Notes from Kevin Wilk's "Coffee and Cases" Sold-Out ACL Workshop
MORE ACL?! Yes, I agree, we are battered with ACL rehab information, and physical therapists like to believe we got it down. Well. We don't. Why has the prevalence stayed the same all these years? We have a lot to learn, but here's some information to make your rehab as efficient as possible. Don't take a shotgun approach!
During the APTA Combined Sections Meeting, I got to wake up at 530am to attend Kevin Wilk's "Coffee and Cases" workshop on the ACL. Here's some key points. I'd like to credit him for ALL this information, and that you can access his information for free on his website at www.kevinwilk.com.
Before we talk about the rehab process, we MUST understand the surgery itself. If you have not seen one, I recommend Youtubing it. This post will go more in-depth.
To start, an ACL surgery can not replace the angle of a native ACL graft. If you look at the picture below (sagittal view of bisected femur), notice how posterior the ACL is within the condyle of the femur. During ACL surgeries, a hole is drilled into the femur, but it will not mimic the original angle (it will always be more anterior).
Because of this, surgeons often do the anterior drawer test after the graft is in to check sturdiness. It will test negative, however due to the new angle of the ACL, lachman's test may often test positive.
Next we look at graft options:
- Patellar: This graft tends to heal best because it is bone-tendon-bone. The bone can better fuse with the tibia and femur. Additionally, it is the most common graft used for the youth.
- Hamstring: This graft can be very long allowing a surgeon to fold it multiple times to make it twice as strong as your native ACL. Due to them taking it from your own hamstring, you can not be aggressive early on because the hamstring can not assist in stabilizing your knee due to the surgical trauma.
- Achilles: This is often taken from another body (cadaver), and is the strongest. Although it is the strongest, it has poor healing potential compared to the other because it is not of your own body. It failed in 44% of active people, and is 4x likely to fail compared to an autograft (from your own body; patellar or hamstring).
Next, we discuss the surgeons. There are GREAT surgeons who have great outcomes due to their experience in the surgery and the rehab process itself. However, here are some stats:
- 147,000 ACL reconstructions performed a year.
- 85% of surgeons who perform these surgeries only do 10 ACL reconstructions a year.
- #1 reason of graft failure is that the angle of the ACL graft not optimal
Next we talk graft healing. Ligamentaization is when the tendon of the graft actually turns into a ligament. In 12-months post-op, only 50% of the tendon is ligamentized, yet that is the same time most athletes return to sport. Looking at the slide below, we see that it is nowhere near the strength of the native ACL if you multiply all the grafts' strength by .50.
What about the achilles graft? Yes, it is just as strong, however remember that it does not heal as well as the other as mentioned earlier. At 2-years the grafts may be 70-100% as strong as the their maximal strength.
So what's this all mean? both for someone going through surgery, or a physical therapist rehabbing it, LATE STAGE REHAB IS KEY! Once protocol allows, you have to load it right and get it moving in proper progressions of velocity.
Below are some clinical pearls in rehabing throughout all stages:
- You have to get swelling down in order to get extension. Key during early rehab is to decrease swelling and get that extension.
- To get extension, prone with leg hanging off the table is not optimal as the hip may rise causing the knee to be slightly bent.
- Mobilization may not be best because the capsule in that area is so thick. Instead, stretch and manage inflammation.
- NMES is still a very good way to get the quads working, both in the literature and clinically.
- To get the quads activated, do closed chain knee flexion with the knee at 60 degrees isometrically. This has the maximum EMG activation of the quads, and puts nearly 0 stress on the ACL.
- You can use the leg press between 45-100 degrees. Yes, you can have them squat, but most people can't squat properly. Are you really going to teach them a squat while they are recovering from a knee surgery?
- Brain imaging shows inhibiton of the cerebellum and motor cortex on the contralateral side of the affected knee. Doing some exercises with their eyes closed can train these areas of the brain as they will get a better sense of their body.
- Prehab shows substantially better outcomes for quad strength, however it's hard to decide whether people should use their insurance visits before surgery or after.
I hope that helps you rehab your knee, or you rehab your patient's knee. Additionally there's A LOT of new ACL research coming out. If you're on Twitter, join the talk. I recommend following Dan Lorenz, Tim Hewett (he has 3 accounts...just follow 1), and Amy Arundale. Here are some of the discussions going on:
- Research showing fatigue DOES NOT increase risk of ACL tear. There's only a few studies showing small correlation. This will likely be a debate or session at CSM 2018.
- Perturbations during gait training does not decrease secondary ACL tear 1-2 years after reconstruction. I would still incorporate static balance exercises, since there's a lot of evidence to show proprioception decreases after ACL reconstruction.
- Return to sport for ACL should be a 2-year plan. This is controversial as athletes get paid millions to compete, with a few people not having secondary ACL injuries. However, there is some very interesting debate about it.
What You Should Watch: How to Teach the Single-Leg RDL
One of the most common exercises done wrong is the Single leg RDL. People have their hips way too open which works the adductors rather than the hip extensors. EXOS provides a great regression for people to understand the movement. This is one of my staple exercises to get them doing loaded reps.
What You Should Read: Environmental Adjustments for Behavior Change
Healthy behavior is hard. Everyone knows the benefits of good eating habits. It's the behavior aspect that is hard to change. Check out the NSCA's article on some adjustments you can make.
Click the picture above or the link here.
Got FOMO? Review of Conference Season So Far.
This month's newsletter is going to sum up some of my favorite presentations this season. So far, I attended the SF Giants Sports Medicine Conference and also the NSCA Southwestern Regional Conference. These are main points that I jotted down. Please don't hesitate to contact me for the actual literature and powerpoints if you want to take a look at them. I do not take credit for any information or content; those materials were put together by the hardworking presenters.
SF Giants 3rd Annual Sports Medicine Conference
- Throwing is not a good thing; it's not natural and is actually very bad for the shoulder and elbow. With that said, athletes have to do it so we have to work to preserve the tissue and athlete.
- Athletes who play baseball more than 8 months in a year are 5x more likely to injure their shoulder or elbow. Athletes need to have off-season or play different sports. Playing multiple sports has actually been shown to increase athletic performance while preventing overuse injury, especially for developing youth athletes.
- As throwing velocity has increased over the years, so has Tommy John surgery. Trauma and damage are common, and not because of a certain throwing style or pitch; it's simply due to overuse. Not only do we have to manage this through pitch count, but assess training methods to dose both volume and intensity correctly.
- Don't tell the youth athletes to keep throwing hard, and don't use all the special velocity programs being sold. Each year a youth athlete ages, they throw 1.5 mph faster. Each inch they grow, they also throw 1.2 mph faster. Increase in throwing velocity is not the training that may be increasing speed, it's just a part of the body maturing. It can also be due to proper strength and conditioning of the entire body.
- There are salesman out there claiming their amazing patented weighted-ball programs increase speed. They are having kids throw upwards of 7 pound balls for training. Research has only studied programs with 4-17 ounce balls, and even at these weights, athletes have high injury risks. Athletes are 27% more likely to injure themselves using weighted balls. There was no significant difference in velocity, yet in 6 weeks there was a 10 degree increase in range of motion (external rotation of the shoulder). Although that sounds good, 10 degrees is an insane amount for a youth athlete to gain within 6 weeks. This means tissue is nearly at failure and being stretched too aggressively due to these programs.
- Tubing and light dumbell programs have shown to safely and significantly increase ball velocity without the risk of weighted-ball programs.
He presented a few studies showing the results of increased velocity through select programs as an alternative and safer way for athletes to increase velocity in conjunction with proper strength and conditioning.
- When throwing a ball lighter than a baseball, a huge amount of stress occurs. Imagine how painful it is to throw a wiffleball as fast as you can. Although studies show less stress is caused by heavier balls, that stress still occurs over a long period of time which still equates to risk of injury. Meanwhile, lighter balls should not be thrown as a means of training.
- Weighted-ball programs can be used conservatively and carefully to return an injured athlete back to normal throwing speed, but should not be used to increase velocity past normal. There is currently no protocol or proper dosing. Coaches need to get guidance from a physical therapist or qualified strength coach for advice. Better yet, if the athlete is injured, they should be managed by a physical therapist.
- Long toss is very intense on the shoulder. It is okay to perform it, but within a well-capable range; not as far as they can.
- The best program is to play catch rather than throw the ball as fast as they can. An arm care program and strength and conditioning program must be implemented however the rotator cuffs should never be worked until failure.
Rafael Escamillo, PT, Ph.D.
- Rafael has so much amazing research on everything movement that I couldn't even begin to sum it up. If you are interested, just send me an email asking for some content. Most of his current presentations and research has been on overhead athletes. If you are getting into sports PT, they are definitely materials you'll want to read. Definitely an amazing researcher.
Geoffrey Head, RSCC - Managing Fatigue and Team Culture
- The body needs to take care of basic needs before it can focus on other aspects such as performance. Geoff talked about trophic changes in ecosystems and related it to how humans can't expect their body to be ready for high performance, when it is trying so hard to survive. Essentially recovery is just that, givng you body what it needs in order to perform other functions at it's best. These are all prioritized, For example, want great sleep? Hydrate. You can't expect to sleep well if the body is trying to stay awake for you too look for water since it is dehydrated.
- Data is king, but it has to be actionable. Great, you invested in nutrition monitoring and measurements. Now what? Athletes are busy, may not understand what you understand, and need things given to them in a clean format. If you plan to present someone what's wrong with them, simplify it and tell them exactly how to fix it. Additionally, don't present everything at once; prioritize it.
- Athlete's are busy, keep everything accessible. Athletes are busy and have many things going on. If you want them to take the actions you tell them, you have to make things as accessible as possible. Want them to take multi-vitamins? Leave a packet and bottle of water at each of their lockers. Need them to eat a particular condiment? Have it next to their food station, and not around the corner at some designated area.
- Culture is king. Some people will not buy-in, so you may need an extra effort. Remember, no matter what you do you can't affect everyone. Just continue to have things available, and they may give in sooner or later when they have performance problems, they see their teammates buy-in, or they just want to make a change. Geoff collects urine regularly to check hydration levels. He implemented a trophy of a urinal for the person who was most hydrated each week, and for the month they received a "I piss excellence" shirt. This added a component of fun for his team.
2017 NSCA Southwestern Regional Conference
Nick Tumminello, CPT and Nick Clayton, MBA, RSCC - Movement Assessment Testing: Evidence vs. Claims
- There is a lot of evidence that popular movement screens are not valid, and people need to read the evidence rather than listen to "gurus". Many reasons for this exist including low-load and slow testing does not relate to fast-paced sports contexts. Movement Screens can still be useful as a means of interdisciplinary communication, and screening of red flags, which I also talked about in a previous newsletter here (link).
- Personal Trainers are not qualified to treat pain, as they may be missing many red flags. It is best to refer out to a physical therapist and get clearance. Personal trainers need to let their egos go and stop pretending to be psuedo-physical therapists. Inversely, physical therapists should know when to refer out to a personal trainer for general fitness and behavior change. Although PT's like to think they can do it all, personal trainers may be better in weight loss, strengthening, and lifestyle change; PT's may not have time since they're treating patients in pain. Disciplines need to drop their egos and work together to give the patient the best care possible. Referring, picky networking, and trust will build a strong community and career for both sides.
- "Poor" posture does not equal pain. Many in the physical therapy world have adapted this concept, and trainers are now being taught this. Acute and neurological symptoms can be due to posture, however there is substantial evidence that "improving" posture does not decrease pain. People need to get away from analyzing and working posture claiming their "system" is the best and previous trainers suck. Instead, trainers need to focus on what they do best...getting people to move. The point was not to say trainers are useless, but it's to say exercise is medicine. What they do works to relieve pain at times, however not for the reasons they think; so stop the bogus guru claims. Additionally as mentioned, back pain could be cancer so they need to be sure to refer their clients out before exercising if any pains exist.
- Don't spend so much time on "special" correctives. People claim their special correctives can fix lives, yet the problem usually isn't stretch this or strengthen that. Nowadays in the general population, it is more of a motor control problem. It's not the correctives that are effective, it's the movement in general compared with proper motor learning structuring.
Brandon Beamer, MD - Orthobiologics: Surgical Alternatives for Sports Injuries
- Stem cells (specifically BMAC) are being used to promote growth of tissue in areas and individuals with poor tissue restoration potential. Stem cells are new cells that are produced by the body that have yet to specialize, therefore they can adapt and turn into any cell around the body. Stem cells can be drawn from red bone marrow, often from the pelvis. once marrow is extracted by a needle, it is then put into a machine (centrifuge) to extract multipotent cells. Multipotent cells are the 3rd of 4 stages of stem cell development. They are still able to specialize, but are not as adaptive as the stage one types. Unfortunately stage 1 cells can not be used because they must be harvested from infants.
- It is most often used for bone marrow lesions and restoration of bone. Bone marrow becomes fatty, and therefore yellow, as we age. This can happen faster in some regions of the body. If there is damage on a bone that reaches the marrow, stem cells from a healthier region of the body can be injected into the more fatty yellow marrow. The injected marrow can adapt to the "good" type of marrow and repair the bone and stimulate new marrow.
- Studies show the new bone growth within joints is hyaline cartilage rather than scar tissue. This is a good thing for joints as hyaline cartilage is more resilient and forgiving to joints.
- There is still hesitation to use it on patients with osteoarthritis. Osteoarthritis is the presence of certain cells and chemicals that break down cartilage and bone tissue. Doctors fear that by using stem cells, the stem cells will adapt the features of the damaging cells and actually make the problem worse. There is no guarantee or control of which cells the stem cells will adapt too.
- There is 1 unit of stem cell to 100,000 units of blood. A fair amount is drawn from the pelvis.
- Stem cells can also be harvested from abdominal fat and the fat pad of the knee. Some surgeons may be cleaning the knee and take some stem cells from the fat pad for re-injection since they are already inside the joint for surgery.
- PRP is being injected into sites for faster healing, using a person's own biological material. PRP stands for platelet rich plasma. Doctors draw blood from one area of the body, use a machine (centrifuge) to concentrate certain materials, then inject it into a damaged part of a body.
- All PRP is not made up of the same material. Some are filled with white blood cells, white some are filled with red blood cells. White blood cells attract and promote inflammation and healing. This mixture is often used for tendinopathy and tendonitis. Specific studies on lateral epicondylitis and patellar tendinopathy have been done showing decent results. For osteoarthritis, inflammation actually causes pain, so red blood cell PRP is injected. This acts as a anti-inflammatory. The high concentraion of red blood cells (lacking the fluid volume) enters the site and that signals the body to stop the inflammation process since there are enough chemicals there.
- From over 8,000 studies, the success rate of pain relief is 50%. There were no studies comparing it to corticosteroids. Corticosteroids can damage tendons, and is not biologically produced so if people want to try a more natural option, PRP is suggested.
- PRP is more expensive than corticosteroids, but it is getting cheaper.
- PRP does not restore tissue, it either promotes or stops inflammation to decrease pain and encourage normal tissue healing the body potentially has.
- Pain may be decreased, but rehab and healing time may not differ. There is not documented change of pace in rehab and return to sport after PRP. Protocol and progression is all based on the patient's symptoms.
- Decision to use PRP is dependent on many factors. The doctor takes into account lifestyle, age, goals, and more into account over joint replacements and corticosteroids.
[Originial Content] Lower Body Primers for Optimal Force Production
Primers are an excellent way to warm up the body, while making sure the right muscle groups are activated for optimal performance. These exercises prepare specific muscle groups to move, but are done at a very brisk pace; imagine dynamic warm-ups on steroids. Although they can be tiring, make sure you dose them right to ensure activation of the muscle group, but not fatigue of them.
The Role of Balance
Balance is important for force production because force can only be adequately transferred along a sturdy, rigid, and stable object. If there are wobbly ankles or hips, force coming up is reduced, and muscles above can not produce optimal force without pulling on a sturdy anchor. A lot of these exercises progress through stages of balance and work their way up to the hip. In youth athletes, it's actually recommended that they perform at least 4 weeks of balance training before more dynamic agility and plyometric drills begin. NSCA has published studies that show having a strong balance foundation increases power and force production. Although the studies were for youth athletes, it can be applied to novices or those with poor balance,
Try the primer below. They are ranked in order from easy to hard. Because time may be an issue, feel free to pick 2-3 to do rathet than them all. No rest in between each exercise, but 30-60 minutes rest between cycles is okay. Remember, fatiguing the cardiorespiratory system is okay, but do not fatgiue the muscles; we're merely just activating them. If possible, I recommend doing them barefoot if you're on a forgiving surface.
- Single-leg Stance (30 seconds each leg): pretty straight foward here. Stand on one leg and try to avoid letting your ankles move and fidget. Doing them with eyes-closed, eyes-open on foam pad, and eyes-closed on foam pad are some progressions.
- Single-leg landings (10 each leg): Jump as high as you can, and land with one foot and pause for 2-3 seconds making sure you're completely still rather than trying to survive until the next jump. For regression, decrease the height you jump.
- Ankle bounds (10 each leg): We begin moving into more dynamic plyometric-like exercises here. Only using your ankle, push off the ground as much as you can while minimizing ground contact time. Imagine the ground is on fire. There are arm mechanics here, but because the purpose of this is not speed training, I will not go over it.
- Straight knee bounds (10 each leg): Same as above, but now flex your hip. When you bring your knees up, don't get higher than 80 degrees of hip flexion.
- Lateral Jumps (5 each leg): These are lateral hops, but with pauses (3 seconds). Hop as far as you can twice before switching legs mid-air and landing on a single leg. Pause to ensure you have stability, and then repeat to the other side. To regress, don't hop as far.
- Banded side walks (10 steps each direction): These are just to prime the glutes. Walk side ways, with minimal pelvic and shoulder motion. Stay low with your hips back. Start with the band above your knees, and if it's easy, move the band to the ankle or forefoot.
Once you perform these and get into your power and strength work, you'll feel amazing and ready to go. Below are some videos.
[What You Should Watch] Vision Training for Athletes
If you have not heard about vision training, you need to look it up. Vision training has been around for a long time in the optometry field for learning impairments and treatment of A.D.D. and A.D.H.D. In the last decade, it has become popular in sports to help athletes track objects and people. Although evidence goes both ways on whether it can improve peripheral vision, there is substansial evidence showing that attention and object tracking can be improved. Acuity can not be improved so make sure you have corrective lens via glasses, LASIK, or contacts before you begin training.
Check out the video below for a few exercises by my buddy Shane over at Sensory Speed. I've attached one of their videos explaining what they do. Too lazy to read the scholarly articles? Stephen Curry, Victor Cruz, USA Volleyball, and many other professionals are among people using it with the majority of them in the NFL and MLB. Through the years, SJSU softball did not do too stellar with stats or batting averages. In the last 4 years, they have broken league and school records. The same staff remained, but Sensory Speed was added to take the freshmen through 4 years of training to shatter those records. Non-relavent to sport, but GPA's went up as well. Vision training is here to stay, and Sensory Speed is my preferred company to send them to.
[What You Should Read] Which Supplements Should You Take?
Here's an article by the NY times that makes you think critically of what supplements you should take. People rely heavily on supplements, yet the best athletes in the world don't even take many of them. In fact, D1 athletes are even limted on the amount of creatine they can consume, even when it is one of the most researched and effective supplements. There are some proven ones, but for the most part the field is unregulated and companies make false claims. The NY article sheds some light on which ones to choose and why to avoid others.
See article here: [link]
In addition, here is an older post on ergogenic aids I made talking about popular ones, effectiveness, and amounts you should take:
See article here: [link]
Plyometrics: Training vs. Testing
This month we talk plyometric training. By definition, it means exercises in which muscles exert maximum force in short intervals of time, with the goal of increasing power (speed-strength). Basically power is how much force can you produce in the shortest amount of time? This is different from maximal strength because maximal strength does not account for time; you can go as slow as you want to get to your maximal force.
Many of you already know all of that, so let's go over training power through plyometrics. Many people TRAIN WRONG, because they are TESTING! Check out J.J. Watt jump a 61-inch box in the video below.
A lot of people see this video and will attempt to recreate it, by consistently jumping up a box as many times as they can, however jumping on the highest box possible is TESTING power, not training power. Proper plyometrics training is actually more about how you land than how high you can jump. The benefit of jumping as high as possible for a few reps is that you may develop muscle endurance for that height, not power. Instead, train smart by following the principles below:
- Get triple extension. Triple extension means your hip, knees, and ankle are fully extended. This ensures the training will be directed at all muscle groups that propel you or an object forward. This also maximizes power output. A good exercise for this is to simply jump in place while keeping your lower extremities straight (squat jumps). A great cue is "try to touch the ceiling with the top of your head".
- Keep ground contact time short. The phase between landing and initiating another movement (either the next jump or a sprint), is called the amotorization phase. The shorter this phase is, the faster your stretch and shortening cycle (SSC) can adapt to producing more force. By starting from a low height and practicing short contact time, you will get better motor control for shortening you amotorization phase. A good exercise to get the feeling down is simply jumproping with quick short hops. To progress, increase the height of the hops while keeping the amotorization phase short. A good cue for this is "Imagine the floor is on fire, stay off of it".
- Land quietly. By landing quietly, one is developing muscles via eccentric training. Eccentric training is has been shown to have similar improvements as concentric training. By landing quietly, the muscles feel the need to develop strength to dampen the load. It also teaches athletes how to land safely so that articular cartilage in joints does not get excessively damaged over time. Good cues for this include, "land like a ninja", "land and float on the ground, don't sink", and "land like a spring".
- Land from a higher height. By landing from a higher height AND quietly, one is increasing the load that the body needs to eccentrically load while landing quietly. This principle only works if one is landing quietly and with proper form. If there is a lot of noise from landing, it is a good idea to shorten the height for optimal improvement. This principle is more of a means of progression.
- Rest adequately. Plyometrics develop power which is a high energy task. This taxes the ATP and creatine phosphate energy system of muscles, which takes 3-5 minutes or more for recovery. The point is to give maximal effort per repetition, and not to get fatigued or out of breath.
Try this basic plyometric progression out below
1) Jumprope (work on short ground contact)
2) lateral hops (single of double leg, focus on short ground contact time)
3) Stepping off a 12-18 inch box and landing on two feet (focus on quiet soft landing)
4) Broad jumps (focus on triple extension and soft landing)
5) Depth jumps: come down from a high height (24-36 inches), and jump as high as you can after you land. Keep ground contact time short between landing and max jump
6) Cyclical box jumps: jump on and off multiple boxes while keeping ground contact short
Remember, training power and vertical jump is all about how soft and quiet you can land, and how fast can you produce another movement right after landing, NOT how high of a box can you jump.
What You Should Watch: Shortness vs. Tightness by Quinn Henoch
"My hamstrings are tight". We hear it all the time, and people begin stretching. Now stretching is appropriate if you actually have shortened muscles, however that may not be the case. Dr, Quinn Henoch of Clinical Athlete and Juggernaut Training Systems explains more in the videos below:
What You Should Read: Debunking Bad Exercises by Human Performance Lab
With my clients, I like to teach movement over specific exercises. For example, I teach the horizontal push, horizontal pull, vertical push, vertical pull, squat, hip hinge, rotation, and lunge. We take these movements, and add equipment, lines of pull, and different moment arms to train all muscles that create the movement. This develops independence in the gym and understanding exercises that work specific muscle groups.
Often times, people ask me, "Is this a good exercise?", "Is this a bad exercise?". My reply is always "It depends". This month's read comes from Michael Lau's Human Performance Lab website blog. Click here to read his great post on the matter.
Mike, along with his friends/colleagues Craig and Arash, also created "The Prehab Guys" and collectively post excellent options of exercises selection. They also describe the function for people to better understand movement. Click the picture below to see their instagram page. They are also on twitter and facebook; give them a follow and like!
Functional Movement Screen (For Practitioners and For Consumers)
In the past few years, you may have heard about the "FMS" or Functional Movement Screen. Here's what you need to know about it.
It's a system that looks at 7 particular movements (each graded 0-3) and is used as a SCREENING tool. A screen is not an assessment, but rather a quick observation or tests that may indicate that a thorough assessment needs to be done to see what exactly is happening if severe pain or lack of mobility/stability exists. A total score of 15 or above (out of 21) indicates that the athlete is fairly safe in their movements (low risk for injury during performance). Scores of 14 or less indicate some exercises need to be performed to address deficiencies of the particular movement (they are at a higher risk for injury). A total score can be an indicator for higher injury risk, however individual scores of each movement should be analyzed as well. 0 is graded for presence of pain, and that is when someone should be referred to a healthcare professional such as a physical therapist.
For the practitioner: Should you get certified? For physical therapists, knowledge from your schooling goes well beyond the FMS. Physical therapists learn how to evaluate every part of the body in addition to normal/abnormal movement, not just screen. Chances are you can catch a lot of similar findings through your traditional evaluations in orthopedic outpatient settings by asking clients to perform certain movements. The one thing the FMS is excellent at is standardization. If I told you a patient received a score of 3+/5 on gluteus medius testing, you would understand exactly what I mean: you would know what position I was in, what position the patient was in, how much relative strength was present, and how strong the patient is. Similarly, FMS certified professionals understand each other when they say "patient scored 2/3 on overhead squat", rather than "patient had excessive trunk lean, poor overhead upper extremity mobility, and trouble balancing during overhead squat test". It can be especially valuable in collegiate and professional sports settings. You will have to work with Athletic Trainers and Strength and Conditioning coaches who may be certified through FMS, and assess all athletes coming through. Not only will you be able to be a team player and assist them, but you can speak the same language. It allows for a little more crossover since you will be seeing the same athletes. EXOS (formerly Athletes' Performance) is a company that works with many elite athletes and it's imperative all departments communicate well for the betterment of the athletes. It was not mandatory, but that was a reason I got my certification before I start the internship there.
For the consumer: Someone is certified if they have the letters "FMS" or "FMSC" next to their name, or on their card/resume. It is most beneficial when you are getting assessed for your body composition, weight, etc. This enables to make sure you are good to go for any exercise, and also areas that you can improve on. It is NOT appropriate after you get hurt. It does not help with diagnosing anything. In addition, the FMS certification alone does not teach trainers exercises on how to improve certain weaknesses. Lastly, patient history is huge! The test does not account for a subjective interview of the patient's past history, symptoms, pain, and prior therapy. All these play a huge part in risk of re-injury.
***Clinical Pearl: Train movement in general, not for a movement test. Many times people perform a movement test, and improve it by practicing the same movement over and over as an exercise to refine it. Once they test again, they perform better, but only at that specific movement. It is important to make sure you train movements with similar principles, and then re-test to see if they have truly become better at movement, not just the test.***
What You Should Watch: Hard-Style Kettlebell Swing
The kettlebell swing is an excellent tool for development of power in the hips while quickly engaging trunk muscles to form a strong pillar. Hip power, and fast onset of trunk stability is key in many sports.
When people talk Russian vs. American swing, I will always choose Russian. The American style has a lot of energy leak because momentum freely takes it to the overhead position without any engagement of trunk muscles to stop it. Additionally, you are going overhead in an ADducted arm position, when we know that a key component to normal pain-free overhead movement is ABduction. Lastly, arms overhead increases thoracic extension, and some people can not control their trunk muscles to offset the force that pulls the trunk into extension. "Hardstyle" emphasizes compression of joints and muscles to develop a rigid body with no energy leak at the joints. Notice the thumbnail of the video below, the instructor is at the top of his swing, yet he looks very grounded and tough to move. This is because at the top, the glutes tighten up at full hip extension, the lats are contracted to compress that shoulder joint, and the rectus abdominis (your 6-pack muscle) is engaged to avoid hyper extension of the spine. Watch the video below to see how a hardstyle kettlebell swing should look.
What You Should Read: Recovery Monitoring
This week we look at Andrew Read's article on recovery (here). A lot of athletes want to find out what they can do to be better. They work hard in and out of the gym, and even put in extra hours after scheduled team lifts. The job of a strength and conditioning coach is to primarily get athletes stronger, but equally important is keeping athletes on the field and avoiding burnout. An athlete's job is to stay fresh, while we control how much volume, intensity, duration, and frequency they go through for their whole season and off-season.
Andrew's article goes over a system that helps them monitor their own recovery easily by applying a numerical model to recovery. Every time you work out, you have a negative net balance. Certain recover methods will help you get back to net 0, or even better.
Above is the values of each recovery modality, and the article digs deeper into how athletes determine how much total recovery they need, and timeline of getting to 0. See the article by clicking here.
Building a Strong Base in the Lower Extremities: Using "Rehab" Exercises for the Uninjured Athletes
During my clinical rotation, I was placed at a location with close ties to physical therapy's greats such as Dr. Chris Powers. Dr. Powers taught a closed workshop over the weekend to clinic staff. In most PT clinics, therapists will not get to do actual "strength and conditioning" due to insurances stopping authorization if a patient has met their "functional goal". Instead, we should educate patients on how to incorporate our exercises everyday in a practical manner. Dr. Powers runs a cash-based PT clinic where he is not limited by insurance.
His 2-day workshop was about lower extremity progression. Since other similar work by him is publicly accessible via peer-reviewed journals, I will be discussing how integrate and apply his findings into high level sports performance, rather than repeat what he said. Below are the 5 levels of lower extremity progression from injury to athletic performance by the man himself.
Most clinicians will only get to see Levels 1-3, rather than more traditional core lifts such as deadlift, squat, lunges, etc. On the opposite side, most lifters, athletes, and general public are ONLY doing traditional core lifts and maybe a few from Levels 4-5. In addition, it's probably with poor muscle recruitment (Don't assume all athletes have great form and understanding! They've got other things to put effort into such as the actual game plans). They rarely do anything from Level 1-3.
***CLINICAL PEARL: Dr. Powers suggested fixing the hip before the foot. Although the impairments may be seen on the foot as well, the hips have larger musculature and therefore giving you more bang for your buck in treatment. The foot is still important, but may be fixed if the glutes are addressed. This is different than common belief that injury should be addressed from the bottom up. With that said, keep this pearl in your head, but it is not meant to address every single case.***
The Significance and Application
For the athlete, lifter, general public: You may already be doing Levels 4-5 in addition to bigger core lifts, but it's important to still do certain exercises in Level 1-3. This helps reinforce proper muscle recruitment, and ensures the wrong muscles don't dominate a movement when instability is present. For example, many athletes squat heavy, but when I ask them to recruit their glutes during testing, they end up compensating with their erector spinae, TFL, and quads. This leads to eventual injury, pain, less time on the field, and reduced performance. Do not assume Levels 1-3 are for the weak, but rather those stages are filled with exercises for "prehab" or injury prevention. I recommend choosing 2-3 of these exercises to do at the end of all your workouts, taking no longer than 5-10 minutes (Most athletes only have 1 hour lifts, and as short as 30 minutes during the season). Below is a example template for a 1-hour session for a football player on leg day in-season.
- Hip Flow Warm-Up - (6 min)
- Double KB Cleans (3x5) - (3 min)
- Hang Clean (3x3; 60% max) - (4 min)
- KB Squat (5x5) - (4 min)
- Romanian Deadlift (3x5) - (5 min)
- Reverse Lunges (2x15) - (3 min)
- Side Squat w/ slider (2x15) - (3 min)
- Standing Fire hydrant (2x1 min hold) - (3 min)
- Sidelying Hip Abduction (2x1 min hold) - (3 min)
Notice this total work time is roughly 34 minutes. This accounts for time to re-rack or change weightts and other logistics that occur; final time should be roughly 1-hour even with partners and supersets. As athletes advance, more work time can be added. For in-season athletes we reduce volume significantly, and loads are heavier than hypertrophy and endurance. They are already getting volume at their practices, so overuse and volume need to be addressed in the weight room. No need to run them to the ground. People forget the secondary goal of a strength and conditioning coach is to keep players on the field year around.
***STRENGTH AND CONDITIONING PEARL: During workouts, look at things such as ankle mobility. Always be assessing to see if workout and practices are taking a toll. Stiffness is an indicator that future workouts need to be adjusted.***
For the physical therapist and trainers: We need to educate our patient's on how to program for injury prevention alongside their strength work. Most physical therapists either forget, or do not know how to program exercises. Certified Strength and Conditioning Specilists (CSCS) have it memorized: Warm-Up, Power, Strength, then accessory. The accessory portion is where most PT's live as far as treatment goes, so it's where we have to shine. Cue your patients for good pelvis and scapular stabilty on core lifts, and remind them to include these in their programming even when discharged. Of course you will need to talk to the strength coaches to implement this rather than the athletes; the strength coaches are on your side.
Thanks for reading,
CSCS, USAW-1, ACSM-CPT
What You Should Watch
Mike Reinold is a well-known physical therapist in the sports world, and always produces great content. Below is an older video of his, but is a basic cue and concept most people forget or get lazy with.
For trunk stabilization, we always move from the middle out to our limbs; the trunk must be stable while the limbs move. Once a athlete can keep their pelvis steady in a regular bridge, the next progression is to fire those abs and glutes while moving a foot or an arm. Here are some key points in developing progressions for the bridge:
- Pay attention to where you feel it. You should feel it in your glutes and abs. If you feel it primarily in your back, or hamstrings, then reset at the bottom and fire your glutes and abs before going up.
- It's important to move arms, legs, or both eventually to learn shoulder dissociation and hip disassociation for trunk control. Depending on the sport, one may be more applicable than others, but all should be attempted eventually.
- When moving an arm or a leg, a fully extended limb will tax the trunk more than a bent limb. This is because a longer lever can crank harder.
- For the REALLY advanced person, move one limb from bent to extended repeatedly and quickly to test your stability during high velocity actions. Only go as quick as you can maintain trunk and pelvis stability. Reminder that sports transferability will always triumph sports specificity.
What You Should Read
This month I followed the Strength and Conditioning coaches over at Cal Poly San Luis Obispo led by Chris Holder. If you don't know who Chris Holder is, a quick google will tell you he is the man with a plan. He may be most known for his introduction of kettlebells to pro and college teams, but he is all-around strength and conditioning genius when it comes to programming and mindset.
Below is a article he wrote for Breaking Muscle on his foundations to his programming that have kept his athletes on the field and performing at an unstoppable pace. See article here.
Vien is Doctor of Physical Therapy Student and also a Certified Strength and Conditioning Specialist through the National Strength and Conditioning Association. He has 6 years of experience training youth, college, and pro athletes in 1-on-1 and team settings. He has shadowed several Strength and Conditioning Programs in a addition to having clinical rotations in sports settings.