vollmer G, Docheva D. The effect of estrogen on tendon and ligament metabolism and function. J Steroid Biochem Mol Biol. 2017 Sep;172:106-116. doi: 10.1016/j.jsbmb.2017.06.008. Epub 2017 Jun 16. Review. PubMed PMID: 28629994.

Park SK, Stefanyshyn DJ, Ramage B, Hart DA, Ronsky JL. Relationship between knee joint laxity and knee joint mechanics during the menstrual cycle. Br J Sports Med. 2009 Mar;43(3):174-9. doi: 10.1136/bjsm.2008.049270. Epub 2008 Aug 26. PubMed PMID: 18728055.

 

 

 

Healthy Arms Baseball

eBook Download

This is a special program designed with baseball players in mind. The purpose of this program is to monitor the throwing athlete throughout the year with quarterly check-ups to address risk factors associated with common throwing injuries, and to provide a plan of action to help maintain the strength and mobility essential for a healthy season.

Serious elbow and shoulder injuries continue to rise among youth, high school, collegiate and professional baseball players. Major League Physicians and Executives believe that the recent spike in Tommy John surgeries is due to excess pitching volume and intensity at the youth and amateur levels.

This is not a performance program but monitoring arm health throughout the year will decrease the risk for serious injury and indirectly lead to improved performance on the field, because healthy arms perform better.

For more information email me at chrisbutlersportspt@gmail.com

BFR & Muscle Injuries

Hamstring pulls or strains are one of the most common injuries amongst athletes. They have a reputation for lingering and reoccurring throughout the season.

When a muscle is injured, Myostatin and TGF beta act together to fill in the tear with fibrotic tissue. Unfortunately fibrotic tissue or scar tissue, is not as elastic as muscle and tends to break or rip instead of stretch.

BFR has been proven to produce muscle hypertrophy & protein synthesis at loads far below the traditional 65-85% 1RM without the coinciding muscle breakdown, which makes it a great way to load injured muscle tissue.

Low load BFR exercise takes away oxygen as a fuel source and allows aerobic movement tasks to be carried out by the anaerobic system.  Anaerobic muscle activity creates lactate build-up which initiates Growth Hormone release and subsequent collagen synthesis essential for tissue healing.

BFR has been found to down regulate Myostatin, this means that if we use BFR with our muscle injuries we may have a better chance of obtaining true non-fibrotic healing of the muscle tissue.

Above is a progression of low load exercises that have been working for my athletes.

High vs Low Ankle Sprains

By Grant Uyemura, DPT

High ankle sprains are more common in high impact sports and usually occur when the
foot is forced into external rotation with a planted, dorsiflexed foot. This mechanism of injury will cause the talus to widen the ankle mortise which can injure or tear the syndesmosis. The syndesmosis is made up of the anterior inferior tibiofibular ligament, interosseous ligament, interosseous membrane, posterior inferior tibiofibular ligament, and transverse ligament.

Lateral ankle sprains also known as inversion sprains are the most common orthopedic
injury and account for 85% of all ankle injuries. Lateral ankle sprains usually happen when the foot is point down, plantarflexed and rolls inward. The anterior talofibular, calcaneofibular, and posterior talofibular ligaments are the most common ligaments to get injured during a lateral ankle sprain.

High ankle sprains will take longer to heal and are more likely to create long-term
dysfunction compared to lateral ankle sprains. However, high ankle sprains are less common than lateral ankle sprains. Both injuries can be treated through physical therapy with conservative treatments.

The first phase will be protecting the joint while minimize pain, inflammation, weakness, and loss of motion.

The second phase will focus on normalizing joint mobility, strength, neuromuscular control, and return to activities of daily living.

The last phase will prepare the athlete for return to sport activities.

Blog post written by Grant Uyemura, DPT Student from University of St. Augustine. At the time of publishing Grant was in a clinical rotation with me at Catz PTI.

References:

1. Williams GN, Allen EJ. Rehabilitation of Syndesmotic (High) Ankle Sprains. Sport Heal A Multidiscip Approach. 2010;2(6):460-470. doi:10.1177/1941738110384573.

2. Hunt K. J, Phisitkul, P Pirolo J, Amendola A. High Ankle Sprains and Syndesmotic Injuries in Athletes. Journal of the American Academy of Orthopaedic Surgeons. .
2015;23(11):661-673. doi:10.5435/jaaos-d- 13-00135

3. Albin, S. Rehabilitation of the Athlete Following Ligamentous Injury. Oral Presentation at: 12 th Annual CU Sports Medicine Fall Symposium. Meeting; September 22. 2017; Boulder,
CO.

Concussion: When Can I Return to Sport?

By Grant Uyemura, DPT Student

A concussion is a mild traumatic brain injury (TBI) that occurs when a head impact jars or shakes the brain inside the skull. This can damage neural pathways, which can lead to neurological disturbances. Symptoms can affect your physical, cognitive, behavioral, and emotional well-being.

Physical signs such as headaches, dizziness, sleep disturbances, nausea, vomiting, noise & light sensitivity, loss of consciousness.

Cognitive signs are confusion, slow reaction time, memory problems, poor judgement, inability to focus.

Behavioral changes may be confrontational demeanor, explosive temper fearfulness, impatient, hypervigilance.

Emotional changes such as depression, agitation, irritability, anxiety, and frequent mood changes man also be experienced. 90% of diagnosed concussions do not involve loss of consciousness, so it is important to understand common signs and symptoms.

Return to Sport Stages

Following a concussion, it is recommended to rest for 24-48 hours before starting stage
1 of the return to sport protocol. If the athlete is able to complete the stage without concussion related symptoms, then they can progress to the next stage. There should be at least 24 hours for each step of the progression. At minimum, it would take athletes 1 week to proceed through the full rehabilitation protocol before returning to play.

 Blog post written by Grant Uyemura, DPT Student from University of St. Augustine. At the time of publishing Grant was in a clinical rotation with me at Catz PTI.

References:

1. McCrory P, Meeuwisse W, Dvorak J, et al Consensus statement on concussion in sport—the 5 th  international conference on concussion in sport held in Berlin, October 2016 Br J Sports Med Published Online First: 26 April 2017. doi: 10.1136/bjsports-2017- 097699

2. Parker M, Lecture presented: Mild Traumatic Brain Injury, How to Identify and Treat
Concussions with Compassion at the University of Saint Augustine for Health Sciences, San Marcos, CA.

Why is the Rotator Cuff Important?

By Grant Uyemura, DPT Student

Rotator cuff tendinopathies affect 20-30% of the general population and becomes more prevalent and disabling with age. 1 The rotator cuff is made up of 4 muscles supraspinatus, infraspinatus, teres minor, and subscapularis. These muscles help stabilize the humeral head within the glenoid fossa and prevent superior humeral head migration during overhead movements. 2

Weakness of the rotator cuff can lead to shoulder impingement, tendonitis, bursitis, and labral tears. Looking at Jobe’s instability continuum. 3
1. Rotator cuff weakness generally occurs first
2. Functional instability follows prolonged rotator cuff weakness
3. Capsular laxity, which develops over time
4. Subluxation due to inability of the humeral head to center in the glenoid during motion
5. Rotator cuff/labral tearing (late-stage disease of secondary impingement)

Best Exercises

Reinold et al., 2,4 found that the best supraspinatus exercise was a standing or prone full can. A standing full can was found to have decreased deltoid activation compared to the prone full can. Sidelying external rotation with 0º of abduction was found to be the best exercise to strengthen the infraspinatus and teres minor. Internal rotation at 0º or 90º of abduction was the best exercise to strengthen the subscapularis. Click here or photos for link to videos.

   

 

These isolated exercises are a good starting point and are great for a basic home program.  However, for best results they should be used in conjunction with a more comprehensive and integrated rehab routine.

Blog post written by Grant Uyemura, DPT Student from University of St. Augustine. At the time of publishing Grant was in a clinical rotation with me at Catz PTI.

References:

1. Wies JT, Humphreys H, Latham M, et al. A randomized placebo-controlled trial of PT for RTC tendinopathies [abstract]. J Orthop Sports Phys Ther. 2005;35:A5.

2. Reinold MM, Escamilla R, Wilk KE. Current Concepts in the Scientific and Clinical
Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature. J Orthop
Sport Phys Ther. 2009;39(2):105-117. doi:10.2519/jospt.2009.2835.

3. Page P, Frank C, Lardner R. Assessment And Treatment Of Muscle Imbalance. Champaign [etc.]: Human kinetics; 2010.

4. Reinold MM, Wilk KE, Fleisig GS, et al. Electromyographic Analysis of the Rotator Cuff
andDeltoid Musculature During Common Shoulder External Rotation Exercises. J Orthop
Sport Phys Ther. 2004;34(7):385-394. doi:10.2519/jospt.2004.34.7.385.

Why are Strong Glutes Important?

By Grant Uyemura, DPT Student

What do the glutes do?

The glute is made up of 3 muscles glute maximus, medius, and minimus. The main action of the glute maximus is hip extension and external rotation. The glute medius acts as a hip abductor with anterior fibers assisting internal rotation while the posterior fibers aid in external rotation. The glute minimus is responsible for hip abduction and internal rotation.Why are strong glutes important?

Weak glutes can cause low back/hip pain, iliotibial band syndrome, patellofemoral pain
syndrome, and chronic ankle sprains.

Best exercises for glutes?

According to Distefano et al. they found the best glute medius exercises were side-lying hip abduction and the best glute maximus exercises was the single leg deadlifts and single leg squat. Boren et al. found that a front plank with hip extension was the best glute maximus exercise while a side plank with hip abduction was best for the glute medius. Both studies found that the best overall exercise for glute strengthening was a single leg squat.

Blog post written by Grant Uyemura, DPT Student from University of St. Augustine. At the time of publishing Grant was in a clinical rotation with me at Catz PTI.

1. Boren K, Conrey C, Le Coguic J, Paprocki L, Voight M, Robinson TK. Electromyographic
analysis of gluteus medius and gluteus maximus during rehabilitation exercises. Int J
Sports Phys Ther. 2011;6(3):206-223.

2. Distefano LJ, Blackburn JT, Marshall SW, Padua DA. Gluteal Muscle Activation During
Common Therapeutic Exercises. J Orthop Sport Phys Ther. 2009;39(7):532-540.
doi:10.2519/jospt.2009.2796.

3. Macadam P, Cronin J, Contreras B. an Examination of the Gluteal Muscle Activity
Associated With Dynamic Hip Abduction and Hip External Rotation Exercise: a Systematic Review. Int J Sports Phys Ther. 2015;10(5):573-591.

What is Femoroacetabular Impingment?

By Grant Uyemura, DPT Student

Femoroacetabular Impingement (FAI) is abnormal contact between the femoral head and acetabulum, which can cause hip pain, labrum, and/or cartilage damage. There are three different types of FAI’s: Cam, Pincer, and mixed. Cam impingement lesions are more prevalent in younger males than in females. Pincer lesions are more common in middle aged, active women.1 A study by Tannast et al. found that 86% of patients have a combination of both cam and pincer impingement.2

Types of FAI

Cam: Aspherical femoral head tries to fit into a spherical socket. Can cause chondrolabral junction separation due to shearing force.

Pincer: Over coverage of acetabulum socket, can cause labrum crushing and degeneration/ ossification.

Mixed: Combination of cam and pincer deformities.
Clinical Presentation

• Anterior or anterolateral hip/groin pain

• Stiffness

• Painful hip flexion past 90º and internal rotation

• Pain with prolonged sitting

What Physical Therapy can do?

The goal of physical therapy is to increase range of motion, increase strength, and decrease pain in order to maximize function and return to your prior level of function. Surgery should only be considered when conservative treatments do not control symptoms or functional limitations are unacceptable.4

 Blog post written by Grant Uyemura, DPT Student from University of St. Augustine. At the time of publishing Grant was in a clinical rotation with me at Catz PTI.

References:

1. ​Kuhns BD, Weber AE, Levy DM, Wuerz TH. The Natural History of Femoroacetabular Impingement. Front Surg. 2015;2(November):1-7. doi:10.3389/fsurg.2015.00058.

2. ​Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular impingement: Radiographic diagnosis – What the radiologist should know. Am J Roentgenol. 2007;188(6):1540-1552. doi:10.2214/AJR.06.0921.

3. ​Stephanie Pun, MD, Deepak Kumar, PT, PhD, and Nancy E. Lane M. Femoroacetabular Impingement. Nih. 2016;67(1):17-27. doi:10.1002/art.38887.Femoroacetabular.

4. ​Enseki K, Harris-Hayes M, White DM, et al. Nonarthritic Hip Joint Pain. J Orthop Sport Phys Ther. 2014;44(6):A1-A32. doi:10.2519/jospt.2014.0302.

 

 

 

Progressive Overload: A Strength Training Model for The Rehab Professional

   

By Teddy Wilsey, DPT, CSCS

It is well known that the body must be broken down in order to build up. This is the fundamental principle of exercise: stress adaptation occurs in order to strengthen our bones, condition our cardiovascular system, maintain our joint range of motion, and optimize our muscular function. If you don’t use it, you will lose it. This idea of invoking stress is an area that rehabilitation professionals often fall short in. The physical therapy curriculum is designed to prepare a generalist who can work with all levels of patients including pediatrics, hospital work, and neurological rehab. These are all very important aspects of healthcare, however, the major downfall of a generalized therapist degree is a lack of knowledge in sports rehab and basic strength and conditioning. This article will touch on the need to stress the system in orthopedic rehabilitation and the idea of progressive overload within a linear periodization rehabilitation model.

Performance is a relative term, as the performance ceiling for a 75 year old recovering from a knee replacement is vastly different than that of a college basketball player recovering from an ACL rupture and patellar tendon autograft. Either way, they are both knee injuries and the principles remain the same. Regaining quadriceps strength will be an integral part of both of their programs, and the exercises might be very similar at the beginning phases. As mentioned in the introduction, physiological adaptation and increases in performance require stress to the system. It’s important to understand that stress is relative. An exercise or weight load that might cause stress and elicit strength and gains for the 75 year old would probably not be of the same benefit for the college basketball player. This same weight could even create negative adaptations over time if it is not sufficient to stimulate the system. For example, if a 400 lb. squater is only doing goblet squats with 25 lb., they will actually get weaker while working with you.

The therapist’s job is help their patients increase function. From an orthopedic recovery standpoint, therapists must cause some amount of stress in order to help their patients improve function. Most therapists typically see their patients for 2-6 months at the most, depending on the injury. Although linear progress is not a long term solution to training, it lends itself well to this shorter time period and rehabilitation type of recovery where exercise selection is constantly being progressed. Strength and conditioning periodization models are helpful to understand from a theoretical standpoint, but are typically more complex than we need for therapy. In the simplest of terms: just make sure your patient is doing more than they were two weeks ago.

To examine progressive overload, stress, and a linear model, let’s look at integrating the squat into rehabilitation for both of these patients. Outside of gait, the squat is arguably the most functional movement that exists. Standing up is an essential skill for nearly everyone. To start with the 75 year old patient s/p total knee, their sit to stand would likely begin with an upper extremity assist and a very short range of motion to a high box. Loading the knee will assist in gradually restoring range of motion and alleviating stiffness. Manual therapy, stretching, and other passive modalities can help with managing pain and improving range of motion as well. This patient’s knee will likely be stiff, and the soft tissue structures surrounding the knee may be weak and shortened as well. The typical arthritic knee experiences months to years of progressive weakening and range of motion loss prior to surgery. Rehabilitation prior to surgery should focus on maintaining and regaining full range of motion and improving strength to tolerance.

The first day or two after surgery for these two patients might look very similar. The college basketball player ACL repair will also start a squat with a TRX. After the second or third PT session, the college athlete will require much more challenge to make progress. They might be more comfortable achieving parallel depth sooner, as their tissue was supple prior to surgery. In this patient, there will also be a need to be emphasize slowly increasing the stretch across the patellar tendon. This is due to the patellar tendon autograft. The squat will start with a vertical tibia, and the therapist will gradually cue the patient and modify exercises to allow more dorsiflexion and knee flexion over time in order to rebuild the surgical site and increase patellar loading.

By 6-8 weeks, both of these patients should be squatting with weight. The total knee might be nothing more than 10-20 lb. goblet squat, or it could be up to a 50 or 60 lb. goblet squat, depending on their prior function. The basketball player might be in that 40-60 lb. range for a goblet, or even back squatting 135 lb. or more. Again, this depends on prior strength levels.  Both of these patients should be exposed to similar relative stressors. They should both feel muscular soreness at times. They might both even feel some increased knee soreness during periods of introducing new movements or taking big steps forward. That’s usually OK. The important distinction here is that the stress for a college athlete’s rehab needs to be significantly higher than that of a knee replacement patient in order to evoke adaptation.

Rehabilitation professionals often fall short in is creating enough stress and adaptation for their higher level athletes. The typical outpatient therapist’s caseload is probably only 10-20% athletes, at the most. Hence, the potential blind spot and need for a greater understanding of how to help challenge athletes. The concepts are the same across the board, but there needs to be a greater understanding of the nuances of higher level and more challenging exercise and movement. Remember, without stress and progressive overload, there is very minimal adaptation.

To learn more about how to challenge athletes and what exercises to use, check out my instagram at @strengthcoachtherapy.

Dr. Teddy Willsey, DPT, CSCS, is the director of sports medicine at Healthy Baller, a sports performance gym located in Rockville, MD, a suburb of Washington D.C. In addition to his daily practice, Teddy writes, speaks, and posts on social media regularly with the goal of educating therapists, fitness professionals, and recreational exercises on practical approaches to exercise and rehabilitation with a sports medicine and performance focus. Teddy’s work can be found on Instagram: @strengthcoachtherapy

Meniscal Tears & Consideration of PT Instead of Surgery

   

By Greg Louie, DPT

The menisci lie between the tibia and femur. They stabilize the knee into flexion and extension, assist in joint lubrication and nutrition, and distribute compressive forces to reduce stress on the articular cartilage with load-bearing and load transmission.(1) Meniscal tears are quite common,the mean annual incidence of meniscal injuries are 66 for every 100,000 individuals.(2)

There are two classifications of meniscal tears: traumatic and degenerative. For a meniscus tear to classified as traumatic, the meniscus must be healthy and there must be an injury to the knee as a result of a forced movement.(3) These types of tears are higher amongst young adults because of an increased percentage of this population participating in high-level activities and sports.(4) A forced twisting movement with the knee bent is the common mechanism of injury for traumatic lesions. Degenerative tears occur in the absence of trauma and result from deterioration of the meniscus from abnormal loading forces to the knee.(3) Individuals with a body mass index greater than 25, those who are older then 60, and those who work in jobs requiring increased kneeling, squatting, and stair climbing are at a significantly higher risk for degenerative meniscal tears.(4)

Meniscus injures are often accompanied by other ligamentous injuries of the knee.(3) A combination of injury to the meniscus, medial collateral ligament, and the anterior cruciate ligament is known as the unhappy triad of the knee.(5)

In the United States, partial meniscectomies are the most common orthopedic surgical procedure(6) but does this mean everyone with a torn meniscus should opt for surgery? Several studies have found that surgery is not always necessary and that physical therapy should be considered prior to surgery. Sihvonon and associates found no difference in partial menisectomy compared to sham surgery.(7) Katz and colleagues found no difference in outcomes with arthroscopic partial meniscectomy combined with physical therapy compared to physical therapy alone.(8) Surgery should be considered as a last resort when all other interventions (including physical therapy) have failed.

A physical therapist will assess the severity of the tear and provide interventions to control the pain, inflammation, and swelling. As the knee beings to heal, they can help you regain full range of motion, get you back walking pain free, and build strength and coordination to prevent reinjury.

 Blog post written by Greg Louie, DPT Student from University of St. Augustine. At the time of publishing Greg was in a clinical rotation at Catz PTI. Follow him on Instagram @sportsperformancerehab

References:

1. Makris EA, Hadidi P, Athanasiou KA. The knee meniscus: structure-function, pathophysiology, current repair techniques, and prospects for regeneration. Biomaterials. 2011;32(30):7411-7431.

2. Hede A, Jensen DB, Blyme P, et al. Epidemiology of meniscal lesions in the knee. Acta Orthop Scand. 1990; 61:435–437.

3. http://www.physio-pedia.com/Meniscal_Lesions

4. Snoeker BA, Bakker EW, Kegel CA, Lucas C Risk factors for meniscal tears: a systematic review including meta-analysis. J Orthop Sports Phys Ther 43: 352–367. 2885

5. Sbourne K, Nitz P. The O’Donoghue triad revisited. Combined knee injuries involving anterior cruciate and medial collateral ligament tears. Am J Sports Med. 19(5):474–7.

6. Englund M, Guermazi A, Gale D, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008; 359:1108-1115.

7. Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013; 369(26): 2515–24.

8. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013; 368:1675-1684

Rotator Cuff Rehab Management

   

By Garrett Holle, DPT Student

The function of the rotator cuff is colossal in the performance of our athletes and everyday individuals.  So much so, in fact, it has formerly been called the kiss of death for the career of overhead athletes.  Rotator cuff injury in sports is climbing in part due to an increased emphasis on strength in college programs. Moreover, in a study of NCAA college football players, rotator cuff injury was the 3rd most commonly reported shoulder injury (1). This high rate of occurrence holds true in the general public as
this study showed that of a random sample, 20.7% of patients had full-thickness rotator cuff tears (3).

As you can see, the ability to treat rotator cuff injuries and treat them well is going to be a valuable skill in your practice. The rehab is not easy, but we can make a huge difference with our patients if we handle them correctly.

How to Avoid a Common Oversight of Rotator Cuff Rehab

When prescribing exercise for the small intrinsic muscles of the cuff, it can be easy to throw the typical 3 sets of 12 to a patient.  However, I think we should reconsider this.  In addition to the typical explanation that every patient is different, there is also physiological evidence that supports this notion. This study explored the fiber composition of the rotator cuff muscles, indicating a mixed composition of fast and slow twitch (2). Although 44% of rotator cuff fibers labeled positively as slow twitch, the remaining fibers lie somewhere on the fast-twitch continuum.

Now if that study is a little too far into the physiology for you, let me make this applicable.

This knowledge of fiber type composition allows us to better determine and prescribe exercise volumes and intensities that satisfy the demands for muscle development. This concept aligns with the strength and conditioning principle of specificity. In the training realm, if you’re working with a sprinter, you’re going to utilize high intensity, low volume and if you’re training an endurance runner, you will use lower intensity with higher volumes. This example applies to training of the rotator cuff as well.

This concept is no nuance in the strength and conditioning realm, and it is a great illustration of how we can successfully begin to close the chasm between our two professions.

 Garrett Holle is a DPT student at the University of Kansas Medical Center. You can find him on all social media platforms @Holle_Per4mance 

References

1. Kaplan, L. D., Flanigan, D. C., Norwig, J., Jost, P., & Bradley, J. (2005). Prevalence and Variance of Shoulder Injuries in Elite Collegiate Football Players. The American Journal of Sports Medicine, 33(8), 1142–1146. https://doi.org/10.1177/0363546505274718

2. Lovering, R. M., & Russ, D. W. (2008). Fiber Type Composition of Cadaveric Human Rotator Cuff Muscles. Journal of Orthopaedic & Sports Physical Therapy, 38(11), 674–680. https://doi.org/10.2519/jospt.2008.2878

3. Yamamoto, A., Takagishi, K., Osawa, T., Yanagawa, T., Nakajima, D., Shitara, H., & Kobayashi, T. (2010). Prevalence and risk factors of a rotator cuff tear in the general population. Journal of Shoulder and Elbow Surgery, 19(1), 116–120. https://doi.org/10.1016/j.jse.2009.04.006

4. Rotator Cuff Image: Henry Vandyke Carter [Public domain], via Wikimedia Commons

 

Groin Strains

   

By Ashley Pena, DPT

Groin strains make up 8- 18% of all soccer injuries and also occur in many other high intensity sports such as Ice Hockey, Football, Basketball, and more. They are typically found to occur during kicking, cutting, pivoting, changing directions, or when planting the lead foot. In a prospective research study looking at the athletic population, Serner et. al. found that in soccer players, kicking was the most common mechanism of injury at 40%. In other sports, changing directions was the most frequent mechanism at 31%. In addition, Serner found that 66% of these groin strains resulted in injuries to the Adductors (primarily Adductor Longus). Iliopsoas and Proximal Rectus Femoris were also found to be frequently injured with 15-25% of the groin strain participants sustaining these injuries.

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❗️Groin strains❗️make up 8- 18% of all soccer injuries and also occur in many other high intensity sports such as Ice Hockey, Football, Basketball, and more. ⚽️🏒🏈🏀 They are typically found to occur during kicking, cutting, pivoting, changing directions, or when planting the lead foot. 🎥🎥🎥⬆️ Here are a few frontal & transverse plane movements that integrate groin loading with the rest of the body. 💻Blog Post by @ashpena3r coming 🔜 to chrisbutlersportspt.com 🎙 🎵.rl

A post shared by Chris Butler, MPT, CSCS (@cbutlersportspt) on Aug 10, 2017 at 8:14pm PDT

Some factors which have been found in past research to be related to an increased risk of groin strains include older age, level of competition or experience, decreased range of hip abduction and rotation, isometric adductor muscle weakness or high abductor/adductor strength ratio, and poor performance in vertical jump tests. Specifically, in a cohort study done by Moreno-Perez et. al. it was found that players with groin injuries showed weaker isometric hip adductor strength and smaller Adductor/Abductor strength ratios than those without groin injuries giving evidence that screening for adductor strength deficits or Add/ Abd. muscle imbalances may be helpful in avoiding groin injuries.

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​❗️Groin Strains❗️ A study by Moreno-Perez et. al. found that athletes with groin injuries showed weaker isometric hip adductor strength and smaller Adductor/Abductor strength ratios than those without groin injuries. 🏈🏀⚽️ Screening for adductor strength deficits or Add/ Abd. muscle imbalances may be helpful in avoiding groin injuries. 🎥🎥🎥 Above are some advanced SL bridge variations that can help with controlling hip Add/Abd & ER/IR control. 💻 Blog Coming 🔜 ❤️💬Share 📚📚📚 Moreno-Pérez et al. Comparisons of hip strength and countermovement jump height in elite tennis players with and without acute history of groin injuries. Musculoskeletal Science and Practice. 2017 🎵.rl

A post shared by Chris Butler, MPT, CSCS (@cbutlersportspt) on Aug 12, 2017 at 8:27pm PDT

Blog Post written by Ashley Pena, DPT Student from Cal State Northridge. At the time of publishing, Ashley was in her final clinical rotation with me at Catz PTI.

References:

1. Elattar O, Choi H-R, Dills VD, Busconi B. Groin Injuries (Athletic Pubalgia) and Return to Play. Sports Health: A Multidisciplinary Approach. 2016;8(4):313-323. doi:10.1177/1941738116653711.
2. Moreno-Pérez V, Lopez-Valenciano A, Barbado D, Moreside J, Elvira J, Vera-Garcia F. Comparisons of hip strength and countermovement jump height in elite tennis players with and without acute history of groin injuries. Musculoskeletal Science and Practice. 2017;29:144-149. doi:10.1016/j.msksp.2017.04.006.
3. Serner A, Tol JL, Jomaah N, et al. Diagnosis of Acute Groin Injuries. The American Journal of Sports Medicine. 2015;43(8):1857-1864. doi:10.1177/0363546515585123.
4. Tyler TF, Silvers HJ, Gerhardt MB, Nicholas SJ. Groin Injuries in Sports Medicine. Sports Health. 2010;2(3):231-236. doi:10.1177/1941738110366820.

Brain Vandalism

   

By Nick Hannah, PT

I need to begin this blog by emphasizing a very important fact about your body: YOUR JOINTS ARE INHERENTLY STRONG AND STABLE! In the absence of rare circumstances like severe traumas (i.e. joint dislocations) and certain genetic disorders that can physically make your joints ‘loosey-goosey,’ the joints making up your body simply won’t go out of place from day-to-day activities.

However, there are times you could swear they really WERE out of place. Joints and body parts can feel shifted, “off,” “out-of-sorts,” wonky—sometimes as if they were no longer a part of you. These kinds of perceptions are NORMAL and many feel this way. Weird right? So how can it be that your joints FEEL out of place when in reality they’re rock solid? Let’s find out. 

Within your brain different cell groups build a DETAILED map of your body—a helpful analogy is to think of this body map in the brain like a detailed painting (every nook, cranny and unique aspect of your body is represented and accounted for). This means that certain brain areas control the movements and feelings of certain body parts. It’s more complicated than this but that’s the gist of it.

When we have pain in a certain body area (i.e. a hip), our body painting changes—that once crisp, clear image of the hip in the brain gets smudged. The actual brain tissue changes: we call this neuroplasticity. If the pain persists long enough, the brain’s representation of the hip gets even more distorted—the smudging grows and spreads to surrounding body parts of your painting (your once beautiful work of art is under ruin).

With time, this brain ‘vandalism’ alters how you perceive and control movement of the hip & surrounding body parts. THIS is why you feel weird, out of place, and ‘off.’ It also accounts for why pain spreads, and it can happen to any body part.

Side note: these changes aren’t unique to pain. Ask any seasonal golfer what their VERY first swing feels like after many ‘golf-less’ months in the winter—it feels weird! More smudging at work here.

So how do you improve your ‘brain vandalism’?

• First, find yourself a good physiotherapist (or another health professional—I’m biased of course). Education is paramount here: you must understand that the strategies adopted early on and meant to protect you—like fear avoidance, limiting painful movement, rest etc.—are now creating maladaptive changes in the brain and actually making things worse.
• Second, slowly but surely re-expose the painful body part to the normal movements and activities it once performed. This is called graded exposure—and the starting point for everyone will be different. In this way you start to re-trace what was smudged, and begin the process of re-painting the body part as represented in the brain.

Stop thinking you’re out of place. You might FEEL like it, but now you know why.

As always. Don’t sit still. Make moves.

Blog post written by Nick Hannah, PT.  Nick is the winner of the Blog Post Competition I challenged my Instagram followers with this July.  You can find Nick on Instagram @hannahmoves.

What is Kinesiophobia?

 

   

By Ashley Pena, DPT Student

Patients with re-occurring injuries that become chronic conditions such as chronic low back pain or chronic ankle sprains can be a challenge for medical professionals for many reasons. Risk factors for the array of chronic conditions have been studied and identified. However, one problem in this population that is less frequently discussed is that of Kinesiophobia. Kinesiophobia (KPB), or Fear Avoidance Beliefs, are defined as “excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or re-injury.”8 While this may sound like an extraordinary occurrence, these beliefs to some degree are often a factor in chronic conditions.

To summarize, KPB can be broken down into “Harmful factors” (HF) which reflect the patient’s belief that something is seriously wrong with the body; and “Activity avoidance factors” (AAF) which represent the belief that avoiding exercise/activity will prevent an increase in pain. These beliefs generally lead to a vicious cycle involving an avoidance of movement or any activities that might cause pain or reinjury (see Figure above). Over time, the inactivity that stems from this fear leads to physical consequences such as muscle atrophy, loss of spinal range of motion, and psychological consequences. Psychological consequences include reduced calibration to painful stimuli and behavioral changes. This in turn can affect patient prognosis and healing times.10

Figure 2

The physiological and psychological changes that occur in chronic pain conditions are well- studied and is described in David Butler’s “Explain Pain.”1 Essentially, your body adapts to what is being sent it’s way, so if pain or “danger” messages keep being sent to the brain, the sensory neurons become more sensitive to incoming excitatory chemicals, the sensors stay open longer, eventually more sensors are produced and neuronal sprouting can occur. Another change which occurs in the brain is homunculus “smudging”. With this occurrence, the area of the cerebral cortex which is devoted to sensation and representation of the involved body part becomes larger, with less distinct outlines and overlaps with surrounding areas of the cortex. All of these things can contribute to perpetuating pain.

Figure 3

The good news: many of these changes are reversible. As depicted below, after injury the body has a new tissue tolerance level (Figure 2). The key to combating this over-sensitivity is pacing and graded exposure (Figure 3). Finding a Baseline tolerance to a task which you can perform without a flare up is essential, since your body will alert you of the need to stop at the “New Protect By Pain” line (Figure 2). By exercising just below the “Flare Up” line one can begin to slowly make changes in their tolerance and eventually resume to their original Tissue Tolerance.1

Blog Post written by Ashley Pena, DPT Student from Cal State Northridge. Ashley is currently in her final clinical rotation with me at Catz PTI.

References:

1. Butler DS, Moseley GL. Explain pain. Adelaide: Noigroup Publications; 2015
2. Crombez G, Vlaeyen JWS, Goubert L. Muscle Pain, Fear-Avoidance Model. Encyclopedia of Pain 2013:1963–1966. doi:10.1007/978-3-642-28753-4_2531.
3. Crombez G, Vlaeyen JW, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain 1999;80(1):329–339. doi:10.1016/s0304-3959(98)00229-2.
4. Feitosa AS, Lopes JB, Bonfa E, Halpern AS. A prospective study predicting the outcome of chronic low back pain and physical therapy: the role of fear-avoidance beliefs and extraspinal pain. Revista Brasileira de Reumatologia (English Edition) 2016. doi:10.1016/j.rbre.2016.03.002.
5. Guclu DG, Guclu O, Ozaner A, Senormanci O, Konkan R. The relationship between disability, quality of life and fear- avoidance beliefs in patients with chronic low back pain. Turkish Neurosurgery . 2012. doi:10.5137/1019-5149.jtn.6156-12.1.
6. Heymans MW, Ford JJ, McMeeken JM, Chan A, de Vet HC, van Mechelen W. Exploring the contribution of patient-reported and clinician based variables for the prediction of low back work status. Journal of Occupational Rehabilitation 2007; 17(): 383-397. doi:10.1007/s10926-007-9084-1.
7. Lethem J, Slade P, Troup J, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception—I. Behaviour Research and Therapy 1983;21(4):401–408. doi:10.1016/0005-7967(83)90009-8.
8. Neblett R, Hartzell M, Mayer T, Bradford E, Gatchel R. Establishing clinically meaningful severity levels for the Tampa Scale for Kinesiophobia (TSK-13). Eur J Pain European Journal of Pain 2015;20(5):1–10. doi:10.1002/ejp.795.
9. Peña A, Plotkin L, Eagle M, Riehl J, Mathiyakom W. American Physical Therapy Association: Combined Sections Meeting. In: San Antonio; 2017.
10. Vlaeyen JW, Kole-Snijders AM, Boeren RG, Eek HV. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain 1995;62(3):363–372.

BFR & Post-op ACL

   

One of the biggest challenges in ACL rehab is regaining adequate strength in the surgical leg. Even at 1 year post-op, many patients still demonstrate significant strength deficits compared to the non-surgical leg. Traditional early post-op ACL rehab consists of ROM, swelling control, gait training, muscle activation and proprioceptive exercises. Unfortunately the leg continues to atrophy and remain in a state of anabolic resistance caused by the trauma of the surgery and subsequent relative or literal immobilization. Early post-op treatments and exercises, while necessary, do very little to help the muscles hypertrophy. The ACSM recommends that in order for hypertrophy to occur, resistance training needs to be loaded at 70% of 1RM. While in the early stages of rehab, loads in that range are unrealistic and potentially dangerous.

Blood Flow Restriction Therapy can be introduced as early as a few days post-op and can also help stop anabolic resistance by initiating protein synthesis, which leads to muscle hypertrophy even at loads of 30% of 1RM and lower. This is possible because the tourniquet creates a hypoxic environment which forces the recruitment of type 2 muscle fibers, even though the load is more appropriate for type 1. Type 1 muscle fibers require oxygen and are important for endurance and low load exercises. While exercising under BFR the stored oxygen becomes depleted and the remaining reps are carried out by type 2 muscle fibers. Type 2 muscle fibers are responsible for speed and power and their byproduct is lactate. The cuff not only restricts the venous return flow, it also holds the lactate in the limb which initiates a systemic response that causes the pituitary gland to release Growth Hormone.  Growth hormone is responsible for collagen synthesis which is how muscle, tendon, ligament, cartilage and bone heal.

Equipment

Tourniquets are considered medical devices and their use needs to be monitored, there are inherent dangers to improper use of tourniquets. Currently a few types of BFR tourniquet systems and wraps are available and present on social media, but only one is FDA approved as a medical device. The Delfi Personal Tourniquet System contains a Doppler that can accurately measure the amount of blood flow restriction and can adjust for pressure changes during exercise. The Delfi System comes with 3 cuff sizes, each one is wide and tapered for comfort and safety. When deciding to incorporate BFR into your rehab, look for a certified provider on the Owens Recovery Science website.

Treatment Session

A typical treatment session will usually consist of 3-5 different exercises.  Each exercise will be performed for 75 reps broken down into 4 sets.  1 set of 30 reps and 3 sets of 15 reps.  There is a 30 second rest period between sets with the cuff inflated.  The cuff will be deflated for at least 1 minute between exercises.  You can expect to see swelling, color change and muscle fatigue after each treatment.  Because loads are very low there is no muscle breakdown and little to no subsequent DOMS.

For more information visit  OwensRecoveryScience.com

Forward Head Posture

   

By Ashley Pena, DPT Student

Although “forward head posture” (FHP) has long been regarded as a problem leading to pain and disability, with increased time spent on smartphones in recent years, it is becoming a very common source of pain. In a study performed by Kim et. al. which studied the effect of duration of smartphone use on muscle fatigue and pain caused by forward head posture in adults using EMG analysis, it was found that prolonged smartphone use resulted in increased upper trapezius and cervical erector spinae fatigue.

As a result of FHP, compensatory motions occur such as severe extension of the upper cervical spine. Often seen in conjunction with FHP, rounded shoulder posture (RSP) occurs when the acromion protrudes anterior to the shoulder joint. Scapular elevation, protraction, and downward rotation are also seen. Several studies have found that this combination of FHP and RSP promote an imbalance in muscle strength and length leading to Janda’s Upper Crossed Syndrome:

• Weakness of the deep neck flexors, middle and lower trapezius, and serratus anterior
• Stiffness of the pecs, upper trapezius, levator scapulae, SCM and suboccipitals.

Together, these impairments can lead to dysfunctions at the OA joint, C4/C5 segment,  CT junction, or GH joint resulting in neck and/or shoulder pain and increased disability.

Below is a 3 part video series to help you gain mobility and build postural strength to combat our love affair with cell phones and laptops.

Blog Post written by Ashley Pena, DPT Student from Cal State Northridge. Ashley is currently in her final clinical rotation with me at Catz PTI.

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❗️4th Student of the year❗️ Welcome Ashley, from my alma mater Cal State Northridge. Continuing with the BFR hazing. Stay tuned for some 💻blog posts from her soon. #CSUN @ashpena3r

A post shared by Chris Butler, MPT, CSCS (@cbutlersportspt) on Jun 13, 2017 at 12:18pm PDT

References:

1. Kim E-K, Kim JS. Correlation between rounded shoulder posture, neck disability indices, and degree of forward head posture. Journal of Physical Therapy Science. 2016;28(10):2929-2932. doi:10.1589/jpts.28.2929.
2. Kim S-Y, Koo S-J. Effect of duration of smartphone use on muscle fatigue and pain caused by forward head posture in adults. Journal of Physical Therapy Science. 2016;28(6):1669-1672. doi:10.1589/jpts.28.1669.
3. Kwon JW, Son SM, Lee NK. Changes in upper-extremity muscle activities due to head position in subjects with a forward head posture and rounded shoulders. Journal of Physical Therapy Science. 2015;27(6):1739-1742. doi:10.1589/jpts.27.1739.
4. Upper Crossed Syndrome. Muscle Imbalance Syndromes RSS. http://www.muscleimbalancesyndromes.com/janda-syndromes/upper-crossed-syndrome/. Accessed June 13, 2017.

Lateral Ankle Sprains

    

By Michael Joseph, DPT Student

Ankle sprains are a common injury; in the United States there is an incidence rate of 2.15 ankle sprains per 1000 people every year. Nearly half of all ankle sprains (49.3%) occurred during athletic activity, with basketball (41.1%), football (9.3%), and soccer (7.9%) being associated with the highest percentage of ankle sprains during athletics.

This article will focus on lateral ankle sprains, which occur as a result of excessive ankle inversion, when the foot rolls inwards under the leg. The three lateral ligaments that may be affected are the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. Ankle sprains are divided into three categories: Grade I, where the ligament is stretched and may have slight tears. Grade II where the ligament is partially torn. And Grade III where the ligament is completely torn.

Management:

The PRICE (Protection, Rest, Ice, Compression, Elevation) protocol is an important part of treatment during the acute phase, as it is an effective method for reducing pain and inflammation. However, combining PRICE with exercise may be more beneficial. A randomized controlled trial from Bleakley, et al. evaluated the effectiveness of accelerated rehab after an ankle sprain. One group of subjects followed the PRICE protocol for the first week after injury and then began exercise rehab during the following four weeks. The experimental group began the PRICE protocol and exercise rehab immediately, during the first week post injury, and then followed the same 4 week exercise rehab. The authors stated the early exercises were from a “general protocol” that included ankle range of motion and strengthening exercises. The study found short term outcomes (4 weeks) were significantly better in the group that began exercising immediately, but there was no significant difference in long term outcomes (16 weeks).

 Rehabilitation and Prevention:

There is some evidence to support that taping and/or bracing is effective at reducing the risk of recurrent ankle sprains in sports. However, the decision between tape or bracing depends on the individual and the requirements of the sport. There is no evidence that one is significantly more effective than the other.

Kerkhoffs et al, identified four intrinsic risk factors that predispose individuals to lateral ankle sprains: strength, proprioception, range of motion, and balance. A rehab exercise protocol should address all four of these risk factors in order to prepare the athlete to return to sport and to prevent recurring sprains. Proprioception exercises should be sport specific and should focus on the demands of the sport. For example, a basketball player’s program needs to include takeoff and landing ankle mechanics in an square stance (jump shot) and off of one leg (lay up).

Blog Post written by Michael Joseph, DPT Student at Mount Saint Mary’s University. Michael is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.

Sources:

1. Bleakley CM, O’connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010;340:c1964.
2. Kerkhoffs GM, Van den bekerom M, Elders LA, et al. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med. 2012;46(12):854-60.
3. Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010;92(13):2279-84.

Speed to Perform

    Chris Butler Sports PT

By Darelle Noel

Most people believe speed is something you’re born with and that you’re genetically inclined to be fast. But it has little to do with that – it’s a science. You can train your body to produce more force and the way you deliver force to the ground. And once that happens, it will completely change your perception of how fast or explosive you ever thought you could be.

Speed is an integral part of every sport and can be expressed as one of or a combination of Power(Elastic Strength) for acceleration, absolute speed and speed endurance. Speed is the quickness of movement of a limb generated by the athletes ability to apply force and generate it with great frequency.

(Force X Frequency=Speed)

Maximizing stride length and stride frequency is mainly influenced by the athletes stability, mobility, strength and technique. Having good hamstring flexibility and hip mobility improves stride frequency (the ability to strike and recover) and stride length is improved by developing muscular strength and explosive power i.e. olympic Lifts and Plyometrics.

Developing speed is a rather complex process that is controlled by the nervous system, learning the movements needed to develop speed and learning how to perform them are equally important. In order to move faster the muscles have to adapt and contract faster, The brain and the nervous system have to learn the motor skills to control these fast movements efficiently. Practicing the basic fundamentals of running will not only improve your running ability but also improve your brains ability to adapt and perform the movements quickly. Complex coordination and timing of the motor units and muscle groups must be performed beginning with slow speeds transitioning to high speeds to improve patterns. Maintaining some form of speed training on a consistent basis will ensure that your movement patterns and nervous system will stay in sync.

General Principles for speed development are:
•Work on your mobility to develop ROM, range of motion in your hips will drastically effect your speed and assist in preventing injuries.
•Improve flexibility to improve your turnover ability.
•Perform explosive and plyometrics movements such as jumping, hopping and bounding to develop explosive power that translate to running.
•Implement skill development for sports specific speed. IT HAS TO TRANSLATE TO THE SPORT!!
•Train Energy System specifically to maintain and maximize endurance and speed over time.

 Blog Post written by Darelle Noel, Athletic Gaines Performance Specialist.  I have had the good fortune to work with him at Catz Physical Therapy/Athletic Gaines Pasadena. You can find him on Instagram @dmn_1of1

Is Your Lack of Ankle Mobility Increasing Your Risk for Knee Injury?

 Follow Chris Butler Sports PT

By Ashley Pena, DPT Student

 According to the NCAA Injury Surveillance system, knee internal derangements accounted for the highest percentage of more severe injuries sustained by college athletes (44.1% in games and 25.5% in practices) and approximately 70% of all game and practice injuries affected the lower extremities. As a result of these studies, much thought has gone into what factors contribute to this in an attempt to prevent, or rehabilitate these injuries while decreasing pain and improving performance. Although there are many factors which have been found to contribute such as muscle weakness, body type, training factors and others, little thought is given to the ankle joint unless it is giving the athlete pain.

When a person lacks dorsiflexion range of motion, often times compensations begin to manifest such as excessive pronation or “fallen arch”,  hip external rotation or “out-toeing” during walking, or lack of knee flexion with landing, all of which can increase the valgus forces on the knee and decrease shock absorption which can place a person more at risk for ACL injury, meniscus injury, or collateral ligament strains. In a systematic literature review done by Mason-McKay et. al, strong evidence was found that a restriction in DF ROM alters landing mechanics with specific studies reporting that altered frontal plane ankle motion (inversion and eversion), reduced sagittal knee excursion, and greater peak knee valgus.

 Blog Post written by Ashley Pena, DPT Student from Cal State Northridge.  Ashley is currently in her final clinical rotation with me at Catz PTI.

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❗️4th Student of the year❗️ Welcome Ashley, from my alma mater Cal State Northridge. Continuing with the BFR hazing. Stay tuned for some 💻blog posts from her soon. #CSUN @ashpena3r

A post shared by Chris Butler, MPT, CSCS (@cbutlersportspt) on Jun 13, 2017 at 12:18pm PDT

Sources:

1. Arendt E, Dick R. Knee Injury Patterns Among Men and Women in Collegiate Basketball and Soccer. The American Journal of Sports Medicine. 1995;23(6):694-701.
2. Dick RM, Putukian M. Descriptive Epidemiology of Collegiate Women’s Soccer Injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 Through 2002–2003. Journal of Athletic Training. 2007;42(2):278-285.
3. Kerr ZY, Marshall SW. College Sports–Related Injuries — United States, 2009–10 Through 2013–14 Academic Years. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6448a2.htm. Published December 11, 2015. Accessed June 5, 2017.
4. Mason-Mackay A, Whatman C, Reid D. The effect of reduced ankle dorsiflexion on lower extremity mechanics during landing: A systematic review. Journal of Science and Medicine in Sport. 2017;20(5):451-458. doi:10.1016/j.jsams.2015.06.006.
5. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Llyod-Smith DF, Zumbo BD.  A retrospective case-control analysis of 2002 running injuries.  Br J Sports Med 2002; 36: 95-101.

What is Turf Toe?

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By Meggie Morley, DPT

During Game 3 of the Clipper’s series against the Utah Jazz, Blake Griffin suffered an injury to his toe that would rule him out for the remainder of the playoffs. He recently underwent surgery to treat his injury, which was reported as an injury to the plantar plate of his big toe. This injury is also known as turf toe, and even though it may seem like a small injury it can greatly affect the ability to participate in sports, recreational activities and even walking.

Toe Anatomy

Turf toe typically refers to an injury to the big toe. The big toe is comprised of two bones, known as the distal and proximal phalange. The proximal phalange attaches to the metatarsal bone in the foot, forming the metatarsal phalangeal joint (MTP). Underneath the MTP is the plantar plate, a small sesamoid bone, and various ligaments and muscle attachments.   

Mechanics of Injury

Turf toe typically occurs when the first toe is hyperextended. In other words, when the toes are planted on the ground and the rest of the foot is lifting off the ground. This position places strain on the bottom of the MTP joint, causing damage to the plantar plate and surrounding structures. This injury occurs commonly on turf due to the harder surface, which can cause the toes to be stuck in place. The symptoms of turf toe include pain, tenderness, bruising, stiffness and swelling at the joint.  Parents should watch for avoidance behaviors and painful gait patterns in their children.

Ligament Sprain Grade

Grade I: The ligament is stretched and there may be small tears

Grade II: Large tear, but the tear doesn’t completely go through the ligament

Grade III: Complete rupture of the ligament

Recovery time depends on the grade of the sprain, and in the case of complete tears surgery may be necessary. For any turf toe injury, rest is required in order to allow for healing.  Bracing, splinting and taping are often used for weight bearing tolerance so it is important to prevent adhesions in the injured structures. Passive ROM can be initiated within a few days of Grade I and II injuries along with non-impact activities. Grade III injuries require immobilization but even if surgery is needed, ROM can be performed at 5-7 days post op.  Make sure to see a PT and find out what you can be doing throughout all phases of recovery.

Blog Post written by Meggie Morley, DPT.  At the time of posting Meggie was in her final clinical rotation with me at Catz Physical Therapy Institute.

References

1. Stanley, Laura. Physical Therapist’s Guide to Turf Toe. Retrieved from http://www.moveforwardpt.com/symptomsconditionsdetail.aspx?cid=6db543a6-7a53-4dcd-8141-3137c4391f07

2. McCormick JJ, Anderson RB. Turf toe: anatomy, diagnosis, and treatment. Sports Health. 2010; 2(6):487–494.

3. Garguilo, C. (2015). Foot and Ankle Orthopedics (Power Point slides). Retrieved from https://courseworks.columbia.edu/access/content/group/PHYTM8610_081_2015_2/Lectures/Ankle/Camtasia%20Foot%20and%20Ankle%20Lectures/Camtasia%20Lecture%20Foot%20Ankle%20Disorders%20Handout%202015%20Section%203.pdf

Bike Fitting Basics: Keep Riding, Reduce Your Injury Risk

 Chris Butler Sports PT is Social

By Michael Joseph, DPT Student

In my three years working as a professional bicycle fitter I have done fits for every level of cyclist, from individuals who were purchasing their first road bike to professional level cyclists and national team members. A properly fit road bike is imperative to ensure the frame and components are the right size for the rider.  The purpose of professional fitting is to reduce pain, increase comfort and maximize speed and efficiency. The following article will cover basics of fit measurements, positioning, and reasons why riders may be experiencing pain or discomfort on the bike. The bulk of this content is based on my professional experience as a bicycle fitter and the training I received from GURU Cycling.

Saddle Height 

Saddle height is measured with the rider seated on the saddle with his or her foot at the 6 o’clock position. The rider’s pelvis should be level on the saddle and there should be 40 degrees of knee flexion (plus/minus 5 degrees). Measure both legs to ensure no there are no imbalances. Common symptoms of a saddle that is too high include IT band syndrome, posterior knee pain, and hip or low back pain. Common symptoms of a saddle that is too low is anterior knee pain from stress on the quadriceps and patellar tendons.

Saddle Setback

Saddle setback refers to the fore and aft position of the saddle. When the foot is in the 3 o’clock position, the front surface of the knee should be directly over the pedal spindle. This can be measured using a plumb bob or laser. The rider should feel like they are pushing the pedal straight down, not in front of them or behind them; the pedal stroke should feel powerful and efficient. If the saddle is set too far back, it can irritate the IT band and hamstrings tendons. If it is too far forward, it may put excessive pressure on the quadriceps and patellar tendons.

Type of saddle  

Saddle selection is highly subjective. Every manufacturer seems to develop their own way of fitting a saddle to a rider. This can include basing it on width of the pelvis, sit bone pressure points, or spinal flexibility. However, the best way to determine the which type of saddle to use is to test ride it. Saddle selection is all about finding the saddle that fits the rider’s body type.

Cleats  

Cleat fitting might warrant an entire article all on its own, but here are some basics.

The fore aft position of the cleat on the shoe should align the ball of the foot with the pedal spindle. The medial/lateral position of the cleat should position the knee directly over the foot. The rotational position of the cleat should position the foot so it is facing directly forward. Knee pain can be caused by improper foot and cleat positioning. If a rider has knee pain and the saddle height and setback are positioned correctly, cleat positioning may be the culprit.

Handlebar Reach

Handlebar reach is defined as the distance from the saddle to the handlebar and is measured from the front tip of the saddle to the center of the tubing of the handlebar. When fitting reach, the rider should place his or her hands on the brake hoods. The reach should be as long as possible, while still feeling comfortable. A longer reach allows for a longer stem, which makes the front of the bike more stable and makes steering more responsive. However, in this position the shoulder should not exceed 90 degrees of flexion. There should also be about 15 degrees of elbow flexion. If the reach is too long, the rider may experience elbow pain, tension in the neck and shoulders, and back pain.

Handlebar Drop

Handlebar drop is defined as the difference in height between the saddle and the handlebar. Increasing the drop makes the rider position more aggressive and aerodynamic. This may be ideal for a rider participating in stage or criterium racing. However, for a leisure rider, a more upright position will likely be more comfortable. If the drop is too low, the rider will experience symptoms in the hands and wrists, such as pain from too much weight on the hands. This can also cause nerve irritation; riders may experience numbness, tingling, and burning sensations in the hands.   

Blog Post written by Michael Joseph, DPT Student at Mount Saint Mary’s University. Michael is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.

Sources:

1. www.gurucycling.com
2. Asplund, Chad, St. Pierre, Patrick. Knee Pain and Bicycling: Fitting Concepts for Clinicians. The Physician and Sports Medicine. April 2004. 32(3).

What are Shin Splints?

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By Michael Joseph, DPT Student

Definition and Risk Factors:

Medial Tibial Stress Syndrome (MTSS), better known as shin splints, is a common athletic injury caused by repetitive stress to the tibia. MTSS is more prevalent in activities involving a great deal of running and jumping, like distance running, sprinting, basketball, tennis, gymnastics, and dancing; it is also common in military personnel. MTSS can be caused by many factors stressing the tibia, including: periostitis (inflammation of connective tissue surrounding bone), periosteal remodeling, tendinopathy, and dysfunction of muscles surrounding the tibia, like the tibialis posterior, tibialis anterior, flexor digitorum longus, and soleus muscles. Risk factors for MTSS include flat feet and/or over-pronation, repetitive running and jumping, excessive hip range of motion, smaller calf girth, and a body mass index above 20.2.

Symptoms:

Symptoms include pain of the middle and lower thirds of the medial shin. Individuals may experience pain during and/or after physical activity. During the early onset of MTSS, symptoms may be felt at the beginning of exercise, but may subside as activity continues. As MTSS progresses, pain may be felt throughout exercise and may linger afterwards.

Diagnosis:

A thorough physical therapy subjective and objective exam is usually sufficient to diagnose MTSS. However, patients may require further imaging or work up to rule out pathologies like stress fractures, exertional compartment syndrome, or peripheral vascular disease.

Management of Shin Splints:

Acute Phase:

The goal of physical therapy in the acute phase is to reduce pain and inflammation. This can be done through stretching, manual therapy of the injured tissue, taping, icing, and rest. For many athletes prolonged rest from their sport is not ideal. MTSS management may require “relative” rest, meaning their activity level may need to be adjusted but not stopped completely. This depends on the activity and severity of the pathology.

Subacute Phase:

The goal of physical therapy in the subacute phase is to modify training regimens and correct biomechanical abnormalities. According to Galbraith et al, reducing weekly training frequency and intensity by 50% will likely improve symptoms without completely stopping training. However, this depends on each patient’s case and may need to be adjusted. Training can also be augmented with low impact exercises, like swimming or cycling, to help maintain strength and cardiovascular endurance.

Create a Physical Change in Your Body and Movement

Another treatment of MTSS is to strengthen the arch of the foot and hip, and increase core stability; this will help to improve jumping and landing mechanics, as well as single leg stability. Specifically, strengthening the tibialis posterior and intrinsic foot musculature will help increase arch support and prevent excessive pronation. Improving hip extensor and abductor strength can help improve lower extremity mechanics. Stretching and eccentric strengthening of the calf has also been shown to be beneficial by decreasing muscle fatigue with running and jumping.

Changing running biomechanics may also be beneficial. A study from Leiberman et al, found that heel first strike during initial contact, when running, creates an impact transient equal to nearly three times the individual’s body weight. Not only is this incredibly inefficient, but this creates a large force traveling directly up through the tibia with each step. The impact transient with forefoot first strike during initial contact is seven times lower than with a heel strike. This evidence suggests forefoot running is more efficient and less injurious. 

Blog Post written by Michael Joseph, DPT Student at Mount Saint Mary’s University. Michael is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.

Sources:

1. Budde, Kari Brown. Physical Therapist’s Guide to Shin Splints (Medial Tibial Stress Syndrome). http://www.moveforwardpt.com. Accessed May 11, 2017.
2. Galbraith, R. Michael, Lavelle, Mark E. Medial tibial stress syndrome: conservative treatment options. Curr Rev Musculoskelet Med. 2009 Sep; 2(3):127-133.
3. Lieberman, Daniel E., Venkadesan, Madhusudhan, Werbel, William A., Daoud, Adam I., D’Andrea, Susan, Davis, Irene S., Mang’Eni, Robert Ojiambo, Pitsiladis, Yannis. Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature. 2010 Jan; 463:531-535.
4. Moen, Maarten Hendrik, Holtslag, Lenoor, Bakker, Eric, Barten, Carl, Weir, Adam, Tol, Johannes L., Backx, Frank. The treatment of medial tibial stress syndrome in athletes; a randomized clinical trial. Sports Med Arthrosc Rehabil Ther Technol. 2012 Mar; 4(12).

What is Platelet Rich Plasma?

 Chris Butler Sports PT is Social

By Meggie Morley, DPT Student

In recent years the use of platelet rich plasma has been on the rise as a means of promoting healing in soft tissue structures such as tendons, muscles, ligaments and joints. With professional athletes such as Tiger Woods and Steph Curry receiving the injections as a method to promote healing, it may be useful to take a closer look at the possible effects and uses of PRP injections.

How it Works

Platelets are a component of the blood with the main function of promoting blood clotting. They also release numerous growth factors, including Platelet Derived Growth Factor (PDGF), which is a protein that helps regulate cell growth and division. PRP is made by collecting a blood sample from the patient, then centrifuging the blood to separate out the platelets.  The platelet rich plasma is then treated and injected into the patient, often with the use of ultrasound to guide the placement of the injection. PRP is made from the patient’s own blood, so there are very few side effects associated with the injections, however it is recommended to stop taking anti inflammatory medications before and after the injection. 

Article Review

In an article by Pandey et al., the effects of PRP were examined in patients who underwent arthroscopic rotator cuff repairs compared to subjects that underwent the same procedure without PRP.  The effectiveness of the treatment was measured by four different clinical scores and by ultrasound to view if there was a re-tear and the general vascularity of the rotator cuff. The results found that three of the four clinical scores demonstrated significantly better outcomes in the PRP group versus the control group at various follow up times. The other score (The American Shoulder and Elbow Surgeons Score) was comparable between the PRP and the control group at all follow-up visits. The incidence of re-tears was significantly lower in the PRP group, but only for large tears. The ultrasound also showed that there was significant vascularity at the repair site three months post operatively.

While this article showed positive outcomes for patients who received PRP, overall the evidence for the use of PRP in human subjects is still lacking. As with any medical procedure it is important to be informed and discuss your options with your physician.

 Blog Post written by Meggie Morley, DPT.  At the time of posting Meggie was in her final clinical rotation with me at Catz Physical Therapy Institute.

References

Boswell SG, Cole BJ, Sundman EA, Karas V, Fortier LA. Platelet-rich plasma: a milieu of bioactive factors. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2012 Mar 31;28(3):429-39.

Kohen R, Warren R, Rodeo S. (2010, October 5). Platelet Rich Plasma (PRP) Treatment: An Overview. Retrieved from https://www.hss.edu/conditions_platelet-rich-plasma-prp.asp

Pandey V, Bandi A, Madi S, Agarwal L, Acharya KK, Maddukuri S, Sambhaji C, Willems WJ. Does application of moderately concentrated platelet-rich plasma improve clinical and structural outcome after arthroscopic repair of medium-sized to large rotator cuff tear? A randomized controlled trial. Journal of Shoulder and Elbow Surgery. 2016 Aug 31;25(8):1312-22.

Filardo G, Di Matteo B, Kon E, Merli G, Marcacci M. Platelet-rich plasma in tendon-related disorders: results and indications. Knee Surgery, Sports Traumatology, Arthroscopy. 2016:1-6.

High Intensity Interval Training vs. Steady State Cardio

By Darelle Noel

Whether you use cardio workouts to improve your health or performance in sports, one common goal of cardio training is to improve the function and capacity of your energy system. Many people decide the intensity of their workouts based on what they’re looking to accomplish during training. Some prefer steady state cardio (Aerobic) while others prefer high intensity interval training (Anaerobic).  Both yield great cardiovascular results so neither is a wrong way to go.

Slow steady state cardio or aerobic activity is when an exercise is performed at one steady pace for an extended period of time, maintaining a relatively constant intensity level or heartrate.

High Intensity Interval Training or anaerobic training is a technique that alternates between short intense activity with a maximum recovery period. This technique varies the heartrate expeditiously improving your work to rest ratio (Energy System Capacity).

A blend of both could be an even better option. Instead of slow, plodding workouts, try a combination of utilizing both energy systems. This will have your muscle groups, nervous system, and hormones acting synergistically to help your body work as efficiently as possible. All these benefits result from time-efficient workouts that are much shorter than your average lower-intensity cardio session. The program you choose should reflect a balance of strengthening your weaknesses and challenging your strengths.

Begin by improving your overall aerobic threshold, some great exercises are:

◾Outdoors: Paced walking, walking up hills, biking, rowing

◾Indoors: Biking, treadmill climbing/walking, elliptical trainer

Using the aerobic zone will improve your cardiovascular system and prepare your muscles for the greater speeds.

Next try to move into a little more intensity levels, At this level you’ll ride, run, or climb as hard as possible for between 10-30 seconds with maximum levels of recovery.. In order to get the most out you’ll need to pack as much power and energy into these segments as possible.

Some of the best activities for this are:

◾Sprinting (flat or uphill)

◾Shuttle runs (5 yards and back, 10 yards and back, 15 yards and back)

◾Bicycle intervals

◾Tredmill Sprints

◾Rowing for speed. 

A balanced training program should use different combinations of these exercises and different intensity levels to create varied and personalized workout that will develop both energy thresholds. You can spend more time in aerobic level initially and progress to performing intervals in which you spend more time in higher-intensity zones to improve your overall endurance, strength, and power.

Blog Post written by Darelle Noel, Athletic Gaines Performance Specialist.  I have had the good fortune to work with him at Catz Physical Therapy/Athletic Gaines Pasadena.

Straight Bar Deadlifts vs. Hex Bar Deadlifts

By Michael Joseph, DPT Student

The deadlift is one of the most effective and widely used exercises to build raw strength. There are many variations of the deadlift, including conventional deadlifts, sumo deadlifts, stiff leg deadlifts, Romanian deadlifts, and the popular hex bar deadlift (HBD). As opposed to a straight bar deadlift (SBD), where the bar is sitting in front of the body, this bar allows the lifter to stand within a hexagon-shaped frame and lift the weight from the ground. But, what is the difference between a straight bar and a hex bar? And why would you use one instead of the other?

Research

In a study by Swinton et al, a group of competitive powerlifters were recruited to compare the biomechanical differences between the SBD and HDB. Subjects tested their 1 rep max and submaximal lifts on both bars. 3-D motion analysis was used to measure body position and velocity and acceleration of the bar. The study found the powerlifters were able to lift an average of 45 lbs. more using the hex bar, compared to the straight bar. In addition, across submaximal loads deadlifts using the hex bar produced greater peak force, peak velocity, and peak power compared to the straight bar. This suggests that the HBD is a more effective exercise due to the greater mechanical stimulus produced during submaximal loads. 

A follow up study was done by Camara et al, comparing electromyography, force, velocity, and power characteristics between the two bars. Surface EMGs were placed on the vastus lateralis (quadriceps), biceps femoris (hamstrings), and erector spinae (low back) muscles. Force, velocity, and power were measured by attaching a velocity transducer to the barbells. This study also measured subjects’ 1 rep max and submaximal loads. EMG results found greater quadriceps activation during the HBD, but greater hamstrings and low back activation during the SBD. However, there was not a significant difference in the 1 rep max lifts. This study also confirmed higher peak velocity, peak force, and peak power with the HBD than the straight bar deadlift.

Clinical Application

Both studies confirm the SBD puts greater stress on the hamstrings and low back, while the HBD distributes loads more equally, putting greater stress on the quads. For individuals with low back pain or who are rehabilitating a low back injury, using a hex bar to deadlift may be a safer alternative to using a straight bar. Similarly, for a patient who may not be ready to perform a loaded squat, the HBD may be used as an effective alternative to strengthen the quadriceps.  

Both studies also agree that the HBD produced greater peak force, velocity, acceleration, and power. This suggests the HBD is a better exercise for overall strength training. The HBD may be a more beneficial deadlift variation than the SBD for athletes because it is more effective for improving overall strength, while putting them at less risk of a low back injury. So when should the SBD be used for patients and athletes? If the goal is to strengthen hamstrings and low back extensors specifically, the SBD will be more effective. Similarly, if the SBD is specific to the athlete’s sport, (for example, powerlifting or CrossFit) training the SBD may be more beneficial.

Blog Post written by Michael Joseph, DPT Student at Mount Saint Mary’s University.  Michael is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.

References

1. Swinton PA, Stewart A, Agouris I, Keogh JW, Lloyd R. A biomechanical analysis of straight and hexagonal barbell deadlifts using submaximal loads. J Strength Cond Res. 2011;25(7):2000-9.
2. Camara KD, Coburn JW, Dunnick DD, Brown LE, Galpin AJ, Costa PB. An Examination of Muscle Activation and Power Characteristics While Performing the Deadlift Exercise With Straight and Hexagonal Barbells. J Strength Cond Res. 2016;30(5):1183-8.

5 Things to Do Before Going on a Run

By Meggie Morley, DPT Student

It is well known that exercise is crucial for living a long and healthy life, but recent studies have shown that running may actually be the most effective exercise for increasing life expectancy. In a recent study by Lee et al., it was found that running can increase a person’s life span by 3 years, and reduces the risk of premature death by 40%. The researchers also noted that the benefits are the same regardless of pace, mileage, drinking and smoking or being overweight.

Hopefully studies such as this one encourage people to take up running, so here are a few things to do before going on a run to boost performance and minimize the risk of injury. The idea behind these exercises are to warm up the muscles and joints before running as well as “turn on” the muscles we want to be active while running.

1. Warm Up

Start by simply walking for a few minutes to increase blood flow and prime the joints and muscles for motion.

2. Walking Lunges with Torso Twist-Works: Quads, gluts, hamstrings

Step forward with the right leg into a lunge. Place your right hand next to the right foot then twist your trunk to the left while reaching the left arm up towards the ceiling.

3. Planks with Knee Drive-Works: Abdominals, hip flexors

Hold a high plank with the shoulder directly over the wrists. Alternate driving the knees towards the chest ten times. Then perform ten knee drives toward the same side elbow and ten toward the opposite elbow in order to engage both the rectus abdominus and the obliques.

4. Bridges-Works: Abdominals, gluts, hamstrings

The gluteal muscles are crucial for generating power and maintaining proper biomechanics down the entire lower extremity while running. Do three sets of bridges with a focus on keeping the core engaged and lifting the hips with the gluts in order to prepare the muscles to be active during running.

5. Alternating Lunge with Medial Reach-Works: Quads, hamstrings, gluteus maximus, gluteus medius

Step forward with the right leg into a lunge and reach out to the left with the left arm. Perform ten lunges then switch sides. This places more demand on the gluteus medius, which is important for maintaining proper pelvis alignment during running.

 Blog Post written by Meggie Morley, DPT Student at Columbia University. Meggie is currently in her final Clinical Rotation with me at Catz Physical Therapy Institute.

References

1. Lee DC, Brellenthin AG, Thompson PD, Sui X, Lee IM, Lavie CJ. Running as a Key Lifestyle Medicine for Longevity. Progress in Cardiovascular Diseases. 2017 Mar 30.

2. https://www.nytimes.com/2017/04/12/well/move/an-hour-of-running-may-add-seven-hours-to-your-life.html

3. Yamaguchi T, Takizawa K, Shibata K. Acute effect of dynamic stretching on endurance running performance in well-trained male runners. The Journal of Strength & Conditioning Research. 2015 Nov 1;29(11):3045-52.

Barbell Landmines: Training/Rehab

 

By Teddy Willsey, DPT, CSCS

When it comes to shoulder rehab and training, weight bearing exercises and closed chain exercises are one of the safest and most effective ways to train for size and strength while maintaining healthy joints. During closed chain exercise the body parts doing the work are moving against the ground, or a fixed point. Think of a push-up or squat. Open chain exercise is the opposite, the body parts doing the work are pushing moving a non-fixed point in the air. Think of a bench press or leg extension machine. Closed chain exercises of the upper body increase co-contraction of the rotator cuff and the surrounding musculature. They help contribute to the shoulder’s stability during movement and allow the scapula to move freely. The resultant efficient glenohumeral and scapulothoracic mechanics make them a safe bet for shoulder health and a great exercise for both strength training and shoulder rehab.

The landmine is a hybrid of this closed vs. open chain exercise model. It is open chain in the idea that it the resistance is moving in the air, yet closed chain in the sense that it is still attached to a fixed point on the ground and just pivoting from it. The landmine helps to mimic the feeling of weight bearing, as it’s fixed attachment point on the ground creates a vastly different stimulus to the muscle than a true open chain exercise. The landmine press and it’s variations facilitate more scapular upward rotation and serratus anterior involvement than a typical bench press. It also doesn’t require shoulder extension, thus avoiding a potentially uncomfortable when loaded range of motion for some. This shoulder friendly movement is safe to load and strengthen across almost all populations.

The resistance of the landmine works on an arc, as the bar is fixed and rotating about a pendulum. The motion of every exercise is dictate by this arc, doing shoulder raises on this feels vastly different than using a dumbbell or cable/band. In addition to the grounding effect of the landmine, the rotational bar path can help to mimic PNF patterned shoulder exercises and movement in the scapular plane as well. This creates a functional bar path and movement for the shoulder during front and lateral raises. It is very rare that we use our shoulders in one plane of movement, yet that’s how we often train them with bands, cables, and dumbbells.

The landmine is great for hypertrophy work. It is relatively easy to use and low risk to “cheat” and try to squeeze out a few extra reps. The resistance can be quickly changed by choking down on the bar and decreasing the lever arm as well. These kinds of adjustments allow you to extend out a set for maximal time under tension and create an optimal environment for muscle growth. The landmine is also great for cheating reps, as you can use momentum to swing the bar in it’s set path, and then slowly lower. When hypertrophy and increased muscle size is the primary goal, there are times when this is appropriate, and even necessary. This swinging motion can allow you to complete the set and increase the metabolic stress on the muscle, a necessary evil for hypertrophy.

There are a few rehab specific ideas that make the landmine nice for regressions and lateralizations. The landmine becomes much lighter at the very top of the arc, as more of the bar is supported by the fixed point. This can be advantageous for overhead pressing and decreasing load at the top. A lighter training barbell can also be used to further decrease the load of the landmine. I highly recommend having a 15 lb. barbell for landmines in the PT clinic. This is a great complement to your other supported active motion exercises that are used to regain motion after shoulder surgery.

Without further adieu, the videos below highlight some of my favorite landmine shoulder variations:

Landmine Side-Facing Posterior-Lateral Raise-The side facing posterior lateral raise takes the bar path up and out, targeting the posterior and lateral delts as well as the external rotators.

Landmine Front-Facing Lateral Raise-The front facing lateral raise is more challenging, as the bar path ends up further away from the body. This is a good lateral delt focus movement.

Landmine Bent Over Raise-The bent over raise is a brutal posterior delt movement that also gets the upper traps involved at the end of the bar path. It has a face pull feel to it, as it requires a lot of scapular retraction and does not really “isolate” the rear delts.

Landmine Strict Standing Press-The standing press is by far the landmine shoulder exercise I use the most. It facilitates incredible core support and serratus involvement as the bar path moves up, and is an extremely comfortable and natural pressing motion. This can be made into a push press for more full body involvement: a great movement for athletes.

Landmine Triple Superset-Supersetting these exercises can be a very effective way to burn out your shoulders and create some extra stress leading to muscle growth. In this 3-exercise combo I did half kneeling rear raises, front facing lateral raises, and side facing posterolateral raises: 5 reps of each.

Landmine Standing Scap Press-I call this the “C” press or scapular plane landmine press. The goal here is to flare the elbow and allow the arm to move closer to the scapular plane. The idea is to facilitate more scapular upward rotation. I will also sometimes encourage a trunk rotation away at the top here to create more shoulder flexion.

  

Dr. Teddy Willsey, DPT, CSCS, is the director of sports medicine at Healthy Baller, a sports performance gym located in Rockville, MD, a suburb of Washington D.C. In addition to his daily practice, Teddy writes, speaks, and posts on social media regularly with the goal of educating therapists, fitness professionals, and recreational exercises on practical approaches to exercise and rehabilitation with a sports medicine and performance focus. Teddy’s work can be found on Instagram: @strengthcoachtherapy

 

What is a Bone Bruise?

By Meggie Morley, DPT Student

The term “bone bruise” can give the impression that it is not a very serious injury, when in reality a bone bruise is one step below a fracture of the bone. A bone bruise occurs when several trabeculae in the bone are broken, whereas a fracture occurs when all the trabeculae in one area have broken.  Trabecular bone is also known as spongey bone.

Bone Structure

A typical bone in the body is comprised of cortical bone, cancellous bone and bone marrow. Cortical bone accounts for roughly 80% of bone structure in the adult human skeleton. The outer layer of cortical bone is the periosteum and the inner layer of cortical bone is the endosteum. Cancellous bone is often referred to a trabecular bone. It is found at the end of long bones and contains a dense network of fibers and blood vessels.

Three Types of Bone Bruises

1. Subperiosteal hematoma: A bruise that occurs due to an impact on the periosteum that leads to pooling of blood in the region
2. Intraosseous Bruising: The bruise occurs in the bone marrow and is due to high impact stress on the bone.
3. Subchondral Bruise: This bruise is bleeding between cartilage and bone such as in a joint.

Symptoms of Bone Bruises

• Pain and tenderness in the region of injury
• Swelling in the region of injury
• Skin discoloration in the region of injury

Bone bruises often occur with joint injuries, such as ankle sprains and ACL tears, therefore a bone bruise can also coincide with stiffness and swelling in the joint.

Diagnosis and Treatment

A bone bruise can only be diagnosed with a MRI, but an X-ray may be used to rule out a fracture. The first line of treatment is to rest and limit activity on the limb. Walking with an assistive device such as crutches is recommended for as long as weight bearing is painful. Physical therapy is also a beneficial treatment in order to maintain full joint mobility and strength during the healing process. Bone bruises often take several months to heal, and possibly longer if the bruise is larger. A study by Boks et al found that the average healing time of a bone bruise was actually 42.1 weeks after a traumatic knee injury. 

  When Steelers QB Ben Roethlisberger suffered a bone bruise during the 2015 playoffs Dr. David Chao explained it like this, “Think of the bones in the knee being covered by articular cartilage like the dirt of the football field has grass on top.  If an elephant stomps on the grass the dirt underneath can be damaged/compressed.  In order to allow the grass (articular cartilage) to rejuvenate and heal, you can’t keep playing football on it.  The “keep off the grass” sign allows for a chance to heal.”

Overall, it is important to allow for bone bruises to heal for as long as needed to ensure that the bone does suffer further damage.

Blog Post written by Meggie Morley, DPT Student at Columbia University. Meggie is currently in her final Clinical Rotation with me at Catz Physical Therapy Institute.

Sources

1. ↑ Janice Polandit, 5 Things You Need to Know About a Bone Bruise, 2011; http://www.livestrong.com/article/5521-need-bone-bruise/ Grades of recommendation F
2. Jelić Đ, Mašulović D. Bone bruise of the knee associated with the lesions of anterior cruciate ligament and menisci on magnetic resonance imaging. Vojnosanitetski pregled. 2011;68(9):762-6.
3. https://www.saintlukeshealthsystem.org/health-library/bone-bruise
4. Boks SS, Vroegindeweij D, Koes BW, Bernsen RM, Hunink MM, Bierma-Zeinstra SM. MRI follow-up of posttraumatic bone bruises of the knee in general practice. American Journal of Roentgenology. 2007 Sep;189(3):556-62.
5. Bone Photo Credit click here

Movement of the Week: Standing Stick Press

Pressing is an essential movement in sports, and the majority of sports take place in standing.  While pressing on a bench, chair or floor is the best way to create absolute strength (also important for sports performance) it does not translate directly into sports tasks, unless your sport is Powerlifting.  Drills like the Standing Stick Press, Landmine & Med Ball Shots can’t be loaded like a Bench Press but they train the entire body and its proprioceptors to respond to the standing forces created by pressing or resisting an anterior to posterior force.

The 3 Stance Stick Press is more of an anti-rotation drill and is great to use with patients or clients looking for core stability.

The Dynamic Split Stick Press can be loaded heavier, has a larger range of motion, and hip rotation that translates well for field sports athletes.

Benefits

• Unilateral Pressing Strength
• Scapular Mobility
• Core Stability/Strength
• Hip/Pelvic Stability
• Full Body Proprioceptive Training

Give these a try and comment or share with a friend.

BFR for In-Season Athlete Management

Blood Flow Restriction Training/Therapy is an excellent way to manage athletes during the season.  As athletes progress in competition level, the volume of sport specific activities increase while recovery and down regulation practices decrease.  Over the course of the season, athletes tend to breakdown,  loosing muscle mass & strength while developing ligament sprains, muscle strains, stiffness & acute tendinopathies.  In-season periodized strength training, corrective exercises and mobility work can be helpful in maintaining off-season gains and reducing injury risk.  However, traditional strength training leads to muscle breakdown prior to muscle growth, and some athletes may be dealing with acute injuries that prevent them from being able to load at an appropriate percentage.

BFR allows athletes to build muscle, prevent atrophy, and load irritated tendons at 10-20% 1RM while reaping the benefits of working at 60-80% 1RM.  Because loading takes place around 20% there is no muscle breakdown and is tolerable to achy joints or irritated tendons.

The mechanism of BFR also stimulates the release of Human Growth Hormone which is responsible for collagen synthesis.  Collagen synthesis is how muscles, tendons, ligaments, cartilage and bone heal.  Meaning athletes will be able to recover quicker, maintain strength and optimize performance throughout the season.

Clinical Application

In the video I am working with a College Baseball Pitcher that is experiencing medial forearm wrist flexor pain and stiffness after pitching outings.  The goal of the BFR treatment is to create lactate buildup and cell swelling, stress the irritated tissues at a low pain free load, build posterior cuff strength and strengthen the stride leg in a task specific environment.  The 3 UE treatments are specific to the Right arm tissues while the 1 LE treatment does provide specific Left leg benefits but the goal is more of a global Growth Hormone response because of larger muscle group activation.

Share this article with someone you think it will help, and for more info on BFR check out OwensRecoveryScience.com

Physical Therapy as an Alternative to Opioids for Chronic Pain Management

  

By Meggie Morley, DPT Student

In recent years there has been a rise of prescription opioid use in the United States. On the average day, 650,000 opioid prescriptions are dispensed and between the years 2000 and 2010 the amount of opioid prescriptions nearly doubled from 11.3% to 19.6% among all pain visits .  There are patient scenarios when opioid prescription and use is appropriate such as hospice, palliative care, and acute pain management, but for the treatment of chronic pain (pain lasting three months or greater) there is not clear evidence suggesting that opioid use is beneficial.

As the rise in opioid use becomes a national epidemic, the CDC has released guidelines for prescribing opioids for chronic pain.  The guidelines also recommend chronic pain management with non-drug choices such as physical therapy, cognitive behavioral therapy and weight loss. As opioids have side effects such as sedation, dizziness, nausea, dependence and respiratory depression, treatments such as physical therapy may be a beneficial alternative.

In a systematic review by Hayden et al, sixty-six studies were reviewed to examine the effects of exercise therapy for low back pain versus other conservative treatments or no treatment. 

Sixty-one randomized control trials met the inclusion criteria of evaluating the effectiveness of exercise on acute, sub-acute, and chronic low back pain. The outcome measures for patient improvement were both pain and functional scales. The authors concluded that exercise therapy is effective for decreasing pain and improving patient function among adults with chronic low back pain. The results for sub-acute low back pain were inconclusive, and exercise therapy for acute low back pain was determined to have the same effectiveness of other conservative treatments or no treatment.

The management of chronic pain is a complex issue, but education for both healthcare providers and patients on the various treatment options is critical for addressing the rise of opioid use in the United States. More information can be found on the APTA website, where they have started a campaign titled #ChoosePT to further discuss physical therapy as a method for treating chronic pain.

Blog Post written by Meggie Morley, DPT Student at Columbia University. Meggie is currently in her final Clinical Rotation with me at Catz Physical Therapy Institute.

Sources

Daubresse M, Chang HY, Yu Y, Viswanathan S, Shah ND, Stafford RS, Kruszewski SP, Alexander GC. Ambulatory diagnosis and treatment of non-malignant pain in the United States, 2000–2010. Medical care. 2013 Oct;51(10).

Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opiods for Chronic Pain –  United Staes, 2016. MMWR Recomm Rep 2016;65(No. RR-1):49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.

Hayden J, Van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non‐specific low back pain. The Cochrane Library. 2005 Jul 20.

http://www.moveforwardpt.com/Resources/Detail/physical-therapy-vs-opioids-when-to-choose-physica

Movement of the Week: Landmine Variations for Baseballers

 

 @cbutlersportspt

If you are training or rehabbing baseball players I’m sure the Landmine Press and its multiple modifications are staples of your strength program.  Since you’ve already got your athletes familiar with the Landmine and it’s benefits, here are a few variations that will be ideal for your baseball and softballers.

Landmine Floor Press

The Floor Press is a great supine pressing exercise for throwers because it prevents excessive anterior shoulder stress as the humerus contacts the floor prior to traveling behind the frontal plane of the body.  It works well for training small groups or teams because it does not require a spotter and can be part of a circuit.

Landmine Pitching Deceleration

Decelerating the forward, downward and rotational forces of the pitching motion is essential for arm health.  This drill will train the stride leg, core and posterior shoulder muscles necessary for efficient full body pitching deceleration.

Landmine Renegade Row

The Renegade Row is one of the toughest plank variations you’ll ever do.  This is a fantastic way to train scapular and core stability while effectively loading the row for strength gains.

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Dynamic Scapular Stability

By Meggie Morley, DPT Student

A solid foundation of scapular stability is not only important for optimizing shoulder mechanics, but also the motions of the elbow, wrist, and hand. There are traditional methods of assessing and treating scapular stability, but several articles and studies are exploring new ideas and approaches.  In an article by McQuade et al, scapular stability was defined as “’normal’ scapula movement on the thorax during upper extremity motions.”

One of the core principles of scapular motion is the concept of scapulohumeral rhythm. The idea is that for every two degrees of humeral elevation there is a corresponding one degree of motion of the scapula.   For example, 180 degrees of shoulder abduction is comprised of 120 degrees of arm elevation and 60 degrees of scapular upward rotation. However, recent studies have shown that scapulohumeral rhythm can actually vary from anywhere between a 1:1 to a 6:1 ratio. Several factors such as external load, speed, fatigue, pain, and plain of elevation of the arm where all shown to affect scapulohumeral rhythm.

Traditional treatment methods have also tended to focus on identifying postural “abnormalities” in the scapula and correcting them through strengthening and stretching. However, a systematic review by Ratcliffe et al. studied patterns in subacromial impingement, and found that no ideal scapula position exists and deviations in scapula motion do not cause or contribute to subacromial impingement.  They found that there was evidence for scapula kinematic alterations in people with impingement, but the type and prevalence of those alterations were inconsistent. In other words, one person could present with the same kind of movement pattern and static scapular posture as the next person, but one could have impingement and the other could show no symptoms at all.

After taking these new studies into account there are several ways to optimize scapular mobility and stability for each individual patient. Regardless of the individual’s scapular posture or movement patterns, it is critical that the scapular stabilizers and upward rotators are properly firing before moving the upper extremity, specifically the trapezius and serratus anterior muscles.  Warming up the scapular stabilizers before a shoulder workout is important in order to ensure that the scapula will be optimally supporting the upper extremity.  Single Arm Plank variations are activities that require the scapular muscles of the stabilizing arm to activate in order to keep the rest of the body steady.

It is also important to train the muscles in the range of motion that is weak or required for certain sports and activities. This is demonstrated in the Isometric Band Hold + Rhythmic Stabilization drill. Demand is put on the stabilizing muscles of the scapula and core by holding the band steady as the practitioner attempts to move the arm out of position.

The concept of dynamic scapular stability is continuing to evolve as more studies are published. A focus on optimal scapular stability and mobility with an attention to each patient’s individuals needs is one way to incorporate both new and traditional treatment methods in order to achieve the patient’s goals.

 

Blog Post written by Meggie Morley, DPT Student at Columbia University.  Meggie is currently in her final Clinical Rotation with me at Catz Physical Therapy Institute.

Sources

1. McQuade KJ, Borstad J, Siriani de Oliveira, A. Critical and Theoretical Perspective on Scapular Stabilization: What Does It Really Mean, and Are We on the Right Track? Phys Ther. 2016. 96:1162-1169.
2. Inman VT, Saunders JB, Abbott LC. Observations of the function of the shoulder joint. 1944. Clin Orthop Relat Res. 1996; 330:3-12.
3. McQuade KJ, Smidt GL. Dynamic scapulohumeral rhythm: the effects of external resistance during elevation of the arm in the scapular plane. J Orthop Sports Phys Ther. 1998 Feb; 27(2): 125-33.
4. Mottram, SL. Dynamic stability of the scapula. Manual Therapy. 1997 Aug 31; 2(3): 123-131.
5. Ratcliffe E, Pickering S, McLean S, Lewis J. Is there a relationship between subacromial impingement syndrome and scapular orientation: a systematic review [erratum in: Br J Sports Med. 2014;48:1396]. Br J Sports Med. 2014; 48: 1251-1256.

Movement of the Week: Dynamic DB Squat/Swing Variations

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It's a 3fer1 MOW. Dynamic DB Squat/Swing Variations. Check the link here @cbutlersportspt for the full blog post. #CatzPT #AGatCatz #PhysicalTherapy #PhysicalTherapist #Physio #PhysioTherapy #dptstudent #ptstudent #sportsmed #sportsmedicine #cscs #strengthtraining #fitness #pasadena #sportsrehab #catzpasadena #athleticgaines #crossfit #functionaltraining #baseball #baseballtraining

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Once your patient/client/athlete can squat efficiently and can perform a DB or KB swing safely, it is time to train multi planes.  These 3 variations of DB swings translate well into throwing and swinging sports and can be biased for mobility,  rotational speed or strength, depending on the load.  They can also give you feedback about an athlete’s rotational coordination, timing and range of motion limitations. Lastly, they can easily be integrated into a metabolic conditioning circuit for athletes that participate in rotational sports.

Golf Squat 

Cues: Starting position is a squat with the elbows extended and forearms against the inner thighs.  Start the upward swing from the hips followed by the DB.  At the top diagonal position, the hips should be fully rotated and extended with the spine in neutral.  Watch the feet for inversion rolling or leg external rotation to make up for limited hip internal rotation.

Reverse Golf Squat:

Cues:  Starting position is a squat with the DB tucked against the lateral hip pocket, elbows flexed and body weight shifted slightly to the loaded side.  The opposite shoulder should be rotated towards the opposite hip.  Thrust the loaded hip and let the DB elevate upward and outwards with the elbows extended at chest height.

Square Stance X-Chop:

Cues:  Starting position is a squat with the DB tucked against the lateral hip pocket, elbows flexed and body weight shifted slightly to the loaded side.  The opposite shoulder should be rotated towards the opposite hip.  Start the upward motion by thrusting the loaded hip into extension and opposite side rotation.  The DB will follow and finish over the opposite shoulder with both hips rotated and the spine in neutral.  Watch the feet for inversion rolling or leg external rotation to make up for limited hip internal rotation.

Synovial Plica Syndrome: Symptoms & Treatment for Anterior Knee Pain

By Tom Sutton, DPT Student

Introduction and Anatomy

In a study by Lee et al, synovial plica syndrome (SPS) of the knee is said to be a cluster of symptoms and not one specific presentation or cause. Some of these problems may consist of pain in the anterior region of the knee, clicking, clunking and popping sounds that can occur during functional activities such as squatting or negotiating stairs.  SPS can affect males and females alike, most commonly between the ages of 10-30. Plica is actually the name of a structure in most peoples’ knees, many are non-symptomatic,”inward folds of the synovial lining,”(1) that can be impinged between the quadriceps tendon and femoral trochlea when the knee flexes between 70-100 degrees.   The plica is attached to the articularis genus muscle and runs into the synovial lining of the knee, located on the medial side of the retropatellar fat pad.  Figure 1 presents an image of the plica in the knee. The study performed by Lee et al investigated what synovial plica syndrome is, how it can affect people and how to properly treat this type of knee pain.

Presentation

Given the fact that SPS may bring about a number of complaints and symptoms from patients, it is important to understand exactly what problems are present and how to diagnose SPS in order to demystify this type of knee pain. Lee et al reports is that SPS is most commonly without a mechanism of injury.(1) Plica-related problems in the knee can come about during knee flexion over time such as kneeling and sitting or repetitive exercises like running or biking.(4) The patient is going to complain mostly about pain and a “snapping” sound  on the medial side of the knee joint during flexion.(4) For a complete list by Lee et al, see Table 1 for signs and symptoms of knee SPS.(1) SPS can also mimic other pathologies such as meniscal problems, osteoarthritis of the knee and patellar tendinopathy.(1) According to Schindler, anterior knee pain is the “cardinal symptom” of plica syndrome (5). Since SPS can be caused by a traumatic mechanism of injury, overuse or associated with co-morbidities such as diabetes, (1) obtaining past medical history becomes more pertinent. Additionally, if the patient were to be younger and around the age of 13, it would be prudent to find out if they have been experiencing growth spurts, as symptoms of SPS can occur during this time.(1)

For more specific information on SPS, here is a printable booklet that is courtesy of Houston Methodist. (4)

Application & Closing Thoughts

Furthermore, if there is a stability or strength problem elsewhere in the body such as the back, hip or ankle, it is possible that this may cause problems in the knee that could explain the idiopathic nature of plica syndrome.(1) There are special tests that can be performed including Hughston’s Plica Test and the Stutter Test.(1) Although special tests do not hold diagnostic value, they can be helpful in ruling in and ruling out pathologies. Applying the knowledge from several SPS studies and sources, there are a number of ways to address a patient with SPS. Finding the cause of the problem should be the priority of the physical therapist as they begin to formulate a program for the patient. Treatment may consist of a wide variety of techniques such as soft tissue manipulation, stretching, functional exercise and postural education. Functional exercise and training will be very important because the patient can learn more efficient movements for everyday lifestyle as well as gain the strength needed in both lower extremities in a closed-kinetic chain (CKC) fashion. Below are a few examples of helpful CKC exercises. 

SPS has been shown to respond well to conservative treatment, (6) and most patients have demonstrated improvement and decreased pain.(1) An important takeaway from this is to understand why the patient is experiencing SPS and address the cause. Otherwise, it is possible the plica problem will linger and surgical methods may be weighed as an option. Although some studies have shown that most patients with failed conservative treatment have had success with surgery,(1) avoiding a resection procedure altogether would be a much better alternative.

Blog Post written by Tom Sutton, DPT Student at the University of St. Augustine. Tom is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.

References

1. Nixion A, Chandratreya A, Murray J, Lee P. Synovial Plica syndrome of the knee: A commonly overlooked cause of anterior knee pain. The Surgery Journal. 2017;03(01):e9–e16. doi:10.1055/s-0037-1598047.

2. Griffith CJ, LaPrade RF. Medial plica irritation: diagnosis and treatment. Curr Rev Musculoskelet Med 2008;1(01):53–60

3. Dandy DJ. Anatomy of the medial suprapatellar plica and medial synovial shelf. Arthroscopy 1990;6(02):79–85

4. Houston Methodist. http://www.houstonmethodist.org/orthopedics/where-does-it-hurt/knee/plica-syndrome/. Accessed March 12, 2017.

5. Schindler OS. ‘The Sneaky Plica’ revisited: morphology, pathophy- siology and treatment of synovial plicae of the knee. Knee Surg Sports Traumatol Arthrosc 2014;22(02):247–262

6. Bellary SS, Lynch G, Housman B, et al. Medial plica syndrome: a review of the literature. Clin Anat 2012;25(04):423–428

Sports Hernia: Nomenclature, Examination and Rehabilitation

By Tom Sutton, DPT Student

With every sport that athletes take part in including football, hockey and baseball, it is no surprise that many different types of injuries come about. One injury in particular, that is typically given a general diagnosis of “sports hernia,” involves groin and abdominal pain. According to a study carried out by Ellsworth et al in the International Journal of Sports Physical Therapy, sports hernia could encompass many symptoms and it is important for the practicing clinician to understand their patient’s presentation when treating them. This would of course include performing a thorough subjective examination as well as objective tests and measures. Although there is research in the current literature that discusses what rehabilitative measures should be taken in physical therapy for hernia-type injuries, Ellsworth examines more specific diagnoses beyond the catch-all term of sports hernia and compares conservative treatment vs. operative management.

Athletic Pupalgia vs. Inguinal Disruption
Per Ellsworth, sports hernia is not solely limited to the athletic patient population and can be better described as either athletic pubalgia and inguinal disruption. Athletic pubalgia conveys “separation of the more medial common aponeurosis from the pubis,”(2) and can likely involve tendinopathy of the hip adductors. This term is reportedly the replacement term for sports hernia per Kachingwe.(3) Possible mechanisms of injury include agility type movements involving sharp cuts, turns and twists as well as high-intensity planting of the foot in the ground, “repetitive kicking and lateral motion.” (4) Kachingwe outlines the five signs that are indicative of athletic pubalgia that should be heeded in the clinical setting on Table 1.(3)

Inguinal disruption is an umbrella term for pain syndromes that relate to an injury of soft tissue in the inguinal area. Sheen has suggested through his research that there are 5 possible signs of inguinal disruption and reports that 3 out of 5 increase the likelihood of an inguinal disruption diagnosis. The signs are as follows, per Sheen et al: (5)
1.  Pinpoint tenderness over the pubic tubercle at the point of insertion of the conjoint   tendon.”(5)
2.  Palpable tenderness over the deep inguinal ring.”(5)
3.  Pain and/or dilation of the external ring with no obvious hernia evident.”(5)
4.  Pain at the origin of the adductor longus tendon.”(5)
5.  Dull, diffuse pain in the groin, often radiating to the perineum and inner thigh or across the mid-line.”(5)

Screening & Diagnosis
Keep in mind, differential diagnosis is especially important for these types of injuries because sports hernia can mimic other conditions such as hip impingement, stress fracture and labral tears.(6) When screening for an inguinal disruption may consist of having the patient perform resisted sit ups and adductor squeezes which will likely show muscle weakness.(5) Gilmore reports that having the patient alternate between utilizing the Val Salva maneuver and breathing properly along with palpation of the transversalis fascia can reveal possible findings of inguinal disruption.(1) From an imaging standpoint, the standard appears to be magnetic resonance imaging (MRI) which is coming out with increased literature supporting its use in diagnosing core injuries.(1) The British Hernia Society in 2014 reported that there are two findings on an MRI that should be observed: bone marrow edema noted in the pubis and changes observed in the anterior capsule, adductor longus and rectus abdominis.(2) The MRI will show the degree of disruption present in the patient and may serve as a guide as to whether or not the patient will require surgery.

Treatment
The first line of defense for injuries typically involves conservative treatment before resorting to surgical procedures. According to Ellsworth, there is little evidence in the current literature that fully support conservative management for hernia-type injuries.(1) However there are reported studies that demonstrated patients showing improvement after a rehabilitative program following 6-8 weeks.(1) Like all injuries, there are guidelines and protocols that can be heeded and examined before initiating an exercise program, but the fabric and makeup of a patient’s program should ultimately be determined based on their presentation. Non-operative treatment would consist of essential pillars such as strength, balance and flexibility. It would include activation, strengthening and coordination of the core and hip musculature, soft tissue techniques and neuromuscular re-education.(1) Ellsworth provides a week-to-week protocol that can guide a clinician’s treatment of a patient with athletic pubalgia or inguinal disruption. The protocol for conservative treatment vs. operative rehabilitation differ for imperative reasons such as facilitating healing and controlling swelling. The protocols for conservative treatment and operative management can be accessed here.

Closing Thoughts and Applicability
To apply what has been discussed in a clinical setting, it is important to understand that a patient’s complaints of “groin pain” may be more serious. This is especially true if the patient does not respond well to conservative treatment. Of course, during the examination it is paramount to observe the area affected, perform inspection and palpation. As for exercise, there are numerous possibilities for the patient’s individual program, as long as it is proportionate to their progress. Achieving the goals of optimal strength, range of motion and coordination following a groin injury or post-surgical procedure are focuses of treatment. Being familiar with the protocols and knowing that they are to be guidelines only. Not every patient will fit the protocol perfectly. Once determined what specific diagnosis the patient has, it will be very important starting the patient on a great exercise program to instill changes moving forward, like any other injury.

Blog Post written by Tom Sutton, DPT Student at the University of St. Augustine. Tom is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.

References

1.Ellsworth AA, Zoland MP, Tyler TF. Athletic pulbalgia and associated rehabilitation. Int J Sports Phys Ther. 2014;9(6):774–784. Accessed March 3, 2017.

2.Sheen AJ, Stephenson BM, Lloyd, DM, et al. Treatment of the Sportsman’s groin: British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med. 2013. doi: 10.1136/bjsports-2013-092872.

3.Kachingwe AF, Grech S. Proposed algorithm for the management of athletes with athletic pubalgia (Sports Hernia): A case series. J Ortho Sports Phys Ther. 2008;38(12):768-781.

4.Ahumada LA, Ashruf S, Espinosa-de-los-Monteros A, et al. Athletic pubalgia: Definition and surgical treatment. Ann Plast Surg. 2005;55(4):393-396.
Sheen AJ, Stephenson BM, Lloyd DM, Robinson P, Fevre D, Paajanen H, de Beaux A,

5. Kingsnorth A, Gilmore OJ, Bennett D, Maclennan I, O’Dwyer P, Sanders D, Kurzer M: ‘Treatment of the Sportsman’s groin’: British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med. 2014, 48 (14): 1079-1087. 10.1136/bjsports-2013-092872.

6. Kaar, MD S. Sports Hernia. Sports MD. http://www.sportsmd.com/hip-thigh-injuries/sports-hernia-athletic-pubalgia/. Accessed March 3, 2017.

 

Movement of the Week: Tri-Planar Overhead Carry

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Tri-Planar Overhead Carry. Post is up at #DailyGaines (link in bio) http://bit.ly/2lleFEF #CatzPT #AGatCatz #PhysicalTherapy #PhysicalTherapist #Physio #PhysioTherapy #dptstudent #ptstudent #sportsmed #sportsmedicine #cscs #strengthtraining #fitness #pasadena #sportsrehab #catzpasadena #athleticgaines @ferrarikhairi @catzpasadena @travellegaines

A post shared by Chris Butler, MPT, CSCS (@cbutlersportspt) on Feb 28, 2017 at 1:34pm PST

This is an excerpt from a blog post I did for Daily Gaines:

The Overhead Carry is a well-known movement that can train overhead strength as well as shoulder and core stability. It can also be used as an assessment tool to help guide therapeutic and corrective interventions so that your athlete can continue to progress their overhead lifting safely. 

Life and sport take place in 3 planes of motion, therefore training & mobility work should reflect that. Depending on the type of weighted modality, this movement can be biased for strength, stabilization or assessment. In the video below we use a med ball atop a flat hand and extended wrist to take a look at the athlete’s stability and mobility through all 3 planes. The ball is resting on the hand, so as form breaks down it will roll out of place or compensatory patterns will present themselves.

For the full blog post and more great sports performance content, check out DailyGaines.com

Visual Training: A Possible way to Enhance Baseball Performance

By Tom Sutton, DPT Student

One important aspect of baseball, let alone sports is undoubtedly vision.  The input an athlete takes in while competing in a game or practice environment is paramount for peak performance. Having good hand-eye coordination and tracking skills to locate the ball as a batter or to accurately place the ball across the plate as a pitcher are just a few reasons why a baseball player needs good vision.

A recent study by Dimitrios Palidis and colleagues was conducted to evaluate the dynamic visual acuity (DVA) of 23 males on a high school baseball team in Vancouver, Canada. DVA is evaluated by two tests which are static-object (head rotation, with vision locked on a still object) and dynamic-object (head still with vision locked on moving target) fixation. This study was published in the Public Library of Science (PLOS) in February 2017.

Distinct Eye Movement Patterns Enhance Dynamic Visual Acuity
Dimitrios J. Palidis1, Pearson A. Wyder-Hodge1, Jolande Fooken1,2, Miriam Spering

Background
In a study by Palidis et al, the investigators tested whether or not there is a relationship between a high school baseball player’s eye movement kinematics and DVA performance. With both static and dynamic methods of testing DVA, static-object is used in a variety of practice settings and requires the athlete to utilize the vestibulo-ocular reflex (VOR) to maintain fixation on the object.(2)

Methods
The study consisted of 23 males on the same high school baseball team with an average of 19.5 years. The study was performed at the University of British Columbia (UBC) in Vancouver, Canada. The researchers reported that the baseball players had either normal or corrected-to-normal visual acuity and those who did not have normal acuity wore contact lenses or glasses during the study. The study tested dynamic visual acuity by using black Landolt-C rings (see figure 1) and had the athletes track the “gap” in the letter “C” as it was spinning and moving horizontally on the screen from left to right. The athlete then had to decide with 4 arrow keys whether the “gap” in the letter “C” was located in the top right, top left, bottom right or bottom left corner. The “C” on the screen moved at a constant speed of either 50 or 70 degrees per second with random speeds and movements every trial.(1) Every time the athlete was correct in guessing which the corner the “gap” of the “C” was located, the width of the gap would decrease. The static acuity test (see figure 2) was performed with a visual acuity chart with numbers that the athletes were instructed to read from top to bottom while rotating their head.
Figure 1: The Landolt-C Ring test evaluating dynamic object acuity.(1)
Figure 2: The static acuity test,(1) utilizing VOR.(2) The top numbers signified a visual acuity of 20/800 vision and the bottom numbers were indicative of 20/20 vision. (1)

Results
The study showed that when athletes used smooth pursuit to track the object during the test as opposed to using anticipatory saccadic movements, their perceptual performance improved and translated to better DVA. As reported by Paladis et al, players who utilized anticipatory saccadic movements showed less accuracy and acuity during the dynamic object test.

Applicability and Conclusion
Have you ever noticed when watching a baseball game, the pitcher may squint as he is trying to see the signals given by the catcher? Sunlight is one thing, but when this happens during a night game, this may cause some viewers to wonder. In this case, the catcher may have highlighted marks on their hands and fingers to make it easier for the pitcher to see the calls made before he makes his pitch. If the pitcher is having trouble seeing the signs by the catcher, this may warrant a visit to the optometrist.

There are a few different ways to apply visual evaluation and training to a clinical setting before seeing an optometrist. A clinician or trainer can test an athlete’s vision with the static-object test using an acuity chart. Additionally, to further evaluate or enhance an athlete’s ability on the field, it may be prudent to find out what their dominant eye is. Although it is an older study from 2006, Shneor et al found that the dominant eye of given individual processes visual information better and faster and additionally takes over primary visual processing as seen in tests such as bionocular rivalry and hole-in-the-card.(3) Additional ways to test to see what the athlete’s dominant eye is, more can been seen here.

Utilizing computer-based tests to help facilitate better tracking skills and VOR training can be useful ways to assess an athlete’s visual ability and acuity to enhance their skill set and take their game to the next level. As suggested by Deveau et al, eye movement exercises can be a great intervention in an athlete’s training program. (4)

Blog Post written by Tom Sutton, DPT Student at the University of St. Augustine. Tom is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.

References

Dimitrios J. Palidis DJ, Wyder-Hodge PA, Fooken J, Spering M. Distinct eye movement patterns enhance dynamic visual acuity. PLOS ONE. 2017;12(2):e0172061. doi:10.1371/journal.pone.0172061.
Demer JL, Crane BT, Tian JR, Wiest G. New tests of vestibular function. Ann N Y Acad Sci. 2001; 942: 428–445. PMID: 11710482
Shneor E, Hochstein S. Eye dominance effects in feature search. Vision Research. 2017;46(25):4258–4269. doi:10.1016/j.visres.2006.08.006
Deveau J, Ozer DJ, Seitz AR. Improved vision and on-field performance in baseball through perceptual learning. Curr Biol 2014; 24:R146–R147. doi: 10.1016/j.cub.2014.01.004

Femoral Acetabular Impingement: Kira

Early in the year I had a hip injury and I couldn’t dance for a few months. Thanks to Chris and Catz I am back dancing with my team and am headed with them to compete at USA Nationals in a few weeks.

-Kira

Movement of the Week: Med Ball Pitching Step Up

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*Blog Post (link in bio)* Building strength in the stride leg of a pitcher is essential for developing a stable balanced support as the arm and body aggressively enter the acceleration and deceleration phases of throwing. #CatzPT #AGatCatz #PhysicalTherapy #PhysicalTherapist #Physio #PhysioTherapy #dptstudent #ptstudent #sportsmed #sportsmedicine #cscs #strengthtraining #fitness #pasadena #sportsrehab #catzpasadena #athleticgaines #armcare #baseball #baseballtraining #pitching #pitchingdrills

A post shared by Chris Butler, MPT, CSCS (@cbutlersportspt) on Feb 22, 2017 at 6:52am PST

Building strength in the stride leg of a pitcher is essential for developing a stable balanced support as the arm and body aggressively enter the acceleration and deceleration phases of throwing.  The arm reaches its highest velocity and greatest range of motion during these two phases, so it’s critical for the pitcher to land on a solid, stable base.  This is a task specific a drill that can be added to a traditional strength training routine for building stride leg strength while rotating and weight shifting  from back to front and right to left.

The Relationship Between Rotator Cuff Weakness & UCL Tears

By Tom Sutton, DPT Student

The following is a study that was published in International Journal of Sports Medicine that researched the relationship between the strength of the rotator cuff and ulnar collateral ligament (UCL) tears. There are a variety of reasons why baseball players of all ages, from youth to the majors, injure their arms. The results of this study found that baseball players who had a torn UCL had deficits in strength of the rotator cuff vs. players with a healthy UCL.

This study shows that it is very important to make sure the baseball player, whether a position player or pitcher, has adequate strength of the rotator cuff musculature. Muscles can act as dynamic stabilizers and ligaments only prevent unwanted movement. With that, a strengthening program for the rotator cuff may play a role in preventing UCL tears in baseball players.

BASEBALL PLAYERS WITH ULNAR COLLATERAL LIGAMENT TEARS DEMONSTRATE DECREASED ROTATOR CUFF STRENGTH COMPARED TO HEALTHY CONTROLS   Garrison JC, Johnston C, Conway JEGarrison JC, Johnston C, Conway JE

In a study performed by Garrison et al, the investigators researched the possible relationship of ulnar collateral ligament (UCL) tears in baseball players with deficits in rotator cuff muscular strength. The study consisted of 33 players who had been diagnosed with a UCL tear and 33 players that were healthy and without UCL tears. All participants were not exclusively pitchers, as both groups were matched by position. All participants had baseball experience at the high school and/or collegiate level and volunteered for the study.

The hypothesis of the study stated that baseball players with a torn UCL would have decreased isometric strength in external rotation (ER) and internal rotation (IR) at 0 degrees glenohumeral (GH) abduction. All participants’ strength was evaluated on both throwing and non-throwing arms.

In closing, the study demonstrated that the group of players with a torn UCL showed a great decrease in strength on the throwing and non-throwing arm in both ER and IR when compared to the healthy control group.

  Blog Post written by Tom Sutton, DPT Student at the University of St. Augustine.  Tom is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.

Movement of the Week: Pitching Lateral Speed Lunge

This movement is part of a pitching deceleration series. Pitchers need to be able to decelerate not only their arm but their entire body. I like to use this not only for deceleration but also for training: foot placement, coordination, hip/shoulder disassociation and agility.

How it’s done:

Hold a pair of lighter dumbbells at shoulder height in 90 degrees of external rotation.  Shuffle once to the side and open up towards the shuffle direction leading with the foot followed by the hip, trunk and finally allow the opposite arm to fall across the body in a pitching motion. The key is allowing the arm to fall, this should not be an active throw, it should be a faster but controlled fall. The trunk should hinge forward at the hip over a flexed knee and ankle. Keep the opposite arm up in an externally rotated position, reverse the motion and repeat in the opposite direction.

Standing Multi-Plane Core Stability

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They're a great place to start, but life happens upright. Try this (link in bio) as a second step. http://bit.ly/2k8yd3d #CatzPT #AGatCatz #PhysicalTherapy #PhysicalTherapist #Physio #PhysioTherapy #dptstudent #ptstudent #sportsmed #sportsmedicine #cscs #strengthtraining #fitness #pasadena #sportsrehab #core #corestrength #corestability

A post shared by Chris Butler, MPT, CSCS (@cbutlersportspt) on Feb 11, 2017 at 6:27pm PST

Dead Bugs, Bird Dogs, Bridges & Plank variations are a great place to start a core stability routine.  The problem is that we don’t live our lives on a table.  Once the core musculature is activated and we can move our limbs while stabilizing our spine in a safe gravity reduced position its time to get off the table and introduce gravity and resistance.  This routine is a nice place to start because the majority of these movements are isometric at the spine yet they are able to introduce stability in 3 stances and 3 planes.  This is the environment that most of us live and play in.  The upper extremities do the majority of the movement while the spine and core musculature need to respond the increasing demands created by the changing lever arms of the band resistance.  This routine works well as a second step to traditional core stability movements because it complies with post-op restrictions and provides a more challenging environment where safety is still a priority.

Movement of the Week: Band Resisted Lunge + Reach

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*New Blog Post* Movement of the Week: Band Resisted Lunge+ Reach (link in bio) #CatzPT #physicaltherapy #ptstudent #dptstudent #physio #physios #physiotherapy #physicaltherapist #corestability #corestabilitytraining #trunkstability #hipstability #cscs #csun #csunpt #fitness #strength

A post shared by Chris Butler, MPT, CSCS (@cbutlersportspt) on Feb 6, 2017 at 3:06pm PST

This is a more advanced version of a standing core stability series I take many of my lumbar patients through. I like this for clients with hip & pelvic stability issues as well as for athletes having difficulty controlling frontal plane knee forces during lunge tasks. The purpose of these movements is to maintain posture through the ankles, knees, hips, trunk and shoulders while performing a single plane movement and resisting isometric multi-plane forces applied by the horizontal pull of the band as the lever arm.

How it’s done:

Start with the hands against the body and take a fencing lunge forward, once the lunge posture is stable reach the hands forward or overhead. Make sure the hands go straight forward or straight upwards and there is no deviation towards or away from the pull of the band, then reverse the sequence back to the starting position. After the desired number of reps turn and face the opposite direction and repeat.

Movement flaws can easily be observed from side and front views, look for over compensation strategies as well. Modifications can be made by changing the band resistance or shortening the lever arm by remaining in the starting position with the hands close to the body during the entire task.

Below are a few additional variations:

1. Overhead Stick Reach: This makes it easier to get overhead, sometimes clients have difficulty getting overhead witch the narrow grip.

2. Long Arm Rotational Lunge +  Reach:  This is a more advanced version of the rotational lunge + reach movement. The longer lever arm intensifies the rotational core demand.

There are many other variations, feel free to share some of yours with me in the comments.

ACL Reconstruction: Kyle

Thank you so much for helping me through my recovery. Lacrosse tryouts went well and I made the varsity team again, and I have been back to playing lacrosse since just before the new year. My knee feels excellent, and if not back to full health it is at least 99%.  It is crazy to me to think that about 8 months ago I was barely able to crutch around and couldn’t do a leg lift, and I can’t believe how far I’ve come. In addition to making varsity, I have been coaching and attended a tournament, and I really cannot stress enough how good it feels after so long away from the sport. I have attached pictures of me in a tournament last weekend, and I hope they show how helpful you were in my recovery. Thank you so much, I could not have done it without you and hopefully I can find a time to swing by CATZ soon to say thanks in person.

Sincerely,
Kyle

 

Basic Scapular Loading & Stability

In order to progress to more complex shoulder loading its important build a solid base.  Here are a few simple scapular loading and shoulder stability exercises that can be made more challenging and once mastered will help with the performance heavier and more dynamic overhead activities.  These exercises are part of a larger arm care routine I have my overhead athletes perform after the manual tissue and joint prep, and prior to a full body movement prep.

These can be easily replicated out on the field using the dugout bench.