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Improve Your Shoulder Health and Overhead Position

10/17/2019

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So, let’s talk about the shoulder:

It is a very dynamic joint with little surface area between the humeral head and the glenoid fossa. The analogy we often use is a golf ball on a golf tee. There’s a reason why you hear more about shoulder dislocations than hip.

We have numerous muscle attachments and ligaments that surround the joint itself. These can be broken down into active (muscles/tendons) and passive stabilizers (ligaments). When we are going through different movements at the shoulder (whether that’s an overhead press, push up, clean, etc.), if we do not have the requisite range of motion, coordination or strength, then our passive stabilizers take on a lot of that stress. As I’ve said before, every single tissue (muscle, tendon, ligament, bone, etc.) in our body has a certain capacity and threshold. Stress is how we build those thresholds up. Stress is also how we break those down. When those thresholds are surpassed significantly or repeatedly, pain and injuries start to pop up. The dosage is the difference in having the poison or the antidote (- quote from someone smarter than me).
​

Now, how can we create more buffer room or bandwidth to withstand these stressors?

Smart and well thought-out training. Sure. 

But, what about creating more freedom and control at the shoulder joint? Then, those tissues are less prone to getting overstressed and everyone is doing their jobs. 

Today, our focus will be on the overhead archetype – which is an expression of shoulder flexion and external rotation. This can be anything related to pressing, reaching overhead, hanging, or throwing overhead.

I see people in the clinic every day that have pain with these movements and when we break these positions and joints down, we tend to see a limitation in one or both flexion and external rotation. Next, we’ll go through a test that you can utilize to see how your overhead position checks out.

Wall Test:
Common faults we see related to this are:

  • Lower back extends/comes off the wall
  • Rounding of the upper back
  • Shrugging
  • Rib cage flare
  • Elbow bends

Try to avoid these mistakes and see where your true baseline overhead position is. After the techniques provided below, come back to this test and re-test the movement. Can you go further? How does the quality of getting there feel?

Next, we’ll look at some strategies to improve the mobility aspect of the shoulder joint.

Subscapularis Mobilizations:

​Shoulder Overhead Opener:

When discussing the shoulder joint, I would be remiss not to mention the thoracic spine. The shoulder blade and thoracic spine/ribcage are very intimately related which directly impacts shoulder mechanics and position. Next, we’ll go through some techniques to address the thoracic spine.

T-Spine Mobilization:

​Half-Kneeling Wall T-Spine Rotation with Lift Off:
Lastly, we will cover my favorite component in the performance process which is the strength and control of the shoulder joint for the overhead position.

Supine Eccentric Shoulder Flexion – Dowel or Single Arm with Plate:

​Dowel Shoulder Flexion PAILS/RAILS:

​Chaos Overhead Band Carry
:
Now, you may be thinking, "These are great exercises, but how do I implement them?" Try them as movement prep prior to an overhead workout, accessory work on upper body days or even on recovery days. Do you have to do all of them? Nope. Find the ones that you feel had the best impact on you via the test-retest on the Wall Test and start implementing them in consistently. An active approach tends to work better in the long term compared to the passive approaches and exercises. You’ll be surprised how quickly your overhead position will improve and your overall shoulder health.

If you’re dealing with an injury, reach out with any questions. We design and implement rehab and performance programs to help our athletes, whether you’re someone who doesn’t know where to start or has had an unsuccessful rehab experience. It is our goal for the people we work with to return to their sport or activity performing better than they did before. 
​

Cheers,

Dr. Ravi Patel, PT, DPT, CSCS

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Shoulder Pain in Tennis Players

10/10/2019

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Tennis is a sport that demands an incredible amount of strength, stability, and performance out of one of the most unstable joints in the human body… the shoulder. Not only do you need to drive your shoulder through some truly incredible velocities with something like a serve, but you need to be able to control that power through finely tuned movements in multiple planes of motion with an almost endless list of types of swings. 

The demands on the shoulder are pervasive in tennis and because of this we have successfully treated endless amount of shoulder related injuries from the tennis players we see at Athletes’ Potential. However, through all these injuries that we’ve worked with, we have started noticing some trends in common strength deficiencies and biomechanical limitations that, when addressed, can have serious impacts on reducing injury risk and improving performance.  

Trend #1: Inadequate Shoulder External Rotation Range of Motion 

Arguably the most violent swing in tennis is the serve. To generate the amount of torque required for this swing, you need to have an appropriate amount of external rotation at your shoulders. 

The video below goes over a quick and easy drill to assess your shoulder external rotation. Essentially you should be able to lay on the ground and get the back of your wrist to the ground while keeping your low back pinned to the floor. 
Some common mistakes to avoid when doing this assessment include:
  • Hitting the floor with the back of your hand and your wrist bent
  • Letting your low back come off the ground 
  • Not having your shoulder at 90 degrees (elbow at the same height as your shoulder) before externally rotating 

If you can’t bring your wrist to the ground, or you have pain when you do or feel like you really have to fight to get there, then try some of my favorite drills to improve shoulder external range of motion. 

Drill #1: Front Rack Opener

​Drill #2: Lat Stretch

​Drill #3: Upper Back Mobilization

Trend #2: Upper Back Strength 


In order to have a strong, effective swing you need to have a strong back. This may seem a little counter-intuitive, but let me explain. Your body is innately intelligent and it’s not going to let you produce more force than it feels it can control. Therefore, to have a better swing, you need to have a strong back to be able to eccentrically control your arm as you go through the swinging motion. 

Some of my absolute favorite exercises to make sure you have a strong upper back are listed below. 

Exercise #1: Deadlifts​

​Exercise #2:  Pendlay Row

Exercise #3: W, Y, Negative ​

Trend #3: Lack of Rotational Core Strength

Your power in your swing comes from having a strong core. If you don’t have a strong core, then you have no foundation to deliver a strong swing, and if you are trying to have a strong swing without a solid foundation, well, you’re begging for an injury. Check out my favorite exercise to improve rotational core strength. 
​

Exercise #1: Med Ball Rotational Throws

​Exercise #2: Deadbug Pallof Press

​Exercise #3: Landmine Twists

If you’re a tennis player struggling with shoulder pain (and yes, even elbow pain) or are looking to improve your performance, these drills are a great place to start. They are the three main problem areas that we find ourselves addressing with the tennis athletes who come to us for help. However, If you’re dealing with an injury and want more guidance and help, reach out with any questions. We design and implement rehab and performance programs to help our athletes, whether you’re someone who doesn’t know where to start or has had an unsuccessful rehab experience. It is our goal for the people we work with to return to their sport or activity performing better than they did before.
​

Thanks for reading, 

Dr. Jake, PT, DPT, CSCS

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PEACE & LOVE: An Updated Guide to Managing Soft Tissue Injuries

7/29/2019

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            [https://blogs.bmj.com/bjsm/2019/04/26/soft-tissue-injuries-simply-need-peace-love/]


Have you ever pulled a muscle or tweaked something playing a sport? Maybe overdid it in a workout and didn’t notice it till after or the next morning? Every single person has experienced a soft tissue injury before – that can be muscle, tendon, ligament, etc. There’s a lot of mixed information out on the internet about what’s the best approach to hand a soft tissue injury when you experience one.

For the longest time, it was RICE – Rest, Ice, Compression, Elevation – while this isn’t completely wrong, it doesn’t meet the full standards of what we know today with science and research.

Here’s a handy acronym to help remember the essential components of how to manage injuries better in the future: PEACE & LOVE

Immediately after injury, PEACE:

PROTECT
  • Avoid threatening movements or exercises that are going to provoke the injured area. You should minimize your time in this phase as too much “protection” can cause deconditioning to the injured area as well as systemically. Use pain as your guide – as soon as you can start moving that area, do it.

ELEVATE
  • This is one that’s stood the test of time – elevate the injured tissue above the level of the heart to reduce fluid retention and manage swelling

​AVOID ANTI-INFLAMMATORIES
  • While NSAIDs are commonly used post-injury to manage pain, it actually can impair our body’s natural healing process. If you can manage it, try to reduce anti-inflammatories. If it is costing you the ability to sleep due to the pain, then choose appropriately or consult with a healthcare professional. Our body is remarkable and able to heal itself – let it do what it’s designed to do naturally.

COMPRESSION
  • Applying pressure to the injured area allows for decreased swelling/edema and tissue hemorrhaging.

EDUCATION
  • If you’re a medical professional, it is your job to educate your patients on this process and taking an active approach to best manage the injury – most importantly, putting the control within the patient’s care. Setting the expectations are huge here – being realistic about tissue healing times and a better understanding of the process as a whole. Below, I have included some great infographics by Drs. Mike Giardina and Caleb Burgess on the science behind the stage of tissue repair and tissue healing timelines.
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Once some days have passed, it’s good to give it some LOVE:
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LOAD
  • Utilizing an active approach is key here – use pain as your guide to allow appropriate loading and movement of the specific tissues (i.e. ankle sprain – ankle pumps, circles, or isometrics in 4 different directions) – early loading has been shown to be very beneficial to get back to normal activity and life for a soft tissue injury and also improves the risk of a future reinjury.

OPTIMISM
  • Are you a glass half-full or half-empty person? Perception is everything. We know that the mind is very powerful in how injuries impact us. There’s plenty of research that shows us an individual with a negative expectation has strong correlation with worse outcomes. The goal here is to stay positive and know that mother nature will take its course to get the appropriate tissues right with some accompanied TLC by the individual.

VASCULARIZATION
  • Blood flow helps drive a lot of healing. Move early and move often. Get out an walk. Try to push your heart and lungs with other areas that are not injured (i.e. shoulder injury – ride a stationary bike or go for a walk). This plays into the healing process of getting new blood flow into the area and mitigating pain, ultimately, speeding up the recovery process.

EXERCISE
  • The research is strong with this area. We know that exercise is what’s going to bring us back to level ground after an injury, and most importantly, prevent it from happening again. This exercise should be progressive and should incorporate range of motion, mobility, flexibility, strength, power, proprioception. This will make you the most bulletproof following an acute injury.

The thought to keep in mind is to try to play the long game. I see athletes often who come in and get out of pain then go right back to high-level activity without taking appropriate measures to progressively build it back up. What happens? Reinjury. Take the time to put in the work and I promise it’ll be worth it in the long run. 

​If you’re dealing with an injury and want more guidance and help, reach out with any questions. We design and implement rehab and performance programs to help our athletes, whether you’re someone who doesn’t know where to start or has had an unsuccessful rehab experience. It is our goal for the people we work with to return to their sport or activity performing better than they did before.
 
Cheers,

Dr. Ravi Patel, PT, DPT, CSCS


References:

https://blogs.bmj.com/bjsm/2019/04/26/soft-tissue-injuries-simply-need-peace-love/

Axe MJ, et al. Potential Applications of Hyaluronans in Orthopaedics. Sports Medicine. 2005.

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Load Management and Training Volume, Part 2: Are You Prepared?

3/7/2019

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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:
  • Acute
    • Defensive football player tackles a running back at his knees, helmet makes contact to one knee and tears his ACL and MCL – the force of the defensive player exceeded the running back’s ACL and MCL’s capacity to withstand the tackle
    • It’s Monday a.k.a. International Chest Day and a gym bro is trying to get his pecs huge – his goal is to finish his workout with 100 dips. He feels a pop from his left pec on dip 69 -  the force/load of the dips exceeded the left pec’s capacity to withstand more dips
  • Chronic
    • Crossfitter has ring muscle ups in her workout 3 times within a given week. Her last metcon of the week was for time and she had to get to the top of the leaderboard. She pushed through, but her right anterior shoulder is screaming at her. The load on her biceps tendon has been toe-ing the line with its capacity. This a great example of overloading beyond the body’s ability to recover from the stressor (in this case – ring muscle up).
    • Soccer player is practicing 3-4 times per week as the season kicks off with 1-2 games each weekend. The bottom of his right foot starts to hurt after the first two weeks. He takes a practice off to see if it feels better, but it comes right back. The load on his foot has been toe-ing the line with its capacity. This a great example of overloading beyond the body’s ability to recover from the stressor (in this case – soccer practice and his plantar fascia).

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:
  • Maximize the positive effects (i.e. fitness, readiness and performance)
  • Minimize the negative effects (i.e. excessive fatigue, injury and illness) 

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
  • External load - distance run, distance walked, weight lifted, repeated sprints/jumps, etc.
  • Internal load - heart rate (HR), rate of perceived exertion (RPE) and/or well-being scores


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.
  • Acute workload is the total load over a 1 week time frame.
  • Chronic workload is the average acute load over a 3-6 week time frame (very commonly 4 weeks).

​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.
  • Week 1 – 1700 units
  • Week 2 – 1850 units
  • Week 3 – 1780 units
  • Week 4 – 1900 units
  • Average Week 1-4 Workload: 1808 units

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.
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.
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These two graphs give a great depiction of what happens when load is applied appropriately:
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Compared to excessive load and/or lack of recovery:
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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:

  • The training—injury prevention paradox: should athletes be training smarter and harder?” Br J Sports Med. 2016 Mar; 50(5): 273–280.
  • Debunking the myths about training load, injury and performance: empirical evidence, hot topics and recommendations for practitioners. Br J Sports Med. 2018 Oct 26
  • The athlete monitoring cycle: a practical guide to interpreting and applying training monitoring data. Br J Sports Med. 2017 Oct;51(20):1451-1452
  • Pain and fatigue in sport: are they so different? Br J Sports Med. 2018 May;52(9):555-556
  • Monitoring Athlete Training Loads: Consensus Statement. Int J Sports Physiol Perform. 2017 Apr;12(Suppl 2):S2161-S2170
  • Why do workload spikes cause injuries, and which athletes are at higher risk? Mediators and moderators in workload-injury investigations. Br J Sports Med. 2017 Jul;51(13):993-994.
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Training Volume & Load Management, Part 1: How Much Is Too Much?

2/28/2019

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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:

  • Flexibility, mobility, lululemon leggings, biomechanics, nutrition, national emergencies, etc.

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)
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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
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Three Easy Tips to Reduce Injury During the CrossFit Open

2/21/2019

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It’s baaaaack. The largest fitness competition on Earth, the CrossFit Open, is finally here. Maybe you’ve trained all year for this, maybe you’re still new to CrossFit and are curious about all the excitement. Maybe you’re a seasoned vet, maybe this is your first Open you’ve ever participated in. Regardless of your CrossFit background, your fitness will be tested, your mental toughness will be challenged, and you will certainly have a blast working through these workouts with your crew at your local CrossFit affiliate.

That being said though, this is typically a time where we start seeing an uptick in the people we see coming in for CrossFit related injuries. Having an athletic background, where I had to personally sit out multiple seasons due to injuries, I speak from experience when I tell you there is nothing worse than working all year towards a goal/competition/test and not being able to perform at an optimal level, if at all, because of an injury. And, look, I get it. There is inherently an increased risk of injury when you're pushing yourself in a competitive environment. However, there are some very important things you can do to minimize this risk and allow you to perform your best. Let’s take a look at the three easy things you can do:​

#1 Don’t Be Reckless
This is huge and something I see year after year. If you’re a CrossFit coach, or even just an observant CrossFit athlete, I’m sure you’ve seen what I’m about to explain...You’ve worked all year to create movement patterns that are both safe and effective. You know the importance of good, quality movement. However, throw in the element of an international competition and it seems like all these lessons about technique go out the window.
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For example, last year’s first Open workout (18.1) consisted of three movements:  toe-to-bar, dumbbell clean and jerks and rowing. Can you guess what type of injury we saw coming into our clinic after this workout? If you said back pain, you’re correct. But why? Well, with this workout people were trying to perform as many rounds as possible for 20 minutes. To get better scores people weren’t maintaining core control for a solid hollow position with their toes-to-bar, they stopped getting full hip and knee extension for optimal power production during the drive portion of the clean and jerks, and/or they started to over-extend during the rowing component.  All of these create situations that are destined to increase stress on your low back. Keep in mind that this was just the first workout! Now you’re either completely unable to participate in the other workouts or will not be performing at an optimal level because you’re trying to grind through an injury.​

#2: Protect Your Sleep
There are four main pillars of health care that we look at with every patient who walks in the door at Athletes’ Potential: Movement, Stress, Sleep, and Nutrition. Sleep is easily on of the biggest problems that we see out of these pillars. And check this out: Sleep affects everything you do and everything you do is positively affected by quality sleep. Good, quality sleep literally improves everything: every marker on a blood panel, weight management, sport performance and recovery, productivity, and numerous types of disease management. The list goes on and on, yet the percentage of sleep deprived Americans, particularly in Urban areas, continues to rise at an alarming rate. In fact, the U.S Centers for Disease Control and Prevention reports that more than 30% of Americans are sleep deprived getting fewer than 6 hours of sleep per night.

If you’re not getting enough sleep, you’re not giving your body a chance to recover. If you’re not recovering appropriately, then you're leaving yourself at risk for injury and decreased performance. So, bottom line: create an optimal sleeping environment, protect your night time routine, and get some good, quality sleep.

For more info on how to optimize your sleep, check out this article we wrote.

#3: Maintain Perspective
This comes full circle with tip #1. For those of you trying to make it on to Regionals, those extra few reps I mentioned could be the difference in making the cut vs staying home. However, for the vast majority of athletes competing in the CrossFit Open this is not reality. You all have careers, kids you need to take care of, and numerous other responsibilities that you need to keep rocking with once you leave the gym. Is bouncing off the top of your head to get an extra rep or two really going to mean that much if by doing so now you can’t look over your shoulder while driving? (yes, this is a real scenario that we’ve worked on at our clinic...I’m looking at you 17.4). Or is that two position jump on the leaderboard really all the important if now you can’t bend over to pick up your kids? ​

CrossFit is meant to be a competitive, fun, and challenging way to make all aspects of life outside the gym a little easier. This time of year is huge for all CrossFit athletes and it is truly impressive to see the physical accomplishments and PR’s that happen every single year in the Open. However, the Open isn’t an excuse to throw all safety out the window, but it isn’t something you should be afraid of either. Following these three easy tips will ensure that you have a great time, reduce your risk of injury, and maybe even hit a PR or two.

Thanks for reading, 


Dr Jake, DPT, CSCS, CF-L1
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Soccer: An Analysis of the Sport

1/31/2019

1 Comment

 
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:​

  • Evaluation of the Sport
  • Assessment of the Individual

Today, our primary focus will be on evaluating the sport itself. This can be further broken down into:

  • Movement/Biomechanical Analysis – body and limb movement patterns and muscular involvement
  • Physiological Analysis – required physiological characteristics such as strength, power, endurance, speed agility, etc.
  • Injury Analysis – common sites for joint and muscle injury and causative factors


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:
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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:
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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.
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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.
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Pressing
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Kicking
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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.
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Optimizing the Return-to-Sport Paradigm Following ACL Reconstruction (Part 2)

1/17/2019

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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: 
  • Definition: Upsetting or intrusive feelings that prevent a person from optimal performance.
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​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:
  • Definition: belief in one’s ability to succeed in a particular situation or execute actions.
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  • ​Here’s where showing them what they CAN do versus what they can’t is a huge game-changer. It’s easy to fall into comparisons of others, especially if other friends or teammates have gone through a similar process. Highlight the fact that they have increased range of motion, can rep out multiple squats or that their quad looks strong AF. Give them the small wins to keep them engaged with the process and instill confidence within themselves.


3. Locus of Control:
  • Definition: belief in the relationship between action and outcome; feeling like one has control.
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  • ​This is usual broken down into external, internal and chance. External is believing someone else’s actions impact your outcomes. Internal is believing your actions impact your outcomes. Chance is believing your outcomes are based on fate or luck. Which one do you think should win? Internal. Which one do you think can take over? External. This is too common in the rehab process, which is why clinicians have to gut-check themselves and make sure they are facilitating independence and an internal locus of control. We’re the GPS while the patient is the driver. This should not change. It goes back to instilling confidence in the athlete and having them realize the outcome is in their control and not anyone else.


4. Athletic Identity:
  • Definition: degree to which one identifies with the athlete role.
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  • ​​This is an interesting area. The more the athlete identifies with their sport, the increase in adherence during rehab, but also decrease in self-esteem. This can be a slippery slope. If there’s less identity in sport (i.e. recreational sport compared to collegiate), then athletes are able to disconnect easier, but rehab adherence may decrease. With athletes who identify highly with their sports, the main goal is to keep them involved - whether that’s through team workouts or sessions. You can have them do upper body work and train the non-injured leg as well. This is where communicating with the coaches, family members and others involved can make a huge impact on the psychological recovery and readiness as an athlete builds to full return-to-sport.
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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
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Optimizing the Return-to-Sport Paradigm Following ACL Reconstruction (Part 1)

1/10/2019

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Here’s what we know:
​

  • Secondary ACL injury risk after ACL reconstruction (ACLR) is approximately 15-23% (Wiggins 2016).
  • Female soccer players after ACL reconstruction have 5x increased risk of new knee injuries than controls (Faltstrom 2018).            
  • 81% of athletes returned to some sort of sports, but only 65% returned to the pre-injury level of sport activity. 50% returned to competitive sports level (Ardern 2014).
  • No gold standard exists for evaluating return-to-sport readiness after anterior cruciate ligament (ACL) reconstruction.

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.
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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.
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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. ​

  1. Time: > 9 months after ACLR.
  2. Patient-Reported Outcome Measures:  IKDC2000, Tegner Activity Scale, ACL-RSI, K-SES.
  3. Clinical Exam: Full range of motion, no pain, swelling, or laxity.
  4. Muscle Strength: Pivoting, contact, competitive sports (>100% limb symmetry index); non-pivoting, non-contact, recreational sports (>90% limb symmetry index).
  5. Hop Tests: Multi-directional (90% limb symmetry index).
  6. Assessment of Movement Quality: Multi-segment movement quality with and without fatigue
  7. Task and Environmental Constraints: Gradual progression of controlled tasks and environments to progressive, uncontrolled tasks and environments to replicate sport.
  8. Medical and Sport Risk Modifiers: Age, sex, personal medical history, type of sport, level of sport, position played, ability to protect (e.g. taping/bracing).
  9. Decision Modifiers: Timing of the season, external pressure from club, trainers, parents, conflict of interest (e.g. financial), lifestyle changes, priorities.
  10. Psychological Factors: This one is commonly overlooked – that is why next week, we will dive deeper into psychological readiness and how we can make sure this becomes just as important as the physical component of ACL rehab and performance.


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.
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Pay More, Get Less - Our Healthcare System

10/30/2018

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​“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.
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​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
Ready To Come See Us?
​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
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