Health professionals are magnets for those questions that everyone asks in hope of an easy answer. Athletic trainers are not immune. And working in the industrial setting, we may be more inclined to incur the thoughts of inquisitive minds. We often run into folks that are trying to get in shape, trying to be healthy, or just want to be an informed consumer.

Some of more recent questions that you probably have faced recently: “Should I start running barefoot?” “I hear those BOSUs are really good, should I go out and buy one and start exercising with it? And another that has raged for the last while: “What do you think of those Skecher Shape-Ups?”

At first glance – you see an elevated heel which will lead to an anterior pelvic tilt which is not a good starting point. You see an unstable surface  at the heel which is disturbing as well. And then you examine the claim that walking in these shoes will help promote toning, etc.  While I would certainly want someone to walk and move around versus sit around and watch TV all day, walking is not the best exercise vehicle on the planet when related to strengthening and fat loss, etc. and I am less than convinced that these shoes will somehow elevate walking to some elite exercise status. So, I am already skeptical.

So I came across this review that I figured I’d share with you so that you can add this information in your memory bank and use it however you see fit the next time someone asks you about these shoes.

It is important to stay informed and be able to give information when asked. People look to us for sound advice and when we can back it up with facts and research, this certainly adds to our credibility.

Here are some recent random thoughts and musings:

  • Anyone interested in Detroit Lion’s Quarterback Matthew Stafford’s Beighton Score? I’d be really curious to see what it is. With 4 injuries in the last two years and all four injuries being ligamentous in nature, I’d just be curious to see what it is.
  • Mulligan techniques are probably my favorite manual therapy technique. We indicated, they work like magic. If you have yet to incorporate these techniques into your repertoire, you are missing out. Best CEU course I ever attended because I was able to take back some principles and instantly apply them.
  • I am puzzled about the new Affordable Care Act that is part of the health care reform legislation. Part of that legislation involves Flexible Spending Accounts. For those of you not familiar with what a Flex Account is – in a nutshell, an employee can have money deducted from his/her paycheck (tax-free) and use this money towards non-covered medical expenses. Such examples would be eyeglasses, dental work, prescriptions, and more. Well, one of the great benefits is that one could buy over the counter meds via this account. So you get the pre-tax benefit as well as not having to buy OTC meds out of pocket – you simply tap into you Flex account at any time and there you are. Well, not anymore. OTC meds will no longer be able to be reimbursed (unless you have a prescription from a doctor- huh?). So an act that actually makes it more expensive for an individual and actually pushes someone to the doctor increasing medical costs is part of the Affordable Care Act?!?! Way to take something that has been a tremendous asset to the individual and totally mess it up.
  • Lots of great webinars on Strength and Conditioning Webinars.com – good investment if you looking for some final CEU spending this year or planning for next year.

Take care and have a great week!

Here are some items that I came across recently that I thought may be of interest to you:

  • The standard Pallof press (or cable press) is probably one of my favorite exercises. Well, Nick Tumminello has taken this exercise and added to it. He has taken the traditional exercise and added a frontal plane component and a sagittal plane component making this a tri-planar exercise. Check the links out for great stuff from Coach Nick.
  • Here is a blast from the past – this was my review of a phonophoresis study that has been one of my more popular posts.
  • Another blog that you may not have checked out yet is Charlie Weingroff’s blog. Charlie is a DPT, ATC, CSCS and he always has thought provoking material on his blog. Make sure the check it out.
  • Barefoot running seems to be a raging topic everywhere you turn. Here is a blog post on Mike Reinold’s blog discussing this topic. With this topic, and seemingly every other trend in the field of sports medicine, people have a tendency to go overboard. I don’t remember the exact quote from Alwyn Cosgrove but he talked about a pendulum and how people have a tendency to go to the extremes of one side or another and the answer is probably somewhere in the middle.
  • If you are a baseball fan, I am sure you have paid attention to Stephen Strasburg’s injury. What a shame. And yet, do things like this curb the way our youth train and participate in sport – even though they head down a similar path. Eric Cressey has a good write-up on his thoughts about this case.
  • Finally, here is an article that was posted in the local paper this past weekend concerning concussions. I was disappointed in the article to say the least. There were some signs and symptoms and precautionary measures sandwiched between an account of a former player who reportedly played in a game after suffering a concussion and a poll (not a study as indicated) of coaches and how they handle the situation of concussions.  The most shocking thing about the article is that the player said that if they had to do it over again, he would have done the exact same thing. Kids reading that are going to disregard the experts and even the coaches and listen to what a fellow student-athlete says. Please take a read of the article and give me your comments. Am I overreacting or is this a pretty irresponsible piece?

Thanks again, enjoy the great resources, and please share your comments on the concussion article.

The best option?

I read an article in the local paper today that was entitled “A Pain in the Budget: More back surgeries, not improvements.” The essential point of the article was that back surgery is not necessarily the answer to back problems. In a past blog post, I have discussed how diagnostic tests don’t always tell the whole story. And yet a patient presents with a positive MRI result or a patient’s complaint of pain that goes unresolved, surgery is quite often the next option.

I found this quote by Dr. Richard Deyo from the article quite profound.

“Intense pain is not necessarily an indication for surgery.”

If you have heard Mike Boyle speak or read his recent book, Advances in Functional Training, you have probably heard him talk about the 3 I’s. When a patient goes to see a surgeon – there are three options.

  • Ingestion – take anti-inflammatories; if that doesn’t work
  • Injection – if that doesn’t work;
  • Incision or surgery

Those are really the three choices when a patient goes to see a surgeon. Injury rehabilitation may be part of that picture but is not always a given. Essentially, there are three options for a patient with pain that doesn’t subside.

And so that is where the rubber meets the road: a patient presents with pain and the conundrum is what is the best way to rid that patient of the pain. When it comes to back pain, 80 percent of the population will suffer from back pain at some point in their life.  And yet the article alludes to several studies that indicate that 90% of low back pain will heal (or let’s just say the pain will dissipate) on their own.

So what is the best choice? – that is the question.

Deyo went on to offer another great quote:

“Many people have a very mechanical view of how the body works and imagine it is like a car. So if a tire wears out, you’ll just put in a new one. It just doesn’t work that way.”

And yet I think he is correct. Many of us look at our bodies like that. And yet we all know that the replacement parts are not as good as the originals.

So what does this mean for us – I think it means what it always has. We owe it to those in our care to continue to improve our skills and make sure we are providing the best service possible. Some surgery can’t be avoided – we know that. But let’s keep improving – expanding our knowledge and examining all that we can to do best by those in our care.

I’ve always maintained that just because everyone is doing something or just because that is how we have always done things, it doesn’t mean it is right. Just because surgeries, such as spine fusion operations, are on the rise doesn’t mean this is the best option. Let’s keep searching…

I have long had an interest in body’s myofascial system and have pursued continuing education on this subject. I often use myofascial release techniques as part of my treatment programming. One book that helps to lay out the body’s myofascial system and puts it on a “shelf that everyone can reach” is Anatomy Trains by Thomas Myers. (I was able to borrow it from my local library). There is a ton of fascinating information in this book.  It doesn’t speak to technique in regards to the treatment of myofascial release so much as it lays out several “myofascial meridians”.  It lays out these “lines of pull” in a unique way that is relatable and can be put into practice. I highly recommend this book  – whether you have a firm understanding of the myofascial system or if you have little to no knowledge.

Here is a little nugget from the book you can try our yourself:

One little test that you can use as both an evaluation tool and a treatment that helps to demonstrate the integration of the myofascial lines into function involves the region of the plantar fascia. (I tried this myself and the results were undeniable).

Have an individual (again, you can be the model) bend over to touch the toes keeping the knees straight. Pay attention to the resting position of the hands and to how things feel posteriorly. Once you get a baseline, roll the bottom of your foot on a tennis ball, golf ball, or even a baseball. Spend about 3-5 minutes rolling – heel to toes, medial and lateral and be slow and deliberate as opposed to fast and haphazard. Once you have finished rolling, recheck to see how far you can reach on the “treated” side and also pay attention to the level of tightness.

In most cases, you should see some pretty dramatic results. I saw about 2-3 inch difference in reach after rolling. I then repeated on the opposite side and again saw improved ROM.

The point of this particular exercise is to demonstrate how the myofascial system intertwines and how restrictions in a single area can cause decreased function in another region.

The bottom line – if you have yet to delve into the body’s myofascial system, this book is a great place to start. If you think you have a pretty good knowledge of this subject – my guess is that you have yet to see the subject presented in this way.  Regardless, this book will help you gain new perspective and certainly give you more insight as you apply this knowledge to the treatment of your athletes and patients.

As both an Athletic Trainer and a sports official, I was very pleased to see some of the changes that the state of Michigan is implementing regarding concussion management.

Here is a link to a news article covering this story. Here is a link to Michigan’s protocol for handling players with concussions.

In the past, the language regarding an athlete and their participation in a contest after sustaining a concussion was always a little gray. The new language helps to take all of the ambiguity out of the decision making process.

I particularly like the language:

“Any athlete who exhibits signs, symptoms or behaviors consistent with a concussion (such as loss of consciousness, headache, dizziness, confusion, or balance problems) shall be immediately removed from the contest and shall not return to play until cleared by an appropriate health care professional.”

In the instances where a health care professional is not available, this clearly lays out to coaches that if a players exhibits any of these signs, they are to be withheld from competition.

I am unfamiliar with other states regulations but the Michigan High School Athletic Association (MHSAA) has measures for monitoring players that are removed from a contest resulting from a concussion. A report is filed to the State of Michigan following the contest in which an athlete sustained a concussion. The athlete must receive physician clearance to return to participation and if this clearance is not received and an athlete participates, they will be treated as an ineligible player and the contest is subject to forfeit. This is particularly harsh language but certainly drives home the point that any lenience on this issue will not be tolerated.

While many of us still want to see a Certified Athletic Trainer at every school and contest, the likelihood of this happening any time soon is simply not reality. However, I do commend national and state associations for taking concussions seriously and doing what they can to help ensure the safety of high school athletes. The issue of concussions involves a “global effort” and requires involvement from physicians and athletic trainers, national and state associations, school administration, coaches, parents, and athletes. This is a great step in the right direction and I am very pleased the state of Michigan has adopted this new policy on concussion management.

Has your state adopted additional language in support of new federation rules? Has your state included severe penalties such as possible game forfeiture for schools that allow participation without medical release? Please share what your state and local associations are doing to help confront this issue.

Outstanding and Exceptional

Today’s post is a little bit of a challenge. I will briefly discuss a book entitled Outstanding: 47 Ways to Make Your Organization Exceptional by John G. Miller and yet this blog has been unremarkably silent over the last month and half or so. (Not outstanding in the least). But here’s to getting back in the swing of things.

This book is an excellent piece on making your company (whether it is composed of 1 employee or 1,000) better. It speaks to customer service and about how to treat employees and more. While the title specifically talks about an organization, realize that whether you work at the collegiate level with a big staff or if you cover high school football games by yourself on Friday night, you can benefit from reading this book.

Sometimes, I think that those in the field of Athletic Training and Fitness don’t place much emphasis on improving and polishing our “business skills”. Unfortunately, that is a huge mistake. Understanding the human body and the best evaluation strategies and evidence based treatment practices are extremely important, but understanding the principles that will impact your ability to deliver those services are equally important.

Here are a couple of excellent excerpts from the book that give a little insight into how poor business skills can impact service delivery:

Do people fire companies? Yes, they do! I just fired an airline I’ve flown for years, “ Steve continued. “Not just because they left me stranded again in Phoenix for the second time in a month but because of the attitude and actions of the employees. Not only did the people on the ground just say, “Sorry, that’s the best we can do’ while appearing not to care at all, but the attendants on the plane stood in the galley complaining about their own company and other flight attendants. So I fired them and won’t be flying them anymore.

And here is another one:

I entered a coffee and bagel shop one morning and ordered a salt bagel with cream cheese. As an afterthought, I added, “Oh, may I have my bagel toasted, please? Without looking up, the person helping me said, “We don’t toast bagels.” More out of curiosity than anything else, I said, “I’d think a lot of people would like their bagels toasted in the morning.” At that, he stopped his work mid-slice, looked at me, and said, “Sir, if I toasted your bagel, I’d have everybody in her wanting toasted bagels!” This made me wonder, Hmm, would it be so bad to have customers lined up out the door and down the block ready to trade their hard-earned cash for a toasted bagel? I think not!”

So if you have neglected improving your business and customer service skills, make sure you read this book. It is a quick and easy read and full of practical tips that will allow you to become OUTSTANDING!

In case you are looking for an additional resource to add to your research toolbox, you may want to check out the Journal of Sport Science and Medicine.

This journal gives you free access to full text articles in relation to sports, science, injuries and more.

Any opportunity that gets you closer to research and perfecting your craft is a worthwhile investment – this resource simply requires your time to delve into the research.


There was a recent study in the Journal of Medicine and Science in Sports and Exercise that discussed the effect of post-exercise massage on blow flow and lactic acid removal. You can see the abstract here. There is additional coverage here.

Here was one of the key premises of the study:

More to the point, “most people think that one of the main benefits of massage is that it removes lactic acid,” he says, whether such dispersal is important or not. “We wanted to see if massage fulfills” that promise.”

The study wasn’t designed to determine the negative affects of lactic acid (or not) and that is up for debate as well. It was simply to determine if massage improved blood flow and thus helped to remove lactic acid post-exercise.

Volunteers went through a forearm exercise regime that caused muscle fatigue and lactic-acid build up.

Following the exercise: “they either lay quietly for 10 minutes (passive recovery), intermittently squeezed a handgrip at about10 percent of their maximum strength for the same 10 minutes (active recovery) or had their arm massaged by a certified sports-massage therapist for 10 undoubtedly pleasurable minutes. Throughout, blood flow to the forearm muscle of the volunteers was measured by ultrasound, while their lactic acid concentrations were monitored via blood samples.”

Here was the result of the study:

“It turned out that massage did not increase blood flow to the tired muscle; it reduced it. Every stroke, whether long and slow or deep and kneading, cut off blood flow to the forearm muscle. Although the flow returned to normal between strokes, the net effect was to lessen the amount of blood that reached the muscle, particularly compared with the amount that flowed to the forearm muscle during 10 minutes of passive recovery. Meanwhile, active recovery reduced blood flow as well, since muscular contractions, however slight, compress blood vessels in the muscle briefly. But the overall reduction of blood flow was significantly less during active recovery than during the massage session.”

So at the end of the day – massage did not improve blood flow and did not reduce lactic acid significantly.

So does this mean that massage has no benefit. I don’t believe you can come to that conclusion from this study and neither do the authors of the study. They obviously feel that more research is necessary. It is quite possible that there are additional physiological changes that transpire with massage that are not reflected in this research piece.

So…if our premise behind using massage post exercise or post activity is to help improve blood flow and to help reduce lactic acid, then we need to understand that this particular goal of treatment is not going to be accomplished based upon this reasearch.

What are your thoughts on this study? Massage following exercise is still going to be popular – what is the rationale for use? Interested in your thoughts?

There is a presentation in the Supplement to the Journal of Athletic Training entitled Anterior Compartment Syndrome and Tibial Stress Fracture in a Lacrosse Goalie.

This is a case study that: 1)underlines the use of injury prevention techniques to help reduce injury potential, and 2)highlights an unique cause of anterior compartment syndrome, which is generally an overuse-type injury.

In this case, a collegiate female lacrosse goalie sustained repeated blows to her left tibia with a lacrosse ball. She was repeatedly coaxed by the Athletic Trainer to wear proper shin protection but to no avail. The goalie refused to wear proper shin protection until it was too late and ended up anterior compartment syndrome and a tibial stress fracture of the left lower leg.

As a result, she was disqualified from participating in lacrosse in order to allow for proper healing and missed playing time as a result. In the end, a preventable injury ended up costing both the player and the team.

So some lessons learned from this:

    1. We need to be aware that anterior compartment syndrome and tibial stress fractures are certainly not limited to overuse mechanisms – repeated blows can also cause this type of injury
    2. Coaches and players need to comply with injury prevention strategies recommended by the athletic trainer.
    3. We may need to be pretty creative, emphatic,…(add word here) to get people not thinking real clearly to do so – for their own good

      One final comment – as athletic trainers, we need to do our best to find ways to make that decision a no-brainer. Maybe this case study will serve as proof that you can use to help convince those you work with to make better decisions. I am certainly not laying any blame on the athletic trainer – there is an old saying that goes “Those convinced against there will are of the same opinion still” – but for emphasis, let’s try to exhaust every available option outside of brute physical force (sarcasm intended) to drive home the perils of making dumb decisions.

      Thank you to the authors for sharing this case study with us so that we can use this as a teachable moment for our athletes who may not always be looking at the big picture.

      What situations have you encountered where someone has gone against your advice and ended up worse off?