An ounce of prevention…

I’ll tell you right now – this is post is a little off topic from my typical posts but still hopefully informative nonetheless.

I must admit – I am a bit of a germaphobe. Not sure when this really came about but this “condition” has gotten progressively “worse” as the years have gone by. I am usually not too far away from the nearest sink and bottle of hand sanitizer is generally well within reach.

So…as we are knee deep into the flu season, cleanliness becomes even more paramount. Well I came across this promotional video (organizations can actually purchase this to promote proper hygiene) about “proper ways ” to cough. I found the video entertaining and informative. Very well done. Then when I go out and view the public, I become mightily disturbed when I see folks out totally butchering proper coughing technique. Call me crazy but my guess is that most people probably aren’t too keen on getting sick – so then why in the world do their hygiene habits leave little to be desired.

I know this is not really a sports med related post but hey, it’s pretty tough to work when you are in bed and unable to move because you have the flu and feel like death warmed over. So put some of these tips to work and better yet – compliment those who use good “coughing technique” and help those with bad technique to get a clue.

Here’s hoping for a healthy holiday season.

Photo Credit by daveparker

Shoulder Course Wrap-Up

This past weekend, I had the privilege of being able to attend the shoulder course presented by Mike Reinold and Eric Cressey. It was an outstanding seminar and those who attended were not disappointed. Mike and Eric are two of the best and brightest in their field and they were able to put their vast knowledge and experience on a shelf “that everyone could reach”. The mixture of rehabilitation and exercise professionals worked seamlessly and really the only thing that stood out – everyone in attendance was trying to learn as much about the shoulder as possible. Thanks to Eric and his staff for opening his facility – they were fantastic hosts (plus the food prepared for us was outstanding) . And also special thanks to Mike and Eric – each is an expert and they did a great job putting together a course that brought fitness and rehabilitation professionals together (what a concept).

The information shared was vast but here were some of my personal takeaways – (click here to see Eric’s recap of the course):

• I=NF/AR (Law of Repetitive Motion); Injury= Number of Repetitions x Force or Tension of each repetition/Amplitude of each repetition x Relaxation time between repetitions
• Total Motion of ER + IR compared between shoulders may be a better measuring stick than simply deficiency in one range or the other: both ranges together shoulder equal about 180 degrees
• Irritation > Inflammation > Fraying > Tearing: It is important to catch problems in the irritation stage; Once the inflammation stage is reached, the rotator cuff quits functioning.
• The posterior capsule probably is not involved in joint tightness as we much as we credit it for; this paper thin structure that can have a light shined right through it is probably not as responsible for joint tightness as we are led to believe
• The “shrug sign” = the rotator cuff is not working
• Don’t work through the shrug sign or through pinch points. People won’t progress through these red flags. Back off – concentrate on symptom reduction, improving inefficiencies, and rotator cuff dynamic stabilization and progress through from there.
• The Beighton Laxity Score can be a nice supplemental test to help you determine laxity of a patient or client; as you measure joint mobility, this series of mobility tests can serve as nice cross-reference
• The scapula and humerus are really like a seal balancing a ball on it’s nose. The seal is the scapula and the humerus is the ball – not much contact area. The function of the labrum really serves to expand that area of contact and give more depth to the joint.
• Internal (anterior) and external impingement (posterior/superior) are completely different – they are assessed via different testing and require different rehab protocols
• Scapular protraction and anterior tilt put the shoulder at risk of injury – retraction and a posterior scapular tilt are goals to move toward when determining rehab protocols and exercise selection
• Rhythmic stabilizations are great techniques to utilize to establish the function of the rotator cuff – this can also serve as a great warm-up to “turn on” the cuff prior to activity
• Serratus and Lower Trap function are very important to the integrity of the rotator cuff; to strengthen the lower trap properly, Y-exercises need to be aligned with the fibers of the lower trap

Obviously – there was a ton more that was taught in this course and I will still be reviewing my notes months from now – this was a brief overview to get those gears in your mind turning.

If you ever have an opportunity to see Mike and/or Eric speak at a seminar, it is well worth it and I’d highly encourage you purchase the DVD from the course once it comes available. Check Mike and Eric’s sites for more details in the next month or so.

What is your focus?

First of all, if you aren’t a member of Strength and Conditioning Webinars, you should really consider joining. There are currently over 18 webinars available and more to come. The presenters are top notch and Anthony Renna does an outstanding job with the site.

Secondly – a couple of related points from two separate webinars on the site:

In listening to an archived webinar by Mike Boyle, he talked about the pain site and the pain source. Two different things – separate entities. In the most recent webinar by Gray Cook, he discussed how you can treat someone and take away their pain but not necessarily take away the problem. Again the pain site and the pain source.

These are great points to remember. Symptoms vs. source and it is so easy to get caught up in attacking the region of pain and we can neglect the true cause. We get so tunnel visioned that we can miss the global picture.

Case in point:

You have someone that complains of left heel pain and has a diagnosis of plantar fascitis. You dig right in and go to town treating the left heel pain. You break out the modalities, the massage, the stretching, the taping, and everything else at your disposal to treat the heel pain.

That’s kind of how we tend to think but as we take a step back, we may find out that this individual is lacking in internal hip rotation or maybe he presents with glute weakness, etc.

So back to the treatment plan – IF the cause of the heel pain is the lack of hip internal rotation or glute weakness, etc – and even though you may alleviate most or all of the pain, have you solved the REAL problem???

So the next time you are performing an assessment – consider not just the pain site but the actual cause of that pain.

Photo Credit by procsilas

No Excuses

One of my favorite all-time quotes is from a former high school coach:

“There are Big C’s and there are Little c’s but there are no C’s like excuseeeees.”

That leads in to today’s post. There was a time when continuing education was probably a bit more challenging to achieve. The providers were fewer than today. Information was somewhat limited to seminars and conferences – text books and magazines – VHS videos -in-services – phone conversations with colleagues and so on. While this did not make learning impossible, it was a little bit of work.

Those days are long gone.

Quite frankly, you can stumble upon more education and information than at any time in history. You can learn more on accident than some could learn on purpose in the past. Because of that – there are no excuses as to not learn something new everyday. Furthermore, there aren’t any excuses to continue to use outdated and archaic methods that the research clearly shows is ineffective.

I can request a book online from my library and have it within the next week in a matter of minutes. I can join a professional website group and have access to more information than I’ll know what to do with in a matter of moments. Blogs have excellent information. Websites have more. I can get unlimited web access to online seminars and more. I can even go to Twitter and find links to great information.

You almost have to not try to learn in order to not learn anything if that makes sense. Unfortunately, there are some that no matter how easy it is will still choose NOT to learn.

For me, it is not an option. Every single day I stare face to face with how much I don’t know. I can’t afford not to try and get better. I hate it when I don’t know the answer to how to help someone. Which leads me to try to find out what? why? when? how? and more.

So bottom line – the opportunities to improve clinically and professionally are unprecedented. The resources that are available to you are just about limitless. Don’t waste the resources that are at your disposal. Make an effort (it won’t take much) to learn something new every day. You’ll be glad you did.

Beyond Four-Way Hip Exercises

Have you ever done this ? Someone has a lower extremity, hip, or back injury/condition. We know(due to the importance of the hips in lower extremity function) that we should probably address the hip in some capacity. As a result, we figure we’ll have them do some four way band exercises for the hip and figure that this grouping of exercises will help to strengthen any glute weakness. Easy enough, right? Well, if you said yes – you aren’t alone. I have made this one size-fits-all “mistake” in the past as well. Are we missing something?

Enter “Dispelling the Glute Myth” by Bret Contreras. This is an article that I recently ran across on www.tmuscle.com and read with great interest. Bret is self-proclaimed glute-fanatic. Not only has he written over 650 pages on glute function and glute exercises but he has also served as his own personal guinea pig taking EMG readings to record muscle activity associated with various glute exercises. Impressive and fanatical in the same breath. You really have to admire someone that would do one of those, let alone both.

More importantly – you have to consider what they have to say in discussing the complexity, function, and appropriate exercise progression with these muscles. A few paragraphs in to Bret’s article and you’ll quickly find that 4-way tubing by themselves probably falls terribly short in addressing the needs of our patients and athletes.

In reading the article, I thought that this was a great nugget from that article:

“If you belong at phase one and start off at phase three, you’ll just end up improving your existing dysfunctional patterns, which will lead to a pulled low back, hamstring, or groin muscle. You’ll have to be the judge as to which phase you start at, but I suggest playing it safe and starting on phase one, spending two to three weeks in each phase.”

Bret gives us a ton of data to consider and even more in the way of exercises to incorporate into our daily practice. I appreciate the progression of exercises and the variety of exercises that are offered in this article alone. If you have been one to simply give 4-way tubing exercises for the hip without much consideration otherwise, make sure you take a moment to learn from Bret’s research. It is at the very least very interesting and at most will help you to strongly reconsider your exercise approach when addressing glute strength and function.

How can a basketball referee possibly be overweight? Part III

I recently spoke with someone who was slightly interested in losing some weight. I say slightly interested because he mentioned more than once that his wife said he should lose some weight. During our informal conversation, I mentioned at least two or three strategies that he could utilize in trying to lose weight. With each suggestion, there was a reason or reasons why he would not (not could not) implement this strategy. This individual subsequently never came back to see me to follow-up about weight loss.

I mention this story because there is that line between those who want to lose weight and those who are actually successful. It is not easy – no question- but here are some of my own insights as to what can help one be successful.

1. You have to decide that YOU want to lose weight. There are many external things that can motivate us. People’s comments. The way we look and feel. Our current and future health status. And so on. There usually are some extra factors that bring us to that point. The key though is that we have to decide to do it. Someone can’t decide for us. Pretty elementary but probably the biggest determining factor.
2. Pay attention to what you put in your mouth. I became acutely aware of what I was putting into my mouth. I knew I needed to decrease my intake and part of that was understanding WHAT I was putting in my mouth and consuming. When I began to understand that, then I was much more aware of how to go about consuming less.
3. As mentioned before, that great quote from Mike Boyle that “Overweight people overeat” is paramount to understand. As a result, you have to start with what is inserted in the piehole. The amount of food that we consume often far exceeds what we need. So when you understand what you are consuming (and you’ll probably be surprised) now you can be more equipped and able to attack how to cut back.
4. Again back to something that really stuck with me that Mike Boyle said. Diet is the hammer and we have already discussed that. I thought about that and the analogy that I formed in my mind was that exercise would be the nail file. In finish carpentry, a hammer is used to drive the nail into the wood but the nail file is used to make the job look better and push the nail below the surface without damaging the wood. So exercise plays a similar function – makes everything look better and function better. But trying to pound in a nail with a nail file would be extremely tedious and extremely inefficient. Exercise helps to bring completion to the process. Using both in combination will provide you with the best results. Otherwise, using one without the other will leave the job incomplete.
5. With exercise in mind, what type of exercise? Cardio, resistance training, where do I begin? The studies and research shows that higher intensity training is much more effective than steady state cardiovascular training. Whether you are talking about interval training or metabolic resistance training, these are much more effective in burning fat and losing weight. As a result, these would be the exercise options of choice – again, if you are trying to lose weight and burn fat.
6. With that being said, the first part is to start with what you can handle. There was no way in the world I was going to be able to go out day one and run 4 miles out of the gait or do a 15 minute metabolic circuit day one. I would have done that one time and wouldn’t have been able to walk for three days. Begin with what you can handle and then build up from there. I simply began walking, then quickly added a walk with an interval of jogging, and then progressed to more jogging with intervals of running and so on. (This is what I chose and worked for me – you’ll need to choose a progression that interests and challenges you). It was a progression however and this kept me injury free on the road to weight loss.
7. With that being said, you do have to challenge yourself. Back to the overload principle. So starting off the first day with 5 minutes of exercise and you handle this fine with no issues and a month later you are still doing 5 minutes at the same level of intensity -  not an effective plan. In order to achieve results, you’ll need to continue to progress yourself through by challenging the body through overload.
8. Know where you are at, set a goal and measure a goal. I had to find out where I was at and where I wanted to end up. Aimlessly saying you want to lose weight but not having a progression and an end goal in mind will get tedious. I set up an ultimate end goal and then on a month by month basis set smaller mini goals. This helped me to stay accountable to myself and did allow me to help track my progress and identify potential areas of improvement.
9. Finally, and probably the most important, seek the professional counsel of folks that know what they are talking about. I’ve read numerous blog posts and listened to webinars, etc from people that are respected in the industry. I’ve done this for my own professional knowledge and personal application as well.  So folks like Alwyn Cosgrove, Mike Boyle, Eric Cressey, and Craig Ballantyne,  and more are outstanding PROFESSIONAL resources that are experts and are able to slice through a lot of the garbage that is out there. Many times we don’t know what we don’t know. As you listen to experts on this subject, the real information and solutions become clear very quickly.

Again, the last point is the most important of the whole group. Seeking good counsel. (And infomercials are not good counsel. The latest talk show may not be very good counsel.) There is a lot of information out there and even more misinformation. Talking to your friends or the guy at the gym is not necessarily receiving good counsel. And this is important because we follow and do what we hear. If we listen to garbage, that is what we will experience. Listen to people that not only know what they are talking about but have helped people achieve these results and that will help you on the path to a healthier you.

How can a basketball referee possibly be overweight? Part II

Today, we live in a microwave society. Even those of us in the health profession can get sucked into this mentality. If it is quick and relatively pain-free, we have a much greater propensity to gravitate toward this than toward things that require sacrifice and discipline.

Exercise, while hard work, often leaves us feeling better and feeling energized. The elevated heart rate and sweat are clear indicators that we have partaken in an activity that has burned some calories and hopefully moved us one step closer to health.

Being disciplined with eating however is a different story.  Reducing our portions and/or eating something healthy as opposed to partaking in our favorite calories-ridden, heart clogging dish can seem downright sinister. There is no real immediate gratification.  You generally don’t jump for glee knowing that you have just deprived yourself of your favorite dish. There is that feeling of being denied something that you really like and that is quite a bit different from the physical and emotional high you receive after exercise.

Yet – again to quote Mike Boyle – “overweight people overeat”. The next time you go to your favorite restaurant, take a look around you and observe the crowd. Observe their physical condition and the portions they are eating. That “experiment” is not meant to be condescending – it is simply a fact.  We consume so much food that all the exercise in the world is going to be hard pressed to make nary a dent in our condition. I have been that person in the booth across from you eating those gargantuan portions and then wondered why the weight just continues to increase.

As I mentioned in my previous post, I have had bouts of exercise where I would exercise 5 days a week in addition to my officiating and maybe lose a few pounds here and there but never really make any significant progress. Why? Because I was still jamming my mouth full of food at just about every turn. I was that overweight person who continued to overeat.

The equation remains simple. Burn more calories than you consume and you will lose weight. Consume more than you burn and weight loss will escape you.

So yes – refereeing can be good exercise at times – but if I remain a bottomless pit, that exercise will not be enough to overcome my dietary deficiencies.

Exercise is an important part of the equation but it starts with what and how much we consume. I use my example of trying to exercise my way to weight loss with little to no success. I know of others that have really tightened the belt on how much food they consume with little to no exercise and have been successful in weight loss. Diet truly is the hammer when trying to make gains in the weight loss battle.

A balance of both is really the best solution and in the next post, I’ll give some of the tips that I have followed over the last few months. Combining diet and exercise to accomplish something that I have spent the last few years trying to be successful at.

In closing, I love this video by Craig Ballantyne demonstrating how diet can completely sabotage exercise. This clearly paints the picture that exercise cannot overcome poor dietary choices. So eat less -eat better – and those two combinations along with exercise will help you on the way to losing weight.

Photo credit by suneko

How can a basketball referee possibly be overweight? Part I

Most of you know that in addition to being a Certified Athletic Trainer, I also referee high school basketball and umpire softball and baseball as well. One of the most common things someone says to me when they find out that I referee/umpire goes something like this:

“Refereeing – that’s pretty good exercise – you must be in really good shape.”

Good shape – as in round – sure. But good shape in terms of lean, fit and conditioned – not so much.

And isn’t this is one of the great conundrums of our time? How can a basketball referee possibly be overweight? Individuals running up and down a court trying to keep with a bunch of teenagers. They’ve got to be in great shape, right? Do they even have an option?

I have been officiating approximately 12 years – I started in my mid to late 20’s and it is very ironic that I was never overweight until – the mid to late 20’s. Now I am not suggesting that refereeing caused my girth to increase but it is a pretty interesting paradox nonetheless wouldn’t you say?

Conventional wisdom says that an increase in activity level should result in weight loss, not weight gain. Sounds perfectly logical, right?

I use the basketball refereeing example to bring across a larger point.

The first thing that we (those in the health profession) typically do when someone wants to lose weight is prescribe some exercise. Increase your exercise level and the pounds will surely come off. As we all know, if you burn more calories than you take in, you will lose weight. Simple enough.

To add further validation – what is the first thing that most people who are overweight say when confronted with their weight issue? “I need to start exercising.” That is usual response.

Well, I have tried this approach as well and have been frustrated more than once with less than desired results. I’d workout on the stair stepper and see some brief initial results but would then quickly plateau and wonder why.

How can this be? I would go from little exercise outside of officiating to doing cardio 4 to 5 days a week and 1 to 2 months in, nary a pound has been lost? I am burning more calories and still not losing weight?

I recently listened to Mike Boyle speak and he said something that really drove home the point – Diet is the hammer when trying to accomplish fat loss, not exercise.

Diet IS the primary mover and shaker when it comes to fat loss and yet, why do we always start with the “secondary” instrument?

In part II, the role of diet and how it applies to our overweight zebra will be discussed and in the series finale, I’ll discuss how I’ve used these principles to lose over 20 pounds in the last two months.

Photo by mikebaird

The Use of a Tuning Fork and Stethoscope to Identify Fractures – Study Review

As an Athletic Trainer, one of the things that I take a lot of pride in is trying to provide those in my care with the most accurate information possible so that they can make the best decisions regarding their own health.

So in light of that, a study entitled The Use of a Tuning Fork and Stethoscope to Identify Fractures in the latest edition of the Journal of Athletic Training was of particular interest.

The study assessed the accuracy of using a stethoscope and tuning fork to help assess the probability of a fracture.

If you are working in a high school or other setting and may not have immediate access to x-ray facilities, this technique may be able to help make your assessment a little more accurate.

Thirty seven people with suspected fractures less than 7 days old were the subjects for this study.

The author used a 128 -Hz tuning fork, a standard stethoscope (conical bell), and an x-ray machine to confirm the findings. The author used the technique on the uninjured limb first and then repeated on the injured limb. The tuning fork was placed on the bone distal to the fracture and the stethoscope was placed proximal to the fracture.

Overall here is a breakdown of the results when assessing 37 potential fractures using the stethoscope and tuning fork method described in the study:

• 10 of the suspected fractures were assessed as positive for a fracture and were confirmed as a fracture
• 20 of the suspected fractures were assessed as negative for a fracture and were confirmed as a non-fracture
• 5 of the suspected fractures were assessed as positive for a fracture but were confirmed as a non-fracture
• 2 of the suspected fractures were assessed as non-fractures but were confirmed as a fracture

Utilizing this method, transverse fractures were the most easily detected. Of the two false negative assessments, one fracture was buckle fracture and one was an avulsion fracture.

All in all, 30 of the 37 (81%) potential fractures were accurately assessed using a tuning fork and stethoscope. Previous studies show accuracies of this methodology at 87% and 94%. Those previous studies assessed fractures of the femur and tibia. This study noted tested a wider range of potential fracture sites.

In this study, I found it particularly interesting that 100% of the potential fractures assessed for the phalanges of the foot (6), phalanges of the hand (6), and metacarpals (3) were assessed correctly.

Overall, this study provides some additional information that we as athletic trainers can keep in our “box of tools”. This information is probably of the highest value to those covering high school and club or recreational events.

The author properly summarizes at the end that a tuning fork and stethoscope cannot and should not be used in isolation when a fracture is suspected. Thorough evaluation and sound clinical judgment must be employed.

In closing, this study does validate the use of this methodology when assessing potential fractures. If this technique can help you to provide better information to your athletes and their parents, the it should be added to your toolbox.

Especially for those potential fractures that are assessed as positive, the reliability of this study gives you some additional firepower if you will to try and convince someone who may be more unwilling to seek additional care.

At the end of the day, this technique should be able to enhance your decision making process so that those in your care can receive the best assessment information possible.

What are your thoughts? Have you ever used this technique before and what have the results been? Feel free to share your experiences with the group.

Photo Credit by Biology Big Brother

Change you – and your patient – can believe in

During the Presidential race, everyone was talking about change. Each side was trying to make their case for why their change was better than the other. We all seemingly want change but do we really put this into practice? Think of one of your patients or maybe an athlete that you are currently working with. They have plateaued or maybe haven’t made any significant improvements at all and yet we keep hammering away at the same exercises hoping something will change.

Are the symptoms any better? Any ROM increases? Any strength increases? Can they do anything today that they couldn’t do a few weeks ago? No? And by the way, continue with your same exercise routine.

Changing up someone’s program can be challenging. It requires thought and attention and sometimes it requires us to admit that we may have been wrong. And in the end…we suffer because we aren’t getting much satisfaction from really helping someone and the one we are treating is confused as to why they aren’t getting any better.

So here are some thoughts:

1. Have a plan with the end goal in mind
2. Measure the plan and determine if you are moving and making progress toward that end goal
3. Reevaluate the plan and make appropriate changes
4. Repeat until you meet the goal (or in some cases,until you have feasibly exhausted every option)

I’ll admit that this is always an area that I have to fight against. It’s real easy to show some tubing exercises to a rotator cuff patient and call it good. They leave treatment in pain because they couldn’t tolerate the exercises and you had nothing better for them. Again, it isn’t easy – be willing to challenge your thought process and work to find what works for that individual patient. Ask questions.  Maybe you don’t know all the answers. That’s okay. Work to find out who may.

He or she will be thankful you did!!!