Return to Play Testing After ACL Reconstruction

This week’s article is a guest post from Lenny Macrina.  Lenny discusses a really important topic right now regarding the safe return to sport after ACL reconstruction.  Are we returning people too fast? Also, our HUGE 50% off sale on our online course teaching you exactly how Lenny and I evaluate and treat the knee is back!  You can learn more below, but it is $200 off now through Sunday 5/20/18 at midnight EDT. Click here to learn more and save big on our acclaimed program before it’s too late!

 

ACL reconstruction surgery continues to dominate the sports medicine and orthopaedic world. Research surrounding ACL surgery is abundant and I have written about it in previous posts on LennyMacrina.com and for Mike on his website. It’s an important topic because of the lack of general consensus on what’s the best way to assess return to play testing, never mind the relatively high failure rates.

For this post, I wanted to discuss the return to play testing after an ACL reconstruction to see what the literature says. I’m not going to lie, I don’t have a formal algorithm like some. I have people hop, skip and jump but don’t necessarily do a formal hop test.

I believe in slowly returning my athletes to their sport in a time that is safe. I carefully watch them move, advance their strength and power exercises and chat about how they feel about their knee.

With that, I wanted to do an extensive literature search to figure out what was the best way to truly test our athletes to determine their readiness.

Is there a best algorithm that will decrease retear rates? If so, why are we not using it for injury reduction programs…or are we?

 

Risks for ACL Reconstruction Failure

The risk of a second ACL injury in a young, active individual is high after a previous ACL reconstruction and return to sport.

Paterno and his group reported 23.5% of young, active patients suffered a second ACL injury in the first 12 months after RTS following ACLR.

Another study by Paterno and his colleagues showed 37.5% suffered a non-contact retear within 24 months after the initial reconstruction.

Surprisingly enough, this group also reported that 29.5% of young, active athletes who returned to cutting and pivoting sports after an ACL reconstruction suffered a second ACL injury 24 months after return to their sport.

A recent review by Wiggins et al showed that young, active athletes are at greater risk to suffer another ACL injury after ACL reconstruction and return to sport compared with uninjured adolescents.

With retear rates so high, there has to be a better strategy to get our athletes back to their sport safely.

 

ACL and Kinesiophobia

We know the mental component involving fear of movement/reinjury, or kinesiophobia, is often the last to come back for the athlete. A good majority of patients have some form of kinesiophobia after an ACL reconstruction and we need to be able to address that too. Numerous studies have shown this and it definitely needs to be understood and addressed as the program is progressed. Here’s another one for you to check out.

Those are just a couple of articles that discuss the self-reported fear that is involved in an athlete’s head. My pubmed search gave me 36 total articles that you may want to check out here.

There’s no denying the power of the mind when a return to play decision has to be made. I want them feeling as strong and confident as possible. It takes time and the days of trying to return someone back in 4-6 months seems to be a thing of the past. I did it.

Some self-reported outcome measurements that are commonly used are the TSK-11, known as the Tampa Scale for KInesiophobia. This is a shortened version of the original TSK-17 that was published previously.

 

 

Another questionnaire that can be use is the ACL-RSI or the Return to Sport after Injury Scale. It is used to assess psychological impact that may be in the athlete’s head. The goal of the questionnaire is to the athlete’s emotion, confidence and self-risk appraisal.

There are many other tools out there that can gauge a patient’s knee function such as the IKDC, KOOS, VAS scale, Lysholm, Tegner, and the Cincinnati Knee Scoring scale. I just wanted to add those in as an informational thing but they don’t necessarily measure the psychological component ad readiness for return to play.

 

Slow and Steady ACL Rehabilitation

I’ve gotten high school seniors back to their sport quickly and bragged about it. Despite their isokinetic test being marginally ok, the docs would clear them because of other circumstances. It’s the last game of the season or it’s their senior year or they made the playoffs and the team ‘needs them.’

It seems as if the literature supports some form of formal testing but there is no clear answer, in my opinion.

The tests that many currently utilize in the clinic have just never felt right to me. I’m not sure we can simply do some hop tests or a step down test and have enough information to decide on whether an athlete is ready to return to their sport. Both tests are in the sagittal plane and don’t account for fatigue or other planes of movements such as the frontal plane (side to side) or transverse plane (rotational motions.)

Never mind that when we are comparing the involved leg to the uninvolved leg during functional testing to determine limb symmetry index (LSI), are we inherently flawed? Does the strength and proprioception of the uninvolved leg diminish months after the ACL reconstruction which makes our battery of tests invalid by inflating the LSI?

 

Rethinking the Way We Determine Return to Play After ACL Surgery

Delaware researchers seem to think that the LSI can overestimate knee function after an ACL surgery. They have shown that doing baseline functional tests soon after the ACL tear gives a better estimate of the body’s strength and functional output.

So if we’re using the uninvolved leg as the comparison leg and it has undergone strength and proprioceptive changes during the 6-12 months of rehab, are we flawed from the start and our LSI testing is invalid and over-estimates an athlete’s return to play?

Maybe that’s one reason why our retear rates are so high.

 

Physical Therapy Is Not Good at Advanced Stage Rehab

Never mind the pink elephant in the room…  many PT’s are poor at prescribing higher level exercises. We just don’t see people past 8-12 weeks after surgery because of insurance visit limitations. We don’t have experience or the access to these patients once they’re discharged from PT.

It’s at this point that the real strength, power, endurance and agility activities really take shape. Unfortunately, most patients are on their own or working with other professionals. It is key that we maintain our relationships with other fitness professionals so we can influence and guide the later-stage rehab process.

But we often don’t, sadly.

It’s a long process, longer than we think and longer than the patient wants it to be.

 

Should We Delay Return to Sport Longer Than 12 Months?

This article talks about how the rehab is multifactorial and can often take 1-2 years to feel comfortable enough.

Even renowned ACL researcher Tim Hewett, known for his injury reduction programs, has advocated for a 2 year return to sport in one of his latest papers.

Most are not functionally ready to return to their sport even though they are cleared by their surgeon. It seems as if time is the number one decision maker and not necessarily functional tests of strength power and endurance.

This paper showed that at 6 months, 2 patients (3.2%) passed all criteria. At 9 months, seven patients (11.3%) passed all RTS criteria. Patients improved in all RTS criteria over time except for the IKDC score. Twenty-nine patients (46.8%) did not pass the strength criterion at 60°/s at 9 months after ACL reconstruction.

While this research paper looked at younger athletes cleared for sports participation After an ACL Reconstruction.  Only 13.9% of the participants passed all of the criteria (IKDC, quadriceps and hamstring strength limb symmetry index (LSI), and single-leg hop test) 1 year after surgery

This study looked to assess the changes over time in patients tested at 6 months and 9 months after ACL reconstruction.  At 6 months, only 2 patients (3.2%) passed all criteria. At 9 months, 7 patients (11.3%) passed all criteria.

What if they had a previous ACL tear and then they subsequently tear the contralateral side? What does the PT use for an index?

A study by the Zwolski group that the use of LSI’s during strength and performance tests may not be an appropriate means of identifying residual deficits in female patients after bilateral ACL reconstruction. They also concluded that “a better indicator of strength performance in this population may need to include a comparison of strength performance values to the normative values of healthy controls.”

There seems to be a persistent issue with getting the quadriceps muscle to return in our athletes. Despite our efforts, there seems to be a neuromuscular component that requires time and persistence.

This study showed that in patients an average of 7.5 months out of surgery demonstrated nearly a 30% weakness. They said diminished motor neuron recruitment or decreased motor-unit–firing frequency was likely contributing to reduced isometric quadriceps strength and interlimb asymmetries.

Another study looked to compare adolescent athletes ages 15-20 years old with adults ages of 21-30 years old. At the 8-month follow-up, 29% of the patients, in both age groups, who had returned to sport had recovered their muscle function in all 5 tests of muscle function (unilateral vertical hop; unilateral hop for distance; and unilateral side hop, isometric quad at 60° and knee flexion at 30°.) At the 12-month follow-up, the results were 20% for the adolescents and 28% for the adult patients.

Again, a large strength deficit at 12 months post-surgery despite our objective testing.

Never mind that most of these studies lum everyone together and don’t account for graft differences. In my opinion, we need to consider graft type as another variable that could contribute to retear rates and return to sport testing. I talked about graft selection in this blog post.

 

How Do We Determine When Safe to Return to Sports?

That’s the million dollar question. There are a few common ways that we can determine when it is safe to return to sports after ACL reconstruction.

 

Isokinetic Testing 

Isokinetic testing has been used for many years and seems to be valid and reliable. Although ths recent systematic review in BJSM stated that  isokinetic strength measures have not been validated as useful predictors of successful RTS.

Oh great, now what?

Don’t forget, back in 1994 Kevin Wilk and his group looked to determine if a correlation exists between three commonly performed clinical tests: isokinetic isolated knee concentric muscular testing, the single-leg hop test, and the subjective knee score in anterior cruciate ligament reconstructed knees. They noted a positive correlation was noted between isokinetic knee extension peak torque (180, 300 degrees/sec) and subjective knee scores, and the three hop tests (p < 0.001).

The problem lies with many clinics having limited access or just don’t use them anymore.

Because of that, we’ve had to adjust our thinking and use ground based testing such as hop tests, isometric strength testing and agility tests.

The research says that “athletes who did not meet the discharge criteria before returning to professional sport had a 4x greater risk of sustaining an ACL graft rupture compared with those who met all 6 RTS criteria (isokinetic strength testing at 60°, 180° and 300°/s, a running t-test, single hop, triple hop and triple crossover hop tests.) In addition, hamstring to quadriceps strength ratio deficits were associated with an increased risk of an ACL graft rupture.

This study says that the single hop for distance and ACL-RSI were found to be the strongest predictive parameters, assessing both the objective functional and the subjective psychological aspects of returning to sport. Both tests may help to identify patients at risk of not returning to pre-injury sport.

 

Hand-Held Isometric Strength Testing

This is another test that is commonly used in return to sport testing after an ACL. I think it could be used but it gives limited information and can be painful if not done correctly. The painful response has been shown to statistically influence outcomes and needs to be modified to prevent alterations in true quadriceps force generation.

Also, the measurements using a hand held dynamometer are often lower than what can be obtained with an isokinetic device, as seen in this study.

I know many use hand-held dynamometry but I just can’t see its value as a return to sport test that is valid.

There are just too many questions about where to put the device to minimize pain while kicking. Also, at what angle do we place the knee to best isolate the quadriceps? Ninety degrees or 60 degrees of flexion? Research seems to look at both methods.

Plus, does a concentric, isometric contraction REALLY give us the information that we truly need to make an informed decision or have we sought a cheaper alternative to isokinetics and embraced it. We PT’s are suckers for the easiest way to diagnose, treat and test and often miss the big picture.

Research can guide us but common sense and experience must play some role as well.  

 

Hop Tests to Determine Return to Play

Hope tests are often utilized by rehabilitation specialists to determine an athlete’s ability to generate and dissipate a force when compared to their contralateral knee. As far as I can see, Noyes was one of the 1st to talk about hop tests in the literature in 1991.

Four common tests are utilized and reported in the literature. They include single leg hop for distance, triple hop for distance, crossover hop for distance and 6-meter time hop. The general rule is to obtain an LSI ≥ 90% compared to the reference limb.

 

As usual, both limbs are tested and the uninvolved limb is used as the reference, which we mentioned previously as an inherent potential flaw (the Delaware study.)

Using these tests can help the rehab specialist reduce ACL re-tears as noted in this study from BJSM in 2016. They showed reinjury rates were “significantly reduced by 51% for each month RTS was delayed until 9 months after surgery, after which no further risk reduction was observed.”

Furthermore, 38.2% of those who failed RTS criteria involving hop tests and quad strength symmetry within 10% suffered re-injuries versus 5.6% of those who passed all of the testing criteria.

 

Closing Thoughts on ACL Return to Sport Testing

My research has confounded my thoughts even more and added to the questions. It seems as if there is no clear way to determine readiness to return to sport after an ACL. Our testing seems somewhat flawed and despite our efforts, ACL retear rates are too high.

To simply say it comes down to strength is not enough. We’re so focused on quadriceps strength that we’re missing the big picture. Of course the quadriceps are highly important, bt don’t forget about hamstring:quadriceps ratios, gluteus strength, force attenuation, and fatigue-state rehab.

Never mind there’s the mental component and the ability to attenuate forces in game situations. These are things we cannot truly test.

We’re missing something but it does seem that the time-based scenario may be an option to consider, meaning they need to stay out of their sport for at least 9 months, and ideally 12-24 months, or as long as they are continually doing their progressive strength training.

I think therein lies the answer. As physical therapists, we don’t do a very good job at advanced strength training and periodization. We can learn a lot from our fellow strength coaches. Plus the fact that the athlete is all too eager to return to their sport without fully understanding the consequences.

Despite all of our testing, we continue to show poor outcomes even 12+ months after reconstruction. I can’t blame the tests, right? It’s the preparation for the tests that seems to be lacking.

What do you do to test your athletes when they’re considering a return to their sport?

 

Learn Exactly How We Evaluate and Treat the Knee

online knee seminarIn our online course at OnlineKneeSeminar.com we discuss the many pathologies of the knee, including ACL reconstruction. We outline a progressive program that starts preoperative and goes until the athlete is ready to return to their sport.  If you are interested in learning are full approach, our course has a lot to offer. You’ll learning exactly how we evaluate and treat the knee and become an expert at knee rehabilitation.

We have a huge sale going on right now as well.  The course is normally $399 but we are offering a HUGE sale for 50% off this week only.  Save $200 and get the full course for only $199!  Click below to learn more and be sure to sign up before Sunday May 20th at midnight EST:

 

 

Special Tests for Rotator Cuff Tears

Rotator cuff tears are one of the most common injuries we see in orthopedic physical therapy.

During the clinical examination of the shoulder, we want to perform special tests designed to detect a rotator cuff tear.  

Below are my 4 favorite special tests for rotator cuff tears that I perform during my clinical examination of the shoulder.  These 4 tests do a good job detecting larger tears that are causing dysfunction.

As rotator cuff tears become more common, we are starting to see them in younger and more active patients.  In these patients, they often have smaller tears and it is much more difficult to detect with our special tests.  These types of patients often present with pain and weakness, and not as much dysfunction as you would see in a traditional older patient with a more degenerative tear.  

This is likely because their rotator cuff tear is either small or partial.  These are often just isolated to the supraspinatus muscles as well, and their other rotator cuff muscles are functioning well.  

As a rotator cuff tear becomes larger, retracted, and more degenerative in nature, the patient’s shoulder dysfunction will become more apparent as it becomes difficult for the rotator cuff as a group to function well.

 

Shoulder Shrug Sign

The first special test I perform to diagnose a rotator cuff tear is the shoulder shrug sign.

During this test, the key to check if they can actively elevate their arm if you help them past their shrug arc.  When the shoulder is positioned below 90 degrees, the line of pull and the force vector of the deltoid muscles is superior.  This is often counterbalanced by the line of pull and force vector of the rotator cuff.

In the image below, the left is the line of pull of the deltoid at various shoulder positions.  The picture on the right is the supraspinatus. Notice how the deltoid starts to have a similar line of pull as the rotator cuff once the shoulder reaches 90-120 degrees of elevation:

If the rotator cuff is torn, then the deltoid is the dominant muscle and the resultant force vector is more superior.  

This is the shrug.

However, one you get the arm overhead, the deltoid is now more in line with the rotator cuff and can help center the humeral head within the glenoid fossa.  

So, you want to passively help them get above this position to see if they can elevate towards the upper range of elevation.

There isn’t really any information in the literature regarding this test.  It’s not something you’d probably find as a specific test for a rotator cuff tear, but something I have clinically found to be relevant to me.

 

Shoulder Drop Arm Test

The next rotator cuff tear special test that I perform is the drop arm test.  The concept of this test is pretty similar to the shrug sign. You passively elevate the arm and see if they can hold that position without the arm dropping, or shrugging.

If the arm drops or shrugs, then the rotator cuff likely isn’t able to counterbalance the superior line of pull of the deltoid.

The research has shown that the sensitivity of the drop arm test is low to moderate, but specificity is high from 80-100%.  This is consistent with most of your clinical examination of the shoulder. You usually have to have a significant tear to start seeing these tests positive.

 

Rotator Cuff Lag Sign

The rotator cuff lag signs are similar special tests as the drop arm test.  Essentially, they are like a drop arm for external rotation of the shoulder instead of elevation.

As rotator cuff tears get larger, they tend to extend from the supraspinatus into the infraspinatus.  The lag signs show a difficulty in the external rotators holding the arm against gravity.

The test appears to be specific in the literature with specificity between 88-100% and several studies in the 90% range.  Sensitivity has varied in studies, but has shown 45-56% sensitivity to detect full thickness supraspinatus tears, 70% in infraspinatus tears, and 100% in teres minor tears.  This makes sense to me as it’s a better test for larger tears extending into the infraspinatus and teres minor.

 

Lag Sign at 90 Degrees

I also like to perform a variation of the lag sign at 90 degrees of elevation.  It is the same test as the traditional lag sign, however, I have found this test to be even more challenging.  I have seen patients that had a positive lag sign at 90 degrees of elevation, and a negative lag sign at 20-30 degrees.  It’s simply a more challenging position for the cuff.

The research has shown this to have specificity between 70-100%, however varying sensitivity from 20-100%.  But again, for the same reasons as the lag sign above.

 

Special Tests for Rotator Cuff Tears

If you use all four of the above special tests as a cluster, I think you’ll often be able to detect a large full thickness rotator cuff tear during your clinical examination.  These tests tend to be more sensitive to larger tears in older and more degenerative patients.

But remember, special tests are just a piece of the puzzle.

 

 

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”

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

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

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

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

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

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

If 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.

 

Want a Comprehensive Online Training Program?

champion strong online training - multiple devicesWe’re super excited to now offer an amazing online training program, Champion Strong.  It’s our flagship training program that we use at our gym Champion PT and Performance with many of our clients.  It’s designed to give you a comprehensive program to follow at the gym that focuses on helping you look, feel, move, and perform better.

We have video demonstrations of all the exercises, plus a bunch of great educational videos to teach you the major movements.  Plus it has an awesome training app to view, schedule, and log your workouts.

We’re really proud if it.  Click below to learn more and sign up for less than $1 a day:

 

 

4 Mistakes People Make When Rehabilitating Hamstring Strains

When it comes to hamstring strains, two things are certain:

  1. They are very common in athletes, with research showing almost 30% of all lower extremity injuries in sports are hamstring strains.
  2. The recurrence rate is high, with research showing up to a 30% recurrence rate for hamstring injuries.

Call me crazy but I feel like the recurrence rate is just way too high, showing that we either are rushing people back too soon, don’t have an adequate return to sport criteria, or simply are not rehabilitating these hamstring strains very well.

It’s likely a combination of the three. We can do better.

 

4 Mistakes People Make When Rehabilitating Hamstring Strains

In my experience, people often make 4 common mistakes with hamstring strain rehabilitation. By focusing on these 4 key areas, I think we can do a better job returning athletes to their sport following hamstring strains, and keep them out on the field without reinjuring their hamstrings.

 

Loading the Hamstring Too Early

The first mistake I often see is simple. People often load the hamstring tissue too early.

I think it’s obvious that contracting a strained hamstring causes pain, so this is often avoided, but for some reason people tend to want to stretch through this pain and discomfort, thinking that if they get looser it will feel better.

I don’t think this is true, and overstretching too early is just going to delay healing. In fact research has shown that too much stretching can actually delay the return to sport.

This can occur in the rehabilitation setting, but also from the athlete themselves as the constantly want to stretch or “test” the area throughout the day.

One of the easiest things you can do acutely after a hamstring strain is to avoid stretching. Don’t get me wrong. I want to start some gentle range of motion in the acute phase, but I don’t want to stretch the tissue that was essentially just damaged by an overstretch type of injury.

Trust me, take a step back in the acute phase and avoid stretching and you are putting the tissue in a position to succeed in the future phases on rehabilitation when we need to start applying more load.

 

Not Performing Eccentric Exercises

It has been theorized that hamstring strains are so common due to the large eccentric contractions observed during the swing phase of running as the hip flexes and the knee extends.

This seems to make sense.

So it also makes sense that hamstring strain rehabilitation and even prevention programs that incorporate eccentric hamstring exercises tend to have better results.

After a hamstring strain, it has been shown that eccentric hamstring strength is impaired.

The common theory is that there is a change in the force-length relationship of the hamstring after an injury, resulting in peak force at a shorter length. But, eccentric training shift this relationship and allow peak force at a longer length.

This makes is important to include eccentric exercises for the hamstring during rehabilitation. I also recommend you include eccentrics with exercises at various degrees of hip flexion, for example the Nordic hamstring exercise at 0 degrees, and a single leg RDL, which includes hip flexion.

 

Not Performing Dynamic Hamstring Exercises

While it’s important to include eccentric exercises, I’m actually surprised at how little I read about people recommending dynamic exercises.

It’s one thing to perform a slow eccentric contraction, and another to perform a dynamic and explosive contraction.

I often use lower body plyometrics for this, as it allows both a rapid eccentric contraction, followed by an explosive concentric contraction. That’s what happens in sports.

 

Returning to Sports Too Early

Several studies have been published showing that many athletes return to sport too early, showing signs of hamstring weakness and imbalances.

Part of the problem is that there is no validated criteria to determine return to sport. But, we are getting there.

It’s probably best to understand the factors that are associated with prolonged hamstring injuries, you can read a nice review of those in AJSM.

But we also may have a new clinical test that can be performed. The Askling test involves have the person rapidly perform an active straight leg raise to assess their ability to perform and pain.

It has been shown that the recurrence rate of hamstring strains that passed the Askling test was less than 4%, much lower than the normal rate.

 

How to Diagnose and Treat Hamstring Strains

For those that want to learn more about how I rehabilitation hamstring strains, including the postoperative rehabilitation follow hamstring repairs, I have an Inner Circle presentation on the Diagnosis and Treatment of Hamstring Strains that overviews my approach to these injuries. Click below to learn more:

 

 

My Favorite Articles of the Year

Over the years, I have always published an article at the end of each year that highlights some of the best articles of the year from my website.  I always enjoy looking back at the site analytics to find what my readers thought were my best articles.

However, sometimes I don’t agree, haha!

Sometimes some of the articles that I enjoyed writing the most weren’t the most “popular” when it comes to site visits.  Plus, I now have more websites that you may find my content, like EliteBaseballPerformance.com.

So this year, I thought I would write up a list of my “favorite” articles of the year, instead of the most “popular.”  I bet after reading them, you’ll agree!

Thanks so much to all of you for another awesome year.  For those that like sneak peeks…  We have some BIG stuff in store for 2018:

Online Training

We have just launched our new online training platform with our first flagship program, Champion Strong.  This is based on our most popular programs we use at Champion.  It’s an awesome online program for those looking for an amazing workout program that progresses each month.  You can take it to the gym with our phone app that allows you to view, schedule and log your workout for the day to track your progress.  Plus, there are great exercise demos and educational content.  If you’ve ever wanted to work with us at Champion, this is the program for you!

Our Performance Therapy and Training System

We’ve been alluding to this for a few months but we’ve been working hard to bring together everything I have learned in the last 20 years into a complete system of performance therapy and training.  We’re getting close, but it’s going to be EPIC.

Stay tuned…

My Favorite Articles of the Year

Research Updates on K-Tape, Self Myofascial Release, and Topical Analgesics

This was my favorite podcast of the year.  Lenny and I got together with Phil Page at our annual ICCUS Society meeting and asked Phil to summarize some of the latest research on K-Tape, SMR, and Topical Analgesics.  This was a fun one.  Phil is the best.

 

Should We Delay Range of Motion After a Total Shoulder Replacement?

I recently updated my online program teaching you how I evaluate and treat the shoulder over at ShoulderSeminar.com and added a new lesson on Rehabilitation of the Arthritic Shoulder.  I wrote this article to share some of the research about ROM after a total shoulder replacement.  I think there are still some misconceptions out there.

 

3 Popular Exercises I Am No Longer Using

Sometimes what is popular on the internet and social media is not best.  In this article, I show a few videos of 3 common exercises that I have stopped using, as I just think they aren’t the best.

 

Velocity Down After Weighted Balls and What Pitchers Should Do After Games

This was another fun episode of the podcast where I team up with Will Carroll, Dan Blewett, Kevin Vance, and Dave Fischer to talk about some of the things we learned at the big Sabermetrics meeting in Boston and how they are using it with their high school and college pitchers.

 

Working with the Hypermobile Athlete

This was my favorite Inner Circle presentation of the year.  I sat down with Dave Tilley and talked about some of the things to consider when working with hypermobile athletes.  This is essentially a lot of what Dave and I do each day, so there is a ton of nuggets of info in here for everyone to learn.

 

5 Ways to Get More Out of Self Myofascial Release
Self myofascial release is super popular but often performed poorly.  Follow these 5 tips and you’ll get even more out of performing them in your programs.  I have a bunch of great videos in the post for you to watch.

 

Are Weighted Baseball Velocity Programs Safe and Effective?

This was a review of our 2-year research project that we conducted at Champion in conjunction with Dr. Andrews and Fleisig of ASMI.  I published this on Elite Baseball Performance while the manuscript is in the press as I wanted the information to get out to the public and it takes months for a proper peer review and publication process.  Unfortunately, based on the reaction observed on Twitter, I’m not sure people wanted to hear the results…

 

6 Hip Mobility Drills Everyone Should Perform

In this article, I have 6 more videos going over my favorite hip mobility drills.  This is the cornerstone of most of my hip mobility programs.  I’m not a fan of torquing the joint or working into (or pushing through) end range of motion, which is, unfortunately, becoming more popular lately.  I much prefer these drills.

 

4 Ways to Modify the Squat So Everyone Can Perform

Another great Inner Circle presentation where we look at how different people may present and how that could impact their squat form and mechanics.  This is a very important concept to apply to your clients.

 

What is the Best Graft Choice for ACL Reconstruction?

Lenny Macrina wrote a great guest post discussing some of the options for ACL reconstruction.  We get questions like this a lot on the podcast, so thought an article was long overdue.

 

The True Hip Flexor Stretch

The hip flexor stretch has become a very popular stretch in the fitness and sports performance world, and rightly so considering how many people live their lives in anterior pelvic tilt.  However, this seems to be one of those stretches that I see a lot of people either performing incorrectly or too aggressively.  I talked about this in a recent Inner Circle webinar on 5 common stretches we probably shouldn’t be using, but I wanted to expand on the hip flexor stretch as I feel this is pretty important.

I’ve started teaching what I call the “true hip flexor stretch.”

I call it the true hip flexor stretch as I want you to truly work on stretching the hip flexor and not just torque your body into hip and lumbar extension.  It’s very easy for the body to take the path of least resistance when stretching.  People with tight hip flexors and poor hip extension often just end up compensating and either hyperextend their low back or stress the anterior capsule of the hip joint.

I explain this in more detail in this video:

 

The good thing is, there is a simple and very effective.  Once you adjust and perform the true hip flexor stretch, most people say they never felt a stretch like that before, hence the name “true hip flexor stretch.”

 

True Hip Flexor Stretch

To perform the true hip flexor stretch, you want to de-emphasize hip extension and focus more on posterior pelvic tilt.  Watch this video for a more detailed explanation:

 

Key Points

  • There is a difference between a quadriceps stretch and a hip flexor stretch.  When your rationale for performing the stretch is to work on stretching your hip flexor, focus on the psoas and not the rectus femoris.
  • Keep it a one joint stretch.  Many people want to jump right to performing a hip flexor stretch while flexing the knee.  This incorporates the rectus and the psoas, but I find far too many people can not appropriately perform this stretch.  They will compensate, usually by stretching their anterior capsule too much or hyperextending their lumbar spine.
  • Stay tall.  Resist the urge to lean into the stretch and really extend your hip.  Most people are too tight for this, trust me.  You’ll end up stretch out the anterior hip joint and abdominals more than the hip flexor.
  • Make sure you incorporate a posterior pelvic tilt.  Contract your abdominals and your glutes to perform a posterior pelvic tilt.  This will give your the “true” stretch we are looking for when choosing this stretch.  Many people wont even need to lean in a little, they’ll feel it immediately in the front of their hip.
  • If you don’t feel it, squeeze your glutes harder.  Many people have a hard time turing on their glutes while performing this stretch, but it is key.
  • If you still don’t feel it, lean in just a touch.  If you are sure your glutes and abs are squeezed and you are in posterior pelvic tilt and still don’t feel it much, lean in just a few inches.  Our first progression of this is simple to lean forward in 1-3 inches, but keep your pelvis in posterior tilt.
  • Guide your hips with your hands.  I usually start this stretch with your hands on your hips so I can teach you to feel posterior pelvic tilt.  Place your fingers in the front and thumbs in the back and cue them to posterior tilt and make their thumbs move down.
  • Progress to add core engagement.  Once they can master the posterior pelvic tilt, I usually progress to assist by curing core engagement.  You can do this by pacing both hands together on top of your front knee and push straight down, or by holding a massage stick or dowel in front of you and pushing down into the ground.  Key here is to have arms straight and to push down with you core, not your triceps.

 

 

I use this for people that really present in an anterior pelvic tilt, or with people that appear to have too loose of an anterior hip capsule.  In fact, this has completely replaced the common variations of hip flexor stretches in all of our programs at Champion.  This works great for people with low back pain, hip pain, and postural and biomechanical issues related to too much of an anterior pelvic tilt.

Give the true hip flexor stretch a try and let me know what you think.

 

 

How to Perform Lower Body Plyometrics

The latest Inner Circle webinar recording on How to Perform Lower Body Plyometrics is now available.

How to Perform Lower Body Plyometrics

This month’s Inner Circle webinar is on How to Perform Lower Body Plyometrics.  In this presentation, I demonstrate the different types of plyometric exercises you can perform for the lower body and show some of my favorite progressions.

This webinar will cover:

  • The different types of plyometric exercises you can perform for the lower body
  • How I progress from two leg to one leg drills
  • How I progress different planes of motions
  • The keys to choosing the best exercise for your goal

To access this webinar: