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Archive for the ‘athletic trainer’ Category

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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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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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.

Enjoy!

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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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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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There was an article in the New York Times recently entitled Sports Injuries: When to tough it out.

The part of the article that stood out involved diagnostic testing. Here is a quote from the article:

“Sometimes going to a doctor for a diagnostic workup can be precarious, with scans that can show all sorts of apparent abnormalities and injuries that are not causing any problems.

For example, in a study reported at a recent meeting of the American Orthopedic Society, Dr. Matthew Silvis, an orthopedist in Palmyra, Pa., did M.R.I.’s of the hips of 21 professional hockey players and 21 college players. They showed abnormalities in 70 percent of the athletes, even though these hockey players had no pain or only minimal discomfort that did not affect their playing. More than half had labral tears, rips in the cartilage that stabilizes the hip.”

“M.R.I.’s are so sensitive,” Dr. Musahl said. “They frequently show little tears or fraying everywhere. And it is very, very common to have a small labral tear in your hip — it doesn’t mean you have to have the particular symptoms.”

The same is true for rotator-cuff tears, rips in the tendons that help stabilize the shoulder. Studies have found that about half of all middle-age people with no shoulder pain have these tears, although they are unaware of them and have no symptoms.

Testing certainly has it’s place but it is important to understand that testing is only one piece of the puzzle. The assessment, symptomatology, mechanism of injury, and experience also play a critical role because:

  • Hockey players are going to have hip labral tears
  • Baseball players are going to have labral fraying
  • Middle aged people are going to have degenerative changes
  • Assembly line workers are going to have tests positive for carpal tunnel and rotator cuff tears
  • Individuals over the ages of 50-60 are going to present with lumbar spine pathology
  • And so on…

And all of these test results could appear in someone who is completely asymptomatic.

It gets interesting when the individual reaches threshold – when symptomatology now presents itself.

Here are a couple of examples to consider from several years ago – both involved individuals diagnosed with carpal tunnel syndrome.

  • One individual fell on their wrist and aggravated their wrist. Within about a week of developing symptoms, an EMG was done and the test came back positive for CTS. So…in 1-2 weeks someone is going to go from not having CTS to now having it???
  • A individual was having significant wrist and shoulder pain – a recent flare-up. They were previously diagnosed with CTS via EMG (chronic case). With the latest flare-up in symptoms, another EMG was ordered since it had been awhile from the previous EMG.  Here this individual was in pretty severe pain and the new EMG results were…EMG results were improved from previous testing and were now within the “normal” range. A person who is in pretty severe pain now is being told that they no longer have CTS???
  • Add your own story or example here.

Everything is fine when 2 and 2 equal 4. It starts to get dicey when things don’t add up as easily. Again, the assessment – the symptoms- mechanism of injury – and your experience as a clinician play a significant role in bringing together the full picture.

As a young athletic trainer, I was under the impression that MRI and other diagnostic testing were the final determinant regarding someone’s injury status. Years of experience, research, professional discussion, and lots of “huh??? This doesn’t make sense” moments have changed that thought process over the years.

Diagnostic testing does have it’s place but it is important to keep testing in the proper perspective. It is a piece of the puzzle and requires putting the other pieces together as well. Diagnostic testing does not slam the door on the case necessarily – plenty of detective work needs to be done so that the entire case can be properly evaluated.

What are your thoughts? Have you had similar experiences when diagnostic testing and reality weren’t quite meshing?

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Any time you attend a conference, you are going to learn some things and unfortunately you are simply going to be unable to retain all of the nuggets shared. So while you do pick up some new skills, there will be some valuable pieces of information that get missed.

So with that being said, the other day I received my DVD copy of the Optimal Shoulder Performance course I attended in November. While watching it, I experienced one of those “I completely missed that” moments. It involved proper execution of the sulcus sign.

For those unfamiliar with this test, here is a video showing execution of the test:

One of the keys when doing this test is head position. In this video, the patient is looking straight ahead – and this is the correct position. Mike Reinold did a nice of job of demonstrating and explaining what can happen if the patient is looking toward the shoulder being tested.

People get curious and want to see what in the world is going on with their shoulder. We, even as the ever educating professional, may even want to show them what is or is not going on with their shoulder and encourage them to look at the shoulder as we do the test.

While this sounds innocent enough, as Mike explains, turning the head causes the upper trap and additional muscles around the shoulder to tighten and tense up. As a result, when you perform the sulcus sign on the patient with the head turned toward the tested shoulder, you most likely will get a negative result. The tightening of the muscles causes motion to be reduced and the real result of the test is possibly altered. Therefore, you could end up with a false negative test while proper execution of the test may actually reveal a positive finding.

Make sure the patient is looking straight ahead as shown in the video. As a result, the shoulder musculature will be relaxed and a true test result will be generated.

One of many great tips on the DVD I figured I’d share. So remember – tell the patient to look straight ahead and relax – you’ll get a much more accurate test result.

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