In clinic, we get a lot of questions about pain because it is the main reason people walk through the door. Today I am going to go through a brief review about pain and imaging. Imaging refers to radiographs (x-rays), MRI, and CT scans. These are typically used to help a medical provider determine what is causing the pain and the best intervention to resolve the problem.
What do we know?
Here are a couple things to consider:
Imaging is a critical tool that we use in specific situations, but it is rarely the first tool we use in diagnosis.
When we refer for imaging, we use these guidelines:
The best brace that is the most difficult to put on
At SPC, we use the SERF strap a lot. It is a useful tool that can be applied for short term, volume increases when breakdowns occur. It can be used for pain for the ankle, knee and hip. The strap helps by controlling the hip into internal rotation and adduction and therefore can prevent excessive hip adduction, internal rotation, knee valgus, or too rapid pronation and tibial internal rotation.
But it is hard to put on. So I made a video to help.
Today we are going over the basics of the plank that we use in our strength training methodology. Let us know what you think.
Tuck Jump Assessment: A review of our recent publications and the impact on physical therapy, injury screening, and protocol
In the last few months, some of our research efforts in physical therapy, strength training, and injury screening have been published by the Journal of Strength and Conditioning Research and the International Journal of Sports Physical Therapy along with a commentary in the Journal of Sports Science and Medicine. The publications were focused on jumping test performance and the underlying methods.
These tests are useful in a full rehabilitation program to determine readiness for activity, however even the best tests have limitations that need to be understood. There is no such thing as perfect test but we can use a variety of tests to gain a more complete perspective.
After a publication, it’s fun to look back at the results and figure out how to use it to improve the outcomes at Smith Performance Center, which is the major reason our team is involved this deeply in research.
Here is my attempt to unpack the results of two of these papers, explain how we approach jumping tests differently from this work and how it feeds into our model of long term development. I will highlight the commentary on the Modified Tuck Jump Assessment in another post.
Lininger, M. R., Smith, C. A., Chimera, N. J., Hoog, P. & Warren, M. Tuck Jump Assessment: An Exploratory Factor Analysis in a College Age Population. J Strength Cond Res 31, 653–659 (2017).
A factor analysis just sounds confusing. A factor analysis is a useful tool to evaluate the psychometric properties of a test (kinda like the theory and construct of the test, including the validity and reliability). We used it to investigate the structure of the Tuck Jump Assessment which proposed a single composite score along with 5 categories for the 10 flaws (Figure 1).
First, what is the Tuck Jump Assessment? An athlete is asked to perform a tuck jump continuously for 10 seconds. This is recorded from the front and side. The video is reviewed and the rater uses 10 flaw criteria to create a total score. If you demonstrate the flaw during the 10 seconds, you receive a 1. This is done for every flaw. All of the flaws are then added up so you can have a score ranging from a 0 (the best possible score) to a 10 (which means you are a walking ACL tear). I love this test because it makes you work surprisingly hard for 10 seconds. Everyone in our strength training program performs this test.
The creators of the original Tuck Jump Assessment used their clinical and research experience to compile the list of 10 flaws associated increased risk for knee injury. These 10 flaws were then grouped into 5 categories that described the neuromuscular deficit leading to these flaws. As I write this, it seems confusing so look again at the picture showing the flaws with their matching categorization (Figure 1). After scoring the Tuck Jump Assessment, a look at the total number of flaws or at the category with the most flaws will decide which neuromuscular deficit should be targeted first.
What did we find?
Our factor analysis did not fit these categories. Instead we found 3 categories (Figure 2) which we named Proximal Control, Fatigue, and Distal Landing Pattern. This changed how we target problems, which anecdotally has worked better.
The Dynamic Recursive Model of Long Term Development: A key principle in our strength training and physical therapy methodology
Activity brings benefits and risks. Every step, competition or practice is an exposure that impacts the body. The questions - how do I get better and how do I stay healthy - are part a dynamic and constantly changing system (Figure 1). We can model that system to show how the activity, like running or playing football, impact your next exposure.
Figure 1. The Dynamic Recursive Model of Long Term Development: The integration of physical therapy and strength training to reduce injury while allowing for adequate exposure for improvement. Modified from Meeuwisse, W. H., Tyreman, H., Hagel, B. & Emery, C. A Dynamic Model of Etiology in Sport Injury: The Recursive Nature of Risk and Causation: Clinical Journal of Sport Medicine 17, 215–219 (2007).
If you are a runner, you need to run.
If you want to get stronger, you need to lift.
If you want to be a great triathlete, you need to swim, bike, and run.
If you want to shoot well during a basketball game, you have to shoot over and over.
You get the picture (maybe). There are no prodigies (Ericsson 2004). Reaching your potential requires effort and time. However the very activity you participate in impacts the next time you do it. This process is endless until you stop being active or competing in sport.
Dynamic Recursive Model of Long Term Development: What does this model mean?
We get one body when we start our life’s journey. There are things like sex, age, injuries, and how you move that impact your performance along with your risk for having an injury. These are intrinsic factors (Figure 2).
Some can be changed, like your strength while your injury history is what it is. From these factors we can build and analyze our Athlete profile . Previous ACL tear increases your risk for subsequent ACL tear. Ankle sprains increase the likelihood you will have another ankle sprain and a more serious knee injury.
Next we look at the sport or activity. Using football, we can look at the playing surface (turf or natural grass), which change the risk for ACL tear. For Volleyball, we can look at how many jumps are required to participate (more exposure to a high risk movement). These are extrinsic factors, meaning they are external to the person. As you can see from Figure 3, the extrinsic factors impact the athlete during every exposure and can include equipment, game rules, training volume, competition or training, game surface, and shoe wear.
The participating athlete has decided to do an activity. The activity can be anything from running to jumping to a walking program. It can be organized with formal rules, or a random game of tag. The intrinsic factors and extrinsic factors slam together in the participating athlete during the exposure to the activity.
The exposure is critical if the activity is important. You only get better by doing something over and over and over (purposeful or deliberate practice - the topic of another post). You only get significant adaptation from exposures so we want to get as many as possible.
So far, this has been a pretty abstract review. Lets look at an example to make it more clear.
Dynamic Reclusive Model of Runner
I perform running analyses everyday in order to improve performance or get an athlete past an injury. Viewing the changes in muscle action and joint angles of each phase from stance to float to swing phases provides insight into a runner’s performance and problems. The incredible coordination of running is not conscious and lets me get a glimpse of person’s overall nervous and musculoskeletal system. It is a natural process (at least prior to coaching).
But if it is natural, what about it hurts us? Can we analyze your gait in enough depth to figure out why you are hurting?
The truth is that analyzing running gait is not enough. The how and why someone runs with their current pattern or why they may be susceptible to injury cannot be determined by watching them run without checking out other ‘things’. Injury prevention is not as simple as a switch to a midfoot or forefoot (which anecdotally is the most common statement I hear from repeat injury offenders). AND injury prevention is never a clear proposition- it is more of moving probability that you are constantly trying to lower through screening and intervention.
What are these other ‘things’?
We have to dig into the exam, which seems to surprise runners that come to see us because we have a reputation as gait specialists. There have been runners who come in for a running analysis who I do not analyze for running gait because of the glaring problems in the basic exam that must be addressed before we move on to a gait correction. Without a thorough exam, running gait cannot be explained. Sure, I can determine how much pelvic drop is present, but the ‘why’ is missing. And the ‘why’ is critical for injury prevention and overall performance.
Today’s post will give an overview of how to use running analysis within a framework of diagnosis.
At our clinic we dig into 5 general areas:
What is the Speed and Strength Program?
Over the past month, Smith Performance has received numerous requests to start a speed program. We were initially very reluctant to offer this program. We have seen a short sighted view toward athlete development that did not fully mesh with our belief system for training, especially the long term athletic development model we follow (see below). A summer program does not provide a long term vision for a developing athlete, which we believe is critical to fully reach an athlete's potential while minimizing injury. Further it minimizes the foundation of strength for the developing athlete.
Therefore, we decided to add a speed program as a component of our overall training plan. The speed work will focus on running form and technique, as well as acceleration and change of direction. This is not a conditioning program, however the strength component will add this for athletes that need it.
Starting tomorrow, Smith Performance Center is going to be offering Speed and Agility for athletes aged 11-18 years old.
This will take place Tuesday and Thursdays at 3:00 pm or Wednesday and Friday at 1 pm.
Athletes who strength train with us, will be free to lift right after the speed work on Tuesdays and Thursdays at 4:00 pm or on Wednesday and Friday at 4:00 pm. We, at Smith Performance Center, believe strength is a main contributor of speed and encourage you start a strength program along with the speed and agility program.
When does it start?
The classes will run two months and will include pre and post testing to monitor progress. The strength and speed program fit into our long term development program and allow for continued training past the two months if the athlete would like to continue beyond this program.
This program is developed to meet you based upon your current skill level and age. We will be adding new athletes throughout the summer. If you start after June 6, the speed and strength program will still be developed based upon you, not where the other athletes are currently at in their program.
What is the cost?
The price of the Speed Program has a couple options:
1. ) $150 a month if you choose not to do any strength training
(you just meet twice a week for an hour of speed work)
2.) $100 a month in addition to your strength training
(ex - strength train once a week + speed school = $215 a month)
(ex - strength train twice a week + speed school = $250 a month)
If you start after June 6, the cost of the camp will prorated based on when you begin.
What is different about this program?
We will use a combination of performance and injury testing on all athletes. We will also use a high speed biomechanics system to analyze every athletes running form during starts, jogging, and deceleration. The tests will include:
If you are interested in signing up, or if you have any more questions, please email Brian Pieper at email@example.com
Neuromuscular fatigue has been implicated as a significant problem for individuals returning to sport following an anterior cruciate ligament (ACL) injury and reconstruction. Due to the high rate of re injury in those that have had an ACL reconstruction, one hypothesis is that neuromuscular fatigue will negatively impact strength performance, postural stability (single leg balance), and biomechanics during jumping and landing. It blows my mind that a female athlete with an ACL tear is 16 times more likely than a healthy female athlete to tear an ACL again.
The interplay between a previous injury, the resulting changes to the input to the brain, modified motor planning, and re injury is an interesting development in research. Today I wanted to dive a little more into fatigue, the impact on biomechanics, and how physical therapy and strength training can start to augment the problem.
Neuromuscular fatigue is a decrease the ability of an athlete to produce voluntary force in a muscle or group of muscles (McLean), which is combination of central and peripheral fatigue. Peripheral fatigue is a related to muscle damage and metabolic factors distal to the connection between the motor neuron and muscle fiber. Central fatigue can occur anywhere prior to the connection between the muscle and motor neuron (Figure 1). On the surface, quantifying or even getting a clear view of central fatigue seems impossible to examine in detail with any moving or jumping test. When I was reading over all the information on fatigue, I kept imagining when I ran a 400 meter race in track (just a horrible experience). The first two hundred meters felt fine but by the final curve, my ability to run and pick my legs up was basically gone. This fatigue was due to the metabolic byproducts produced from all out effort along with bumping against a central governor.
Should I stop running?
Running related injuries are commonly seen for physical therapy at Smith Performance Center. Unlike some of the advice you may hear, stopping can prolong the problem. Rest does not automatically equal recovery or resolution of an injury. A nice tool to consider learning is the modified low dye. It can help to reduce foot and lower leg pain while allowing for you to continue training.