Strength Training for Runners

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

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

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

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

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

Let’s simplify running a little more.

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

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

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

 

Strength Training for Runners

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

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

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

 

Running on Resistance: A Guide to Strength Training for Runners

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

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

 

 

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! 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 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 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 use of biofeedback is the belief that the patient should begin use their own “electrical system” as soon as possible through volitional contraction.  

The concept known as 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 of 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 over activity, a light weight 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 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 normal neurological function of the inhibited muscle group.  Don’t allow decreased EMG function 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.

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.

 

 

 

Measuring the Position and Mobility of the Patella

Measuring the position and mobility of the patella is still a very important component of my clinical examination of the knee.  It gives me a great sense of soft tissue restrictions that may be present when patellar hypomobility is noted.  This is especially common after knee surgery.  But measuring patella mobility is also important to assess generalized laxity when patellar hypermobility is observed.

The first time you feel either of these during your clinical exam, you’ll know what I mean.

But if you read through the literature, you may find conflicting results regarding the validity and reliability of assessing patella position and mobility.

The Reliability of Measuring Patella Mobility

One study that I reference often is a systematic review by Smith, who looked at the reliability of assessing patella position, specifically in the medial-lateral position.  Like any examination technique that is commonly performed, it is necessary to establish that the test has adequate intra-rater and inter-rater reliability. The test needs to be easily replicated and produce accurate results both between two different clinicians but also when repeated during re-evaluation with the same clinician.

Otherwise, the test may have limited use and not be able to provide helpful information.

The authors conclude the intra-tester reliability is good to assess medial-lateral patellar position, but inter-tester reliability was variable.  The variability is interesting to me and makes me wonder if we just aren’t standardizing how we look at patella mobility.

Another study by Herrington demonstrated that a group of 20 experienced therapists could reliably measure patellar position.  This tells me that a group of similar trained or skilled clinicians will show greater inter-tester reliability than a randomized selection of clinicians.  When I see that a test has good intra-tester and worse inter-tester reliability, I think one of two things:
The test is difficult to perform and/or is more accurate with more experience.

Reliability can be enhanced if we all use the same examination techniques. There may be subtle differences in techniques that may produce poor inter-tester reliability. This is what came to my mind when the Herrington study showed good inter-tester reliability with a group of experienced clinicians.

The Validity of Measuring Patella Mobility

In regard to validity of the measurements, the authors conclude that the criterion validity of this test is at worse moderate, based on limited evidence.  However, a couple of interesting studies were referenced.  A study by McEwan demonstrated that a lateral tilt of the patella greater than 5 degrees can be detected.  This was confirmed with MRI measurements.  The previously reported study by Herrington also reported that medial-lateral patellar position could accurately be measured as confirmed by MRI measurements.

A Simple Way to Measure Patella Mobility

It appears that clinical measurements of patellar positions can be both reliable and valid.  While intra-tester reliability, or your own ability to accurately repeat a test, appears to be more accurate, inter-tester reliability may be enhanced with a standardized examination technique.

Taking all this into consideration, I honestly do not try to “measure” patellar position.

I will assess the position but I do not try to place a label, such as millimeters or degrees, on the exact position.  If I want or need this information, I would much rather obtain this from a MRI.  I focus more on assessing the amount of hypomobility or hypermobility.

And there is a really simple way that we can do this that I think will great enhance our reliability.

To simplify this measurement, I try to just use a percentage of the patella that I feel can displace.  Here is how I do it:

  1. I break the patella down into 4 equal segments representing 25% of the width of the patella each.
  2. I visually try to establish where I believe the midline of the trochlea is located when I am measuring position.  If I am measuring displacement, I will visualize the edge of the lateral trochlea.
  3. I then measure the percentage of the patella that is positioned beyond the midline of the trochlea and then displace the patella and attempt to determine if 25%, 50%, 75%, or 100% of the patella can displace beyond the lateral edge of the trochlea, as in the image below:

Measuring the Position and Mobility of the Patella

I’ve learned over the years that knee experts, such as Dr. Frank Noyes, consider 50% displacement to be “normal.”  I use that as a frame of reference, but comparing side-to-side is probably even more important.

I feel that this provides me with plenty of information to compare to the other extremity and simplifies the process, which I hope would enhance intra- and inter-tester reliability.  If we all do it this way, I think we’ll be far more accurate.

What do you think? Is this too simple? How do you measure patellar mobility?

 

How to Perform a Thorough and Systematic Clinical Examination – Part 2

The latest Inner Circle webinar recording on How to Perform a Thorough and Systematic Clinical Examination – Part 2 is now available.


How to Perform a Thorough and Systematic Clinical Examination – Part 2

This month’s Inner Circle webinar is on How to Perform a Thorough and Systematic Clinical Examination – Part 2.  In this presentation, I discuss some of the concepts behind how to structure an excellent clinical examination process.  This will assure that you are always following a systematic process to detect an structural and functional issues, and that you can easily create a plan of treatment to help the person reach their goals.  This is part 2 of 2 and will focus on the objective, assessment, and planning portions of the exam.

This webinar series will cover:

  • The 4 main buckets of any clinical examination process
  • How to assure you follow a systematic approach each and every time
  • How to look for structural pathology, as well as find any suboptimal areas of function that may be related
  • How to take your exam and make an effective assessment and treatment plan

To access this webinar:

 

 

How to Perform a Thorough and Systematic Clinical Examination – Part 1

The latest Inner Circle webinar recording on How to Perform a Thorough and Systematic Clinical Examination – Part 1 is now available.


How to Perform a Thorough and Systematic Clinical Examination – Part 1

This month’s Inner Circle webinar is on How to Perform a Thorough and Systematic Clinical Examination – Part 1.  In this presentation, I discuss some of the concepts behind how to structure an excellent clinical examination process.  This will assure that you are always following a systematic process to detect any structural and functional issues, and that you can easily create a plan of treatment to help the person reach their goals.  This is part 1 of 2 and will focus on the general concepts and subjective component of the exam.

This webinar series will cover:

  • The 4 main buckets of any clinical examination process
  • How to assure you follow a systematic approach each and every time
  • How to look for structural pathology, as well as find any suboptimal areas of function that may be related
  • How to take your exam and make an effective assessment and treatment plan

To access this webinar:

 

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.

 

 

Want 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.

 

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? If you want to learn exactly how Lenny and I return people after ACL reconstruction be sure to check out our acclaimed online program on the Evaluation and Treatment of the Knee.

 

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.