Injury Prevention Article Archives

Check out all my articles on how to prevent injuries.  Explore the archives below or click the button to subscribe and never miss another post.


Strength Training for Runners

There are still a lot of misconceptions about running and how to best train runners to minimize injuries and enhance performance.

Part of the problem is that there is a low barrier to entry to running.  All you need to do is start running, right? No gym membership, no equipment, heck most people don’t even do anything to prepare themselves for running.  They just decide to start running.

For recreational runners, running also tends to be a fitness choice.  Many people pick a way to get in shape and start exercising, and feel like they need to choose.  Do I want to do strength training or do I want to do cardio work?

Competitive runners also have some misconceptions when it comes to training to enhance their performance.  In the past, many have believed that strength training will bulk you up too much, make you less flexible, and may even slow you down.

There is no doubt that running requires cardiovascular conditioning.  But we can’t ignore how the rest of the body is biomechanically involved.  

Let’s simplify running a little more.

Running is a series of little jumps.  The rear leg has to propel the body forward.  The stride leg has to absorb force.

To minimize your chance of running related injuries and enhance your running performance, you need to understand both of these concepts.  

The key to both of these is strength training.  We can build tissue capacity to handle these forces much more efficiently, especially if we build a specific strength training program for runners with these two concepts in mind.

 

Strength Training for Runners

When it comes to runners, my go-to resource for injury rehab and performance enhancement is Chris Johnson.  Chris has an excellent website and clinic that specializes in runners.  He’s helped me a ton over the years.

Chris has an amazingly comprehensive book right now, Running on Resistance: A Guide to Strength Training for Runners.

We had been talking online recently, and I thought that my readers needed to benefit from Chris’ amazing knowledge on runners.  So we sat down and talked about the book, as well as a bunch of other topics related to strength training in runners:

 

Running on Resistance: A Guide to Strength Training for Runners

If you’re interested in learning more, Chris’s book is an amazing resource for both runners, as well as rehab and fitness professionals that want to work with runners.  It is a detailed guide and program to building capacity, becoming more resilient to injuries, and enhancing running performance.

Chris was nice enough to extend a special 15% off discount just for my readers.  Check out the book below:

 

 

Is Icing an Injury Really Bad for You? What the Science Says

Today’s article is an excellent review of the effects of cryotherapy, or ice, from my good friend Phil Page, PhD, PT, ATC, CSCS, FACSM.  Man, icing an injury sure has taken some heat (see what I did there…) lately on the internet.  There is a HUGE anti-ice movement.  I’m always amazed at how polarizing social media can be, with people screaming their black or white opinion, when in reality much of what we do is in the grey.  I get questions all the time about wether or not icing is good or bad for you, with many people quick to jump to the conclusion that we should not be icing.  Well, let’s find out what the research actually says.  Phil’s the Director of Research & Education with Performance Health, and one of the best at analyzing the research.

 

Is Icing an Injury Really Bad for You?

You’ve probably heard the debate on whether icing is helpful or harmful. You might be strongly on one side or the other, or maybe you aren’t sure which side you’re on because you’ve heard so many different things.

Despite what you might hear from anti-ice gurus that tend to be sensationalized on the Internet, let’s look at the facts and how we got here.

Ice isn’t the bad guy. Yes, we tend to apply ice in some situations that probably doesn’t help and claim we do so for the wrong reasons.  But the bottom line is that there are several benefits to ice, and ice has not been proven to impede the healing process as many claim.

About 30 years ago as a student athletic trainer at LSU, we frequently used ice, following the research of Dr. Ken Knight, who literally wrote the book on cryotherapy. I, as most other athletic trainers, was keenly aware of the mechanism of ice after an acute injury. As a graduate assistant athletic trainer for baseball at Mississippi State, I continued to advocate ice for my pitchers after they threw. Ice was my best friend.

Suddenly, stories came out that icing was bad for pitchers. As a matter of fact, one story back then was that it actually caused bursitis! Knowing a little about pathophysiology, I quickly dismissed that hogwash…  but the gears were in motion against using ice after pitching.

Fast forward to a few years ago. All of a sudden, ice is again demonized, but this time, it’s a vicious attack:

“Icing is wrong.”

“Ice impedes healing.”

“Icing is harmful.”

Say it ain’t so! Wha are we supposed to do?  Those are some bold claims!

The argument against ice tends to center around ice impeding the healing process as an ‘anti-inflammatory.’ Throughout the healing process (injury, inflammation, repair, remodeling), we need each of those stages to occur in order.  As an anti-inflammatory, the question was if ice actually creates an environment that does not allow the tissue to repair itself?  Interestingly, this same argument came out around the same time as people started questioning NSAIDS for the same reason!

Well, one study did get published (Tseng et al. 2013) titled, “Topical Cooling (Icing) Delays Recovery from Eccentric Exercise-Induced Muscle Damage.” The authors found increased signs of muscle damage after applying ice following eccentric exercise compared to a ‘sham’ application (although I’m not sure how you actually can apply ‘sham’ ice).

Bingo. Proof that ice impedes healing!  Right?  Hold on cowboy. That’s not the whole story.

What you didn’t hear about unless you actually read the study was that the authors concluded:

This study does not provide evidence on whether recovery from pitching-induced muscle damage would be slowed down by topical cooling.”

And while the authors found increased biomarkers in the group receiving cold therapy, there was no difference in strength or pain between the groups.  And I won’t even get into the question of adequate power with an n of 11.  You could argue that the study did not have enough subjects to have much clinical relevance.

Yet, ice was under attack again.

In addition, a few review studies of ice after ankle injuries raised more doubt on the practice of “RICE” (Rest, Ice, Compression, Elevation). The conclusion was that the quality of the research was generally poor quality, and the outcomes were inconclusive.

Note the word, “inconclusive” is not the same as “ineffective.”

And many times, effectiveness of icing was measured by the amount of swelling, rather than the actual healing process and return to activity. And while we know that ice doesn’t do much for swelling after the first 48 hours (Cote et al. 1988), modest cooling has been shown to reduce edema in animal studies (Collins 2008, Deal et al. 2002).

Yet, there we were, left to question if icing for recovery or after acute injuries was actually helping or hurting our athletes.  How did we get to this point?

 

The Claims Against Ice are Largely Based on Pseudoscience

The claim that ice is harmful by delaying the healing process is not supported by science. You may have seen bits and pieces of “science” in the false claim, but it’s a play on science that doesn’t give you the full picture or ability to make such a bold statement.  It’s called pseudoscience….statements that appear to be based on the scientific method, but are not.

Icing is not harmful or wrong to use.

You have witnessed a sham. Like the cup-and-ball game. It happens so fast and seems logical, but it’s a mind-trick.  Here are several things to consider.

Confirmation Bias

This is the tendency for us to accept evidence to confirm our own beliefs or theories. If you think ice is bad, you will tend to accept the information that supports your belief.  This makes us feel good because it confirms our prejudice.

False Logic

If inflammation (A) is necessary to get to healing (C), and ice (B) reduces inflammation (A), then ice (B) must reduce healing (C). FALSE. There is no direct evidence that icing reduces the healing process. In contrast, research supports the fact that ice does not impede healing (Vieira Ramos et al. 2016).  Granted, this was a study from an animal model, but who wants to be a human subject to test that theory?

Circumstantial Evidence

Evidence that attempts to prove a fact by connecting a related event or condition to a conclusion, as opposed to direct observation, is considered ‘circumstantial.’ This could be one of the most common ways science is used to incorrectly support claims. The presence of biomarkers in the blood may be an indirect measure of muscle damage, but it does not prove ‘cause-and-effect’. (Remember the DOMS study I referenced above?) Guilt by association is not the same as ‘causation.’ Using surrogate measures to make a definitive conclusion is a slippery slope.

Inconclusive Conclusions

Poor research (or no research) cannot serve as a basis for a conclusion on efficacy, let alone harm. The evidence on applying ice after an acute ankle injury is ‘inconclusive’ based on only a few studies of poor quality (Bleakley et al. 2004; van den Bekerom et al. 2012). There are no studies that applying ice after an ankle injury reduces recovery time (Hubbard et al. 2004). In fact, one study showed that early application of ice (< 36 hours) resulted in significantly faster return to play compared to delayed cryotherapy (Hocutt et al. 1982).

Comparing Apples to Oranges

Equating 2 things that appear similar, but are actually different, is not a fair comparison. Comparing DOMS to the healing process is not an accurate comparison. We know more about soft tissue healing after an injury than we do about the mechanism of DOMS, which is not a true model of an acute injury. Don’t forget, inflammation is not the same thing as swelling and edema!

Selective Science

Unbalanced reporting. Cherry-picking the literature. All signs of pseudoscience. The anti-ice movement has neglected years of research on the mechanism of ice after injury, focusing only on a select few studies that support (but in reality DON’T support) their argument. Dr. Knight explained that ice is not an ‘anti-inflammatory’ per-say (Knight, 1976); rather, it prevents the secondary injury to tissues by dampening the negative physiological effects of widespread inflammation. His position has been supported by other researchers as well (Ho et al. 1994, Merrick et al. 1999). And to top it off, one study quoted against icing (Bleakley et al. 2004) even concluded, “The sooner after injury cryotherapy is initiated, the more beneficial this reduction in metabolism will be.” Hmmm…the anti-ice crowd must have missed that statement.

 

The Benefits of Ice

Ice is not wrong or harmful.  The theory that ice impedes the normal healing response by limiting inflammation is not well documented in the literature. If you have been swayed by this on the internet, I would urge you to try to research this more and scrutinize the literature.  Be careful of what you see on the internet and ALWAYS seek to validate anything yourself.

Ice has plenty of benefits and clinical validation.

Proper application of cryotherapy can reduce secondary injury and reduce edema formation if applied within the first 36 to 48 hours (remember, ice doesn’t reduce swelling after the acute injury phase, and may not play a huge role in inflammation or recovery).  We do know that ice helps reduce pain, spasm, and guarding, allowing more mobility (Barber et al. 1998, Raynor et al. 2005).   More than anything, ice is a convenient and potent pain reliever, so it’s ok to apply ice to ‘chronic’ conditions as a safer pain reliever at any time. In fact, cryotherapy has been shown to decrease the amount of prescription pain medications needed after surgery (Barber et al. 1998, Raynor et al. 2005).

Sure, there are some times that ice is overused or erroneously used fort the wrong reasons, like reducing swelling after 48 hours.  The clinical research may not be conclusive, but there is no direct evidence that ice impedes healing. The argument that ice is ineffective or harmful is based on pseudoscience, and we need to be aware of this tactic.

Just be careful what you read, everyone has a bias.  #StandUp4Ice.

 

Understanding Tommy John Surgery and How to Avoid It

Note from Mike: Today’s post is an excellent article from New York Yankees team physician, Dr. Chris Ahmad, and Frank Alexander, ATC.  We know that Tommy John injuries continue to rise. Chris and Frank have written a new book to help educate your baseball players, parents, and coaches about Tommy John injuries, and more importantly, how to avoid them.

We have an epidemic on our hands in youth baseball.  With nearly half a million participants, baseball is one of the most popular high school sports in the United States.1 Injuries to the throwing arm continue to grow every year and there is no slowing down in sight.

While there are a number of injuries that a baseball player can succumb to, the most well-known are Tommy John injuries, also known as ulnar collateral ligament (UCL) tears. Once considered a career ending injury, Dr. Frank Jobe revolutionized baseball and all of sports medicine in 1974. That summer, he performed the first UCL reconstruction on the most famous recipient – and namesake – of the surgery, Tommy John.  

UCL injuries are the most studied condition in all of orthopedic surgery and its popularity in the media has made it a preeminent sports injury.

It is estimated that 1 in 4 Major League pitchers will need Tommy John Surgery in their career. In 2000, 13 MLB pitchers had UCL reconstructions. Over a decade later, in 2012, that number had increased nearly three-fold to 32 pitchers requiring the season ending surgery.2

Unfortunately, the increasing numbers of players falling victim to UCL injuries translate to the younger levels of baseball as well.

Evidence suggests the trend has impacted adolescent athletes with a 50% increase in UCL reconstructions in high school baseball players aged 15 to 19 years old.3 In New York State alone, the volume of UCL reconstructions increased by 193% over a 10-year period.3  These younger players may feel pressures within the competitive culture in youth baseball. This may lead players to play through pain and more talented players may be told they have to throw more frequently and with greater intensity.

While there are several reasons why there are so many Tommy John injuries, research has described overuse to be the main cause of player injury.

There is a 500% increase in risk for surgery for those players that pitch more than 8 months per year and a 400% increase in risk is observed for those that throw more than 80 pitches per game.3

Not only are younger athletes enduring this big-league problem, their understanding of the injury leads many of them to want the surgery even in the absence of injury.  There are still many myths about Tommy John Surgery.

Many players see their idols in Major League Baseball have surgery and return to the field throwing harder. What the younger athletes don’t see is the painstakingly long hours that the pros put into their rehab. Mike Reinold recently had a podcast episode with several Tommy John patients to describe their experiences.

There is a common belief among players, parents, and coaches that the rehab program post-Tommy John was shorter than 1 year and allowed for a quick return to throwing.4 We are now seeing players at the higher levels of competition returning to sport around 14-16 months and the average at the Major League level is 15 months post-operatively.

The popularity of Tommy John Surgery in addition to the perceived glamor players receive upon their return is what leads the younger players to think surgery is necessary. Research from our office has shown that 51% of high school baseball players believe that they need Tommy John surgery in order to enhance their performance.4  This is in the absence of an injury – meaning, players that are healthy think they need surgery just to get better at the game of baseball.

Players should have surgery for UCL insufficiency (i.e. tear), not to improve their performance. While we want to celebrate the return of our favorite athletes to the playing field, we only hear about the successes and not much about the players that are unable to make it back. The success rates of Tommy John Surgery range between 80 – 90% and even though players make it back to the field, pitchers throw fewer innings post-operatively.2,4 Having surgery places an enormous burden on the player mentally, physically and emotionally.

As the numbers of youth athletics participants continues to rise, it may seem that elbow injuries have become a part of America’s pastime.  Leaders in the field have established guidelines for our younger players in hopes that they will remain injury free and continue a long, healthy career.

 

A Guide for Young Baseball Players

Even with the implementation of these guidelines we continue to see a rise in throwing arm injuries leading us to write our book Understanding Tommy John Surgery and How to avoid it: A Guide for Young Baseball Players.

 

Understanding Tommy John Surgery and How to Avoid It

 

Our vision for Understanding Tommy John Surgery is to help younger players better understand elbow injuries and that it is not okay to play through pain. Some warning signs may include decreased velocity, elbow tightness, and difficulty warming up.  We also discuss a number of different ways for youth baseball players to stay healthy such as keeping a log of the number of innings or pitches thrown, proper warm-ups, and sport diversification.

By allowing our players to understand their elbow and know that playing through pain is not a good idea, we may finally see a reverse in the trend of Little Leaguers being diagnosed with Big League problems.

If you’d like to learn more and join in our efforts you can visit Dr. Ahmad’s website and get your own copy of Understanding Tommy John Surgery and How to avoid it. If you or a family member has a baseball related elbow injury, Dr. Ahmad will happily review the images with you as a free service and is available to all baseball players across the nation. You can learn more at his website!

 

References

 

  1. Saper, MG, Pierpoint, LA, Liu, W., et al. (2018). Epidemiology of shoulder and elbow injuries among United States high school players. American Journal of Sports Medicine, 46(1), 37-43.
  2. Erickson, BJ (2015) The epidemic of Tommy John Surgery: the role of the orthopedic surgeon. American Journal of Orthopedics, 44(1), E36-E37.
  3. Hodgins, JL, Vitale, M, Arons, RR, & Ahmad, CS. (2016). Epidemiology of medial ulnar collateral ligament reconstruction A 10-year study in New York State. American Journal of Sports Medicine, 44(3), 729-734.
  4. Ahmad, CS, Grantham, WJ & Griewe, RM (2012) Public perceptions of Tommy John Surgery, The Physician and Sportsmedicine, 40(2), 64-72.

5 Exercises You Should Perform If You Sit All Day

Do you sit all day? Don’t worry you are not alone.

Sitting throughout the day, and a more sedentary lifestyle in general, has dramatically increased over the last several decades as desk jobs have become more popular and our devices have taken over as our form of entertainment.

The media loves to tell you that “sitting is the new smoking.” This is backwards in my mind, and something I’ve discussed in detail in a past article Sitting isn’t bad for you, not moving is.

In the article, I listed 3 things you should do if you sit all day to stay healthy:

  1. Move, Often
  2. Reverse your posture
  3. Exercise

For those looking for some specific exercise, here are 5 great exercises to perform to combat sitting all day.

 

5 Exercises You Should Perform if You Sit All Day

I’ve been talking about the concept of Reverse Posturing for years. The concept is essentially that we need to reverse the posture that we do the most throughout the day to keep our body balanced and prevent overuse.

Sitting involves a predominantly flexed posture, so doing exercises that promote the posterior chain would be helpful. These will depend on each person, but if I had to pick a basic set of exercises these would be the 5 exercises to combat sitting all day.

 

Thoracic Extension

The first exercise is for mobility of your thoracic spine. This is the portion of your back that becomes the most flexed while sitting all day. This is probably the biggest bang for you buck exercises in my mind:

If you are looking for more drills, you should view one of my past articles for several more great thoracic mobility drills.

 

True Hip Flexor Stretch

The second exercises is another mobility drill, this time for the pelvis. We always perform mobility drills first to maximize range of motion. This exercise is called the true hip flexor stretch, something I termed several years ago after seeing so many people do this stretch poorly.

This exercise will help prevent your hips from getting too tight, as well as put your entire spine in a better position.

Chin Nods

Now that we’ve done a couple of mobility drills, let’s try to reinforce a few movement patterns to reverse your sitting posture and activate a few select muscle groups.
The first is the chin nod, which is great for the neck muscles and forward head posture. Many have heard of the chin tuck exercise, but the chin nod exercise is a little different in my mind.

Shoulder W’s

The next exercise builds off the chin nods, and now combines the chin nod posture with retraction of your shoulders. This will help turn on your posterior rotator cuff and scapular muscles all in one drill.

Glute Bridge

Lastly, we want to focus on the glutes and their ability to extend the hips, and taking some pressure off your low back. This glute bridge exercise, in combination with the above true hip flexor stretch, will be a great combo to help with your overall posture and core control.

How to Integrate These Exercises into Your Day

An easy way to start and keep it simple is to perform each of these 10 times. These should take less than 5 minutes to perform and will make a big impact on how you feel throughout the day.
Many people ask, “how many times a day should I perform these?” Or even, “do I need to do these every day?”

You don’t need to do these every day. Just on the days that you sit… :)

But seriously, remember these are 5 exercises you should do if you sit all day, so doing them at the end of each day to reverse your posture is a great idea. Many people who sit for a really long time like to perform them during the day as well.

As you get comfortable with them, you may find that certain ones help you feel better than others. Feel free to add repetitions to those as needed.

 

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How to Diagnose and Treat Hamstring Strains

The latest Inner Circle webinar recording on How to Diagnose and Treat Hamstring Strains is now available.


How to Diagnose and Treat Hamstring Strains

This month’s Inner Circle webinar is on How to Diagnose and Treat Hamstring Strains. In this presentation, I’m going to overview a simple 3 phase approach to rehabilitating hamstring strains. Hamstring strains can be tough, and have a really high recurrence rate. But luckily there are things you can do to assure we are helping the tissue remodel and accept load again.

This webinar will cover:

  • The anatomy and injury mechanics behind hamstring strains
  • The best way to diagnose and grade hamstring strains
  • A 3 phase rehabilitation progression to get back on the field
  • What to focus on to reduce recurrent strains in the future
  • The postoperative rehabilitation following hamstrings repair

To access this webinar:

How do SLAP Tears Occur: Mechanisms of Injury to the Superior Labrum

SLAP tears of the shoulder can occur for a variety of reasons, from a traumatic fall to wear-and-tear over time, to more specific injuries that we see in overhead athletes like baseball players.

But that’s a common question I here often.

Now that we have discussed the different types and classification of SLAP tears to the superior labrum, I wanted to now talk about how these shoulder injuries occur. There are several injury mechanisms that are speculated to be responsible for creating a SLAP lesion. These mechanisms range from single traumatic events to repetitive microtraumatic injuries.

This article is part of a 4-part series on SLAP Lesions

Traumatic SLAP Injuries

mechanism of slap tearTraumatic events, such as falling on an outstretched arm or bracing oneself during a motor vehicle accident, may result in a SLAP lesion due to compression of the superior joint surfaces superimposed with subluxation of the humeral head. Snyder referred to this as a pinching mechanism of injury. Other traumatic injury mechanisms include direct blows, falling onto the point of the shoulder, and forceful traction injuries of the upper extremity.

To be honest with you, I don’t know if this is actually the underlying cause of the SLAP lesion. I have questioned this theory in the past and don’t know the answer, but part of me at least wonders if these patients already had a certain degree of pathology to their superior labrum and the acute injury led to a MRI and diagnosis of a SLAP tear.

Essentially the MRI may have found an old SLAP tear.

Repetitive Overhead Activities

Repetitive overhead activity, such as throwing a baseball and other overhead sports, is another common mechanism of injury frequently responsible for producing SLAP injuries.

This is the type of SLAP lesion that we most often see in our athletes. In 1985, Dr. Andrews first hypothesized that SLAP pathology in overhead throwing athletes was the result of the high eccentric activity of the biceps brachii during the arm deceleration and follow-through phases of the overhead throw. To determine this, they applied electrical stimulation to the biceps during arthroscopic evaluation and noted that the biceps contraction raised the labrum off of the glenoid rim.

Peel Back SLAP Tear

Burkhart and Morgan have since hypothesized a “peel back” mechanism that produces SLAP lesion in the overhead athlete. They suggest that when the shoulder is placed in a position of abduction and maximal external rotation, the rotation produces a twist at the base of the biceps, transmitting torsional force to the anchor.

This mechanism has received a lot of attention and several studies seem to show its accuracy.

Pradham measured superior labral strain in a cadaveric model during each phase of the throwing motion. They noted that increased superior labral strain occurred during the late-cocking phase of throwing.

Another study from ASMI simulated each of these mechanisms using cadaveric models. Nine pairs of cadaveric shoulders were loaded to biceps anchor complex failure in either a position of simulated in-line loading (similar to the deceleration phase of throwing) or simulated peel back mechanism (similar to the cocking phase of overhead throwing). Results showed that 7 of 8 of the in-line loading group failed in the midsubstance of the biceps tendon with 1 of 8 fracturing at the supraglenoid tubercle. However, all 8 of the simulated peel back group failures resulted in a type II SLAP lesion. The ultimate strength of the biceps anchor was significantly different when the 2 loading techniques were compared. The biceps anchor demonstrated significantly higher ultimate strength with the in-line loading (508 N) as opposed to the ultimate strength seen during the peel back loading mechanism (202 N).

You can see photos of the study below.  The first photo is a normal glenoid with the labrum and attaching long head of the biceps.  The second photo is the simulation of the traction and eccentric biceps contraction.  The final photo is simulation of the peel-back lesion.

In theory, SLAP lesions most likely occur in overhead athletes from a combination of these 2 previously described forces. The eccentric biceps activity during deceleration may serve to weaken the biceps-labrum complex, while the torsional peel back force may result in the posterosuperior detachment of the labral anchor.

shoulder seminarLearn Exactly How I Evaluate and Treat the Shoulder

If you want to learn even more about the shoulder, my online course will teach you exactly how I evaluate and treat the shoulder.  It is packed with tons of educational content that will help you master the shoulder, including detailed information on the clinical examination and treatment of SLAP tears.

5 Ways to Decrease the Risk for an ACL Injury

Injuries to the Anterior Cruciate Ligament (ACL) are some of the most common injuries in the active population. As incidence of other injuries have decreased, injuries involving the ACL have rose astronomically over the years.  There have been numerous studies done looking at what causes the ACL to tear. More specifically, female athletes are 4-5x more likely to tear their ACL as compared to their male counterparts.

Like with any injury, it cannot be blamed on one thing. Injuries are multi-factorial as well as non-preventable.  Injuries will always happen.  The only thing that we can do is to decrease the frequency or incidence of them. Luckily, as we continue to learn more about the mechanism of injury, we have developed some strategies to reduce your chance of ACL injuries.

 

5 Ways to Decrease the Risk for an ACL Injury

Here are 5 things to focus on when designing programs to reduce ACL injuries.

 

Optimize Mobility

If you look at the human body, there are many joints. Some of those joints require mobility and some of those joints require stability. Depending on which plane of motion you are in, mobility or stability is usually more imperative than the other.

When it comes to mobility, there are certain joints in the body that we need to have optimal mobility in order to decrease the risk for an injury to the ACL. The two joints that come to mind are the talocrural joint of the ankle, and the femoroacetabular joint of the hip.

For the ankle, specifically dorsiflexion range of motion is imperative to decrease strain at the knee. If the ankle doesn’t have the ability to dorsiflex and absorb force during a land from a jump or cutting maneuver, the mid foot or knee are the two joints that will have to have increased mobility to accommodate the athletic endeavor.

 

Ankle Mobility

To assess for adequate ankle mobility, use the Knee to Wall Ankle Mobility Test.

Key Points:

  • Place your foot 4 inches away.
  • Keeping your foot flat on the floor, attempt to touch your knee to the wall.
  • Don’t allow for valgus or varus collapse.

If you can reach the wall from 4 inches, then you have sufficient ankle mobility to run, squat, and perform without playing increased stress through the knee due to poor ankle mobility.

The other joint in the body that needs to have optimal mobility is the hip.  The motions at the hip that need adequate mobility are hip flexion, hip extension, hip abduction, hip internal and external rotation.

Now, you may be saying, “Wow, that’s a lot of areas that need mobility.”  Well, let’s break it down!

 

Hip Flexion

5 ways to reduce ACL injuriesAnecdotally, I like to see clients present with full hip flexion. If there is decreased mobility into hip flexion, this can send a signal to the brain to alter movement and muscle firing patterns and in turn, can affect how someone lands or moves.

A quick and easy test is to test passive hip flexion range of motion.  

This involves bringing your knee towards your chest. Ideally, your thigh should reach the inferior aspect of your rib cage. Now, everyone is made differently and depending upon what sport you play, hip structure can vary from person to person.

If you cannot reach your thigh to your rib cage, slightly abduct your thigh and see if you can go further. If you can, then your hips are structured a little differently.

 

Hip Extension

Key Points:

  • Thigh should be able to reach parallel to ground.
  • Knee should be at 90 degrees to thigh.
  • Thigh should drop straight down and not flare out towards side of body.

Hip extension mobility is necessary to be able to activate the gluteus maximus and hamstrings in order to decrease incidence of a valgus collapse. If adequate hip extension mobility is not present, then muscular compensation will occur and in turn, possible injury.

 

Hip Internal Rotation (IR)

Even though hip internal rotation is part of the combination of movements that contribute to an ACL injury, not having the requisite mobility is a risk factor. If the body doesn’t have certain available ranges of motion, then the brain and central nervous system are not able to prevent going into those said ranges of motion. Therefore, if someone doesn’t have adequate hip internal rotation, then the body has no way to prevent that motion from occurring.

VandenBerg et al. in Arthroscopy: The Journal of Arthroscopic & Related Surgery that “risk of ACL injury is associated with restricted hip IR, and as hip IR increases, the odds of having an ACL tear decreases.”

 

Hip External Rotation

Hip external rotation is important because avoidance of a knee valgus position is necessary to avoid injury to the ACL. Having adequate hip external range of motion will allow the athlete to be able to get into an athletic position to avoid that valgus position.

 

Learn How to Land

You watch any NFL or NBA game and guys are jumping to catch a ball to to tap in a rebound for 2 points. Most injuries to the ACL don’t occur on the jumping portion as it does on the landing portion.

When athletes have to land from a jump, the body has to absorb 7-10x their body-weight in forces from the ground.  If joints aren’t in an ideal position to absorb and adapt to stress, injuries can happen.

landing mechanics ACL injury

Photo credit

Therefore, we need to assess athletes in their landing patterns and mechanics to make sure their body is resilient and capable to land properly.

 

Step Down Test

 

The Step Down Test is a simple way to determine an athlete’s predisposition to absorbing eccentric stress. Ideally, we like to see the pelvis, hip, knee, and ankle remain in a line during descent.

 

If someone steps down and the femur internally rotates and the knee goes into valgus collapse,  this is something that needs to be rectified.

If you want to use a more quantitative analysis of landing mechanics and skill as compared to the contralateral limb, then here are 3 tests that can help with that.

 

Single Leg Hop for Distance

Key Points:

  • Instruct the athlete to jump as far as then can and land on 1 leg.
  • They must stick the landing without hopping around or using their leg/arm for balance.
  • Perform 2 trials.  Measure each jump, take the average of the 2 trials, then repeat on the opposite leg.

 

Triple Hop for Distance

Key Points:

  • Instruct the athlete to jump as far as they can, land on 1 leg, and continue for 2 more hops, sticking the 3rd landing
  • They must stick the landing without hopping around or using their leg/arm for balance.
  • Perform 2 trials.  Measure each jump, take the average, then repeat on the opposite leg.

 

Crossover Hop for Distance

Key Points:

  • Instruct the athlete to jump as far as they can, land on 1 leg, and continue for 2 more hops, sticking the 3rd landing while crossing over a tape line on the floor with each jump.
  • They must stick the landing without hopping around or using their leg/arm for balance.
  • Perform 2 trials.  Measure each jump, find the average, then repeat on the opposite leg.

Now that you have the average for all 3 jumps, we need to determine if the difference between the two limbs is significant. According to Adams in the Journal of Orthopaedic and Sports Physical Therapy, limb symmetry indexes of 90% have previously been suggested as the milestone for determining normal limb symmetry in quadriceps strength and functional testing.

According to Phil Plisky, one of the developers of the Y-Balance Test, he advocates that the athlete’s reconstructed lower extremity be within 95% on the non-involved leg.

To determine if distances hopped are significant, the involved limb must be within 90-95% of the non-involved side. If it is less than 90%, then that athlete is at risk for future knee injury.

Using a regimen consisting of single leg plyometrics in the sagittal, frontal, and transverse planes as well as single leg exercises that focus on power development can help to improve any major deficits.

 

Achieve Symmetry

If an athlete presents with a gross asymmetry, their risk for injury can increase 3-17x. Besides using the Hop Tests, one way to assess gross asymmetry is also using the Y-Balance Test.

The Y-Balance Test consists of 3 lower and upper body movements. For the sake of this post, we will be focusing on the lower body. The movements consist of:

y balance test ACL injuries

Photo credit

If there is greater than a 4 cm difference right vs left on the anterior reach (1st picture), this is considered a risk factor for a lower extremity injury.

Smith, Chimera, and Warren found in Medicine and Science in Sports & Exercise that “ANT (anterior)  asymmetry >4 cm was associated with increased risk of noncontact injury.”

If there is greater than a 6 cm difference right vs left on the posteromedial or posterolateral reaches, pictures 2 and 3, then this is considered a risk factor for a lower extremity injury.

Asymmetry is a normal thing.  Everyone from elite level athletes to the average joe has natural asymmetries right vs left. Some asymmetries may not change and some asymmetries may make someone the elite level athlete that they are. Having a relative asymmetry right vs left is ok, but having a gross asymmetry is not.

 

Enhance Core Stability

The core musculature is responsible for providing a stable base for the pelvis, hips, knees, ankles, etc. to function off of in life and in sport. If a stable base is not provided, then it can create instability and injury further down or up the kinetic chain.

Decreased core stability can cause:

  • Pelvic Drop
  • Femoral Internal Rotation
  • Knee Valgus
  • Tibial External Rotation
  • Subtalar Excessive Pronation

All these movements are associated with injuries of the ACL. By stabilizing proximally and providing a stable base for all of the aforementioned areas to work off of, this can decrease the risk for injury.

In order to test for core stability, the Trunk Stability Push-Up (TSPU) by Functional Movement is a good test.

This is a great test to determine if someone can maintain a neutral spine while performing a push-up, but also to determine if they have a base level of core stability to maintain a certain trunk position during life/sport.

If someone cannot maintain a specific trunk position, this doesn’t mean that they have a “weak core.” or weak upper extremities. It means that the athlete doesn’t have the capability to stabilize their core proximally in order to exude force distally.

 

Learn How to Decelerate

Most athletes are fast or at least quick on their feet. The great athletes can speed up and slow down better than anyone. One common risk factor we see with ACL injuries is the inability or subpar ability to be able to decelerate.

What this means is that if someone is going to stop or change direction, they need to have the necessary skills to control their body in space when going from accelerating, to decelerating, and then back to accelerating again.

All fast cars are fast! All really fast cars have great brakes!

In order to assess an athlete’s ability to decelerate, observe how the do with change of direction drills.  For example, movements such as:

 

Sprint/Backpedal w/ Redirection

Lateral Shuffles w/ Redirection

Sprint with 45 Degree Cut

Sprint with 90 Degree Cut

Backpedal, Stop, to 90 Degree Sprint

Backpedal, Stop, to 45 Degree Sprint

All of these various movements test an athlete’s ability to accelerate, decelerate and change directions in all planes of movement. A coach, personal trainer, or physical therapist should be present to provide the athlete with the redirection component. This makes it more random and unpredictable to make sure the athlete can react and move appropriately.

While observing these various change of direction movements, observe the mechanics of the pelvis and lower extremity.

Does the pelvis and hip/knee stay in a relative stable and neutral position when decelerating and stopping?

Does the pelvis and hip/knee go into a valgus collapse during decelerating, stopping, and accelerating phases of movement? Compare these right versus left lower extremities.

If you are having trouble observing these things with the naked eye, film it!  There are apps such as DartFish or Hudl that you can download to film athletes and then you can watch it in slow motion to observe any differences side to side.

If differences are seen in right and left comparison, then work on change of direction drills. When first starting off, start the athlete at ½ or ¼ speed so that they can work on their deceleration, stopping, and accelerating mechanics.

We don’t necessarily want to bombard the athlete with too much information about biomechanics of the lower extremity, but having a basic discussion with them and showing them how they currently move and how you would want them to move safely and more efficiently is ideal.

Then once, then can master ¼ or ½ speed, then increase the speed of the drills until you are working at full speed on both sides. There are a multitude of drills out there to work on acceleration, deceleration, stopping, and change of direction. Make sure start with the sagittal plane, and then progress into the frontal and transverse planes.  

If you can’t master the sagittal plane, then the frontal and transverse planes will be much more challenging.

Assessing mobility, landing mechanics, relative lower extremity symmetry, core stability, and acceleration/deceleration can all help to improve an athlete’s performance as well as decrease their risk for an ACL injury.

 

About the Author

Andrew Millett is a Boston-based physical therapist in the field of orthopedic and sports medicine physical therapy.  He helps to bridge the gap between physical therapy and strength and conditioning.  Visit his website at AndrewMillettPT.com.

 

 

 

A Simple Approach to Running Analysis for Clinicians

This week’s post is an amazing article by my friend Chris Johnson on what he looks for during a running analysis.  Chris is my go-to resource for running related injuries and rehabilitation.  He’s also recently developed an app on the iTunes app store to help runners, which I have reviewed and found to be really impressive.  Check it out at the end of this article!

 

A Simple Approach to Running Analysis For Clinicians

a simple approach to running analysis for cliniciansThe ultimate special test for runners is RUNNING.

For some odd reason, when runners seek medical consultation, clinicians routinely neglect watching them run during the rehab process. While it may not always be appropriate to take an injured runner through a formal running analysis at the time of presentation, at some point it’s imperative to take the time to watch them run. Only then will you gain a more complete understanding of perhaps what landed them in your hands in the first place.

A great deal of research has emerged over the past several years specifically looking at various characteristics of the running gait and their associated implications. A few prime examples include but are not limited to the following:

  •      Footstrike
  •      Step rate
  •      Hip adduction
  •      Loading rates
  •      Speed

By taking the time to understand the running gait along with ways to shift loads in the lower extremity, clinicians will ultimately be in a better position to help runners return to consistent training in a timely manner through manipulating physical loads on the ecosystem.

While this may seem daunting to those new at running analysis, it can actually be quite simple.  The purpose of this post is to provide clinicians with a simple framework to approach conducting a running analysis using what I call “The Four S’s of Running Analysis.”  These are:

  •      Sound
  •      Strike
  •      Step rate
  •      Speed

While it’s important to appreciate that overground and treadmill running are different animals, approaching every running assessment in a systematic manner is important. Clinicians are encouraged to use the resources at their disposal while understanding their relevance and limitations. By developing proficiency in performing a running gait analysis, clinicians will ultimately refine their clinical decision making and improve their outcomes in terms of restoring one’s float phase.

 

Sound

Before you even watch someone run, close your eyes and listen to the sound of their running gait. As clinicians, there is a great deal of information that can be ascertained by simply listening to one run.

  •      Does the runner land quiet, or is does it sound like they are going to put a hole through the ground or treadmill belt?
  •      Do their feet sound similar or is there a strike asymmetry?
  •      Does the sound of their footstrike change as a function of being shod versus unshod?
  •      Does the sound change as a function of different shoe types?

One of the simplest cues to consider in the event that someone is “overstriking” is to simply instruct the runner to “quiet your feet down.” This may be particularly relevant if the goal is to reduce the vertical ground reaction force (vGRF).

It’s important to appreciate that when one does go to quiet down their feet, that they tend to increase the ankle and knee joint excursions. On the other hand, if landing sound increases, so does the vGRF secondary to decreasing ankle joint excursion while increasing the hip joint excursion (Wernli et al. 2016).

It has been the author’s experience that under a shod condition that a rearfoot strike lends itself to reducing the sound of impact whereas when a runner is barefoot that a forefoot strike serves to quiet down the sound of impact through using the triceps surae to dampen the vertical rate of loading (VRL).

 

Strike

Let’s not complicate things! Does the runner land with a noticeable heel strike or forefoot strike, or do they exhibit a midfoot, or “flat-footed” contact? Is their strike symmetrical?

Also, the point in the race or training session we are discussing matters because one’s strike pattern tends to change over the course of the run, especially during competition (Larson et al 2011).

Over the past several years, there was a considerable buzz around forefoot striking as a means to address common running related injuries. This was due in large part to the book “Born to Run,” in conjunction with Daniel Lieberman’s classic manuscript that appeared in Nature (Lieberman et al 2010) coupled with a craze by the mass media.  It should be mentioned that coaches have long used barefoot training as means to incorporate variability into a runner’s program.

Training runners to incorporate a forefoot strike into their training may prove effective some, such as those with tibial stress syndromes, anterior compartment syndrome, and anterior knee pain.  Caution should be exercised in the context of a past medical history remarkable for injuries involving the calf muscle complex, plantar tissues of the foot, and/or metatarsals as it will bias the load to these regions.

On the other hand, if a runner is dealing with an Achilles tendinopathy or recovering from a calf muscle strain, a heel or rearfoot striking strategy would perhaps be indicated as research has shown that such a strategy reduces Achilles tendon force, strain, and strain rate relative to a FFS pattern (Lyght et al. 2016).

In my opinion, one strike pattern is not necessarily superior to others, but rather, that every strike pattern has unique characteristics and implications (Almeida et al 2015) and serves a purpose pending the context and intent.

By taking the time to understand the implications of each strike pattern, clinicians will be better able to understand the potential changes to consider making as a means to shift load to different regions of the lower extremity. As with any change, however, clinicians must be mindful that it should take place in a slow and gradual manner.

Finally, never take a runner’s word if they tell you that they utilize a certain strike pattern as research has shown that a runner’s subjective report of their strike is not necessarily accurate (Bade et al. 2016).

 

Step Rate

Running is largely about rhythm and timing.

It’s therefore no surprise that over the past several years, a considerable amount of research has focused on step rate or what’s more commonly known as cadence as a simple and practical means to address common running injuries.

The idea is that by increasing the number of steps while keeping running velocity constant, a runner can effectively reduce the magnitude of each individual loading cycle despite increasing the total number of loading cycles for a given training session. This ultimately occurs through a reduction in one’s stride length as when step rate and stride length are manipulated independently, the benefits only occur with a reduction in stride length.

runcadence appBecause I think this is so important, I actually developed a cadence app, RunCadence, which is specifically designed to help runners and clinicians apply cadence to rehab and training for runners through the use of accelerometry coupled with a metronome.

Research has shown that increasing one’s step rate by as a little as five percent above preferred while keeping velocity constant can reduce shock absorption at the level of the knee by upwards of 20 percent. Additionally, increasing step rate by 10 percent above preferred significantly reduces peak hip adduction angle as well as peak hip adduction and internal rotation moments (Heiderscheit et al. 2011).

More recently, a study showed that irrespective of whether one utilizes a rearfoot or forefoot strike pattern that increasing one’s cadence by five percent results in lower peak Achilles stress and strain.

Decreasing one’s stride length through step rate manipulation has also been shown to lead to a wider step width with an accompanying decrease in contralateral pelvic drop (CPD), peak hip adduction, peak ankle eversion, as well as peak ITB strain and strain rate (Boyer & Derrick 2015).

Lastly, clinicians should also bear in mind that increasing one’s step rate greater than 10% above preferred while keeping running velocity constant tends to occur at a greater metabolic cost so as they say, “the juice ain’t worth the squeeze.” So at day’s end, remember that the sweet spot is between 5-10% when it comes to increasing cadence based on the current body of literature.

 

Speed

Anytime one discusses running, it’s important that we account for the amount of ground covered in a given time. This is referred to as running velocity, which is the quotient of distance and time.

The typical units that we go by in the United States are min/mile or miles/hour (mph), though most of the world relies on the metric system (m/s or km/hr). So make sure you have a converter bookmarked on your web browser.

Running is typically classified into one of five categories based on speed (Novachek 1998):

  1. Jogging = 2m/s or 4.5mph
  2. Slow running = 3.5m/s or 7.8mph
  3. Medium running = 5m/s or 11mph
  4. Fast running = 7m/s or 15mph
  5. Sprinting = 8m/s or 17.9mph

Additionally, to run faster, a runner must push on the ground more forcefully, more frequently, or a combination thereof (Schache et al 2014).

At speeds < 7m/s the ankle plantarflexors reign supreme as they contribute most significantly to vertical support surfaces and increases in stride length (Dorn et al 2012). At faster speeds, however, the energy sources tend to shift proximal as a means to increase stride frequency in order to increase speed.

The reality is that most runners seeking our services will fall under the category of joggers and slow runners unless one works with speed based running athletes and short course racers.

Once a runner has reached a point in their rehab where they are a candidate to undergo a running analysis, the question naturally becomes, “what speed should we select?” This question is best answered by primarily considering the runner’s pre-injury status along with the severity, region, type of injury, and agreed upon goals.

It’s also essential to clearly identify the runner’s typical training and race intensities to better understand the entry point to having them run as well as the various speeds worth taking them through as part of the analysis.

It should also be mentioned that a thorough running analysis may require a couple sessions to work them up to faster velocities to ensure tolerance to progressive loading. Unfortunately, a common pitfall in the clinic is reluctance, or failure to have runners work up to faster speeds. This invariably leads to a myopic view of one’s running while engendering the potential for hasty clinical reasoning as we transition runners back to training.

In retrospect, running is an activity that has relatively predictable performance demands. By taking the time to develop proficiency in conducting a simple running analysis while applying the research as it relates to shifting loads in the lower extremity, clinicians will be better positioned to help runners return to consistent and healthy training and beyond.

 

Download the RunCadence App

running_cadence_appRunCadence was developed by two physical therapists to help the running community apply step rate to running via real time step rate notification and metronome.
Start using RunCadence to get more in tune with your running. While no shortcuts or “hacks” to running exist, gait retraining using cadence is the next best thing.  Click below to download:

 

 

About the Author
chris_johnson_headshot

Chris Johnson, PT, is the owner of Zeren PT and Performance in Seattle, WA.  In addition to being a highly skilled physical therapist and performance enhancement specialist for runners, Chris is also certified triathlon coach (ITCA), three-time All-American triathlete, two-time Kona Qualifier, and is currently ranked 16th (AG) in the country for long course racing.