Category Archives: Rehabilitation

Knee Osteoarthritis and ACL Injury

ACLSix months (+/- a few) is the standard time needed for an athlete to return to competition following anterior cruciate ligament (ACL) surgery. To reach this date, therapy must be thorough and exact. Range of motion, neuromuscular control, or strength deficits that go unaddressed, negatively influence return to play and can also lead to other long-term consequences.

Those who suffer from ACL injuries are at greater risk of developing knee osteoarthritis (OA). Knee OA is a condition whereby the cartilage slowly wears away. This is a painful, life-long health issue that can lead to disability. With proper rehabilitation and adequate strengthening of the quadriceps, OA can be prevented. Sounds simple, but clinicians must also deal with arthrogenic muscle inhibition (AMI).

ASpinal tractMI is a neuromuscular dysfunction that limits the ability to strengthen muscle and is common following ACL surgery. With AMI, neurological signals from the quadriceps muscle to the brain and spinal cord are interrupted or slowed. You can read more about Brain and CNS deficits here.  So the question is, how do you combat AMI to properly strengthen the quad and subsequently prevent knee OA? The answer might be vibration training.

Vibration training employs a low-amplitude, low-frequency mechanical stimulation that exercises musculoskeletal structures. Vibration training provides strength gains without joint loading and stimulates osteoblastic and chondrocyte activity through the mechanisms of  Power Platemechanobiology. Subsequently, bone and joint health are improved.

A recent article by UNC’s EXSS Impact site found that vibration training (local or whole-body) improves quadriceps function by improving central nervous system function. Following vibration training, brain activity was altered in such a way that it became easier for these subjects to activate and use their quadriceps muscles. As such, muscle vibration can be an effective method to improve quadriceps strength and reduce the risk of developing knee OA.

Below is the full article from UNC.

Why did you do this study?

Individuals with anterior cruciate ligament (ACL) injuries are at greater risk of developing osteoarthritis (OA). OA is a considerable burden on the US healthcare system and contributes to physical disability and comorbidities such as obesity and diabetes. The lifetime cost of ACL injury amounts to $7.6 billion annually for patients that undergo reconstruction, $17.7 billion for patients that undergo non-surgical rehabilitation. Quadriceps dysfunction is ubiquitous following ACL injury and reconstruction, and is a major contributor to the development of OA. The quadriceps are responsible for absorbing impact forces during everyday tasks like walking and stair climbing, and also athletic tasks like running and jumping. When the quadriceps fail to act appropriately, their ability to attenuate these forces is reduced, and cartilage within the knee joint experiences greater loading. Subtle increases in joint loading are amplified through repetitive activities like walking, and over time, greater loading contributes to a gradual breakdown of articular cartilage.

Given the implication for future OA development, the restoration of proper quadriceps function is extremely important in rehabilitation. However, quadriceps dysfunction is caused by a neuromuscular phenomenon called arthrogenic muscle inhibition (AM), which presents a substantial limitation to muscle strengthening. Essentially, sensory signals from the knee joint inform the central nervous system – the brain and spinal cord – that the ACL as been injured. In response, our central nervous system responds by inhibiting the quadriceps to prevent further damage of the injured joint. While this mechanism may protect the joint in short term, AMI persists for many years following the initial injury and is thought to contribute to excessive cartilage loading and the development of OA. Therefore, strengthening the quadriceps is important in rehabilitation, but traditional exercises do not address AMI. Novel rehabilitation modalities are needed to combat AMI prior to the implementation of strengthening exercises.

Previous work in our laboratory indicates that muscle vibration provided directly (local muscle vibration – LMV) and indirectly (whole body vibration – WBV) may improve quadriceps function. However, what remains unclear is the mechanism by which these vibratory stimuli actually work to enhance muscle function. Given that AMI involves alterations in central nervous system function, it is imperative to understand how muscle vibration influences characteristics of spinal cord and brain function. Therefore, the purpose of this study was to understand how both WBV and LMV influence characteristics of central nervous system function.

What did you do and what did you find in this study?

Left - Transcranial magnetic stimulation to assess cortical neuron excitability; Right - Whole body vibration platform

We recruited subjects with ACL reconstruction for this study. First, we measured various characteristics of quadriceps function (i.e. strength and activation), and also how the brain and spinal cord contribute to muscle contraction. Following baseline measurements, subjects received an intervention of WBV, LMV, or control (no vibration) treatment. We repeated the same measurements of quadriceps function and central nervous system function following the treatment.

Active motor threshold was used to assess corticomotor excitability. In this case, both WBV and LMV lowered AMT relative to the control condition. This indicates that it becomes easier for the brain to activate the quadriceps following treatment. (* indicates P<0.0083)

We found that both WBV and LMV acutely improved quadriceps function (strength and activation) relative to the control treatment, and that this improvement was likely due to greater cortical neuron excitability. In other words, muscle contraction can either be voluntary (the brain tells the muscle to contract) or involuntary (spinal reflex loops). What we found was that following WBV and LMV, brain activity was altered in such a way that it became easier for these subjects to activate and use their quadriceps muscles.

How do these findings impact the public?

These findings indicate that vibratory stimuli acutely improve quadriceps function, and could be useful in addressing deficits in central nervous system function such as AMI. As such, muscle vibration could be an effective method to improve quadriceps strengthening protocols following ACL injury, and in turn reduce the risk of developing knee OA. Overall, knee OA is a major economic burden on the US healthcare system, and these findings could have important relevance for alleviating healthcare costs and physical disability.

A comprehensive rehabilitation program is vital for an athlete’s return to competitive sport. Failure to normalize range or motion, strength, and neuromuscular control can result in performance loss, reinjury, or long-term disabilities, such as knee OA. Make sure your rehabilitation program is inclusive of all components. Of course, the best cure for ACL surgery is preventing ACL tears all-together. If you want to prevent ACL injury, read about the RIDS Program designed to prevent injury. 

12 Booty Exercises to Improve the Back Side

 The glutes (not counting the core) are the single most important muscle group for athletic performance and injury prevention. 

Booty

I prefer a booty that has a functional purpose.

I am an ass man. Not in a sexual context, but in a functional movement context.  I do not care if you are fat, skinny, or look great in a pair of yoga pants. If your glutes function at an optimal level you will have better athletic performance and prevent injury. Over the years, I have worked with a variety of clients and the glutes are a focus for all of my clients. It does not matter what your current fitness level is; if you want to prevent injury, boost performance, or become more fitter, the butt is key.

Ask any client I have trained, and they will tell you that I will destroy your glutes – in a good way. Over time, I have developed some favorite booty-popping exercises.  In clinical research, there isn’t any published data that truly says these exercises are best. What you have here is based on my clinical experience and what I have found to work best. These exercises are designed to give you optimal gluteal function and they might even make you look good in a pair of jeans.

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Blame the Brain: Tips for the Physical Therapist and Athletic Trainer

Novel treatment of muscle weakness following joint injury has sought to develop interventions that can excite the neuromuscular system and allow for more effective interactions between the nerves and muscle.”

Chad and Brent both play the same position for the same basketball team—same practice routine, same strengthening program, same injury prevention program—but Chad is suffering from left patellar tendonitis. Why is Chad injured and not Brent? We have adopted laymen medical terms such as “Runner’s Knee”, “Little Leaguer’s Elbow”, “Tennis Elbow” or “Jumper’s Knee” implying these types of injuries are caused by the activity. But are they? What if Chad’s “Jumper’s Knee” is linked to a brain or spinal cord deficit and not some musculoskeletal dysfunction?

Everything we do —touch, sense, feel, contract, move— triggers an action potential that is sensed by millions of mechanoreceptors, which follows a path to Spinal tractthe brain.

  • The action potential is picked up by peripheral nerves and carried to the dorsal root ganglion cell and travels to the spinal cord.
  • The impulse goes through the dorsal column nuclei and the impulse is taken to the thalamus in the brain via the spinothalamic tract.
  • In the brain, this impulse synapses with the ventroposterolateral thalamus and onto the somatosensory cortex.
  • A motor response is then triggered.

This path is followed every time. Sensory or motor deficits anywhere along this path can lead to injury. Sometimes, as health care providers we get in a rut and look to treat the body part or underlying movement dysfunction. While this practice is not necessarily bad, it might not be what is needed. Correcting muscle imbalance or addressing joint dysfunction may not be the answer. Removing the athlete from activity to reduce overload may not be the answer. Our goal should aim to fix deficits along the neural path. Continue reading

10 Reasons – Icing Injuries is Wrong

iceIf you know me, you are aware of my anti-ice stance. The ice debate continues to heat up. As peer-reviewed data continues to pour in, the evidence for the use of ice to treat musculoskeletal injury still lacks. I’ve written about ice many times, but many of my anti-ice articles are science-y and focused around one topic. I wanted to do something different this time. I wanted to keep it short, sweet and comprehensive. So, I bring you 10 reasons why we shouldn’t ice injuries. Continue reading

Future of Medicine

cocaine1In time everything we do to treat injuries, prevent disease, or reverse disease will eventually change. Think of all the things we used to do in medicine. Cocaine was used for toothaches. In the 1600’s, “hydrotherapy” was used to would wash away insanity in mental patients. Jan Baptist van Helmont would literally drown people to death and then resuscitate, believing that water would cleanse and the near drowning would snap people back to reality. In the 1800’s ketchup was used to treat athletes foot. In rehabilitation science, we use a myriad of techniques that we think is proper today, but overtime, the way we treat will drastically change and I believe it will come sooner rather than later.  Continue reading

Season of Running and Injury

Illinois MarathonIn April, the Boston Marathon kicks off yet another season of running. Whether it is 5k or a Marathon, from April to October running enthusiasts have no trouble finding a running event to participate in. Here in my town of Champaign, some 20,000 participate in one of the Illinois Marathon events. With these races comes training and where there is training, you can find injury close by. Continue reading

The Great Toe

When you think of the most common lower body injuries, you think ankle sprains, shin splints, runner’s knee, jumper’s knee, fasciitis, or Achilles tendinitis. When you have these injuries, you treat the injured area. We might be overlooking a little, but big deal.  Dysfunction in the big toe influences every step you take, every lunge, every jump, and every stride of every run. Ultimately, it can be a direct result in many of the aforementioned common lower body injuries. If you have dysfunction (pain, instability, or hypomobility) at the first big toe joint (MTP joint), it could wreak havoc on the entire kinetic chain.

Normal range of motion of the big toe is 40° flexion, 80-90° extension, and 10-20° abduction and adduction. Lack of motion, especially extension, will create compensatory movement at other joints. Common big toe issues such as, hallux valgus (bunion), hallux rigidus, turf toe, sesamoiditis, and gout will limit toe mobility. Below is an image of a client who demonstrates normal range or motion on the right and limited toe extension on the left.

N ROM   Limited ROM

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Icing Injuries: Are We Evidence-Based?

Are you an evidence-based practitioner? Think about it; are you really?

An athletic trainer working a Division 1 women’s volleyball tournament with elite Top-25 teams sent me a text: “You should do a study on the average number of ice bags used by volleyball teams after a match… Entire teams are getting ice on both knees and the hitting shoulder. No post-match mobility work, just pounds of ice. Crazy! Some athletic trainers and strength and conditioning coaches are too ignorant and too lazy to provide proper warm-up and cool-down protocols to address mobility.” This is not shocking to me. I worked with Division I volleyball for several years and I observed this too. This is where I learned ice is overused.  This isn’t just a volleyball thing; this is an all-sport issue. Continue reading

The Sit-up: So Simple, Yet So bad!

I have nSit upo idea how long the sit-up has been around – a thousand years maybe? Whatever it is we’ve been doing it for a long time. I don’t know how many times I’ve heard “I do crunches every day.”, “I’m working my core.”, or “Look at my 6-pack.”. My responses to those statements: “No you don’t.”, No you’re not.”, and “great, do you want a cookie for your efforts?”  The fact is I see so many people “working their core” and the only thing they are doing is making a bad problem worse. Something so simple and you are doing it wrong!

I do not have a 6-pack. I do not have a 12-pack. I have what some may refer to as a party-ball of Guinness Extra Stout. Ask my wife, she will vouch for this sexy, fuzzy pillow that serves as my beer containment center. Despite my rather portly and ovoid mid-section, I know my core is a lot stronger, more stable, and less susceptible to injury than the 24 yr. old fitness geek down the street referred to as Jacked Jimmy. Yeah, that guy with glistening abs, who at every chance will raise his extra tight wife-beater tank top up, ever so slightly, just so he can hear the throngs of women fall unconsciously to the ground. Yeah that guy. How do I know that I can beat him in a core-off? Because more likely than not, he’s doing it wrong. I’ve seen too many “fit” clients fail miserably when I put them through a core routine. Continue reading

POS: Reduce Pain and Increase Performance

SwingDysfunction of one movement system can lead to a multitude of injuries. Treatment and care for one movement system can prevent our most common ailments. Most potential clients I interview complain of one or more of the following: sacroiliac joint (SIJ) pain and instability, non-specific low back pain (LBP), chronic hamstring strains or tightness, and peri-scapular and thoracic tightness or pain. Whether these complaints are isolated to one body part or involve many, the pain can typically be resolved by treating dysfunction of the Posterior Oblique Subsystem.

 

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RIDS Program: A New Paradigm for ACL Prevention

ACLThe grandeur of the World Cup is upon us. The world’s most popular sport has its chance to shine. As soccer gets its much deserved pedestal, summer camps fill. High school and collegiate soccer athletes become inspired. Training begins and with that begins the season of the ACL. With approximately a quarter-million ACL injuries per year, it is safe to say the injury is common in sport. Though most common in female athletes, ACL injuries happen to anyone anywhere, with soccer, basketball, and gymnastics athletes being at most risk.

While an ACL injury is traumatic in nature, the injury is rarely due to direct trauma. More than 75% of ACL injuries are non-contact in nature (1). Non-contact ACL injuries stem from a complex interaction of anatomical, hormonal and neuromuscular factors. Recent studies suggest that ACL injuries are caused by both neuromuscular fatigue and unanticipated movements commonly found in athletics, such as evasive maneuvers that involve some form of deceleration, change of direction, or landing. The coupling of these movements with modifiable risk factors (see graphic) is what leads to non-contact ACL injury. The good news is that non-contact ACL injury can be prevented by addressing these modifiable risk factors. Continue reading

Butt Battle

A nice booty is not always a good booty.

A nice booty is not always a good booty.

Everyone loves a nice butt. Walking down the street, at the mall, or at the bar, there is bound to be a butt that catches your eye. Like a kitten following a piece of yarn, there is the occasional butt that walks by and causes heads to turn, leaving onlookers with a severe neck strain and mouths agape. Don’t act all innocent and holier than thou, we’ve all done it! Therapists and rehabilitation specialists are no different. In fact they can spend an entire day staring at booty. However, we are not looking to see if “Baby Got Back” or how that plump bump fills a pair of Wranglers, Levis, Seven, or True Religion jeans. We have a reason to look and it is strictly professional; is the little butt working?

For several years now rehabilitation journals have published articles linking a myriad of lower extremity injuries to poor gluteal control. While the glute max – that which makes our heads turn – and the glute minimus are both important, the glute medius is the real problem. We have learned the important role the glute medius has on controlling lower extremity mechanics. Glute medius inhibition precipitates many lower extremity injuries such as ACL tears, Patellofemoral pain, Iliotibial band syndrome, Achilles tendinopathy, plantar fasciitis, MTSS (shin splints), the list goes on. Rehabilitation specialists must pay special attention in strengthening the glute med., but how? What is the best exercise?

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Pelvic Upslip and Rotation: Evaluation and Treatment

Pop quiz: What musculoskeletal issue could result in chronic low back pain, chronic Chronic-back-pain-image muscle strains, lower extremity tendinopathies, periscapular pain and tightness, glenohumeral and shoulder girdle pain, or tension headaches? I am sure you can think of a few possibilities, but few can result in all. Often, when a patient reports to our care with one of the aforementioned we immediately think locally. Unfortunately, the real problem could be pelvic upslip, anterior pelvic innominate, or both. Despite being oft-overlooked, these malalignments are not hard to identify if you know what to look for. Continue reading

RICE: The End of an Ice Age

Coaches have used my “RICE” guideline for decades, but now it appears that both Ice and complete Rest may delay healing, instead of helping.” – Gabe Mirkin, MD, March 2014


ice-for-injuriesIn 1978, Gabe Mirkin, MD coined the term RICE. Health care practitioners to laypersons are quick to recognize RICE as the ‘gold standard’ treatment option following injury. Followers of my blog know my stance against ice and now there is support from the physician who coined the term. Yes, the very same physician, Dr. Gabe Mirkin, who coined RICE, is now taking a step back. I reached out to Dr. Mirkin and asked for permission to share his story. As you will read below in Dr. Mirkin’s full post, the lack of evidence for cryotherapy is something we must listen to.

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3C’s + P Approach to Successful Outcomes

How many times have you racked your head wondering; why is this not getting better? How come they’re still in pain? How do we have all of this evidence and knowledge at our disposal, yet individuals do not respond as anticipated? The science says, for injury ‘Z’ treat with ‘X’ and rehabilitate with ‘Y’, yet when we apply those tools they don’t work? Why are they not getting better? What are you doing wrong? What are they doing wrong? Continue reading