Some great core exercises, good resource links, and a questionable newspaper article regarding concussions

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.

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Have you gotten on the train yet?

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.

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Concussion Management Changes in Michigan High School Sports

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.

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Does Post Exercise Massage Improve Blood Flow and Reduce Lactic Acid?

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?

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Athletes may want to listen to the ATC afterall

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?

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Apophyseal Avulsions at the Pelvis in the Teenage Athlete

The weekend before Memorial Day weekend, I helped to cover a soccer tournament. We have a good group of folks that work together and it is fun to work with a group of athletic trainers in the athletic setting. Usually the event is rather – well, uneventful. Not so this last go around.

Unfortunately the kids were dropping like flies and there were plenty of weekend ending (and more) injuries – fractured clavicle, probable ACL rupture, two nasty concussions, and more.

One of the injuries that occurred on an opposite field from me was a nasty hip injury. We did get confirmation that the player did suffer at minimum an avulsion fracture (my guess is an apophyseal avulsion)- 3rd and 4th hand information is sometimes hard to decipher.

I bring that particular injury up because in the most recent edition of the Journal of Sports Health there is an excellent submission speaking on this exact subject. Here is a link to the study that is complete with radiographs and MRI images.

So let’s take the rest of post to discuss apophyseal avulsion fractures in youth athletes so that we can be more quick to recognize these injuries.

The submission I will look at is entitled Orthopaedic Magnetic Resonance Imaging Challenge: Apophyseal Avulstions at the Pelvis.

The particular case that spurred the research on was a 15 year old soccer player presenting with left hip pain and weakness for 4 weeks. Radiographs and MRI revealed regularities at the ASIS. The diagnosis was an apophyseal avulsion of the left ASIS.

The authors note that apophyseal injuries of the hip and pelvis account for 10-24% of athletic injuries in children. You guessed it – soccer was one of the primary contributors to that figure. Other injuries with higher incidence are running and ballet. Football, baseball, track, gymnastics and cheerleading can also produce simmilar injuries.

When dealing with youth athletes we need to be more cognizant of the bone-tendon-muscle junction. Often times, the weak link in youth is the physis – the myotendinous junction. In adults, the failure point is more commonly in the tendon. So when we see a strain-type injury in youth athletes, we need to be ever cognitive of this dynamic.

As far as the most commonly affected apophyses that we need to be aware of:

• Ischial tuberosity – hamstrings
• AIIS – straight head of rectus femoris
• ASIS – sartorius and TFL
• Pubic symphysis – adductor brevis, longus, and gracilis

Mechanism of injury: The most common mechanism is a sudden contraction (eccentric or concentric) during running, jumping, or kicking which causes traction on an unfused apophysis. Other mechanisms can be extreme passive stretching or microtrauma.

With an acute injury, the athlete may experience a “pop” and immediate pain. Ecchymosis, swelling, weakness and an altered gait are all signs and symptoms.

Often times, individuals may be referred for x-rays. It is important to understand however that if the avulsion is non-displaced or the apophysis is not yet ossified, radiographs may be negative. So, MRI is probably superior in that allows for view of the tendon attached to the avulsed apophysis. If surgery is a further consideration, the authors noted that CT scan is an even better option than MRI.

In regards to imaging, x-rays can show an avulsion at the apophysis if it is ossified. If not, radiographic imaging may be inconclusive. So if this is the case and an avulsion is still suspected – MRI is the imaging of choice.

Now a couple of specific considerations with MRI that the authors relay that are probably handy to note:

• Fat-suppressed T2 weighted and STIR MRI sequences are best for acute injuries
• T1-weighted sequences are more useful for chronic conditions

As far as treatment considerations, nondisplaced avulsions are usually treated conservatively and the athlete can gradually return to activity after symptoms subside (4-6 weeks for resolution). Displaced avulsion fractures of more than 2cm are considerations for surgery, as are malunited or hypertrophied fragments.

Overall, this was an excellent read and something that anyone who works (even if it is only twice a year covering a soccer tournament) with athletes should be aware of. So let me give a few summary take-home points to wrap this post up:

• Apophyseal avulsions are a common injury, especially within that middle school to high school age range athlete
• The most commonly avulsed apophysis at the hip are the ischial tuberosity, AIIS, and ASIS.
• X-rays may be initially negative depending on whether or not the avulsion is non-displaced or non-ossified; so be diligent if symptoms persist, even if x-rays have already been taken, and understand that an MRI may be a more appropriate test
• Understanding the locations of the apophyses and signs and symptoms to watch for will help you make better decisions for your athletes.

The research article has several pictures of diagnostic tests that also give you some additional information as well.

It was an excellent piece that certainly any athletic trainers working with athletes should read and brush up on. I highly recommend that you give it a read.

Have you had any experience yourself with an apophyseal avulsion with any athletes in your care? Does some of the information in this blog post ring true with your experience?

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Does the method of compression when applying ice have any relationship to tissue cooling?

A little over a year ago, I wrote a blog post reviewing a study that compared crushed ice, cubed ice, and wetted ice and their effect on tissue cooling. The conclusion of the study was that wetted ice was the most effective in providing both surface temperature and tissue cooling.

So, if the goal was to produce the most tissue cooling – the choice would have been to use cubed ice and add about a cup of room temp water to get your wetted ice treatment.

Now, let’s fast forward to phase two that will help us even make better evidence-based decisions when we choose ice as a treatment modality.

The most recent edition of the Journal of Athletic Training published a study entitled: The Magnitude of Tissue Cooling During Cryotherapy With Varied Types of Compression.

This study compared the use of no compression, Flex-i-Wrap, and an elastic wrap as compression methods when applying ice. The study looked at both surface temperatures and intramuscular cooling. An interesting side note was that this study utilized crushed ice. (This is not a criticism – simply an observation that we can take into account at the end of the study when developing some take home points of note).

Going into the study we would probably surmise that an ice bag secured with any type of compression would produce greater tissue cooling than no compression. This was largely true but there were some additional interesting findings.

In respect to surface temperature cooling, there was a statistically significant difference with compression using an elastic wrap and no compression. However, there was no statistically significant difference between using Flex-i-Wrap and no compression or Flex-i-Wrap versus the elastic wrap. So, from this we can conclude that compression with an elastic wrap provides the greatest amount of surface temperature cooling. (Although we must also note that skin temperature is not necessarily a direct reflection of what is happening intramuscularly).

When comparing intramuscular tissue temperature at approximately 2 cm below the skin, again compression with an elastic wrap produced greater intramuscular tissue cooling than both the Flex-i-Wrap and no compression.

This to me was a bit of a surprise. I would not have expected much difference in means of compression. Many athletic trainers utilize Flex-i-Wrap or similar type product for several reasons. Apparently, the elastic wrap adds a level of insulation that is not necessarily provided with the Flex-i-Wrap.

Another point that was also driven home in the study I reviewed last year, was that tissue cooling continues after the ice is removed. Ice, in this study, was applied for 30 minutes and the coldest tissue temperatures were measured at 40 minutes post treatment. So the tissue cooling continues for approximately 10 to 15 minutes following ice treatment.

Please read the study in depth – it was well done and again helps us toward more evidence based practice.

So when we look at this study and compare it with the previous study, what sort of best practices can we establish when using ice as a treatment modality?

• Cubed, wetted ice is the treatment of choice – crushed ice is probably the least “effective” in comparing the methods of cryotherapy using ice
• Use compression over no compression – so instead of simply laying an ice bag on an ankle, calf, knee, etc – make sure to secure it with a compression wrap
• Use an elastic wrap as the choice of compression – This method is more effective than using other plastic wrap methods
• Both studies utilized treatment times of 30 minutes so this probably serves as a great reference point as well

Following these evidence-based parameters will help athletic trainers provide their athletes and patients with proven methodologies that will ultimately provide more effective treatment. If you have these elements at your disposal, the research shows these are more effective.

Thanks again to the authors of this study and to David Tomchuk, MS, LAT, ATC, CSCS who took extra time to answer questions that I had about this study.

What are your thoughts? Do this studies change the way you think about the application of ice?

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Transverse Abdominus Activation: A comparison between healthy subjects and those with a history of low back pain

Transverse abdominus has been associated with low back pain and exercises to activate TrA are commonly given to those with back pain. In this particular study in the Supplement of the Journal of Athletic Training, the researchers wanted to see if there was any difference in TrA activation using two selected exercises between healthy and low back pain patients.

There were 30 healthy subjects and 30 subjects with low back pain. It should be noted that the 30 low back pain patients were not currently experiencing symptoms.

The two exercises chosen to target TrA was the abdominal draw-in maneuver (ADIM) and the bird dog exercise. Each subject was familiarized with each exercise and then asked to perform each exercise. An ultrasound transducer was used to measure activation. Three images were taken at rest and during contraction for each of the subjects.

The findings of this study was that both healthy and low back pain patients were able to activate TrA after brief instruction from clinicians. Results also showed no difference of how activated TrA was during the exercises between the two groups.

Is there anything we can get from this study? Here are some things we know and some other “thinking out loud” moments if you will:

• The abdominal draw-in maneuver and the bird dog exercise each activate tranverse abdominus – this was clearly demonstrated in the research
• The sample size is a decent size and helps to lend additional credence to the results
• Since both healthy and LBP subjects were able to activate TrA to the same level, can we still conclude that TrA is implicated in low back pain?
• In that same vain, are the results as valid since the LBP individuals were not currently experiencing symptoms? Would the presence of low back pain have attributed to the inability to activate TrA? It is certainly interesting and worth noting that there were no differences between the two groups in this particular study. In an perfect world, I think it would have been more compelling if the low back patients were currently experiencing LBP but I still think the research is worth noting.
• Does TrA play as big of a role in low back pain as we have been led to believe?

I don’t know the answers to these questions but I think that this study does yield some interesting results. Is it a slam dunk that the inability to activate TrA is or is not involved in low back pain – no, but it definitely helps us to take a step back, evaluate our exercise selection, and our rationale for exerise selection.

Instead of blindly following treatment trends, we can look at the research ourselves, evaluate the results, make informed decisions, and continue to seek new research.

Thank you to the authors for pursuing this research.

What are your thoughts? What has been your experience?

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Does it really matter how fast you move the transducer during ultrasound treatment?

The 2010 Supplement to the Journal of Athletic Training has a vast number of abstracts contained within. Today I want to discuss the abstract entitled The Effects of Ultrasound Transducer Velocity on Intramuscular Tissue Temperature Across a Treatment Site.

Ultrasound is a commonly used, yet maligned modality. As a result, it is important to have studies that speak to it’s efficacy (or lack thereof for that matter) as a treatment and also help to determine parameters for use.

This study aimed to determine if transducer velocity (how quickly the soundhead is moved over the surface) affected intramuscular tissue temperature. Now the authors stated that the general recommendation for soundhead velocity is 4 cm/s and the recommended treatment area is twice the size of the soundhead. Whether the velocity recommendation or whether there was uniform heating within the treatment area were points of interest for this study.

The researchers had 12 subjects and performed continuous ultrasound treatment for 10 minutes at 1 MHz frequency and 1.5 w/cm2 intensity. Intermuscular temperature changes were assessed via sensor probes at 2.5 cm below skin surface. The researchers used velocities of 2 cm/s, 4 cm/s, and 6 cm/s and compared the results.

The study concluded that sound head velocity had no effect on temperature rise during treatment. The other finding in this study was that tissue heating was not uniform across the treatment area. The further away from the center of the treatment area, the less the increase in tissue heating.

Here is an alternate, yet very similar study from 2006 that yielded very similar results. The parameters of this study were very similar. The treatment area was twice the size of the soundhead. This study measured transducer velocities of 2-3 cm/s, 4-5 cm/s, and 7-8 cm/s. Muscle temperature for this study was measured at 3 cm below one-half of the skinfold thickness. Overall, this study showed very similar tissue temperatures between the three tested treatment velocities.

Overall, the one abstract reveals some compelling evidence regarding ultrasound as a treatment. Both studies when looked at together are even more convincing.

So here are some conclusions that we can come to about ultrasound as a treatment based upon both of these studies:

• There were no significant changes in intermuscular temperature from transducer velocities of 2 cm/s to 8 cm/s.
• The further away from the center of the treatment area, the less the intermuscular temperature increase
• Continuous ultrasound at 1.5 cm/2 x 10 minutes in two separate studies produced tissue temperature increases of 4 to 5 degrees celsius
• Intermuscular tissue temperature was shown to increase during treatment from 2.5cm to approximately 3cm below the skin.

So at the end of the day:

• Transducer head velocity plays little role in the elevation of intermuscular tissue temperature
• Treatment parameters of 1.5 cm/2 x 10 minutes of continuous ultrasound seem to be good starting points to deliver muscular tissue temperature increase
• Using the above treatment parameters, you can expect approximately 4-5 degrees Celsius of temperature increase
• The larger your treatment area is, the less the tissue temperature increase at the outer rims of the treatment area.

So as we try to become more evidence-based in our approach, these findings can help us to make more appropriate choices in the use of ultrasound as a treatment modality.

What are your thoughts? Did you find any other conclusions from these studies?

Photo Credit here

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The collision course of youth sports and injury

Our youth athletes are on a collision course to injury due to overuse and ongoing sports schedules. Our culture is so fixated on the more is better mentality that we’ve become blinded to the consequences of the never ending sports season.

Here are just a few examples that point toward this growing problem:

• Last weekend as I was refereeing some youth recreational basketball games, I couldn’t help but notice the knee braces and sleeves that some of these kids were wearing.
• I recently received word that a teenager I know was on the shelf for a serious elbow injury related to pitching.
• Mike Boyle wrote this blog post responding to a question about hockey training in the summer for a 9 year old.
• Mike Reinold wrote a blog post how Little League recently revised pitch counts to be enforced during the 2010 season in both the regular season and tournament.
• Eric Cressey wrote a great piece about how Baseball Showcases can be a recipe for injury.
• Currently, Dr. James Andrews, Sam Bradford, and John Smoltz are promoting their STOP Sports Injuries Campaign.

The bottom line is that the current practices surrounding kids and youth sports are injuries waiting to happen. As athletic trainers, we need to be proactive in alerting parents and kids to the dangers of playing one sport year round, not properly preparing for activity, not allowing time for rest, and more.

Some will listen and heed the advice. Some won’t as there is that great quote: “Those convinced against their will are of the same opinion still.” But nevertheless, we need to keep beating the drum and alerting anyone who will listen about the dangers and long term effects of youth overuse sports injuries.

What strategies are you employing to help combat this problem? What successes have you had? What strategies have not been as successful?

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