Pop quiz: What musculoskeletal issue could result in chronic low back pain, chronic 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
“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
In 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.
It’s not often I completely take a post from another, but Mr. Yusuf Boyd, of Biomechaniks in Tennessee and North Carolina wrote a post last week that was on point! While I do not agree with everything in the post, what he says has a lot of merit and is worthy of a share.
I love Athletic Training and my fellow Athletic Trainers, but honestly this is the whiniest group on the face of the planet. March is National Athletic Training month; slogans fill my twitter feed: “I love my Athletic Trainer”, “Athletic Trainers’ save lives”, “My Athletic Trainer has my back.” Great, I am glad we are a prideful bunch, but enough of this holier-than-thou attitude. All I hear is “I am a Certified Athletic Trainer! I deserve respect!” It sounds like a crying toddler who didn’t get a lollipop from the dentist.
This very profession that demands respect also has many of its constituents complaining about the BOC’s new Evidence Based Practice CEU requirements. Really, you want more respect, but will moan and complain when our certifying agency and association wants higher standards? Continue reading
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
When we think of running injuries we immediately think lower extremity, IT Band syndrome, Patellofemoral Pain Syndrome, Achilles Tendinopathy, Medial Tibial Stress Syndrome, Plantar Fasciitis, and the like. However, one of the most common and debilitating injuries in runners is low back pain. So why are runners so at risk of developing low back pain? Most musculoskeletal injuries are multifactorial, but more often than not many chronic injuries result from underlying movement dysfunction.
Vladamir Janda (1928-2002) revolutionized human movement dysfunction and rehabilitation in 1979 when he described three compensatory movement syndromes. These syndromes were a result of pattern overload (i.e. running) and static posturing. Janda recognized that certain muscles were prone to weakness while others were overactive. He continually investigated these movement syndromes and later learned that the muscle imbalances were systematic, predictable, involved the entire body, and a common cause of injury. Continue reading
Overview and etiology:
The term “tendinitis” or any [insert any body part] with “itis” is tossed around as if it is the only possible cause for musculoskeletal pain. However, the “itis” is not really true. A tendon, specifically the Achilles tendon, is not really inflamed, rather it is deranged (tendiopathic / tendinopathy). In January 2013 the Annals of Human Genetics published an article that demonstrated Achilles Tendinopathy is associated with gene polymorphism (Abrahams, et al., 2013). COL51A is a gene that encodes the development and organization of Type V collagen. This collagen can be found in ligaments, tendons, and connective tissue. COL51A plays an integral role in development and maintenance of connective tissue. Abrahams, et al. (2013) demonstrated that polymorphisms occur in the COL51A gene causing altered structure of collagen resulting in tendinopathy.
The tendon may become fusiform or thickened, but it is due to cellular derangement rather than inflammation. Kannus and Jozsa in a controlled study of 891 patients with Achilles tendon rupture found that 97% of patients had degenerative changes in the ruptured tendon. The study also found that 34% of asymptomatic tendons also had degenerative changes (2) Continue reading
Introduction and Anatomical Overview:
Muscle is made up of two types of fibers, intrafusal and extrafusal. Extrafusal fibers are the contractile fibers and intermixed within the extrafusal fibers are intrafusal fibers. Housed within intrafusal fibers is a specific type of mechanoreceptor. Mechanoreceptors, in general, are interspersed through the entire body – hair, skin, ligaments – and are responsible for sensing tissue pressure and distortion and give our body a sense of proprioception by detecting position of our muscles, bones, and joint. There are many types of mechanoreceptors, but one specifically – the muscle spindle – lives within the intrafusal muscle fibers. The muscle spindle transmits sensory data regarding changes in muscle length, and therefore movement, to the central nervous system (CNS) via the primary afferent (sensory) neurons. The intrafusal fibers receive neural stimulation from gamma efferent (motor) neurons. Think of the gamma motor neuron as a type of sensitivity adjuster. The efferent input adjusts the length of the spindle so that it remains at an optimal length to detect changes within the muscle.
In 2010, I left clinical rehabilitation and performance training. While I love my current job, I do miss the clinical aspect, which is why I seize opportunities to take on random clients with complex issues. I’ve never written about my clients, but this case is so common, yet complex, that I thought my readers might be challenged with similar clients/athletes, or might be experiencing similar issues themselves. Here is a runner’s story that went from marathon training, to painful walking and an inability to run. Her experiences with continued failed treatment and the road we have taken to get her back to training and setting personal records. Continue reading
In July I posted a blog discussing The Overuse of Cryotherapy. The controversy surrounding the topic made it one of the most popular blogs I’ve written. What is surprising to me is that a controversy exists at all. Why, where, and when did this notion of anti-inflammation start? Ice, compression, elevation and NSAIDs are so commonplace that suggesting otherwise is laughable to most. Enter an Athletic Training Room or Physical Therapy Clinic nearly all clients are receiving some type of anti-inflammatory treatment (ice, compression, massage, NSAIDs, biophysical modalities, etc). I evaluated a client the other day and asked what are you doing currently – “Well, I am taking anti-inflammatories and icing.” Why do you want to get rid of inflammation and swelling? I ask this question for both chronic and acute injury!
Last week Twitter was abuzz due to a job posting on the NATA Career Center. Athletic Trainers on Twitter were up in arms over the posting – a full-time, temporary position with a starting salary of $8.00/hr.
Said many ATs:
Somebody needs to call the Head Athletic Trainer! Why? In most cases the Head Athletic Trainer has absolutely no say regarding salary of his or her assistants.
Call the school! Why? The school simply needs a body to serve as a first responder and to cover its butt in case something does go wrong.
The NATA needs to ban such postings! Why? Is the NATA some totalitarian and tyrannical organization designed to hold the hand of its members and dictate what they can and cannot do?
What an insult! An insult, maybe to the vast majority, but not to the several athletic trainers who do apply for the job.
How could this happen? Easy, we let it happen. Continue reading
Have you heard the old adage “if you don’t use it, you lose it”? Does this really happen? If so, to what degree does one “lose it”? I was riding dirt bikes since the age of three, began racing motocross at age six and ‘retired’ –moved from home and went to graduate school – around the age of 21. After 18 years of riding and racing, I know I can still swing my leg over a seat and take off and ride much better than most. But, I could not go as fast as I once could. I would not have the technique nor would I have the strength power or endurance to ride for long. What about my neural impulse and reaction – that would be nonexistent, wouldn’t it? Countless studies have demonstrated the positive correlation between practice and reaction. I haven’t practiced and with my luck, I’d hit a rock and run in to a tree. Continue reading
Vladamir Janda revolutionized human movement and rehabilitation when he described three compensatory movement patterns as a result of pattern overload and static posturing. Since Janda’s introduction we have continued to learn about hypertonic / hypotonic muscles and the delicate interplay they have on integrated functional movement. Static stretching helps correct dysfunctional movement by elongating shortened tissue. Unfortunately, the manner in which many stretches are performed does not target tissue appropriately. Continue reading
How does an ankle sprain lead to chronic knee pain, such as runner’s knee, jumper’s knee, Osteochondral defects, and/or general patellofemoral pain?
Three simple answers: Continue reading
This blog post is long overdue. I have had countless people – friends, family members, athletes, clients – all ask me about shin splints. OK, before the Athletic Trainers, Physicians, PTs and other health care providers jump down my throat. Yes, shin splints is a junk term. I am talking about MTSS. I understand this, but the people you treat know them as MTSS, so relax. What are they? How can I get rid of them? Can they be prevented? Despite being one of the most common athletic injuries, recreational or competitive, shin splints are easily treatable and very preventable. Too often sufferer’s deal with the pain and never fix the problem. My goal with this blog is to provide tips to fix the problem and resolve shin splint pain.
Shin splints, or Medial Tibial Stress Syndrome (MTSS), is a chronic injury typically described as dull-ache on the medial, mid-to-lower-third portion of the lower leg. Pain is common during or after activity. In severe cases pain may last for several hours after activity and occasionally the individual will experience nighttime throbbing in the lower leg.
The pain from MTSS is attributed to irritation of the periosteum – a saran wrap like covering around bone – or a stress reaction to the underlying bone. Repetitive pounding or muscle pulling from these structures precipitates the injury. Popular belief is that shin splints are due to poor shoes, training intensity, and training surfaces. However, a critical review article written by Moen, Tol, et al., published in 2009 Sports Medicine found this was not the case. MTSS is often caused by poor joint movement and muscle imbalance. These movement patterns and muscle imbalances are easily identifiable. The best part is that you can fix these problems at home by following a simple flexibility and strengthening program.
First, let’s see if you have these movement dysfunctions. Observe yourself (in a mirror) walking or doing repeated squats. Do you see one or more of these four things: hips in, knees in, feet flatten, or toes point out? You may have one or all of these patterns; some may be extremely pronounced or could be very subtle. The image here shows a moderate to severe movement. If you observe this, even to the slightest degree, you are at risk for developing shin splints. Overtime, these movement patterns create a muscle imbalance, where some muscles become overactive and some become underactive.
Using the above figure as an example, here are the typical overactive and underactive muscles we would see in a person with shin splints or with these movement patterns.
|Hip Flexors and Tensor Fascia Latae||Gluteal Group (Maximus, Medius)|
|Lateral calf (lateral gastrocnemius / soleus)||Medial Gastrocnemius|
|Groin muscles (anterior adductor complex)||Anterior and Posterior tibialis|
|Biceps Femoris||Medial Hamstrings|
Our goal is simple, turn-off the overactive and turn-on the underactive; simple as that. Below is a basic 3-step program that can help correct this issue, step 1 -Turn-off, step 2 – elongate, and step 3 – turn-on. This program can be done daily and would take no longer than 30 minutes from start to finish. Here is what a basic program would look like.
Step 1: Turn-off the overactive muscles using self-myofascial release
- Hip Flexors
Foam rolling is the best way to do this if you go at it alone. If you have a qualified therapist, manual release of these muscles will do the trick. When foam rolling, roll each muscle for 90 seconds and hold tender areas for 20-30 seconds. A YouTube playlist I created, provides good examples and tips on how to perform these techniques.
Step 2 – Elongate the overactive muscles with static stretching
- Gastrocnemius/Soleus Static Stretch
- TFL/IT Band Stretch
- Kneeling Hip Flexor Static Stretch
- Adductor Static Stretch
Perform 1-2 sets of the stretch per muscle group and hold the stretch for a maximum of 30 seconds. Brent Brookbush, has a good static stretching playlist that demonstrates these exercises.
Step 3 – Turn on the underactive with isolated strengthening
- Posterior Tibialis Strengthening
- Anterior Tibialis Strengthening
- Glute Medius Strengthening (Clams)
- Lateral tube walking
- Glute Maximus Strengthening (Ball Bridge)
The above exercises are just examples. There are many exercises to choose from. The important thing is to target the right muscles. Fix the core, attack the glute medius and glute maximus, and work the tibialis anterior and posterior.
In summary, too often I see individuals with shin pain ceasing activity, buying new shoes, investing hundreds of dollars in custom orthotics, or giving themselves an ice bath. Shin splints do not have to be the end of training. They are easily preventable and curable as long as you fix the problem. Following a simple and structured program to correct of common movement dysfunction patterns can eliminate shin splints and many other lower body injuries like Achilles pain, runner’s knee or hip pain.
Many years ago I got tired of watching my athletes roll in to the athletic training room and slap on ice. These athletes are in a drug-like induced state of ice addiction. Their athletic trainers keep feeding the disease, by recommending cold treatment and doing the easy – here’s ice, shut-up, leave. I felt I was doing a disservice to my athletes and asked myself, “Why are we icing this injury?” I never had an answer that was supported by evidence. So I began my own case study.
I took 9 Division I athletes (6 patellar tendinopathy, 2 bicipital tendinopathy and 1 subacromial impingement) and had the athletes cease all cryotherapy and electrical stimulation.