Three Huge Fitness Mistakes You Might Be Making

3 Fitness Mistakes: Are You Guilty?

We see people in physical therapy on a regular basis that get injured when starting well-intentioned fitness programs.  This is a bit of a paradox for us because injured folks are our lifeblood, but so much of these things can be avoided!   The staff at SSOR is committed to helping you help yourself avoid having to come see us, so here’s three avoidable things you might be doing:

 

1.  Not getting properly screened before starting.  If you’ve been sedentary for a while or are trying a “couch to 5K” plan, it’s a good idea to see your physician to make sure you’re healthy for activity.  Additionally, you should see one of the physical therapists at SSOR to do a musculoskeletal screen of you to make sure nothing is lurking below the surface that will create problems for you down the road. You should be long, strong, mobile, and stable!

2. Starting too fast/too much too soon.  The hot trend these days is do it fast and do it quickly.  However, without a general fitness base, this will inevitably lead to problems.  If you don’t have appropriate joint mobility or have an injury history that may have caused mobility deficits, you’re asking for trouble.  Without proper work capacity/tolerance, fatigue ensues and with fatigue comes poor technique.  Poor technique almost always leads to injury at some point and a visit to the gang at SSOR.  Ramp things up slowly.

3.  Not listening to your body.  May be you’re working really hard and are really short of breath or light-headed.  Your body is telling you to stop, so you should.  If not, at a minimum, reduce how hard you are working or take a break.  Additionally, if you’re having pain with exercise or things during normal daily living start to hurt, it means you may have a problem on your hands.  If that is the case, give the physical therapists at SSOR a buzz and we’d be glad to help get to the root of the problem.

The physical therapists at SSOR are all about solutions, not stop gaps.  We’ll figure out the problem and get you back to doing the things you enjoy doing as soon as possible.  Give us a call, it would be a privilege to serve you and partner with you in your care.

Udoka Azubuike: MCL Sprain

Rehab Guidelines for MCL Sprains: KU’s Udoka Azubuike

The Big 12 tournament is underway and KU hoops star Udoka Azubuike suffered a knee medial collateral ligament (MCL) injury in practice recently.  Of course, like any in-season sports injury, the timing is not good.  Looks like he’ll miss the Big 12 tournament.  So what’s the deal with these injuries, and everyone wants to know, will he be ready for the NCAA Tournament?

KU’s Udoka Azubuike

 

What’s the MCL?

The MCL is a ligament along the medial aspect of the knee.  It’s more of a thickening of the joint capsule, more “sheet-like.”  It is also an extra-articular ligament, or outside the joint.  On the contrary, the infamous anterior cruciate ligament (ACL) is intra-articular, or inside the knee and is more “rope-like.”  There are four knee ligaments that contribute to knee stability, and the MCL helps prevent the knee from “buckling” to the inside.  Here is a comprehensive link on MCL anatomy and function.

Illustration of the medial collateral ligament of the knee.

Illustration of the medial collateral ligament of the knee.

How is it injured?

Most of the time, the MCL is injured from a blow to the outside or lateral aspect of the knee which causes the knee to buckle inward.  However, the MCL can also be torn from an awkward cut or land from a jump.  It can be injured in the mid-substance over the joint line, or off of its bony attachments on the tibia or the femur.  In this case, there are a number of reasons why Udoka Azubuike could have sprained his MCL – could be contact or non-contact.

Possible mechanism for MCL sprains. Here, the knee buckles inward as the athlete makes a cut

Possible mechanism for MCL sprains. Here, the knee buckles inward as the athlete makes a cut

How long do they usually take to heal?

A general rule in sports medicine with MCL injuries is that it is about two weeks of time loss for each grade of tear.  Therefore, with a Grade I tear, expect two weeks out, Grade II four weeks, Grade III tear would be approximately 6 weeks out.  Certainly, this rule is not an absolute as athletes may require more or less time.  Proximal, or femoral attachment MCL sprains, tend to heal a little faster but can stiffen up.  On the contrary, distal or tibial attachment tears tend to heal slower, but typically aren’t as stiff.  All that said, injury history, concomitant injuries, time of season, level of play, and athlete confidence are just a few of several other considerations that affect return to play.  Sounds like the injury to Udoka Azubuike wasn’t too bad, so we’re guessing on the lower end of this general rule.

Why is an MCL sprain a big deal?

As an elite basketball player, Udoka Azubuike is frequently jumping, landing, cutting and changing direction, let alone getting hit from opponents on the outside of the knee.  Given that the MCL provides medial stability to the knee and helps prevent “buckling” of the knee, it’s critical for him that this ligament is doing its job.  Therefore, he needs stability of the knee during these manuevers.  Without it, he could be at risk for a more serious injury, like an ACL tear.  Typically, you want to avoid surgically repairing an MCL unless it’s part of a more severe injury, like a multiple ligament knee injury.  Even then, surgeons usually elect not to fix it and let it heal over time.  After surgery to repair the MCL, the knee stiffens instantaneously and makes rehab a significant challenge.  Best to rehab these injuries at all costs.

Can’t we just brace his knee and play?

Well, it’s not that simple.  No brace can “prevent” any further injury and if there’s any instability or pain, he’ll still deal with that, even if to a lesser extent than no brace.  Certainly, they can help athletes feel more confident that “something” is there to support the knee, but it’s not much more than a “security blanket.”  Remember too that athletes have to be mentally okay with wearing a brace too.  Some athletes just can’t play their sport with restrictions.  They’re not used to it and it’s “different.”  Because he’s a basketball player and the how the timing of this injury isn’t good, we’re guessing he’ll wear a brace for a little extra protection and support.  It shouldn’t affect his play at all should he choose to wear one.

Physical Therapy for MCL Sprains

The rehab for MCL sprains depends of course on severity of the sprain.  The more serious the sprain, the slower the process.  In the case of Udoka, they’ll likely be a little more aggressive because it’s not a bad sprain and the timing of the injury makes return to play of prime importance.  His rehab will likely be pain relief and modality driven to control his pain and get him back on the court ASAP.  With an acute, severe sprain, the athlete is likely to need crutches, a brace, and graded range of motion progression.  Progressing range of motion too fast with this injury may cause more pain and impede optimal healing of the ligament.  In general though, here’s a rehab outline:

  1. Control pain. Icing, compressive wrapping, a knee brace, and use of a crutch or crutches will all help reduce pain and promote healing of the ligament.  Another “training room trick” is to put a medial heel wedge in the shoe of the affected knee.  Effectively, the medial wedge may decrease strain on the healing ligament by compressing the medial joint line, even if only a little.  It’s one of those interventions that is by no means a game-changer, but can help.
  2. Low-intensity pulsed ultrasound (LIPUS). There was a time when ultrasound was used for everything. Therefore, its effectiveness has continually been debated and questioned.  Unfortunately, it has been discarded as a useful modality and this is actually one injury where it may help.  However, there are some good studies supporting the use of LIPUS for MCL healing here, here, and here.  Laser therapy is also an option and can be effective for these capsular ligaments near the surface.
  3. Restore range of motion. The use of a bike, pool, or heel slides are all ways that can help an athlete restore their range.  The optimum stimulus for regeneration of ligaments is modified tension in the line of stress, and tons of repetitions at that.  That is precisely why cycling is a great modality for these injuries.  With more severe sprains, a graded range of motion progression may be done to help prevent over-straining of weakened, painful tissue.  Therefore, an athlete may have 30-90° for a couple of days, then open 10° in each direction every day or two after until full range is restored.  In more chronic cases with pain in specific ranges of motion, instrument assisted soft tissue mobilization can help break up scar tissue and facilitate healing.  There is one study using these instruments for this injury from the Journal of Orthopedic and Sports Physical Therapy that supports use of these tools to facilitate healing.  Just because of pain, it is not recommended to use the instruments acutely.  They’re best suited for chronic injuries/chronic phases of healing.

    Tools for instrument assisted soft tissue mobilization.

    Tools for instrument assisted soft tissue mobilization.

  4. Strengthening of the lower extremity. All sagittal movements (moving forward) should be painless prior to initiation of lateral and rotational movements.  Lunges, step ups, squats, and leg press are just a few exercises that can be utilized. Of course, strengthening the hips should be a part of a comprehensive program for this injury.  One word of caution – hamstring curls can be painful with this injury.  Proceed carefully.  Once straight-ahead movements are tolerated, progressing to lateral and rotational movements should follow.  In Udoka’s case, they won’t be too worried about how much weight he’s pushing – they’ll just be concerned about his ability to perform on the court.
  5. Graded progression of return to sports activities. Forward jogging can commence once range of motion is restored and the athlete has passed strength testing.  Speed will be gradually increased.  45° cuts, shuffling, and 90° cuts would follow, then the athlete would progress to more field or court-based sport-specific drills.  A good progression is non-contact individual drills non-contact team drills, contact drills, then full release to activities.  Udoka may have some discomfort as they expedite the healing process, but as long as he can perform on the court, this phase of rehab will be a quick one!!

Once sports activities are painless and the athlete’s confidence is restored, return to play should be considered.  Regarding bracing with these injuries, it’s really a personal preference of the athlete.  Offensive/defensive linemen might consider wearing it due to bodies crashing into each other and lots of lateral, contact movements.  Unfortunately, these braces sometimes make athletes a target for insidious actions by opponents.  We’ll see – Udoka might wear a brace for some extra support, especially if he’s still having some discomfort or confidence issues with his knee.  The biggest things to consider are 1) can he protect? and 2) can he perform?

If you suffer an MCL sprain or any other knee injury for that matter, look no further than the expert physical therapists at SSOR to help you.  Remember, you don’t need a physician referral to see a physical therapist in Kansas.  It would be a privilege to serve you and partner with you in your care.  We have locations in Overland Park & Prairie Village to serve you.

How to Treat Muscle Cramps

Ways to Treat Muscle Cramps

If you lead an active lifestyle like many of our patients here, at some point or another, you probably got muscle cramps.  Maybe you got muscle cramps in your calves, or maybe in your thigh muscles.  These are painful!  If you haven’t, you’ve probably seen athletes on TV who are crippled by muscle cramps and see the athletic training staff feverishly working to resolve them.  We typically see cramps most often in really hot weather when athletes have been sweating profusely for a long period of time.  They lose lots of water and electrolytes and for all intents and purposes, their muscles dry out like a raisin.  Certainly various mechanisms for muscle cramps have been proposed, but what are some easy things you can do to avoid muscle cramps?

How to Reduce Muscle Cramps

1.  Hydrate, hydrate, hydrate.  A good rule of thumb is to weigh yourself before activity and weigh yourself after.  For every pound lost, you should replace that with 2 cups of water each.  Unfortunately, this takes a lot of discipline!

2. Stretch!  Whether it’s your hamstrings, quads, or calves, easy stretching usually helps reduce these.  If that’s not doing the trick, putting some deep pressure on the muscle can help too.  So, pressure with a foam roll or an athletic trainer/friend can put manual pressure on it.   Typically, this is what is done “on the court/field.”

3.  Consider changing clothes at halftime or during a “break” in the action if you’re soaked.  When you are soaking wet from sweat, the wet clothes won’t allow the sweat to evaporate.  So, having an extra pair of socks, underclothing, shirts/jerseys, etc may help.

4.  Have fluid replacement products readily available.  This is where sports drink companies make their money.  They have electrolytes in them to help replace some that are lost from sweating.

5.  If possible, have IV’s available.   IV fluids are the fastest way to re-hydrate.  Obviously, medical professionals need to be present for this to happen, so this might not be an option in your situation.

6.  Avoid alcohol.  Alcohol is a diuretic (makes you pee!), and if you lose water from a night of drinking before practice/game, you will be more susceptible to cramps.  Similar argument can be made for coffee.  Coffee is fine, just make sure you’ve had plenty of water prior to vigorous exercise.

7.  Stay loose and stretch between games.  Cramps seem to show up when athletes have had a long bout of playing followed by rest/no activity, then playing again.  That said, this is also an issue of hydration.  Make sure you re-hydrate between games to compliment your stretching. Foam rolling and using massage sticks can help with this too, both before and after games as well as breaks in the action.

8.  Recover!  This one encompasses many of the ones listed already.  Young athletes especially have crazy schedules nowadays.  Many sports and activities going at once.  If they don’t “fuel the power plant” with fluids and a good diet, they’re at risk for muscle cramps.  Make sure water is readily available and proper nutrients from a balanced diet help in the recovery process.  Certainly, things like massages are helpful too.

9.  Acclimatize your body.  With air conditioning being almost everywhere now, athletes sit inside all summer and then start practicing outside in the August heat and really struggle.  This is not to say that they need to be outside for 8 hours a day running sprints.  It is to says that in the weeks leading up to starting practices, you should be outside in gradual increments to get your body used to the conditions.

Muscle cramps hurt and can pull you out of activity, often at the worst time.  While there is some debate about what causes them and the best way to treat them, there’s some easy things you can do to help reduce the risk of getting them as well as what to do if muscle cramps happen.  If you have chronic trouble with this, you should consider seeing your primary care physician for more advanced testing.

Muscle cramps or not, our team of physical therapists are competent, skilled, and understand how to help you recover from injury.  It would be a privilege to serve you and partner with you in your care.  Give us a call!

“Must Do’s” After ACL Surgery

ACL Surgery and ACL Rehab

It’s hard to watch a sporting event anymore without seeing or hearing an athlete tore his or her ACL.  U.S. Women’s National soccer player Megan Rapinoe is one of late that tore her ACL.  Rehab after anterior cruciate ligament (ACL) surgery is a long, arduous process that takes several months.   Unfortunately, the internet is a sea of misinformation on what to do/not to do.  It’s littered with various experts, horror stories, and various pundits who all have a different take, which adds to confusion.  Complicating matters further is that everyone seems to want to base outcomes on a professional athlete’s outcomes, or be married to the idea that it has to be a specific time frame, commonly 6 months, prior to return to sport after ACL surgery.  Your ACL rehab should be a collaboration with you, your operating surgeon, and your sports physical therapist.  The purpose of this blog is to emphasize a list of 10 things that must be addressed in your ACL rehab.

ACL tear

Rehab after ACL Surgery:

  1.  Get your knee as straight as possible as soon as possible.  This is critical for proper muscle function as well as normal walking, and for you athletes, running eventually.  Studies have found as little as a 3° loss of extension adversely affects function, so make sure this is a priority.  Furthermore, Paulos et al showed us in the 80’s in a study in the American Journal of Sports Medicine that scar tissue can form in the joint if you don’t get it straight quickly.
  2. Get your quad muscle working.  In order to walk, it is imperative that your quads work correctly.  These are the muscles on the front of your thigh.   These are the muscles you contract when you stretch in the morning and extend your knees.  As soon as you are able after surgery, you should start “setting” the muscle with brief contractions to get it firing. Think of it almost like a heart beating.  A nice tool to help with this is a muscle stimulation.  Multiple studies have shown that muscle stimulation on the quads helps subjects improve gait and quad functioning than those that don’t.
  3. Maximize your bending as much as your physician allows.  Try not to let that knee get too stiff.  Doing either heel slides, sitting at the edge of the bed, or using a bike for range of motion only are some ways you could do it.  Your doctor may get you a Continuous Passive Motion (CPM) machine but studies show it is not required.
  4. Use crutches until you are walking completely normal!  This one is huge.  Amazingly, many physicians tell people to ditch the crutches and then watch them walk out of the office limping.  This may be my biggest pet peeve with physicians.  All eliminating the crutches does is keep your knee swollen, inhibit your quad, and delay your recovery.  Even if you don’t need two crutches, use one on the opposite side of the surgery (yes, the OPPOSITE side) or even a cane until you are walking completely normal.  Trust us – you’ll thank us later.
  5. Focus on single-leg emphasized training.  Several studies have shown that after ACL reconstruction, subjects unconsciously unload their involved leg up to a year after surgery doing squats on both legs (Neitzel et al, Clin Biomech 2002).  Furthermore, they even unload their leg two years after surgery when landing from a box to floor jump (Paterno et al, JOSPT; Chmielewski et al, JOSPT).  So, even though you think you’re symmetrically distributing weight, you are really not.  Therefore, you should focus your training on single leg movements for most of your rehab.  Lunges, step ups, step downs, leg press, and single leg squats should be the focus of your training.  Once you transition to plyometrics/jumping activities, the focus there should also be on single leg movements.  Eventually, to maximize strength, you’ll need to transition to double-leg activities, but only after your sports physical therapist has determined your readiness.
  6.  You must get your thigh muscle mass no more than 1 cm difference than your non-injured leg.  Many people who have chronic trouble with their involved leg long after surgery is often due to not getting their quad mass back.  Persistent pain, swelling, and dysfunction ultimately affect their function.  Many physical therapists fail to actually measure thigh mass throughout the course of rehab.  An analogy is having no shocks on a car, or having half inflated tires.  What do you think would happen with either of these scenarios?  The car would break down faster and have problems.  Well, your knee is no different.  This may take a year or so after surgery to get back, but someone should keep checking.
  7. What you do in front, you need to do in back.  In real estate circles, people talk about “curb appeal.”  Make the house look nice in front – new paint, trimmed bushes, a nice freshly cut lawn.  Then you look at the backyard.  May be a disaster.  The focus on making the thigh muscle bigger neglects the critical hamstrings.  For the recovering athlete with an ACL reconstruction, your hamstrings are your best friend.  They are the “brakes” that limit the risk of the ACL being torn.  Therefore, make sure you do lots of stiff leg deadlifts, exercise ball bridges, ball curls, leg curls, and eccentric hamstring lowers.
  8. You have two legs, balance training needs to be on both legs.  Humans are a bipedal species – we walk and run on both feet.  Balance after an ACL reconstruction is impaired and needs to be a focus of your rehab.  Further, once you have one ACL tear, you are at risk to do the other.  Why on earth would you only do balance work on one leg?  The other one will get jealous for one, and two, why would you possibly set up your “good” one to be a “bad” one and risk a tear in it by not working on balance for that leg too. Therefore, what you do on one, do on the other.  Speaking of balance, if the only balance exercise you do is throwing a ball at a mini-trampoline while standing on unstable surfaces, it’s time to look for a new physical therapist.
  9. Get your heel to your butt!   This is critical for people that want to play sports again.  When you run, your heel needs to get all the way to your glutes to sprint correctly.  Many athletes get their “active” range of motion back (what they can do), but lack the “passive” range.  The passive range is the “extra” range when you pull.  This is illustrated when you stretch your quads.  If you lift your heel up to try and touch your glute, it can’t get all the way up.   That’s the active range.  When you grab your foot and pull it up to your glute, that’s the passive part – the “leftover” slack.  You have to have that to run right.  If not, you won’t be as fast, and you’re at risk for hamstring strains.  There are many techniques to get this back, and it’s more than just cranking on it till it gets there.   You should wait several months (about 4 months post-op) before you aggressively stretch.
  10. Make sure you get tested before you get “cleared.”  The biggest mistake doctors make is telling patients they’re “cleared” without explaining the difference between being “medically” cleared and “physically” cleared.  Unfortunately, it puts the idea in the patient’s head that he’s good to go.  The doctor clears you medically.  They tell you that your new ACL is healed and you have no infections or any reason to stop training/progressing.  However, physical readiness is totally different.  It shocks me how many people get “cleared” to practice/play when no one has ever watched them cut, sprint, or jump on one leg.  At a very minimum, you should perform a series of single leg functional tests to make sure that your involved leg is at least 90% of your uninvolved one before getting released.  Once you do that, then you are “physically” cleared to begin return to play progressions.

Rehab after an ACL surgery is a long process that requires perseverance, dedication, and a lot of hard work.  Maybe more than you have ever done.  While many factors contribute to the outcome and this list is not exhaustive, the things mentioned in this blog should help you maximize your outcome.

It would be a privilege to serve you and partner with you in your care after ACL surgery.  The physical therapists at SSOR have the most comprehensive and thorough treatments and return to play assessments in the Kansas City metro.  Give us a call, we welcome the opportunity to show you! We have offices in Overland Park and Prairie Village to serve you.

Jimmy Graham Injury Rehab

Patellar Tendon Rupture Rehabilitation

Seattle Seahawks Tight End Jimmy Graham ruptured his patellar tendon a couple of weeks ago.  This is a tough injury for any athlete.  It’s a season-ending one, much like an ACL or Achilles rupture is.  Athletes can definitely return from this, but the rehab process is a long one.  So what will Jimmy Graham’s rehab look like?

Jimmy Graham

Function of the Patellar Tendon

The quadriceps muscles converge to form the patellar tendon and it attaches on the tibial tuberosity below the knee.  Basically, the quad muscles lost their anchor. Without that, the knee cannot function. It really is as simple as that.

Patella-Tendon-Rupture

How long is the recovery?

This can take 6-8 months for sure to recover from, especially for an athlete at that level.  The two most significant limiting factors after this surgery are that the range of motion (ROM) is restricted for the first 6 weeks to allow the repair to heal and the other is regaining the quadriceps strength lost from the injury and subsequent period of protected mobilization.  You just cannot run, jump, cut or frankly, walk or ambulate the stairs without strong quadriceps.   Because of the strength and power needed, especially for him, this injury can take a really long time to get the strength back to perform at a high level.

repair

Rehab after the Jimmy Graham Injury

Usually, ROM is restricted for the first 6 weeks or so.  People are often locked in extension for a week or so, then a graded progression of ROM is allowed – 30°, then 60°, then 90° by 6 weeks post-op.  During this time, the patient should have soft tissue work done on the lower body, strengthening of the hips and lower legs, and for athletes, cardiovascular activity can be accomplished with an arm bike.  Quadriceps strengthening can be initiated with some basic exercises and can be enhanced by muscle stimulation to the quadriceps.  Numerous studies have advocated the use of muscle stimulation after knee surgery to facilitate quadriceps strength both in the short and long-term.  Unfortunately, the first 6 weeks is a waiting game for healing to take place.   Another concern along those lines is that the incision is rather long as the surgeon has to “open up” the knee.  Therefore, a proper healing environment has to be facilitated, but patients will also need extensive soft tissue work to break up any scar tissue from the incision.

Once the patient gets the “green light” from the doctor to begin strengthening, the process really kicks into high gear.  Weight-bearing exercises like squats, step ups, and leg press are initiated. Again, these are initiated in graded ranges so as to not stress the repair too much.  Loading increases over time.  Progress is measured by standardized strength testing as well as measurement of the muscle mass.  We like to tell our patients that their “tires need full inflation” before we release them to sports.  If the quadriceps muscles are smaller, athletes are at risk for a host of injuries.  Hopefully, that makes sense.

The other issue after this surgery is getting ROM back, especially end-range flexion.  Most of the time, surgical procedures are the ultimate “catch-22” – you need protected ROM to allow healing, but as a result, patients often battle getting the last bit of ROM due to stiffness/tightness.  Numerous techniques exist to maximize ROM gains, but the bottom line is that you need a physical therapist that provides hands-on treatment to get it.  Ultimately, athletes (and really all patients, but athletes especially), need to be able to get their heel to their glutes.  If not, a whole myriad of issues can surface.

Once adequate strength is restored, impact activities begin.  Athletes need to develop not only power, but neuromuscular control to tolerate landing from jumps as well as cutting during change of direction maneuvers.  Athletes especially have to demonstrate willingness to load the limb during these activities.  An astute sports physical therapist (like the ones at SSOR!) will be meticulous in their evaluation of the performance of these activities to maximize their return-to-play ability.

Will Jimmy Graham come back the same or better after this injury?

We bet he will.  Most athletes have every resource at their disposal to heal and get their bodies right.  It’s just a war of attrition – will he have the resolve to persist and keep working to get back? Only he will decide that.  Like we said above, expect a 6-8 month recover after this one.

SSOR has a goal-oriented population that demands results quickly.  Our staff understands post-operative protocols and more importantly, how to safely yet effectively progress you back to the activities you want to do.  It would be a privilege to partner with you in your care.  Give us a call! We have locations in Prairie Village and Overland Park to serve you.

Peyton Manning Injury: Plantar Fascia Rupture

Plantar Fascia Rupture

National news was abuzz recently when Denver Broncos future Hall of Fame quarterback Peyton Manning recently ruptured his plantar fascia.  Now, anytime you hear the word “rupture” in sports, particularly in someone with Peyton Manning’s fame, it leads the headlines.  Fans are nervous and deflated, the “haters” have a collective chuckle or sigh of relief when the nemesis is incapacitated.  So what’s the big deal with plantar fascia ruptures?

Peyton Manning

What’s the plantar fascia?

The plantar fascia is a thick band of tissue that runs from the heel to each of the toes. Basically, it serves to support the arch of the foot and helps stabilize the foot during gait.  Think of it as a spring that runs from the heel to the toes.

Plantar Fascia

What causes the plantar fascia to rupture?

Any athlete that runs or jumps is at risk for a rupture, but any athlete who spends their time on their toes is at risk too (i.e. boxers, dancers).  Athletes with a history of chronic plantar fasciitis are at risk.  Steroid shots have also been implicated as a contributing factor in plantar fascia ruptures.   It is the very essence of a “Catch-22” with steroid shots – they help with pain and dysfunction, but over time, they weaken the tissue, making it susceptible to rupture.  Risk of rupture after steroid injections has been reported in the literature.

What are the symptoms?

Usually, athletes report hearing and feeling a “pop” on the bottom of the foot.  They may even be able to see and/or feel the fascia rolled up in the foot.  Pain, swelling, and the inability to walk are also signs of it.

What are the problems with a plantar fascia rupture?

Some may perceive that if it’s painful and bothersome, a rupture might be a good thing.  Sometimes it is.  In an athlete though, it could be problematic.  The support on the bottom of the foot is lost and stress fractures may result in the metatarsals, particularly on the lateral side as athletes tend to shift weight to the lateral border of the foot.  At a minimum, the arch is flattened and may result in pain or cause other problems, similar to people that have “flat feet.”

Do you have surgery to fix a plantar fascia rupture?

No.  Sounds crazy, but the tear is left “as is.”  Sounds like a big deal, but it’s really not with a custom orthotic and good rehab.

Physical therapy for plantar fascia rupture

Athletes are typically non weight-bearing for a couple of weeks.  After this initial period, athletes usually transition to a boot and then will transition to shoes once they have normal gait and minimal pain by 4-6 weeks.  Because the support of the fascia is missing, it is critical that athletes get custom orthotics to support the foot.  Additionally, intrinsic foot strengthening is needed to strengthen the arch muscles since the fascia is no longer there to support it.  It is recommended that athletes complete a comprehensive program of proximal hip strengthening, soft tissue work to the foot, and progressive return of functional activities.  Pool exercises are also a great adjunct to land-based treatment.

"Toe Curls" used to strengthen the muscles of the arch.

“Toe Curls” used to strengthen the muscles of the arch.

So how long does it take to get back to sports?  Well, a 2004 study in the Am J Sports Med found that in a group of 18 athletes with plantar fascia ruptures, the average time to return to sport was 9 +/- 6 weeks.  Much of that depends on the sport the athlete plays, the level of competition, as well as the size of the athlete.  Hard to predict at this time when Peyton Manning will be back running the Broncos offense.

The physical therapists at SSOR have treated plantar fascia ruptures and know how to get you back to the activities you enjoy.  It would be a privilege to serve you and partner with you in your care.  We have locations in Overland Park and Prairie Village to serve you.

Jamaal Charles ACL Injury

Could Jamaal Charles’ Injury Have Been Prevented?

The silence at Arrowhead Stadium last Sunday when Chiefs stud running back Jamaal Charles didn’t get up after a play was deafening.  Chiefs fans held their collective breath hoping that he would be OK.  Turns out the fears of Chiefs nation were realized when it was determined that he tore his anterior cruciate ligament (ACL).   He previously tore the ACL in his other knee in 2011 and once again became the stud he prior to that injury once he returned.

Jamaal Charles

The age-old question after tragedy strikes is “could it have been prevented?”   The same is said with many sports injuries too.  Physical therapists, scientists, athletic trainers, and a host of other professionals are constantly researching ways to prevent sports injuries from hamstring strains to concussions to ankle sprains to anterior cruciate ligament (ACL) tears.  Jamaal Charles is an elite athlete and recovered from a previous ACL tear.  He has performed probably hundreds of thousands of the same maneuvers over the last few years since his previous ACL tear.  The play he injured his knee this time was as benign as it gets.  This begs the question if it could have been prevented or if this is just “one of those things” that happens?

Here’s a link to his injury. If you look closely, you can see that after he plants and cuts, his knee collapses inward a little.  That’s when the ACL tore.

How do you tear an ACL?

We know that about 75% of ACL years are non-contact.   We also know from previous studies that there are basically three main ways they tear: planting and cutting, straight-leg landings, and one-step stops with the leg knee fully extended.  Looking at the video, it is evident that Jamaal Charles had the perfect storm – non-contact, plant/cut, straight-leg landing, and one-step stop with the knee extended.

What does the ACL do?

Ligaments connect two bones together.  The ACL resists forward movement of the tibia (“shin bone”) on the femur (“thigh bone”).  The ACL has a huge job – it resists 85% of this movement.  The ACL also protects against too much rotation in the knee.

ACL

Why did it happen?

This is a complex answer.   There are numerous factors that have been linked to ACL tears including neuromuscular, biomechanical, hormonal, and structural causes.  For the sake of not making this blog really, really long, we’ll just talk about Jamaal Charles’ situation.  As stated above, the ACL protects against the tibia or “shin bone” from moving forward too far when an athlete plants, jumps, or lands.  When an athlete does these movements, the quadriceps muscles contract, and this contraction pulls the tibia forward.  The ACL is there to protect that movement.  Previous studies by orthopedist Chuck Henning found that there is a “quad-cruciate interaction.”  He found that with the knee extended, like in Jamaal’s case, the load on the ACL increased significantly, providing 85% of the resistive force.  The equation is pretty clear here – rapid, forceful quad contraction + full knee extension + ACL resisting so much of the force = ACL tear.  Henning also found that with the knee in flexion (“bent”), the strain on the ACL was significantly reduced.   In this position, the hamstrings can help “pull back” the tibia, almost like pulling the reins on a horse.  Because Jamaal’s knee was fully extended, the hamstrings in effect, could not do their job and protect the ACL.  The hamstrings truly are the “best friend” of the ACL.

How do you prevent ACL tears?

Complete prevention or eradication of an injury, like most things, is likely impossible.  We know from several previous studies that the best prevention of ACL tears involves a combination of education on proper landing and cutting techniques, strength training, jump training or “plyometrics,” and balance training (Hewett et al, Am J Sports Med 2006).   Numerous studies have found a reduction in the incidence of ACL tears after structured injury prevention programs were completed (Caraffa et al, Knee Surg Sports Traumatol Arthrosc 1996, Noyes et al, AJSM, Mandelbaum et al, AJSM).

Could Jamaal’s have been prevented?

This is an extraordinarily complicated question to answer and keeps the physical therapists at SSOR up at night wondering if there’s anything that can be done for people like Jamaal Charles and every other ACL tear!  As stated previously, Jamaal Charles has likely done this exact movement hundreds of thousands of times and didn’t tear his ACL.   Why this particular play? Why this cut?  Was fatigue a factor?  Did his muscles and nerves not “react” fast enough to engage the right muscles to prevent this?  Did he not “practice” the “right” way to cut?”  These questions are almost impossible to answer and quantify.  We just don’t know.   Yes, ideally he would have cut with the knee flexed and not straight, but plenty of athletes still tear their ACL with the knee bent too.   As a sports medicine community, the more we know, the more we learn we don’t know.

We’re certain Jamaal Charles will be a work horse in rehab to get back on the field again.  We’re hoping for a successful recovery for him.

If you have ACL surgery, look no further than the physical therapists at SSOR to help you get back to work, life, and the activities you enjoy.  We’ve done it for athletes at the highest levels and can for you too.  Give us a call – we have locations in Overland Park and Prairie Village to serve you.

Top 5 Toughest In-Season Sports Injuries

What Sports Injuries are Toughest to Manage In-Season?

We see lots of athletes at SSOR who are battling injuries during the season.   Some injuries can be played through, others are season-ending, and some are not season-ending, but need time that the athlete just doesn’t have.  Weeks roll on by, the athlete does rehab diligently every day, but well, some injuries just need time to heal.  These injuries can not only screw up a season, but also screw up a fantasy team!   So what sports injuries are the toughest to manage in-season?

time

In-Season Sports Injuries

  1. High ankle sprains. High ankle sprains, unlike the much more common “rolled” ankle or
    inversion ankle sprain, are a giant headache.  We’ve blogged about these injuries before, but this injury just needs protection and time that an athlete doesn’t have.  Figure 3-4 weeks out, at least, with a high ankle sprain.  All the usual rehab interventions for ankle sprains don’t do much to speed these up. High ankle sprains hurt and they’re really frustrating!
  2. Hip Pointer. Oh boy. These babies hurt.  A hip pointer is basically a bruise at the top of the pelvic bone, the iliac crest.  These hurt so much because it’s just about where every abdominal muscle attaches.  Breathing, coughing, and straining even hurt, let alone running, twisting, cutting, etc.   Again, not a whole lot you can do here – need rest and time.
  3. Rib sprains/rib muscle strains/rib fractures. You can’t exactly “cast” a rib or wrap it with an ACE wrap (if you do, you’ll suffocate!).   Even normal, resting breathing can hurt with these.  How exactly do you rest a muscle/bone/ligament that is critical to breathing?   Well, you can’t.  Just need to rest these injuries.  “3b” in this category is abdominal muscle strains – kind of the same idea.  Just to sit up in bed causes an abdominal muscle contraction and that can even hurt!
  4. Hamstring strains. Without digressing into a blog about hamstring strains, these injuries are tough to manage in-season because it’s not so much the healing time as it is the ability of the muscle to tolerate sprinting and full-speed sports activities. The speed of contraction during sports activities is tough to replicate in physical therapy.  Many athletes have good strength and full motion, but only have pain at high rates of speed.  Even with a minor hamstring strain, most athletes are out at least two weeks.
  5. Concussions. We don’t have to tell you how hot of a topic concussions are right now. These are brain injuries.   We can definitely help the healing process with rehab, but ultimately, the brain needs time to recover after a concussion.  Recovery isn’t just about sports – this affects the ability to live.  Athletes struggle to read, sit in class, and watch TV without headaches or bend over without dizziness.

The physical therapists at SSOR know how to best treat the in-season sports injuries.  We’ve managed them for athletes at the highest level.  It would be a privilege to serve you, give us a call!  We have locations for physical therapy in Overland Park and Prairie Village.

Lorenzo Cain Injury: “Bone Bruise”

It’s Just a Bruise, Right???

 

The American League Central-winning Kansas City Royals are steamrolling into the playoffs that get started this week.  Kansas City has been abuzz this week over All-Star centerfielder Lorenzo Cain and the “bone bruise” he’s battling in his knee.  Lorenzo’s tough and it sounds like he’s going to grind it out and make it through the playoffs (hopefully!).  Right now, the Royals are saying it’s a four-week injury.  Seems crazy since it’s “just a bruise” right?  Or is it?

Lorenzo Cain

What’s a bone bruise?

Think of the ends of bones, like our “thigh bone” or femur, as a snow-capped mountain.  The “snow” is our cartilage, the rocky mountain as the bone itself.   Hopefully that analogy makes sense – a softer material covers a much harder material.  Cartilage acts as a shock absorber for our joint.  Healthy cartilage is similar to a wet sponge – it’s imbibed with water and it can be “squeezed” to tolerate loading or compression.  When an athlete gets a bone bruise, there is damage to the cartilage, like tiny little cracks in an eggshell.  The more severe the bone bruise is, the further it extends down the cartilage and sometimes into the bone itself.

snowcapped

How do bone bruises happen?

Bone bruises basically happen when two bones impact each other.  Think two rams butting heads with each other.  They happen when athletes land or cut awkwardly or when they sustain an injury on one side of the joint that causes an injury on the opposite side of the joint.  For example, when the knee “buckles” inward, the inside of the knee “opens” while the outside or lateral side of the knee is compressed.  The compressed side, the two rams, is what causes the bone bruise.   In baseball, they can also happen too from getting hit by a pitch – but that’s more on the “outside” of the bone, not the weight-bearing surface which is more painful.

rams

 

MRI of a knee.  The white area shows the bruise on opposing surfaces.

MRI of a knee. The white area shows the bruise on opposing surfaces.

Why do they hurt so much?

Basically, a bone bruise just makes it painful to play.  It can hurt to run, jump, cut, and land.  Bruises are tender on our bodies, imagine two bones hitting each other!

Will it really take four weeks?

It sure can.  Usually, the medical staff estimates how long an athlete will be out based on how far the bruise extends into the subchondral (below the cartilage) bone.  That can only be determined on MRI, and again, it’s only an estimate.  Some studies have shown they take 12 weeks to heal.  Whereas, some bone bruises, like after an anterior cruciate ligament (ACL) tear, can take up to a year to heal.

Can you speed up healing with rehab?

Bone bruises ideally need rest and reduced impact.  Not good for Lorenzo Cain on the verge of a playoff run.  Cyclical, non-weight bearing motion like riding a stationary bike or deep water running is the “best medicine” for bone bruises.  The medical staff will likely limit extra running and minimize his impact loading.  Things like pulsed ultrasound and laser therapy may also help a little, but truly, these injuries need time.

Good luck Royals and stay healthy Lorenzo!  Kansas City is pulling for you!

Suspension Training: Is There Any Benefit?

Suspension Training and Muscle Activity

Suspension training is hotter than sunburn in fitness and rehabilitation right now.  TRX, the “Jungle Gym” and other similar models are hanging from the rafters at gyms and rehab facilities all over the fruited plain.  The benefits of suspension training largely center around resistance coming from bodyweight, versatility, and the space as well as cost saving benefit of having them.  Bodyweight training is far safer for most untrained individuals and you can do a total body workout with the bands.  Furthermore, they avoid the cost of having to buy tons of weight equipment.  Plus, the bands are relatively affordable.  All good things to be sure!  There have been several studies that have looked at muscle activity while doing suspension training – so what does the research say?  Does suspension training really do anything different than “traditional” training methods?  As always, the physical therapists at SSOR look to the research to guide our practice.   We try not to “geek out” too much, but it’s important to know what legit studies find rather than what some fitness magazine says they “think” is happening.

TRX

Suspension Training vs. Traditional Methods

Atkins et al in the Journal of Strength and Conditioning Research performed two studies, one in 2014 and one in 2015.  Each study looked at suspension training versus stable surfaces doing abdominal exercises.  In both studies, researchers found that suspension training with the plank exercise resulted in greater rectus abdominus activity than the “traditional” stable surface plank, but not with the erector spinae or the external oblique.

Another study by Byrne et al in 2014, also in the Journal of Strength and Conditioning Research looked at TRX Training with the feet suspended, arms suspended, both suspended, and the “traditional” plank on stable surfaces.  Researchers found that rectus abdominus activity was highest with the arms suspended, abdominal activity was higher in all suspended conditions compared to stable, and serratus anterior activity was highest with feet suspended and in the “traditional” plank position.

Catalayud et al in Phys Sports Med in 2014 looked at chest, shoulder, and abdominal muscle activity with suspension push-ups versus traditional push-ups.   Like Atkins et al, abdominal activity was higher in the suspension condition,  but interestingly, pectoralis major, deltoid, and serratus anterior activity was higher in the stable push up condition.

Snarr & Esco in the Journal of Strength and Conditioning Research (2014) looked at suspension planks, stable surface planks, and Swiss ball planks.  In this study, they found that erector spinae activity was much higher in suspension than other conditions.  Additionally, they found that all surface muscle activity was higher in both the suspension and Swiss ball activity overall compared to the stable conditions.  The study authors suggested that because of their findings, caution should be used in using suspension training in those with lumbar spine pathology.  In another study by Snarr & Esco (2013), they looked at traditional versus suspension push-ups.   In the suspension condition, greater muscle activity of the pectoralis major, deltoid, and triceps was elicited compared to stable push-ups.

Finally, Stuart McGill, arguably one of the top spine researchers, led a study in the Journal of Strength and Conditioning Research (2014) to look at spinal loads during suspension push-ups versus stable push-ups.  Interestingly, greater shear forces in the spine were higher with stable push-ups, but compressive forces in the spine were higher in suspension conditions.  McGill and colleagues concluded that individuals with a resilient low back that need a greater challenge are good candidates for suspension training, but caution should be used in those with low back pathology.

TRXtraining

The Bottom Line: Suspension Training

Based on the current evidence, it appears suspension training is a good choice for increasing muscle activity, but caution should be used in people with low back pathology.  For a person in rehabilitation for any condition, we always encourage exercises be performed on stable surfaces with good form prior to challenging conditions like suspension training is used.  Additionally, we caution those with shoulder pathology to be mindful of how “deep” they go when doing push-ups.  We suggest a good target is to lower yourself as low as you can provided you can still see your elbows.  When you go all the way down (elbows at their highest above your trunk), your shoulder is in a very vulnerable position.  Proceed with caution!!

It would be a privilege to serve you and partner with you in your care should the need arise.  Rest assured, the physical therapists at SSOR understand appropriate exercise progression to make sure you’re safe, but we also know when and how to “turn it up” so you get the challenge you want!