Barbell Landmines: Training/Rehab

 

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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. IMG_8524They 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 IMG_8529friendly 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 IMG_8530can 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.

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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?

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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. FullSizeRender 10A 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.

FullSizeRender 9 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

Hamstring Strains: Article Review & Application

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By Tom Sutton, DPT Student

Before the 2016 Summer Olympics in Rio began, there was some speculation as to whether or not Usain Bolt would make an appearance in the Games. Reports had come out saying that he had sustained a grade I hamstring muscle strain during the Olympic Trials. Fortunately, injuries such as this are the most mild of hamstring strains and are very treatable in physical therapy. A hamstring strain is a common injury from activities such as sprinting because for better performance in sport, the hamstrings require power and increased activation. However, there are ways to prevent and rehabilitate this injury, which a physical therapist can help with. In a study by Valle et al, the investigators evaluate rehabilitation essentials for two different types of hamstring strain injuries.

Hamstring Muscle Injuries, a Rehabilitation Protocol PurposeBy Xavier Valle, Johannes I.Tol, Bruce Hamilton, Gil Rodas, Peter Malliaras, Nikos Malliaropoulos, Vicenc Rizo, Marcel Moreno, and Jaume Jardi

Hamstring strains can be classified as two different types when it comes to the mechanism of injury: sprinting or stretching injuries. Stretching injuries have been seen to have a higher time loss than sprinting injuries and involves movements of the lower extremity with the hip flexed and the knee extended.(3) The stretching injury is mostly located at the proximal attachment of the semimembranosus muscle.(3) As for the sprinting type of injury, it mostly involves the biceps femoris long head and the time it takes the athlete or patient to return to activities is shorter in relation to stretching.(2) This type of hamstring injury can become the focus of a physical therapist to analyze and evaluate the mechanics of a patient or athlete’s running. For example, the hamstrings play a huge role in the running cycle, with muscle activation peaking during terminal swing and early stance phases.(4) The therapist will also know to address hamstring pain, muscle length with stretching, strength and control during rehabilitation because if the patient wants to return to running, power will increase with speed.(4)

Addressing a hamstring strain will involve key physical therapy principles involving normalizing the patient’s muscle length, strengthening the muscles of the lower extremity through functional exercises and neuromuscular re-education for improved coordination of the hip and knee. Injuries have protocols and rehabilitative guidelines that can give the young clinician an idea of how a patient can progress, so minding the patient’s stage of condition and tissue reactivity is important before beginning an exercise program. One interesting point made in Valle et al’s study is the concept of elongation stress on hamstrings (ESH). This can be applied clinically by subtracting the knee flexion angle from the hip flexion angle by evaluating hamstring muscle stretch during functional activities. If the ESH is larger, then there is higher stress placed on the hamstrings. A therapist can apply ESH to the running cycle by knowing that the hip ROM goes from 70 degrees of flexion to 45 degrees extension and the knee ROM goes from 30-130 degrees of flexion.

In closing, addressing the patient holistically is the approach to take. Functional exercise programs that involve the entire body as opposed to just the hamstrings will probably benefit the patient more (Examples shown below in video). One of the more common pillars of exercise treatment include core muscle activation/strengthening due to the influence of lumbo-pelvic muscles during activities such as running.(1) With this, the therapist can address things such as anterior or posterior pelvic tilt, core muscle activation and education to maintain neutral spine during exercise and activities. Additionally, there is published work in recent literature stating that neuromuscular training which includes balance training and stability can decrease the risk of lower extremity and hamstring injuries specifically.(5) Knowing the patient’s mechanism of injury, presentation and impairments will help the clinician to apply the knowledge from this study properly and design an exercise program suitable for their patient.

For more information on Valle et al’s suggestions for examination, diagnosis and treatment, please visit this link here (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4691307/)

Below are some sample exercises, the key is to apply an appropriate load to healing tissues, ranging from isolated isometrics to closed chain, multi joint, multi plane complex movements.  

  1.  Hamstring Curl with BFR- Light load, tissue specific, no muscle breakdown and Growth Hormone release to promote collagen synthesis.
  2. Supine Dolly Curls- Bilateral sagittal plane loading with a focus on simultaneous eccentric hip flexion and knee extension.
  3. Single Leg TRX Squat- Assisted single leg sagittal plane deep squat loading without a balance challenge.
  4. Barbell Side Lunge- Asymmetrical frontal plane loading, hip mobility and tissue stretching with balance.
  5. Traveling Lunge + Anterior Medial Reach- Multi plane functional application of the hamstrings in eccentric and concentric closed chain loading.

img_7501 This blog post was written by Tom Sutton, DPT during his final internship with me at Catz Physical Therapy Institute as a DPT Student.  You can find Tom here @twsutt

References

  1. Valle X, L.Tol J, Hamilton B, et al. Hamstring muscle injuries, a rehabilitation protocol purpose. 2015;6(4). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4691307/. Accessed March 23, 2017.
  2. Askling CM, Malliaropoulos N, Karlsson J. High-speed running type or stretching-type of hamstring injuries makes a di erence to treatment and prognosis. Br J Sports Med. 2012;46(2):86–7.
  3. Askling C, Saartok T, Thorstensson A. Type of acute hamstring strain a ects  exibility, strength, and time to return to pre-inju- ry level. Br J Sports Med. 2006;40(1):40–4.
  4. Chumanov ES, Heiderscheit BC, Thelen DG. Hamstring musculo- tendon dynamics during stance and swing phases of high-speed running. Med Sci Sports Exerc. 2011;43(3):525–32.
  5. Hubscher M, Refshauge KM. Neuromuscular training strategies for preventing lower limb injuries: what’s new and what are the practical implications of what we already know? Br J Sports Med. 2013;47(15):939–40.

Movement of the Week: Standing Stick Press

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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

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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

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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.

FullSizeRender 9Blog 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

 

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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

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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.

 

FullSizeRender 9Blog 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

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

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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 Image-2presents 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 Image-1for 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.

img_7501Blog 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.
  1. Griffith CJ, LaPrade RF. Medial plica irritation: diagnosis and treatment. Curr Rev Musculoskelet Med 2008;1(01):53–60
  1. Dandy DJ. Anatomy of the medial suprapatellar plica and medial synovial shelf. Arthroscopy 1990;6(02):79–85
  1. Houston Methodist. http://www.houstonmethodist.org/orthopedics/where-does-it-hurt/knee/plica-syndrome/. Accessed March 12, 2017.
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