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Archive for the ‘Athletic Setting Posts’ Category

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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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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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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Using the foam roll as method of massage and myofascial release is common in the strength and conditioning field as well as in the fitness and personal training industry. It probably isn’t as common in the athletic training setting, particularly in the injury rehabilitation venue. However, as athletic trainers, w need to become more knowledgable of this modality and how it can effectively help those in our care.

Probably, the first step is understanding what foam rolling actually does. A great way to gain understanding of this process is through the use of analogy.

I’ve heard Mike Boyle speak on this topic and he addresses it in his book Advances in Functional Training. One of the primary roles of the foam roller is to serve as a self massage and self myofascial release. Foam rolling will help to reduce knots within the muscle and prepare it for effective stretching. Mike uses the analogy of a knot in a band. If you don’t roll and remove the knots beforehand, stretching will simply cause the knot to tighten. Rolling removes the knots and allows one to effectively stetch. This is a great analogy and the premise makes sense to me.

However, a colleague questioned this when I shared this analogy with him and he aksed how knots get formed in a muscle to begin with. When you think of a band or a rope, a knot is formed by the strands actually being tied and twisted together. Instead of adhering to each other, a knot actually becomes entangled into each other. Think about your garden hose. The only way to remove the knot in this instance is to feed one part of the band, rope, or garden hose back through the loops until the the knot is completely unwound. Compressing that knot would not really relieve the knot, it may actually make it tighter. This is not really possible to separate muscle fibers and feed them through each other.

So, my colleague’s question caused me to think a little more – while we can’t deny the knots and increased tissue density in these areas, is there another analogy that possibly fits this process better.

So, as I was thinking about this – does a “knot” in a muscle as it relates to the relationship between foam rolling and stretching more closely resemble a ball of dough.

A ball of dough is made up of fibers and is initially tight, dense and inflexible. Stretching a ball of dough in it’s round state is pretty tough and really won’t do much in the way of lengthening the dough. However, as you roll and knead the dough, it becomes more pliable. Adhesions break down and the dough ball begins to become more accepting of change. Once the dough becomes less dense and pliable enough, it can now be stretched and lengthened. Rolling, in this instance doesn’t necessarily “remove a knot” in the tissue in the technical sense but it breaks down aherences, restores muscle density and function, and realigns the fibers into a more workable state. Rolling the dough makes the task of stretching or lengthening the dough much more easier to accomplish.

Ultimately, the point remains the same – foam rolling improves tissue quality, restore normal tissue density and prepares the body for stretching and activity. This is merely a question of semantics. As we explain this strategy to our athletes and patients, does this analogy drive the point home a little more?

This is more of a thinking out loud post. What are your thoughts? Does this analogy work a little better? Do you have another analogy you use altogether? I’m curious to hear your thoughts.

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First, let me say that this idea is totally stolen – I’m not ashamed to admit it. I heard about it from Mike Reinold and Eric Cressey at the Optimal Shoulder Performance course and thought it was an outstanding tip.

This tip will enhance your ability to accurately measure ROM in all joints when using a goniometer.

Simply go to the local hardware store and get yourself a bubble level. (If you are unable to find a single bubble, get a cheap plastic level and take it apart to expose the individual bubble levels). While you are at the hardware store, get yourself some glue. Take the bubble(s) and glue it on your goniometer as shown and you are ready to roll. (Make sure that you put it on the opposite side of the moving arm).

Now, with your newly rigged goniometer, you use the level to determine your measurement baseline. So instead of trying to eyeball whether the goniometer is properly lined up, use the level to make that determination. Once you are level, get your measurement and you are all set.

The great thing is, by using level to determine your starting point – you will always be accurately comparing apples to apples because you are using the same starting point. You no longer have to guess – level never changes and will give you an accurate measurement every time.

This tip will help you to eliminate measurement error and greatly improve your measurement accuracy.

Anyone currently use this set-up? What are your thoughts?

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I came across a newspaper article promoting a youth baseball clinic in West Michigan over the weekend. The fact that former Tiger great Jack Morris was going to be there caught my eye but in reading of the article, some quality injury prevention tips jumped out at me.

There was something in particular that intrigued me. I don’t believe I have seen this before and figured I’d share it with you:

“Do not follow pitch counts just by game, but also by inning, Page said.
“Some studies show that in youth baseball, every pitch thrown after the 25th pitch of an inning will count as two pitches from a stress standpoint. Each pitch after 35 pitches counts as three pitches,” he said. “If a young pitcher throws 45 pitches in one inning, it can actually mean as much as 75 total pitches from a stress and fatigue standpoint.”

As a high school umpire myself, a kid throwing 25,35, or 45 pitches in an inning is not necessarily rare. So this injury prevention tip really resonated with me.

Let’s say you have two pitchers:

  • Pitcher from Team A throws 75 pitches in 5 innings.
  • Per inning breakdown is 21, 10, 13,16, and 15
  • Pitcher from Team A throws 75 pitches in 3 innings.
  • Per inning breakdown is 22, 34, and 19

By looking at the total pitch count, each pitcher has thrown the same amount of pitches.

Let’s examine this a little more closely using the formula presented by Andrew Page in the article.

  • The pitcher from Team A threw 75 total pitches and the equivalent of 75 pitches.
  • The Pitcher from Team B threw 75 total pitches and the equivalent of 84 pitches.

So if you look at these numbers for the “total work” that was done in the game and then extrapolate them to the revised Little League pitch count rules (applying to a high school aged player), this would dictate an extra day of rest between pitching for the starter of Team B – even though the same number of pitches were thrown in the game.

Here is another sign of fatigue mentioned in the article to look for during the course of the game that will probably correlate with the inning pitch counts as well:

“Some visual cues Page noted include: “Loss of control and velocity of pitches, more time taken in between pitches, pitching mechanic changes such as the glove side arm dropping to the side, lateral trunk tilt and head pull to the glove side and shortened stride length.”

As I wrap up and look at this a little more broadly, we are really looking at work to rest ratios. The more work that is required and the less rest that is given in between “reps” if you will changes things. Throwing more pitches in an inning certainly has the capability to promote increased fatigue in a pitcher. As fatigue sets in and muscles begin to shut down, mechanics change and the opportunity for injury increases.

So combining the pitches per inning strategy as well as watching for the visual cues of fatigue appears to be sound advice when dealing with young pitchers.

Putting the whole picture together will be more effective in helping our young athletes avoid injury.

What are your thoughts? What are some of the studies that discuss pitches per inning? Do you agree or disagree with this premise?

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As I stated a while back, I have re-read Hoppenfeld again and of course “new” material is being highlighted that was not previously highlighted.

I just recently finished the chapter on the knee and there was a multitude of information that was great review and I found very interesting.

Let us look at the ligaments of the knee briefly – specifically that lateral and medial collateral ligaments.

We are all unfortunately aware of the unhappy triad. While not nearly as devastating as it was 20 years ago due to surgical advances over the years, there is no denying the severity of this injury.

As we simply look at the structure of the knee, we can begin to understand why the medial collateral ligament and medial meniscus are involved in these type of injuries. Obviously injury mechanism is paramount but anatomy is also important to this discussion.

First off, the medial meniscus is attached to the upper edge of the tibial plateau by small coronary ligaments. Secondly, the medial meniscus is attached to the medial collateral ligament. Thirdly, the medial meniscus is somewhat mobile but nowhere near as mobile as it’s counterpart, the lateral meniscus. Fourthly, the medial collateral ligament is a part of the joint capsule of the knee which can subject it to greater stressors.

As we compare and contrast the lateral side of the knee, there are some significant differences. Again, not understating the mechanism of injury but reviewing the anatomy gives us a great starting point.

As we look at the lateral meniscus and lateral collateral ligament, we’ll first see that the lateral meniscus is attached to the popliteus muscle but not the lateral collateral ligament. So right off the bat, we have a structure in the lateral meniscus that is more mobile than it’s medial counterpart. Secondly, as we examine the lateral collateral ligament, we realize that this ligament is independent of the joint capsule. This can help to explain why the lateral collateral ligament is more readily palpable while the medial collateral ligament is not.

Maybe it has been a while since you reviewed the anatomy of the knee but these reviews can give us refreshed insights into the structure of the knee and will help you in your knowledge of the evaluation and treatment of injuries.

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