 Last week, we covered the training volume in part 1 of load management. If you missed it, go check it out. Today, we’re going to take a deeper dive into components of load management itself and what you as an athlete, coach or healthcare professional can do about it. I geek out on this stuff so get ready. Any injury ever: FORCE/LOAD > CAPACITY This means any force/load that exceeds the capacity of your tissue’s ability to withstand that force/load. Some examples:
Enter LOAD MANAGEMENT. The goal is simple: to protect you from injury and maximize performance Proper training must be prescribed. Over-training and under-training both increase risk of injury. You want to:
I’d be remiss to not give credit where credit is due: Tim Gabbett and company have been leading the front on this area and are really changing the way teams and athletes are handling training. Now, let’s define LOAD: It is broken down into 2 variables – external load and internal load
We use these two variables to create the: ACUTE: CHRONIC WORKLOAD RATIO (ACWR) This is also commonly referred to as FATIGUE compared to FITNESS. Fatigue being the acute workload and fitness being the chronic workload.
With technology nowadays, we have a number of ways to track this type of data. The most commonly cited method in the research is Session RPE (sRPE), which is time (total number of minutes) multiplied by the RPE for a given training session. The RPE is usually taken after a training session to gauge level of exertion/difficulty. This is measured as “arbitrary units” or “exertional units”.  For example, in week 5, let’s say a soccer player practices one day for 60 minutes at an RPE of 8. That gives us: 60 x 8 = 480 units. She practices 4 times during week 5 with a similar intensity. This gives us our ACUTE WORKLOAD (4 x 480 = 1920 units) for week 5. Now we have to look at her CHRONIC WORKLOAD for weeks 1-4.
When we compare the two, you get: 1920/1808 = 1.06 Now what does this number tell us? This ratio helps delineate whether you as the athlete are prepared for the task at hand – what you’ve done compared to what you’re prepared for – that can be a running a marathon, doing a CrossFit Open workout, playing in a professional football game or doing parkour in your living room.  In terms of injury risk, acute:chronic workload ratios within the range of 0.8–1.3 is considered the training ‘sweet spot’ where injury risk is at its lowest, while acute:chronic workload ratios ≥1.5 represent the danger zone. If you look at the trend of the curve before 0.80, you should notice the injury risk climbs back up – similar to a “U-shaped” curve. This relationship between workload and injury demonstrates that both inadequate and excessive workloads are associated with injury. Now let’s say from the example above that week 5 workload came out to 3500 arbitrary units. That would make the ratio: 3500/1808 = 1.94 No bueno.  If you don’t get this reference, we’re not friends. This athlete is at an increased risk of injury. When training load is fairly constant (ranging from 5% less to 10% more than the previous week) players had <10% risk of injury based on the study by Gabbett et al. However, when training load was increased by ≥15% above the previous week's load, injury risk escalated to between 21% and 49%. This is commonly represented by ‘spikes’ in acute load relative to chronic load. To minimize the risk of injury, we should limit weekly training load increases to <10%. There’s room to work within this, but a great starting point. Athletes accustomed to high chronic loads have fewer injuries than those accustomed to lower loads, and this supports Gabbett’s assertion that higher chronic loads can act as a protective effect against future injury.  These two graphs give a great depiction of what happens when load is applied appropriately:  Compared to excessive load and/or lack of recovery:  This is something I use every day with my patients and athletes. I’ll look at their training program and see if there is a mismatch in training volume and load management. We start here then look to optimize other components of injury and performance training such as stress management, tissue tolerance, biomechanics, physiology, strength, power, etc. At the end of the day, ask yourself this question: Is your body prepared for the demand of the task?
Cheers, Dr. Ravi Patel, PT, DPT, CSCS References:
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With the CrossFit Open upon us and beach bod season approaching, people will be fitnessing. A LOT. With this, comes the opportunity for injuries to sneak up and leaving performance on the table. People typically blame certain factors for an injury or lack of performance:
While these factors are definitely important to consider, there’s one that gets overlooked and is quite often the culprit: TRAINING VOLUME I had a patient come in a month ago who was dealing with foot and ankle pain. It has been on and off for months, and she decided to get it checked out due to a recent exacerbation. She’s a ½ marathon runner who also does Orange Theory a few times a week. She was starting to increase her mileage for her ½ marathon coming up. I think you know where this is going… Before trying to change up her running mechanics, change her shoes or blaming it on “overpronation,” we had a conversation about her training volume. I asked her how her running mileage and volume been. In this discussion, she said she went from 3 miles to 6 miles within a weeks time. BINGO. She was confused as she had previously ran this much mileage in the past, BUT... it’s been a couple months. I also asked her about the first time she ever dealt with this same issue – she said she couldn’t really think of why it initially started – “maybe running form or my shoes?”. I asked her when she started Orange Theory – lightbulb went off. BINGO again.  Let me be clear – there’s nothing wrong with her doing both running and Orange Theory. There is when your body is not prepared for the demand of these tasks. This was and is a volume issue, and if you’re reading this, think back to a previous non-contact injury and see if you can attribute any other factors playing into that specific injury – moreso volume in this case. Now, mobility, biomechanics, strength, etc., all play roles into whether we are operating as optimally as possible from a performance standpoint. For this patient, we did work on strength in certain areas and tweaked some things from a running standpoint, but the big component of her rehab was starting at a volume she could tolerate without pain or just a little, and progress forward from there. Training volume falls under the umbrella of Load Management (coming in Part 2) and is a big reason why injuries occur. Some common methods of measuring training volume include counting the number of sets to failure, the volume load (sets x reps x weight), distance, number of sprints, etc. Here are some terms to understand: Maintenance Volume (MV) – How much volume you need to maintain your gains Minimum Effective Dose (MED) – Smallest amount of stimulus needed to drive positive adaptation. If we are below this threshold, then there will be no adaptation. Maximum Adaptive Volume (MAV) – Here we are training at our optimal range of volume that we can adapt to and recover appropriately to drive optimal performance Maximum Recoverable Volume (MRV) – This is the absolute maximum volume that your body can handle and recovery from. Sometimes it’s necessary to pass this threshold from time to time, called overreaching, in order to elicit greater adaptations. Important point here is to make sure it is not often and that deloads are accompanying this high accumulation of volume to allow for supercompensation (the point of overreaching to get the training effect you want – improved strength, power, speed, etc.). When this is not appropriately monitored or constantly overreached without recovery, you open the door for injuries to occur and performance to suffer. (credit to Mike Israetel of Renaissance Periodization for this concept)  The way this is laid out is that you start with your MED, progress to MAV, then MRV to overreach. However, notice that you don’t dance with MRV often, nor do you want to.
Overtime, your MRV will increase, meaning you’ll get stronger and develop more work capacity, as long as you intelligently handle your training volume. A good rule of thumb is The 10% Rule - While there can be some variability here, staying within a 10% increase from the previous week tends to work well for a lot of people. It pushes that threshold in a progressive manner and allows appropriate recovery from the increased demand on the body. Next week, in Part 2, we’ll take a deeper dive into load management and training volume, explore exactly what this concept means, and how to practically apply it to yourself or athletes you work with. Cheers, Dr. Ravi Patel, PT, DPT, CSCS  Recently, I had the opportunity to present to a local soccer club and their coaches on injury risk and reduction for the sport of soccer. In order to understand this, a “Needs Analysis” must be done. A Needs Analysis is a two-part analysis breaking down the sport into two components:
Today, our primary focus will be on evaluating the sport itself. This can be further broken down into:
Movement & Physiological Analysis Soccer is a very lower-body dominant sport involving the hip, knee and ankle joints and muscle groups including the quadriceps, glutes, hamstrings and calves. A soccer athlete must be able to run, jump, accelerate, decelerate, land, cut, kick, pass, head, shuffle, tackle – all while handling a ball and avoiding defenders. Oh, they also need the ability to sprint and jog throughout the duration of a 90+ minute game. Now, you’re talking about a dynamic athlete with a sound aerobic and anaerobic energy system. That’s A LOT.  Here’s a more thorough breakdown:  Injury Analysis Sports injuries are inevitable. It comes with playing sports – exposure already puts you more at risk. You cannot prevent sports injuries, but you can help mitigate and reduce the risk of them happening – especially ones that are non-contact or overuse in nature. Here’s a breakdown of the most common injuries in soccer:  A study done in 2017 by Khodaee et al. tracked detailed information on injury rates among high school soccer players over a 10-year period (2005 – 2014). You can see those below broken down by gender and injury diagnosis.   Muscle strain, ligament sprain and concussions are highest as expected. What’s most interesting is the girls’ ligament sprain – very high for both practice and competition as compared to the boys’ group. Females are 2-5 times more likely to tear their ACL than males in a similar sport. There are a lot of factors that play into this and nothing is definitive. We do know that strength and neuromuscular control are big modifiable factors from an injury risk standpoint. In another study from 2015, Waldén and company analyzed 39 videos for movements related to non-contact ACL injuries in professional soccer players. They found that pressing, kicking, and heading were the 3 most common movements in relation to ACL injuries.  Pressing  Kicking  Heading (check that right leg in D - ouch) Cool, so now what do we do with all of this? Make some superhuman soccer athletes.
Have a plan in place to address these different components. It’s important to create a program for these athletes to develop these athletic characteristics – i.e. lower body strength, power, repeated sprint ability, cardiovascular endurance, change of direction and reactive agilities. Injuries happen all the time in soccer, but if we know what joints and muscles are most at risk, then we can better prepare these tissues to withstand the stress of the sport and build more resilient and robust athletes. Cheers, Dr. Ravi, DPT Sources: Baechle, Thomas R., and Roger W. Earle. Essentials of Strength Training and Conditioning. Champaign, IL: Human Kinetics, 2016. Print. Turner, E., Munro, A. G., & Comfort, P. (2013). Female Soccer: Part 1—A Needs Analysis. Strength & Conditioning Journal, 35(1), 51-57.  Why is this topic so important to me? It’s because I’ve personally been through this process. Twice. And it’s one of the hardest things I’ve had to do in my life. Successful return to sport after anterior cruciate ligament (ACL) reconstruction requires optimal physical AND psychological recovery. The psychological component is quite often overlooked. Fear, emotion, and poor self-esteem can have profound effects on patients' compliance, athletic identity, and readiness to return to sport. An athlete can be physically prepared for return to sport, but if there is fear or anxiety associated, then this process should be prolonged. If you’re a clinician, parent, or athlete reading this, here are four key areas to consider: 1. Psychological Distress:
 This is where education and setting the expectations is huge. When working with an athlete, it’s important to consider this as a part of rehab. Who wouldn’t have anxiety or emotions when they can no longer play their sport and get their knee operated on. It’s completely normal. Rather than hiding it, have a conversation with your athlete. Educate them on what to expect before, during and after the procedure and for rehab. Assure them that everything will be okay and that they will get back to their sport. When an athlete knows what to expect, there’s less psychological distress associated with the process, which can significantly impact the success of the rehab and return-to-play process. 2. Self-Efficacy:
3. Locus of Control:
4. Athletic Identity:
 In addition to the 4 areas above, an objective measure can be very beneficial to quantify where the athlete stands from not only a physical perspective, but psychological. That’s where the ACL-Return to Sport after Injury scale (ACL-RSI) can be helpful. The ACL-RSI is a great outcome measures to assess athletes' emotions, confidence in performance, and risk appraisal in relation to return to sport.
Recognizing positive and negative psychological responses to injury is the first step in initiating treatment and potentially modifying beliefs through psychological interventions. It is important to identify patients who are at risk for poor outcomes because targeted psychological interventions may be successful. If you know of an athlete going through this injury and recovery process, don’t forget that there’s more to it than just what you can see. Cheers, Dr. Ravi, DPT Sources: - Christino MA, Fantry AJ, Vopat BG. Psychological Aspects of Recovery Following Anterior Cruciate Ligament Reconstruction. J Am Acad Orthop Surg. 2015;23(8):501-9. - Sadeqi M, Klouche S, Bohu Y, Herman S, Lefevre N, Gerometta A. Progression of the Psychological ACL-RSI Score and Return to Sport After Anterior Cruciate Ligament Reconstruction: A Prospective 2-Year Follow-up Study From the French Prospective Anterior Cruciate Ligament Reconstruction Cohort Study (FAST). Orthop J Sports Med. 2018;6(12):2325967118812819. - Ardern CL. Anterior Cruciate Ligament Reconstruction-Not Exactly a One-Way Ticket Back to the Preinjury Level: A Review of Contextual Factors Affecting Return to Sport After Surgery. Sports Health. 2015;7(3):224-30. -Schub D, Saluan P: Anterior cruciate ligament injuries in the young athlete: Evaluation and treatment. Sports Med Arthrosc 2011;19(1):34-43. Melissa A. Christino, MD, et al  Here’s what we know:
That last bullet point is a HUGE problem. How do we know when an athlete is ready? Traditional return-to-sport criteria are mainly focused on the time after ACLR and knee-specific impairments, while the return-to-sport decision-making process is only made at the hypothetical “end” of the rehabilitation period. When is this “end” point? When the patient runs out of insurance-covered visits? When the ortho clears them based on a 5-minute exam? When there’s no longer a government shutdown? This “end” point is completely made up and very subjective. That is why we need more concrete, objective measures to allow these athletes return to sport at a high level with the lowest risk of re-injury.  Dingenen et al. proposes: “an optimized criterion-based continuous and multifactorial return-to-sport approach based on shared decision making, with a focus on a broad spectrum of individual sensorimotor and biomechanical outcomes, within a biopsychosocial framework.” I could not agree more.  This means that we need to get away from time- and isolated-based assessments and look at this from a holistic 360 degree view, taking into account not only the biological factors of the athlete, but psychosocial factors as well. Since there are many individuals involved in this process, it takes a team to make the outcome truly successful. This team consists of the individual, their family, physical therapist, athletic trainer, orthopedic surgeon, sport coach, strength coach, etc.
Remember – A single component alone (i.e. time) is not enough to determine whether someone is ready. All of the components below could have the box checked except the last one and this athlete would still not be ready. I hope this provides some insight to you if you are going through this process as an athlete, parent, or clinician looking to return to sport.
Cheers, Dr. Ravi Source: Dingenen B, Gokeler A. Optimization of the Return-to-Sport Paradigm After Anterior Cruciate Ligament Reconstruction: A Critical Step Back to Move Forward. Sports Med. 2017;47(8):1487-1500.  “Since 2008, average family premiums have increased 55 percent, twice as fast as workers’ earnings (26%) and three times as fast as inflation (17%).” “Premiums for employer-sponsored family health coverage rise 5% to average $19,616; single premiums rise 3% to $6,896.” “Deductibles for covered workers has tripled since 2008, growing 8 times faster than wages.” Not trying to be a Negative Nancy, but that’s no bueno. Unfortunately, this is where our current healthcare system stands. This data was released by the Kaiser Family Foundation in a recent survey. The annual survey was conducted between January and July of 2018 and included 4,070 randomly selected, non-federal public and private firms with three or more employees (including 2,160 that responded to the full survey and 1,910 others that responded to a single question about offering coverage). Over the past decade, insurance premiums and deductibles have significantly increased relative to workers’ earnings and inflation. We continue to pay more for insurance, but get less in return. We want a healthier country, but we continue to create barriers to access “healthcare.” So how do we change this? Use the system less and, more importantly, NEED IT LESS. What I’m getting at is taking control of our own health. We have plenty of data to show that chronic disease is impacting this country.  Improving and maintaining our health and wellness through movement, nutrition, sleep, stress management, and social relationships is crucial. With technology, we have this information at our fingertips. While it can be tough to decipher through the guruism and instamodels these days, it’s important to do your research and find professionals that you trust with your health. Here are some general recommendations we give: 1. Move everyday. Strength train at least 2-3x per week. Test your heart and lungs. 2. Eat real food, not too much, mostly plants (but also.. protein is life). 3. Get at least 7 hours of quality sleep each night. 4. Stress management is often overlooked and this can be managed through self-reflection, meditation, counseling, exercise, etc. Find what works best for you. 5. Social connection and relationships is an area I believe is very important for all of us. We all have our people and it’s important to prioritize those relationships for our own health and well-being. If you want to dive further into the details of this survey, you can find the original article here: https://www.kff.org/health-costs/press-release/employer-sponsored-family-coverage-premiums- rise-5-percent-in-2018/?fbclid=IwAR2u9WY8T4eAiEOUaJQkjHXF7-p6xEVXPHXhx5Qpup-o- NKz-slUBSK-1Bc Insurance and healthcare is expensive. Employers and employees are starting to take notice of
this tread. They’re being incentivized to take a proactive approach as well as minimize the use of their healthcare. At the end of the day, let’s get people moving better and eating less shit, and more importantly, realize that we have the power to take control of our health and avoid being imprisoned by this expensive healthcare system. Cheers, Dr. Ravi, DPT  Have you ever been in the middle of a workout and feel an ache or pain? It’s completely normal if it’s something small and goes away. It’s another story if it continues to bother you or increase in pain. Sometimes we just do too much (or too little) and it pisses off some part of our body. You may start to realize it’s impacting the way you move and you may even avoid a particular movement that causes the pain altogether. Often times, people see this as a sign to take some time off and rest. This may be the case in some instances, but it’s not always the best solution. Some people go to a healthcare professional to find out what’s going on. Quite frequently, they’re told to stop that activity or exercise. We hear it all the time from new patients. “Squats are bad for your knees.” “Running will wreck your body.” “Stop doing CrossFit. You’ll get hurt.”  [Credit: Barbell Physio] But, what if you’re an Olympic weightlifter who has a competition coming up? What if you’re a runner who loves a good 5k? What if you have a stressful job and CrossFit is your outlet to relieve that stress? Come on, healthcare - we can do better. If these are your goals, we want to help you get there. Here’s 5 different ways to train around pain and decrease stress on that painful area:
MAIN GOAL: MAKE THE LEAST CHANGES POSSIBLE TO THE MOVEMENT Now, let’s break down each one of these using knee pain with front squats as an example.
 [Credit: EricCressey.com]
 [Credit: Barbell Rehab]
Here are a few other examples for you:
Here’s the overall concept: Pain comes on --> scale back movement slightly --> train movement --> adapt --> progress difficulty --> adapt --> back to prior level --> continue training pain-free --> hit PR  [Credit: kcbi.org] I believe that any great coach or physical therapist should be able to modify and progress/regress any movement or activity. If you have given these methods a shot and pain continues to impact your life, then find a healthcare professional who understands your goals and doesn’t tell you to stop.
Cheers, Dr. Ravi, DPT |
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