In 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
In 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
By now, some, if not most, have read the article of the 6-year-old girl who became the youngest ever to complete a half-marathon. Not only did she become the youngest ever, she finished 5th out of 10 in a group of competitors aged 14 and under – she was the only competitor under 12 years old. Race announcer said “she seemed to be barely even breathing hard at the finish line.” So the question being asked – is this safe and appropriate? The question I ask: is this a real concern or more of an excuse? 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
I have written about knee injuries so much. Every day we are bombarded with research that quite frankly, it gets boring. The problem is with approximately a quarter-million ACL injuries per year, it is safe to say the injury is rampant. The devastating nature and commonality of the injury has provided loads of information on prevention, rehabilitation and mechanisms of injury. I am not going to regurgitate them all, but do want to share some recently published articles that sports medicine experts should read.
Article 1: Negahban, Et al. A systematic review of postural control during single-leg stance in patients with untreated anterior cruciate ligament injury. Knee Surgery Sports Traumatology and Arthroscopy, May, 2013.
I love systematic lit reviews and this SLR aimed to determine postural control on those with ACL injuries. We have many internal systems and senses that help us balance. Beyond the use of our eyes and ears to sense balance, tiny mechanoreceptors and proprioceptors exist in our tissue that sense abnormal movement. This study found that when the eyes are closed individuals with ACL injuries had increased postural sway and loss of balance. This indicates that the injury and inflammation following injury inhibits our body’s internal mechanism to sense balance. When rehabilitating, be sure to emphasize proprioception exercises.
Article 2: Thomas, Abbey, et al. Lower Extremity Muscle Strength After Anterior Cruciate Ligament Injury and Reconstruction. Journal of Athletic Training published online first, 2013.
Despite advances in rehabilitation and the numerous studies published on ACL rehabilitation protocols, we appear to be failing. This study shows that at 6 months Status Post ACL reconstruction that global weakness still exists. When comparing strength output from injured vs. uninjured legs it appears the knee-extensors (quads) and knee flexors (hamstrings) are weaker at 6 months when compared to the contralateral side. Conversely hip and ankle strength was not significantly different at 6 months. The timeline to return a player back to competition and activity is 6 months following activity and/or 95% strength of the uninjured side. This study indicates 6 months might be too early. Also, we may need to adjust our strengthening protocols to further stress knee flexion / extension strength.
Article 3 – Bell, DR, Clark, MA, Padua, DA, et al., Two- and 3-Dimensional Knee Valgus Are Reduced After an Exercise Intervention in Young Adults With Demonstrable Valgus During Squatting. Journal of Athletic Training published online first, 2013.
Darin Padua and the UNC Department of Exercise and Sport Science has done a lot of work on knee displacement and correlating the findings with ankle hypomobility and hip underactivity. This particular model used the NASM Corrective Exercise Model as the intervention procedure. This method systematically turns off hyperactive tissue and activates hypotonic tissues. The data revealed that following intervention of the ankle and hip medial knee displacement was significantly reduced. This information is important as several studies have shown medial knee displacement to be a primary cause of ACL injuries and chronic knee pain.
Article 4: Ericksen, et, al. Different Modes of Feedback and Peak Vertical Ground Reaction Force During Jump Landing: A Systematic Review. Journal of Athletic Training published online first, 2013.
The inability of the body to absorb and control joint movement during high levels of ground reaction forces has been shown to increase risk of ACL injury as well as other chronic knee conditions. This study evaluated the effect of expert provided and self-analysis feedback reduced peak ground reaction forces. This is not a paramount study but does shows the effectiveness of verbal queuing and observation to correct suboptimal neuromuscular control, specifically during landing and absorption of ground reaction forces through the kinetic chain. Rehab practitioners should incorporate feedback to teach clients appropriate muscle control during ACL rehabilitation.
I would like to say thank you to Darin Padua, PhD, ATC for keeping me abreast with current data. Darin is a leader in sports medicine research and specifically has many published papers on ACL injuries. Darin manages his blog site and also shares info on his twitter account. If you are a health and wellness professional seeking important information rehabilitation and prevention of injury, I recommend you give Darin a follow.
Complete Reference: Hubbard TJ, Hertel J. Anterior Positional Fault of the Fibula after Sub-acute lateral Ankle Sprains. Manual Therapy. 2008; 13: 63-67.
Ankle sprains are the most common sports related injury. Unfortunately rehabilitation can be problematic and recurrent injury is possible. A significant side effect of an ankle sprain is decreased ankle dorsiflexion. Research has linked limited ankle dorsiflexion to recurrent ankle sprains, chronic knee injury, ACL tears, increased knee frontal plane movement and excessive femoral rotation. When implementing a recovery program for ankle sprains it would be conducive to perform distal fibular posterior mobilizations to regain lost ankle dorsiflexion.
Recent studies suggest a positional fault of the distal fibula on chronically injured ankles. Studies have not been done to evaluate fibular translation during sub-acute lateral ankle sprains. Additionally studies have not examined the relationship of ankle inflammation and fibular positional fault. Positional fault of the fibula can increase pain, and decrease talocrural dorsiflexion and sub talar range of motion. The purpose of this study is to examine fibular positional fault during sub-acute lateral ankle sprains and correlate positional fault with ankle swelling.
- 22 subjects (10 male, 12 female) recreationally active subjects.
- 11 of 22 subjects (5 male, 6 female) with sub-acute lateral ankle sprains
- 11 of 22 subjects (5 male, 6 female) with no history of previous ankle injury
- Fibula displacement measured with fluoroscope in relation to the tibia
- Figure 8 tape measure method to evaluate swelling.
- Mini 6600 Fluoroscope with a digital mobile C-Arm
- Lateral fluoroscopic images taken with on both legs of the lateral ankle sprain (LAS) group and the control group. Bolsters were added and a fluid inclinometer was utilized to ensure proper positioning.
- Figure 8 measurement following Tatro-Adams, et al, 1995 to evaluate swelling. This was performed on both ankles of the LAS and control group.
- Wilcoxon signed rank test was used to evaluate side-to-side differences within both LAS and control groups
- Mann-Whitney tests to evaluate injured ankle of LAS group and same ankle of control group.
- Mann-Whitney tests to evaluate uninjured ankle of LAS group and same ankle of the control group.
- Pearson product moment calculated side-to-side difference in swelling and the corresponding fibular displacement
- Wilcoxon signed rank test:
- Significant differences within the ankles of the sub-acute LAS group (p=.008).
- No significant difference within ankles of the healthy group (p=.563).
- Mann-Whitney Test:
- Significant difference between injured ankle and matched ankle of control group (p=.045)
- No significant difference between uninjured ankle of LAS group and matched ankle of control group (p=.438)
- Pearson Product moment:
- Significant positive correlation of side to side differences in fibular position and swelling (r = 0.793, p = .004)
- 63% of variance in the fibular position difference was explained by variance in ankle girth measurement.
- Unknown if an altered fibular position existed prior to the injury.
- Study does not indicate any literature review regarding possible translation of the tibia following ankle injury.
- Study did not indicate whether subjects in the LAS group were excluded if they had previous injury on contralateral ankle.
Statistically significant outcomes indicate the fibula takes on an anterior positional fault in sub-acute LAS. Effect sizes were .91 within the sub-acute LAS group and 1.15 between sub-acute involved ankle and control group. These indicate clinically meaningful effects. In addition, the greater the swelling, as indicated by ankle girth measurement, the greater the anterior positional fault of the fibula. Previous studies have been done on this topic. Recent studies indicate posterior or no translation of the fibula, however these studies measured fibular movement in relation to the talus. Mulligan, 1995 showed the talus also translates anteriorly following inversion ankle sprain, which can explain the findings of those recent studies.