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Bulletproof Your Back Series

8/27/2020

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In our Bulletproof Your Back Series (follow along on our Instagram page!), we're bringing our clients 4 videos to help them improve back pain. We go through
  • Stretch exercises for back pain
  • Skill Drills for a strong back
  • How to hinge properly
  • Breathing work to improve back pain

If you are suffering from a form of low back pain, work your way through these videos and see how you can improve your back pain. 
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"Bone on Bone": The Spooky, Scary Stories of PT

11/1/2019

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What’s up, everyone! Doc Jake here. In the spirit of Halloween, I wanted to take a moment to talk about some of the common “scary” comments my patients have heard from other providers, or seen on imaging, and why you shouldn’t be afraid at all. I know we’re all busy getting costumes and candy ready, so let’s jump right in: 

“Worst case of bone on bone I’ve ever seen!”

If I’ve heard this once, I’ve heard it a thousand times. “The doctor said I’m bone on bone!” “Worst case of arthritis he has ever seen!” Most often your physician or other healthcare provider is referring to something called osteoarthritis (also called Degenerative Joint Disease or DJD)  in situations like this, and guess what… it is totally normal to have arthritis! More and more studies are coming out that show many active adults have some form of DJD and that calling this a “disease” is incredibly misleading.

While DJD cannot be reversed, it’s often not the main pain generator and can easily managed with education on symptoms, appropriately prescribed exercise, and just plain out staying active. Walking the dog, playing with your kids, gardening… all great examples of non-exercise based movement that keep your joints moving. As cheesy as it may sound, the old adage of “motion is lotion” is spot on and is the reason that “worst case of arthritis I’ve seen” shouldn’t get you weak in the knees. 
 

Torn Meniscus

This one hits close to home. At the young age of 14, I actually had two knee surgeries. One to attempt to repair my meniscus and one to remove it once the repair failed. Looking back on it and relating my symptoms I was having to what the research is now showing, I had no business getting any of those surgeries and you most likely don’t need one either. Once again, a torn or frayed meniscus is a normal sign of aging and is often found on imaging with people who have NO knee pain at all. 

Even in an acute situation where a tear is found on an image after injuring your knee, as long as you don’t have a physical “block” in your knee, where that meniscus has essentially turned into a door stopper and impeds normal motion at the knee, you will be absolutely fine without surgery. In fact, research consistently shows that conservative treatment will have equal to (or better) results as surgery AND you won’t be setting yourself up for future complications associated with missing portions of your meniscus.  


Herniated Disc 

I’ll keep this one short. Simply put, in most situations, herniated discs do not require surgery. In fact, multiple studies have demonstrated that you can take 10 random people off the street with no back pain, give them an MRI, and an average of 7 out of 10 people’s images will come back with some variation of a herniated disc. In fact, “large low-risk-of-bias trial between surgery and usual conservative care found no statistically significant differences on any of the primary outcome measures after 1 and 2 years” (Jacobs et al). Our bodies are incredibly resilient and will heal just fine with appropriate treatment.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065612/


“You’ll never be able to do ‘X’ again.”

This is the most frustrating thing for me and the rest of the staff here at Athletes’ Potential. We are constantly hearing people come in and say something like, “My doctor said I’ll never be able to deadlift again,” or, “My physical therapist said I shouldn’t do CrossFit.” This is absurd and is a fallacy you shouldn’t fall for. We constantly get people coming into our office and we are constantly getting them back to the activities they love. 

So, in review, there are a lot of scary phrases out there that, in reality, have no right to be scary. New research is being pumped out every day that our bodies are incredibly adaptable. If you’re in the Atlanta area and you’ve heard one of these phrases before, give us a call or fill out the contact request form by clicking the button below. We’d love nothing more than to help you get back to what you enjoy.
Ready To Come See Us?

​Thanks for reading, 


Dr. Jacob, PT, DPT, CSCS
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Improve Your Disc Pain With These Simple Tips

10/24/2019

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I remember the feeling like it was yesterday. A sharp popping sensation in my back and then an odd, almost warm tingling feeling down my left leg. I knew it wasn’t good, and I should have known better.

This was my first week at an infantry brigade I had been assigned to in 2011. I was the only physical therapist assigned to a group of 3,500 soldiers. My job was to treat all injuries, teach injury prevention classes, and help with human performance optimization. I was also attached to an infantry brigade so that meant a lot of physical training and ruck marching.

On my fourth day assigned to this group, I went on a Thursday morning ruck march. For those of you that don’t know, ruck marching is basically walking around while wearing a 50-pound backpack. This morning we had gone on an 8-mile ruck march. When I finished, I dropped my rucksack (i.e heavy ass backpack) and stood around talking with the other soldiers. As I was leaving, I bent over to pick up my rucksack and that’s when I felt the pop. 

I immediately knew something was wrong, but the last thing I wanted to do was get hurt in front of all my soldiers. I was the guy assigned to this group to make sure people didn’t get hurt and there I was in excruciating back pain trying to act like I was fine. I managed to make it to my car before collapsing into my seat. I drove straight to the troop medical clinic to see a fellow physical therapist friend of mine. There was no unringing this bell… the damage was already done.

Over the next six months, I did everything to help fix this back injury I had given myself. Fatigue from the ruck march followed by picking something heavy up, like an idiot, was a recipe for a pretty serious disc injury. I had what’s called an L4-L5 disc prolapse. This caused me to have a lot of numbness and weakness in the back of my left leg.

With a combination of dry needling, hip joint mobilizations, and time, my pain resolved in about six months. It took me roughly another six months before I could get back into deadlifting heavy. 12 months of rehab/recovery from picking up a rucksack wrong. As much as this wasn’t fun, I’m glad it happened to me, and here’s why.

I learned a lot about why I had this back injury in the first place and was able to correct those issues. This injury lead me down the path of better understanding complex movements. I became obsessed with treating my own back and developing protocols to help other people with their back injury. Lastly, I can relate to anyone I see with a back injury on a much deeper level than someone who’s never hurt their back. 


I also got to see first hand that disc injuries do heal. Even when I was in school, the thought process was that a disc injury wouldn’t heal. I have an MRI from one month after the injury and three years after the injury. The MRI from one month post injury shows a significant disc prolapse that’s pressing on a nerve. The MRI from three years post injury looks completely normal. The body heals on the inside just as it does when you get a cut on your skin. It fills in, heals, and you have a scar as a reminder of the thing that happened. 

Dealing with a disc injury can be extremely frustrating. Here’s my advice to you if you’re currently dealing with one from my own experience and from all of the back injuries I’ve seen:

  1. Even though it’s tough, try and stay positive. The brain is a powerful thing and the moment you slip into a negative state, you’ll feel it. You’ll feel more pain, you’ll feel less capable and you’ll start to think worst case scenario. None of this is helpful when it comes to healing.
  2. Focus on small wins and on things you can do. By this I mean focus on the days you have where you feel better. Maybe you were able to walk further without pain. Maybe you work up pain free for the first time in a month. Maybe you sneezed for the first time without back pain. Focus on these little wins because they are signs that your body is healing. 
  3. Avoid activities that cause more pain. I know this sounds like common sense but I think some people love pain. Isolated pain in your back with certain movements should be avoided as much as possible. No pain no gain doesn’t apply with this type of injury.
  4. Stay active. I’ve never worked with someone with a disc injury that couldn’t find something they could do without aggravating their back. Sure, maybe it’s not the CrossFit workout you’re used to but you can still stay strong, flexible and cardiovascularly fit while you heal.
  5. Work with a professional. This isn’t something you want to try and figure out on your own. The spine is complex and making sure you’re working on the right things can dramatically improve your healing time. Also, things like hands on work and dry needling are really effective at decreasing pain as you heal.
  6. Follow a plan to get back into high level activities. If you’re a runner, you probably don’t want to just start back to full on training after your back starts to feel better. You want to follow a specific plan to help get you strong in the right places, mobile where you’re tight and increase your volume in an effective manner. If you don’t know how to do that, again I recommend working with a professional. The only thing more frustrating than a back injury is a back re-injury.
  7. Work on your breathing. This was a game changer for me and for many of my patients. There are a lot of reasons that I won’t explain here for why this is beneficial. Just know that it is and this is my favorite app to work on breathing. 
  8. Read The Obstacle Is The Way by Ryan Holiday. Having a back injury sucks. This booked helped me deal with frustration and realize there was a lesson to be learned. 
  9. Shameless plug… come see us. We help people with disc and back injuries everyday. We are really good at it and have helped hundreds of people avoid surgery. 

I hope this helps and I hope you realize that you can heal. Your body is incredible and often times it just needs time and the right approach to do so.

If you’re in the Atlanta area and are currently dealing with a back injury, we need to talk. We’ve helped thousands of people in Atlanta get back to a pain-free, active life, and we can help you as well.

Click the “Get Started” button below, leave us your information and one of our team members will reach out to find out if you’re an ideal fit for what we do.
Get Started!
Thanks so much for reading,

AP Team
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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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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:
​

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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Is Blood Flow Restriction Training For You?

3/28/2019

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What’s up, everyone. One of the many treatment options that we offer at Athletes’ Potential is something called Personalized Blood Flow Restriction Training (PBFRT). This is something I remember being blown away about while in physical therapy school and seeing the results that research was showing. To put it simply, it’s one of the best evidence supported treatment options out there and we are thrilled to be able to offer it to the Decatur and greater Atlanta area.

There are a ton of awesome benefits with PBFRT, but first let’s take a look at what exactly BFR is. PBFRT is the brief and intermittent use of a tourniquet in order to restrict the amount of blood flow from coming into your limb (arterial flow) while performing low-load resistance training. The way PBFRT works is it reduces the amount of oxygenated blood reaching a working muscle in order to trick your body into thinking it’s working at a higher intensity than it actually is. By using this form of engineered suffering, you’re able to use extremely light resistance and still get the same increases in size and strength as lifting at higher intensities with heavy weight! Exactly how this happens is laid out below:
​
  • Occluding your limb creates an anaerobic environment by limiting the amount of oxygenated blood that reaches a working muscle.
  • This anaerobic environment stimulates your fast twitch muscle fibers (the fibers responsible for power, speed, and strength).
  • In an anaerobic environment with your fast twitch muscle fibers activated, a convoluted process starts called the Cori Cycle, which leads to the production of lactate in the muscles (fun fact: lactate production creates that burning sensation you feel).
  • Because your limb is occluded, the lactate being produced begins to pool in the working muscles, which signals multiple metabolites leading to protein synthesis, muscle stem cells, capillary beds, and a 290% increase in human growth hormone (HGH).

Essentially, PBFRT is a true biohack that allows people to work at loads that are non-stressful on the tissue but still get improved size and strength. A true game-changer in the world of strength and conditioning.


But just like everything else in the world of sports medicine, PBFRT has to be used appropriately and with the right population. Otherwise, you could risk wasting your time and resources. So, who exactly would benefit? Below are three of the most common scenarios that people see the best results.
Post-Injury/Surgery:

Muscle breakdown (atrophy) after a surgery or injury happens incredibly fast. For example, when you’re injured or you’re not allowed to put any weight through one of your limbs, in as little as two weeks that limb goes into a state of anabolic resistance and protein synthesis shuts down leading to a 30% loss of muscle mass in that limb!  

This is obviously extremely problematic and slows down recovery from an injury dramatically. However, with PBFRT we now have the ability to combat that significant muscle loss because we are able to use low intensity and weight levels that are safe and tolerable to the patient and get the same increases in muscle size and strength as lifting at 65% of your one rep max or higher.

A great example of just how beneficial PBFRT can be for patients rehabbing from injury comes from Dr. Zach Long who was working with an elite level olympic lifter after tearing his ACL. With this type of injury, more than 65% of patients demonstrate quadricep weakness even a year out from surgery. However, Dr. Long’s patient’s surgical leg became one inch larger than his healthy leg in just three months time after his surgery!

Sport Performance:

PBFRT has shown numerous benefits to enhancing sports performance, but perhaps the most documented is the ability for athletes to maintain muscle size and strength without the dip in performance caused by muscle soreness. This is possible because there is no muscle tissue breakdown associated with PBFRT since the intensity is kept so low.
  • This is a great way for barbell, endurance, and in-season athletes to compliment their current training programs without worrying about over-training.

PBFRT has also been shown to have a profound effect on your aerobic capacity as well by increasing your VO
2 max and capillary beds.
  • This means that research has demonstrated the ability to improve both your cardiovascular endurance and muscular size simultaneously!

Recovery:

Imagine this. You’re training for an upcoming triathlon and are starting to feel a little banged up from the volume pulling, or you’re gassed trying to prepare for a CrossFit competition, or maybe you’re midseason in soccer and have been trying to push through some nagging issues.

Now, imagine during your recovery day you rode for just 15 minutes, at a pace well below a typical recovery ride pace, and we’re able to give your tendons that increased HGH we mentioned above, all while boosting your VO2 max AND letting your tissue continue to recover.

Sounds pretty cool; right? We have people do that all the time here in the clinic and we are consistently seeing people hit PR’s and feel good doing it.


Rehab, Performance, Recovery. That covers a vast majority of the population, and that’s on purpose. The research (over 600 published studies) is incredible and the results we are getting wiht people speak for themselves. However, as the old adage goes, “If all you have is a hammer, everything looks like a nail.” Personalized blood flow restriction training isn’t for everyone, and that’s okay. At Athletes’ Potential we firmly believe we have the most skilled doctors of physical therapy who can use a vast array of treatment options to help you reach your injury or performance goals. Whether you are training through a nagging injury or looking to improve your performance, we would love to help you achieve your goals. Give us a call at 470-355-2106 or fill out the contact request form below and we will be happy to contact you.
Ready To See Us?



​Thanks for reading,


Dr. Jake, DPT, CSCS
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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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5 Steps For Returning To Exercise Postpartum

1/23/2019

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  1. Start with breathing and gentle movement right away.
  2. Ask your doctor about your delivery.
  3. Schedule an evaluation with a Pelvic Health Physical Therapist.
  4. Focus on healing and strengthening rather than weight loss.
  5. Find a community for support.


Breathing

While structured breathing work may seem simple-even silly- to some, we know that it is a powerful tool for the pregnant and postpartum woman.  Deep breaths have the ability to calm the nervous system which can affect muscle tension, heart rate, and blood pressure.  Additionally, the respiratory diaphragm can mobilize muscles in the pelvis and back due to anatomical connections. Muscles, including those shown in the photo below, are big players in midline stabilization and support.  A great place to start is the 90/90 breathing drill (seen below). Try this out for 10-15 breaths at the end of your day.
Ask questions​

Many postpartum women do not know all of the details after birthing their baby.  Some have told me they were not aware they had stitches down below until the 6-week check-up when the doctor wanted to make sure they were healing well!  The check-up at 6 weeks can be quick so arrive with questions. It is helpful to know about any tearing, episiotomies, tools used during the birth, etc.  These factors are all great to bear in mind as you return to exercise and daily functioning.

Another question to ask-- “Is there a pelvic health PT that you would recommend?”  They may know someone in the area or have worked with them prior.  However, do not become discouraged if they don’t have a name to offer.  A Google search for “women’s health PT” or “pelvic PT” should show professionals in the area.  Compare websites and reviews to see if the PT would be a good fit for you and your goals!​


​Pelvic Health Physical Therapy

Once you have been cleared by the doctor for “usual exercise” and intercourse, I highly suggest visiting a pelvic health or women’s health PT.  They will be able to further answer any questions about symptoms you may experience immediately postpartum and later.

A pelvic PT is specialized on evaluation and treatment of the pelvic floor musculature.  They can perform internal evaluations to test the strength and endurance of your pelvic floor, check for prolapse, address any soft tissue issues, etc.

For the evaluation, the therapist will use a gloved finger to palpate muscles internally. While a great deal of information can be gathered from an internal evaluation, it is not necessary for visiting a pelvic PT.   The therapist can then prescribe exercises to help relieve the symptoms and provide hands-on work to hips, back, sacrum and other involved areas. Your PT should be a huge help in getting you back to fitness postpartum!  Other areas they can treat and improve are bowel/bladder issues, painful sex, and pelvic pain.


Focus on healing and strength rather than weight loss

Social media and advertising may be all about “getting your body back” and fixing “mummy tummy,” but that is not the focus when you are postpartum.  The first step in returning to fitness is addressing foundational strength and continuing to heal from the pregnancy and birth.  Your body will go through so many changes in the months following your pregnancy and the timeline is different for every single woman.

Steer clear of programs that say at week 8 you do blank. It should all be self-paced and based on symptoms, your birth story, and prior activity level.  Do you need help starting out?  This was the number one question I received from women in the clinic.  “What can I do?  Where do I start?” So I developed programming to recover and rebuild your core after having a baby. Check out the THRIVE: Rebuild Bundle programming HERE.
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Find a community for support

Returning to group classes or running groups can be challenging because you will not be jumping right back into the level you were previously exercising.  Having a group of women who understand your needs and have been or are currently at the same stage as you is tremendously beneficial.  If this sounds like something you would be interested in, please join my Back to Fitness Postpartum Facebook page.  We have posts nearly every day and a lot of great discussions- some serious and some silly!

Once you return to group classes, be sure that the trainer knows you are postpartum and if there are any symptoms with movements.  If they offer other movement suggestions that still do not feel great, then modify further!  Symptoms (leaking, pain, heaviness in the vagina) are a signal to decrease the workload by resting or modifying or both!

Getting back to fitness postpartum can be challenging but it is not impossible!  With a holistic plan and support you will be able to recover and rebuild to get back to your favorite activities.  If you are looking for help with learning more about postpartum fitness, the pelvic floor and how to reach your goals, then please reach out at Athletes’ Potential.


Thanks for reading,

    Dr. Jackie, DPT
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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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