Injury Treatment Article Archives

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5 Keys to Returning to Sport After a Knee Surgery

The latest Inner Circle webinar recording on 5 Keys to Returning to Sport After a Knee Surgery is now available.

5 Keys to Returning to Sport After a Knee Surgery

This month’s Inner Circle webinar is on 5 Keys to Returning to Sport After a Knee Surgery. In this presentation, I’m going to review some of the statistics regarding return to play rates and discuss some of the clinical implications. Based on this, we’ll review the 5 keys that I think you need to follow to maximize your outcomes and return to sports, while minimizing your chance of reinjury.

This is an updated version of a past presentation on the keys to ACL rehabilitation, but with some newer research and some broader implications that just ACL. I wanted to provide some updated concepts. The ACL talk still has more specific information, so be sure to check that out too

This webinar series will cover:

  • What the latest research is showing about return to play statistics follow knee surgery
  • The two keys you should focus on during the first couple of weeks following any knee surgery
  • How to structure more advanced strengthening into your rehabilitation programs
  • How blood flow restriction training fits into the postoperative rehabilitation process

To access this webinar:

Does Subacromial Decompression Surgery Really Do Anything?

Subacromial decompression surgery is a very common procedure performed for people with shoulder pain.  The procedure is often recommended for people with “shoulder impingement” and was originally theorized to open up the subacromial space and help reduce biomechanical impingement.  

But recent research has challenged the effectiveness of the procedure, and even the diagnosis of “subacromial impingement” itself.

Subacromial Decompression Surgery for Adults with Shoulder Pain: A Systematic Review with Meta-Analysis

A recent article in the British Journal of Sports Medicine reviewed the results of 9 clinical trials in over 1000 patients with shoulder pain.  The authors includes studies that compared subacromial decompression surgery with placebo surgery and exercise therapy.

The study noted that subacromial decompression surgery provided no important benefit compared with placebo surgery or exercise therapy. 

In particular, they found that surgery did not provide any additional benefit for pain, function, and quality of life at the 6- and 12-month mark after surgery.

Pain-Time diagram

Function-Time Diagram

As you can see, there does not appear to be a significant benefit in undergoing subacromial decompression surgery for shoulder pain or function.

What’s All This Mean?

Based on the results of several studies recently, it sure looks like we’re going to be seeing less subacromial decompression surgeries in the future.

It seems like the benefit of undergoing surgery may be related to the postoperative rehabilitation and application of graded exercise postoperatively.

This is another one of those surgical procedures that seems like it was missing the boat anyway.

Thinking purely biomechanically, rather than addressing the underlying concern that may be causing “impingement,” such as stiffness or loss of dynamic stability, we simply just make more space?  

Seems overly simplistic, right?

We probably haven’t address the underlying cause.

But based on all this, perhaps we shouldn’t even be using the term “impingement” anyway.

From a non-biomechanical perspective, I’m not even sure we truly understand the etiology of shoulder pain at times and always seem to rush towards a biomechanical “impingement” approach.  There could be numerous reasons why graded exercise can help reduce shoulder pain other than purely biomechanical factors.

But let’s not forget one main point here from this study.  At 5 years down the road, these patients still had shoulder pain between a 1.5 and 3 out of 10 on a visual analog scale.  

So advising people to ignore the biomechanics and simply work through some pain may not be an ideal approach as well.  

I’d hate to see us go down that road.

These patients had shoulder pain for greater than 3 months to be included in this study.  It’s difficult to quantify the degree of rotator cuff pathology present in these people, how this impacted their shoulder function, and what their long term prognosis will be going forward.  There is still underlying inflammation of the rotator cuff.

Subacromial impingement

Image from Wikipedia

So What Should We Do?

As research like this continues to be published, we’re probably going to be seeing less of these procedures.

Maximizing the function of the shoulder is going to become even more important, regardless of whether or not something is causing “impingement.”  

I’ve had a lot of success with people by keeping it simple.  Rather than worry about the exact specifics of the pain, just simply focus on normalizing motion, increasing strength of the rotator cuff and scapular muscles, enhancing dynamic stability, and then gradually building tissue capacity through loading.

This is a great example of when focusing on the functional deficits is more impactful than the structural diagnosis.  

Optimize the person, don’t just treat the pain.

Do You Want to Learn More About Optimizing Movement and Enhancing Performance? 

I’m really excited to be launching my brand new course for rehabilitation and fitness professionals looking to help people restore, optimize, and enhance performance.   It’s my Introduction to Performance Therapy Training course.

And you know what the best part is???

It’s absolutely FREE!

Check out the information and video below, and click the link below to enroll today!

Introduction to Performance Therapy and Training

If you’re anything like me, I’m sure you’d love to work with more highly motivated people, and even athletes, that want to focus on improving their performance.

But I remember not really feeling prepared for this or knowing how to get started, I really felt overwhelmed. We all learned the basics, but no one really teaches you how to optimize movement and enhance performance.

Over these years, I’ve learned a ton. Good and bad! But everything I have learned has shaped what I do, and it took some time and experience to realize this.

There so much info out there, but people tell me all the time they’re still confused and that they feel like they just start treatments and training programs and aren’t even confident that they choosing the right ones!

Check out this video for more of what I mean:

Enroll in My Course for FREE

I want to help.  When we started our facility at Champion PT and Performance, one of our biggest goals was to develop a simple system for our physical therapists and strength coaches to help people move and perform better.

My Introduction to Performance Therapy and Training program will teach you our 4-step system at Champion to assure you have everything you need to start helping people move and perform better.

Introduction to Performance Therapy and Training

Best of all, it’s absolutely free to anyone that signs up for my Newsletter. You’ll get all my best articles straight to your email, and immediate free access to the course.

Thank so much, hope you enjoy!

sign up now for free

Why You Should Be Using Biofeedback in Rehabilitation

This week’s article is an excellent guest post from my friend Russ Paine, PT, discussing why and how we should be using biofeedback in our rehabilitation patients.  Russ and I are both big fans of biofeedback but unfortunately, it’s fallen out of favor because insurance companies don’t reimburse it. But that doesn’t mean it’s not effective.  And now, there’s a new biofeedback device, the mTrigger, that uses an app on your phone that is amazingly easy to use and affordable. I think this is going to be a real game-changer.  And mTrigger was nice enough to offer my readers 10% off if they use coupon code REINOLD! More details below, but check out the article and our video first!


Why You Should Be Using Biofeedback in Rehabilitation

I have been involved in the evaluation and treatment of sports medicine injuries for 33 years.  I have been very fortunate to have a “true” sports medicine practice that predominantly includes professional, college, high school, amateur, and aging athletes.  Having this type of clientele has forced me to explore and pursue restoring full function in the timeliest manner, being very careful to not cause harm using an aggressive approach.  

I believe that one of the secrets to having a successful return to sports with minimal adverse effects is fully restoring muscle function.  

Although many aspects of our field have seen excellent advancements and growth, we continue to combat one of the most difficult challenges following injury and surgery, muscle atrophy, and weakness.  

Restoration of muscle function should not only be measured by muscle force output and scores obtained on functional tests but neurological function. In my practice, establishing normal neurological function following knee surgery is goal number one for our patients’ initial step on the path toward a successful return to function.  

The Use of Biofeedback in Rehabilitation

So how do I do this?  The use of biofeedback is my preferential method of attacking the neurological deficit following surgery or injury.  

New advances in biofeedback devices have recently allowed the ability to provide a general assessment of the patients’ EMG neurological status. The subjects’ ability to fire the inhibited muscle may now be conveniently measured by recording EMG activity of the involved extremity and comparing this to the opposite normally functioning muscle group.

The primary rationale for the use of biofeedback is the belief that the patient should begin to use their own “electrical system” as soon as possible through a volitional contraction. 

The concept known as the order of recruitment lends support to the use of biofeedback to enhance volitional contraction.  This order is based on the size principle. Heinemann’s size principle states that under load, motor units are recruited from smallest to largest. In practice, this means that slow-twitch, low-force, fatigue-resistant muscle fibers are activated before fast-twitch, high-force, less fatigue-resistant muscle fibers.  

When using a biofeedback device, the clinician sets the goal for the inhibited muscle so that a strong voluntary effort is required by the patent for each contraction.  This is visible to the patient and forces a strong contraction to reach the pre-set goal. I believe that voluntary contraction using biofeedback produces the greatest results in restoring muscle function early.

Biofeedback or Neuromuscular Stimulation?

Neuromuscular electrical muscle stimulation (NMES) is often used to stimulate muscle contraction.  There is a vast amount of literature supporting NMES for use during rehabilitation. Until recently, NMES has been a reimbursable modality, thus there was much financial support to research its’ effectiveness.  

Biofeedback has not been reimbursable and that may have had an effect on the comparative lack of literature.  One article from Draper and Ballard supports the use of biofeedback over NMES.  This article compared the two modalities during ACL rehabilitation.  After 6 weeks, the biofeedback group was shown to provide greater quadriceps isometric muscle strength than NMES treated group.

I believe in the use of NMES if a patient is unable to make any voluntary contraction, which sometimes happens following ACL reconstruction surgery.  But, once a patient is able to produce a voluntary contraction, detected by the biofeedback, we immediately switch the patient to biofeedback.

When using NMES, all nerve fibers are stimulated simultaneously.  This, in my opinion, is not as effective as biofeedback because the order of recruitment from small to large diameter nerve fibers is not sequential as is the case with voluntary contraction.  NMES actually recruits the large-diameter nerve fibers first because they are more excitable, as large diameter axons have less resistance to firing. Atrophy of muscles has predominate effects on the slow-twitch smaller diameter Type I  fibers, so recruiting these muscle fibers is critical to reverse the effects of muscle inhibition and atrophy.

How to Use Biofeedback in Rehabilitation

I use biofeedback on virtually every knee patient that has decreased neurological EMG output.  As previously mentioned, we are able to use a new device to provide a side to side assessment of EMG activity.  

This information as also very educational and motivational to the patient as they can see the actual deficit via visual EMG numbers between normal and involved.  

Cycles of 10 seconds on and 10 seconds off are utilized during the 10-minute biofeedback session.  My instructions to the patient for quadriceps re-education are to “tighten your muscle and force your knee straight”.  Progress is continued to be monitored on a weekly basis to measure the change in EMG activity, as shown using the biofeedback application.  

The mTrigger Biofeedback device that we use utilize has an amplifier that sends the measured EMG activity via a Bluetooth signal to an android or IOS device with the appropriately downloaded software application.  

This mTrigger is available for home use as well as clinical use.  Patient reported motivation using this type of biofeedback product is very high as they can actually visualize their intensity of muscle contraction when performing home exercise programs.  There seems to be an interesting psychological connection between the use of one’s personal smartphone or computer pad and their muscle activity.

Lack of extension of the knee has been shown to have an adverse effect on knee function.  Loss of extension alters the gait pattern and can produce abnormal stresses to the patellofemoral joint.  Due to a lack of quadriceps control, many quad inhibited patients will ambulate with a flexed knee gait pattern.  

The use of biofeedback can be used to combat this common malady often associated with post-op care of the knee.  Lacking quad control, patients’ are unable to eccentrically control the knee flexion moment that occurs during single-limb balance.  A quad inhibited patient will assume this flexed knee position because they “know” the position of the knee during single-limb balance.

This sets up the knee for a co-contracted state and presents as muscle splinting until normal muscle tone and function are restored.  This muscle splinting will continue to exacerbate the lack of extension in the knee. Biofeedback can be very effective at addressing this issue.  

With muscle splinting, we want to teach the patient to relax the hamstring muscle during knee extension stretching, thus negating the effect of a contracting hamstring muscle.  The patient is placed in a prone position, with both patella over the edge of the table. Electrodes are placed over the hamstring muscle. Unlike the inhibited quadriceps muscle where we are trying to elicit a more perfect contraction, the biofeedback unit is now used for relaxation purposes.  As the patient uses the relaxation mode of the unit and learns to control the overly active hamstring contraction immediate increase in passive knee extension is observed.

This position is maintained for a 10 minute period.  Once the patient has “learned” to control the hamstring overactivity, a lightweight may be applied for the 10-minute period to produce a low-load long-duration stretch.  Change in knee extension can be measured using heel height difference measurement technique. Dale Daniel described this measurement and showed that 1cm of HHD = 1 degree of flexion contracture.

Note from Mike: That’s a great example of how you would use biofeedback to work reducing muscle activity.  It’s not always used to increase activity. Another way we use it is to use both channels together on 2 different muscle groups.  Imagine doing a bird dog or glute bridge with the pads on the glutes and low back. You would focus on performing the drill with high glute activity and low back activity.  It’s pretty neat.

Return to Play

Return to play is a hot topic in rehab right now.  It’s difficult to determine if the athlete is ready to return to sport.  There are many obstacles when assisting your athlete to the ultimate goal of returning to sport with pre-injury level of performance.  

Too often, a shift is made during the rehabilitation process to more functional activities and reduced emphasis on strengthening.  If your patient continues to possess a decreased EMG signal compared to the normal side, it will be highly unlikely that they will be able to resume the pre-injury level of function.  

With biofeedback, we have a tool that makes certain that we have completed one of the early critical steps in the process of rehabilitation – restoring and measuring the normal neurological function of the inhibited muscle group.  Don’t allow decreased EMG function to be one of the obstacles to continue to linger.

The mTrigger Biofeedback Device

I thought that was a great article from Russ.  Many don’t even realize how impactful biofeedback can be as it has fallen out of favor.  Here’s a great video from Russ and I demonstrating the mTrigger device and talking about how and why we use biofeedback:

As you can see, the new mTrigger device is so simple to use and completely affordable.  That has always been a limitation in biofeedback devices, they were just to clunky and expensive.

mTrigger biofeedback device

If you want to get started using biofeedback, mTrigger was nice enough to offer my readers 10% off their purchase, making this even more affordable.  Click the link below and be sure to use coupon code REINOLD to get your 10% off

About the Author

Russ Paine, PT, is known for his experience in sports medicine with special interests in injuries to the knee and shoulder, as well as golfing injuries and conditioning. His client list includes many professional athletes who have sought his expertise to help them recover to their prior level of function. Russ has a long career in sports medicine, having served as rehabilitation consultant to the Houston Astros, Houston Rockets, and NASA. Currently the Director of Sports Medicine Rehabilitation at UT Physicians in Houston, TX, Russ continues to devote his time to research and education while maintaining a busy sports medicine clinical practice.  Russ was inducted into the Sports Physical Therapy Hall of Fame in 2018. As a well-established author and lecturer on topics related to sports medicine, he has lectured at over 500 meetings in the US and abroad. He has published 25 chapters in textbooks and over thirty research articles in peer review journals.

5 Common Core Exercise Mistakes and Fixes

We’ve come along way over the last decade when it comes to training the core.  Not too long ago, training the core consisted of mainly exercises like sit ups, with no specific attention to how the core functions.

One of the key areas of core training that I focus on to enhance movement quality and performance is stabilizing the core while the arms and legs move.  Essentially proximal stability, with underlying distal mobility of the extremities.

However, don’t forget that the body is amazing at compensating to get the job done.

Any lack of mobility or motor control will often result in compensatory movements.  Many people want to fly through their core program, but often times don’t focus on the quality of the movement.

Here are 5 common core exercise mistakes that I see, along with some suggestions on how to fix them.  I posted these as a series on Instagram, if you want to see more posts like this, be sure to follow me there.

Front Plank

A common error I see when people perform a front plank is over relying on the hip flexors to hold the position. You sometimes see them tighten their core but also come up into a bit of hip flexion.

If you hold planks for too long, you may also notice that you slowly creep up into this position as your core fatigues and your hip flexors take over.

There are two easy ways to improve this:

1. Focus on tightening your core AND your glutes.  This should help hold the neutral pelvic position.
2. Perform sets of planks with each rep being ~8-10 seconds, with no break, just a quick reset, instead of sustained holds.⠀This will keep the focus on the core before the hip flexors take over.

Side Plank

Similar to the front plank, the side plank is easy to use larger muscle groups to compensate.  One easy way to ruin a good side plank is simply to lift the body too high off the table. You’ll see too much side bend and will make this a lateral bend motion instead of a core stability exercise.

To fix this, try performing with a mirror so you can see your form. Your body should be in a straight line with a nice neutral spine.

Dead Bug

One of the common faults we see with the dead bug core exercises is a loss of neutral spine when the arms or the legs are full extended. ⠀The person tends to focus on getting there hands and feet extended, rather than keeping their core stable.

Remember the goal of the exercise is to brace and stabilize the core while moving the extremities.

Be sure to keep that brace, but also realize that it’s often better to reduce your arm and leg motion a bit if you are struggling and arching your back.⠀I’d rather you make the exercise less challenging, but performed well, then slowly progress over time.

Bird Dog

I’m a big fan of the bird dog exercise for two main reasons:

1) It’s great exercise to work on driving hip extension with proper core stability. A lot of people hyperextend their back instead of extending their hip.
2) Because you use alternate arm and leg for advanced variations, it also provides some rotational stability through the core.

But people LOVE to perform this exercise poorly by compensating and arching their back.  Many people struggle to extend their hip while keeping their spine stable.  Be sure to keep your core stable and just work on reaching with arms and legs.⠀Similar to the dead bug, I’d rather you reduce the quantity of your motion, and focus on the quality of the motion.

Glute Bridge

A common flaw with the glute bridge exercise (and hip thrusts) is thinking that you need to go as far as possible, as far as your body will go.

But keep in mind, the goal here is the glutes, not the low back. So the exercise should really be performed to extend you hips and NOT your back.

To help with this, really tighten your anterior core during the exercise and focus on squeezing your glutes. Then, simply stop the motion when the glutes are done squeezing. Many people want to keep going.  They tighten their glutes, but then keep pushing the body higher over the ground.  Resist the urge to continue by hyperextending at your back.

FST DVD Cover COREWant to Learn More About How I Train the Core?

Check out Eric Cressey and I’s Functional Stability Training of the Core program.  We discuss the core in detail and how we rehabilitate and train the core.

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.

 

The 5 Biggest Mistakes People Make Returning to Training After a Shoulder Injury

Today’s post is an amazing guest post from two of my colleagues at Champion, Dave Tilley and Dan Pope. It’s really an honor to get to work with these guys everyday, as they are some of the brightest minds in the performance therapy and training industry right now. They recently release an educational product that I recommend everyone check out called Peak Shoulder Performance, learn more about it below, plus take advantage of a special discount for my readers!


We are very fortunate to work at a facility that is on the cutting edge of shoulder rehabilitation and sports performance. As a team at Champion, we have combined our ideas in a collaborative format to innovate some of the most effective methods for optimal shoulder training.

We have also been very fortunate that our professional work has given us first-hand experience helping a very diverse population of clients for shoulder-related issues. We have been lucky to see the systems we’ve created at Champion successfully help clients with shoulder injuries who are Division 1 and professional athletes, elite gymnasts, internationally competitive Olympic weightlifters, CrossFit games competitors, power lifters, and some of the most intense general population fitness enthusiasts out there. We can be very honest in saying that these people push their shoulders to the absolute limit with training and competition.

We mention these things not to seem egotistical or to brag. It is to highlight that a properly designed rehabilitation and performance program can get someone back to the highest level of training in sports.

The 5 Biggest Mistakes People Make Returning to Training After a Shoulder Injury

With this being said, we have found helping someone return to these highly demanding training environments following a shoulder injury is one of the trickiest areas to navigate. The knowledge our mentors have taught us and the experiences working with clients at Champion has given us some great insight to this challenge. We’ve experienced what works, what didn’t, and what really derails people when trying to get back to the training they love. In an effort to help readers out, here are five of the most common errors we see made when trying to return back to training following shoulder injury.

1. Rapidly Increasing Workload When Pain is Gone, or When Athletes are “Cleared”

image

This is without a doubt the most common error we have made as younger clinicians, and see others make regularly. Nothing is more exciting than when an athlete comes into the clinic saying they have been pain-free or got cleared by a doctor to train. However, we have to be very cautious about how much work we allow people to return to following shoulder injury.

Maybe you’ve heard clients say this:

“My shoulder was feeling much better so I jumped back into training. My pain has flared up again pretty bad. What happened?”

Yikes, not fun. We’ve had that stomach dropping moment more times than we care to admit. But, these things happen and it’s how we learn. With that said, it often feels like a problem that could have been avoided.

To help with this, we recommend you educate clients early in the rehabilitation process. Once you start feeling better, it’s not time to return to training full on. Things may be feeling great, but we still need to follow the continual game plan of progressive loading.

Start with the educational process, and then implement an objective plan of attack for rehabilitation. Things to keep in mind are the basic shoulder demands seen in a traditional training program. Things like vertical pushing and pulling, horizontal pushing and pulling, rotator cuff maintenance care and dynamic stability all come to mind. The plan must be outlined well in advanced and must take into account goals, timelines, and mild fluctuations in progress. If we plan and execute fully on this plan we can avoid athletes having flare up when they return to training.

2. Not Restoring Unilateral Strength Symmetry Before Bilaterally Loading The Shoulder

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Everyone is going to have a dominant arm, and many sports require asymmetry for success (throwing sports come to mind). With that said, we see clients every week at Champion who continue to have shoulder pain because they failed to regain the most basic foundation of unilateral shoulder strength and stability before jumping back to training. Must people want to jump back into more fun exercises like bench pressing, pull ups, and push-ups before restoring symmetry.

We have to remember that with almost all shoulder injuries or pain comes protective inhibition and some degree of minor disuse atrophy. The severity of strength loss ranges widely based on the nature and severity of the injury. This is without considering that there may have been unilateral imbalances (right to the left) or training imbalances (push to pull ratios) that may have contributed to the injury in the first place.

At Champion, for athletes that are not asymmetrically biased, we like to see an objective 85% – 90% symmetry index for their baseline strength before progressing to advanced bilateral shoulder exercises in training. Sometimes we do this with dynamometers for basic strength. Other times we follow more multi-joint exercise comparisons for single arm floor presses, single arm pulldowns, single arm bent over rows, and 1/2 kneeling presses. If someone can single overhead press 40lbs for five reps on their uninvolved shoulder but struggles to get five clean repetitions with 20lbs on their involved side, returning to a bilateral barbell press may not be the best route at that time.

There is large variability based on the injury, athlete, and sport, but we suggest trying to write programs that close the gap and then focus in on more progressions. Again, it can save a lot of headaches down the road.

3. Treating the Cause of Shoulder Pain, Not Only The Site of Pain

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This is very cliché in the Sports Medicine world, but remains extremely important. As Brandon Buchard says, “Just because it is common knowledge, doesn’t mean it is common practice.”

Before creating a return to a training program for a client, ask yourself,

“Have I considered all of the variables that may have contributed to this shoulder injury in the first place.”

Common overlooked factors include workload ratios, technique, programming, problems in joints adjacent to shoulder joint (lumbopelvic, thoracic, elbow), necessary baseline range of motion, strength, and exercise selection.

Now, there may be too many factors to address at once. Some factors may be out of your control. With that said as medical providers, athletes, and sport coaches we should try to tackle as many as we can. We should aim to educate the client as much as possible. Prioritize the main issues and have an open conversation with the client, parent, or coach for why addressing these issues is so important for both performance and re-injury risk. This drastically helps minimize a recurring problem snow balling down the road.

4. Medical Providers Not Creating Individualized, Objective, Return to Fitness Programs

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This point goes in line directly with number one. Without a detailed roadmap for getting back to training goals, athletes often feel scattered and overwhelmed. I have found the best method is to start with a conversation on the primary goals or when the athlete desires to be back to sport. From that date, you can reverse engineer the progressions in training needed to aim for that end goal. Once the timeline is established, you can create a progression of exercises, sets, repetitions, and metabolic work in a periodized fashion. Here is a simplified example I use all the time at Champion

Goal: Pain-Free Body Weight Pull Ups in 2 months

Week 1 & 2:

  • Half kneeling single band pulldowns with bent elbow
  • 4×10, 2x/week, with 3-second eccentric tempo
  • Starting in 150 degrees of shoulder elevation and progressing to full 170 of shoulder elevation

Week 3 & 4:

  • Kneeling single arm Kieser or Weight Stack Pull Downs with bent elbow
  • 4×8, 2x/week, with 3-second eccentric tempo
  • Once 90% symmetry established, switch to bilateral Keiser/Weight Stack Pull Downs

Week 5 & 6:

  • Self-spotted pull-ups, standing on box for lower body assistance as needed
  • 5×5, 2x/week, focusing 1 second top and bottom hold

Week 7 & 8:

  • Progression to appropriate band assistance for 5×5, 2x/week
  • Reducing assistance until light or no band is needed

The exercises, sets, reps, and progression rate can be adjusted based on the injury type, client, and training age. Educate clients that the initial program you write is just the first attempt, and that you may need to adjust on the fly based on good or bad days. There may be small amounts of pain, but we personally tell people no more than a 3/10 and it can’t last for more than 24 hours.

Remember it’s less about the specific exercise prescription, and more about understanding the principles underlying the goal the client says they have. Doing this for the primary movements can be extremely helpful for the client and help you design a better program.

5. Not Continuing Basic Soft Tissue and Cuff Care for Maintenance

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This is another shockingly common problem that comes up following successful reintegration to training. Athletes and coaches must remember that just because there is no pain, doesn’t mean you’re back to full function. As athlete’s train more they naturally acquire soft tissue stiffness, fatigue, and imbalances around their shoulder joint. This is variable based on the repetitive activates they are doing. Most commonly, we see the latissimus dorsi, teres major, pecs, upper trap, and subscapularis as culprits that cause losses in basic range of motion. Letting this slowly creep up is an easy way for pain to creep back in.

We must be dedicated to regular soft tissue management, strength balance work and high-level cuff strength. This is for a very similar reason as above. The more athletes tend to train, the more they focus on larger primary muscle groups and miss the same amount of development for their smaller stabilizers. When this imbalance creeps up it may create a situation for injury.

In an ideal world, the importance of this has been explained to the client and they maintain visits coming to see you as a provider. Manual therapy, hands-on strength work, and tweaking programs based on changes are incredibly helpful for athletes to get the most out of their shoulders. We are proud to have a lot of athletes realize the importance of this and continue to come on a bi-weekly or monthly basis for tune-ups.

Bonus – Lack of Communication Between All Parties

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Open communication with parents, sport coaches, trainers and physicians is essential for athletes returning back to sports. Everyone needs to be on the same page with the athlete’s rehab. If any link in this chain is broken, athletes can be left frustrated and injuries can linger around. Having this communication ensures the bridge back to performance is successful and each professional is doing their part for the athlete.

If the athlete is an individual competitor, the most critical communication is between yourself and the athlete. The more transparent you can be, and the more open you are to answering athlete questions, the better.

Never be afraid to answer questions or concerns that come up. Be honest about the reality of ups and downs for returning to training, and also the possible positive or negative outcomes that come with big decisions. Discussing timelines, pain levels, proactive exercises, and prognosis can really ease the athletes mind and help them establish high levels of trust with you.

For what it’s worth, we have found that the higher the level of the athlete, the more they value honest and open communication. High level athletes are just people, and really appreciate the down to earth professionals who have their best interest in mind above all else.

Peak Shoulder Performance: The Ultimate Guide to Getting Out of Pain and Returning to High Level Fitness

Peak Shoulder Performance coverIf you enjoy this information, we’re happy to say it’s just the tip of the iceberg on how we approach returning to training after a shoulder injury. If you want to learn exactly how we return athletes back to high level fitness after a shoulder injury, be sure to check out our recently released online course that has been very well received.

We dive deep into the exact exercise progressions, principles, and maintenance care we use on athletes every day. This course is intended to help athletes themselves, medical providers, and coaches better understand this often-frustrating topic.

We know this information can help a lot of people, so we are going to offer a monster deal and chop off $50 from the original price just for Mike’s readers this week. Check out the link below to learn more, and enter “Reinold50” to cash in on the discount, good for this week only!  Offer ends Friday 3/9/18 at midnight EST:

Dan Pope DPT, OCS, CSCS, CF L1
CEO of Fitness Pain Free
Dave Tilley DPT, SCS, CSCS
CEO of SHIFT Movement Science

Sorry, Sitting Isn’t Really Bad for You

Over the last several years, the health concerns surrounding sitting have really been highlighted by the health and fitness crowds, as well as the mainstream media.  In fact, there have been entire books published on this topic.  I’ve seen articles with titles such as “Sitting is Evil,” “Sitting is the New Smoking,” and even “Sitting will kill you.”

Wow, those seem pretty aggressive.  We’ve been sitting since the beginning of time!  I’m going to really shock the world with this comment…

Sorry, sitting isn’t really bad for you.

Yup.  There is nothing wrong with sitting.  I’m actually doing it right now as I write this article.  You probably are too while you read this article.

Don’t get me wrong, sedentary lifestyles are not healthy.  According to the World Health Organization, sedentary lifestyles increase all causes of mortality and raises the risk of health concerns such as cardiovascular disease, diabetes, obesity, cancer, and even depression and anxiety.

But let’s get one thing straight:

It’s not sitting that is bad for you, it’s NEVER moving that is bad for you.

By putting all the blame on sitting, we lose focus on the real issue, which is lack of movement and exercise.  We are seeing a shift in people switching to standing desks at work, still not exercising, but thinking that they are now making healthy choices.

This is so backwards it boggles my mind.

It it all begin with the negative myth that “sitting is the new smoking” and completely ignores the true issue.

The body adapts amazingly well to the forces and stress that we apply to it throughout the day.  If you sit all day, your body will adapt.  Your body will lose mobility to areas like your hips, hamstrings, and thoracic spine.  Your core is essentially not needed while sitting so thinks it’s not needed anymore during other activities.  And several muscles groups get used less frequently while sitting and weaken over time, like your glutes, scapular retractors, and posterior rotator cuff.

Your body is a master compensator, and will adapt to the stress applied (or not applied) to make your efficient at what you do all day.

Unfortunately, when all you do is sit all day, and you never reverse this posture or exercise, your body adapts to this stress to make you the most efficient sitter.
That’s right, you get really good at sitting.

For example, think about what happens to the core when you sit all day.

One of the functions of your core is to maintain good posture and essentially to keep the bones of your skeleton from crashing to the floor.  The core is engaged at a low level of muscle activity throughout the day for postural needs.

The problem with sitting is that the chair also serves this function, so your core isn’t needed to keep you upright, the chair serves this function. If sitting is all you do, then when you stand up, your core essentially isn’t accustomed to providing this postural support so you rock back onto your static stabilizers by doing things like standing with a large anterior pelvic tilt and lumbar extension.

bad sitting posture isnt bad for you core control

Unfortunately, this becomes the path of least resistance, and most energy efficient, for your body.  Your core gets used to relying on the chair to function, then when you need it, gets lazy.

Despite what you may read in the media, it’s OK to sit all day.  That is, as long as you are reversing this posture at some point.  This can be as specific as exercises designed to combat sitting and as general as simply taking a walk in the evening.

 

3 Strategies to Combat Sitting All Day

I want to share the 3 things that I often discuss with my patients and clients.  You can apply these yourself or use them to discuss with your clients as well.  But if you sit all day, you really should:

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

But the real first step is to stop blaming sitting and start focusing on the real issue.  It’s lack of movement and exercise that is the real concern, not sitting.

 

Step 1 – Move, Often

The first step to combatting sitting all day is to move around often.  The body needs movement variability or it will simply adapt to what it does all day.

I get it, we all work long days, and sitting is often required in many of our jobs.  But the easiest way to minimize the effects of sitting all day is to figure out ways to get up and move throughout the day.

This doesn’t need to be 10 minutes of exercise, it could simply be things like getting up to fill up a water bottle or taking quick 2 minute walk around the office.  When I am not in the clinic or gym, I personally tend to work in my home office.  What I do is try to work in one hour chunks, so I will get up and walk around in between chunks to get a glass of water, snack, or use the bathroom.

This works well for me, but you need to find what works for you.  I know of others that use things like Pomodoro timers, or even some of the newer fitness tracking devices, which can remind you to stand up and move around at set times.

 

Step 2 – Reverse Your Posture

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 a basic set of exercises may look like:

  • Thoracic extension
  • True hip flexor stretch
  • Chin nods
  • Shoulder W’s
  • Glute bridges

reverse your posture

I have another article you should check out on the 5 Exercises to Perform if You Sit All Day.  Perform each of these for 10 reps.  These should take 5 minutes to perform and will make a big impact on how you feel throughout the day.

 

Step 3 – Exercise

Remember going back to some of the past concepts above, the body adapts to the stress applied.  To combat this perfectly, a detailed exercise program that is designed specifically for you and comprehensively includes a focus on total body and core control is ideal.

This will assure that the muscle groups that are not being used while sitting all day get the strength and mobility they need, while the core gets trained to stabilize the trunk during functional movements.

If you want to get the most out of your body and stay optimized, you need to do things like work on your hip and thoracic spine mobility, strengthen your rotator cuff, groove your hinge pattern, and learn how to deadlift and work your glutes.

 

Sitting Isn’t Bad For You, Not Moving Is

As a profession, we need to get away from blaming sitting as the enemy and labeling it evil.  Our society is sitting more and more each generation.  We need to be honest with ourselves and realize that sitting isn’t the problem, it’s not moving enough that is the concern.  We need to stop pointing fingers and get to the root of the problem.

Go ahead and sit, just move more often and use these 3 strategies to combat sitting all day.

 

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