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Archive for the ‘Athletic Training Profession’ Category

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.

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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…

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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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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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I received the Journal of Athletic Training in the mail yesterday along with it’s accompanying Supplement to the Journal of Athletic Training.

Now, I’ll admit – in the past, I have paid little mind to the Supplement. Call it ignorance. For whatever reason, I never paid much attention to it. The fact that it simply contained abstracts and not full studies may have contributed to my lack of interest.

So yesterday, as I perused the more than 400 submissions, I realized that this supplement is a worthwhile read. Unfortunately, I have missed out on some great research and information in the past. So in order to not repeat mistakes of the past, I went through and highlighted all of the abstracts of interest. Needless to say, there is research here that will give insights into the prevention, evaluation, and treatment strategies that I maybe did not have previously.

I read a few of the abstracts this morning during my morning reading time and there is some great information inside those pages that flies under the radar a little bit.

So if you have been inclined to discount this issue in the past as I have, I’d encourage you to not repeat that mistake and make an effort to read the abstracts contained within. They’ll challenge your thinking, reaffirm some of your current practices and possibly fly in the face of current strategies you are using. Nevertheless, you’ll be a better professional for taking the time to glean from the hard work of others.

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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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Stuart McGill is one of the foremost experts of the spine in the world. He is an advocate of training the spine while neutral and continually explains to all who will listen about the ineffectiveness and dangers of exercises such as the crunch or sit-up. I have read his material and listened to him speak in the past – he is passionate about proper training of the spine and is truly an expert in the field.

The New York Times has an excellent video of Dr. McGill explaining and demonstrating his four recommended low back exercises:

  • the modified curl-up
  • side plank
  • stir-the-pot
  • bird dog

You may be familiar with all of these exercises but the reason for this post is to encourage you to watch the video and catch all of the “little” tips that he explains.

Many times we have a tendency to hear about or see an exercise and then try to reproduce it with our patients or athletes. This is all well and good but we have to make sure we understand all the little nuances and the tips that really elevate an exercise to be the effective exercise it was meant to be.

So make sure you take a moment to watch in on Dr. McGill’s expertise as he walks through each of the four exercises and shares the proper execution and variations of them.

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