 Last week, we covered the training volume in part 1 of load management. If you missed it, go check it out. Today, we’re going to take a deeper dive into components of load management itself and what you as an athlete, coach or healthcare professional can do about it. I geek out on this stuff so get ready. Any injury ever: FORCE/LOAD > CAPACITY This means any force/load that exceeds the capacity of your tissue’s ability to withstand that force/load. Some examples:
Enter LOAD MANAGEMENT. The goal is simple: to protect you from injury and maximize performance Proper training must be prescribed. Over-training and under-training both increase risk of injury. You want to:
I’d be remiss to not give credit where credit is due: Tim Gabbett and company have been leading the front on this area and are really changing the way teams and athletes are handling training. Now, let’s define LOAD: It is broken down into 2 variables – external load and internal load
We use these two variables to create the: ACUTE: CHRONIC WORKLOAD RATIO (ACWR) This is also commonly referred to as FATIGUE compared to FITNESS. Fatigue being the acute workload and fitness being the chronic workload.
With technology nowadays, we have a number of ways to track this type of data. The most commonly cited method in the research is Session RPE (sRPE), which is time (total number of minutes) multiplied by the RPE for a given training session. The RPE is usually taken after a training session to gauge level of exertion/difficulty. This is measured as “arbitrary units” or “exertional units”.  For example, in week 5, let’s say a soccer player practices one day for 60 minutes at an RPE of 8. That gives us: 60 x 8 = 480 units. She practices 4 times during week 5 with a similar intensity. This gives us our ACUTE WORKLOAD (4 x 480 = 1920 units) for week 5. Now we have to look at her CHRONIC WORKLOAD for weeks 1-4.
When we compare the two, you get: 1920/1808 = 1.06 Now what does this number tell us? This ratio helps delineate whether you as the athlete are prepared for the task at hand – what you’ve done compared to what you’re prepared for – that can be a running a marathon, doing a CrossFit Open workout, playing in a professional football game or doing parkour in your living room.  In terms of injury risk, acute:chronic workload ratios within the range of 0.8–1.3 is considered the training ‘sweet spot’ where injury risk is at its lowest, while acute:chronic workload ratios ≥1.5 represent the danger zone. If you look at the trend of the curve before 0.80, you should notice the injury risk climbs back up – similar to a “U-shaped” curve. This relationship between workload and injury demonstrates that both inadequate and excessive workloads are associated with injury. Now let’s say from the example above that week 5 workload came out to 3500 arbitrary units. That would make the ratio: 3500/1808 = 1.94 No bueno.  If you don’t get this reference, we’re not friends. This athlete is at an increased risk of injury. When training load is fairly constant (ranging from 5% less to 10% more than the previous week) players had <10% risk of injury based on the study by Gabbett et al. However, when training load was increased by ≥15% above the previous week's load, injury risk escalated to between 21% and 49%. This is commonly represented by ‘spikes’ in acute load relative to chronic load. To minimize the risk of injury, we should limit weekly training load increases to <10%. There’s room to work within this, but a great starting point. Athletes accustomed to high chronic loads have fewer injuries than those accustomed to lower loads, and this supports Gabbett’s assertion that higher chronic loads can act as a protective effect against future injury.  These two graphs give a great depiction of what happens when load is applied appropriately:  Compared to excessive load and/or lack of recovery:  This is something I use every day with my patients and athletes. I’ll look at their training program and see if there is a mismatch in training volume and load management. We start here then look to optimize other components of injury and performance training such as stress management, tissue tolerance, biomechanics, physiology, strength, power, etc. At the end of the day, ask yourself this question: Is your body prepared for the demand of the task?
Cheers, Dr. Ravi Patel, PT, DPT, CSCS References:
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With the CrossFit Open upon us and beach bod season approaching, people will be fitnessing. A LOT. With this, comes the opportunity for injuries to sneak up and leaving performance on the table. People typically blame certain factors for an injury or lack of performance:
While these factors are definitely important to consider, there’s one that gets overlooked and is quite often the culprit: TRAINING VOLUME I had a patient come in a month ago who was dealing with foot and ankle pain. It has been on and off for months, and she decided to get it checked out due to a recent exacerbation. She’s a ½ marathon runner who also does Orange Theory a few times a week. She was starting to increase her mileage for her ½ marathon coming up. I think you know where this is going… Before trying to change up her running mechanics, change her shoes or blaming it on “overpronation,” we had a conversation about her training volume. I asked her how her running mileage and volume been. In this discussion, she said she went from 3 miles to 6 miles within a weeks time. BINGO. She was confused as she had previously ran this much mileage in the past, BUT... it’s been a couple months. I also asked her about the first time she ever dealt with this same issue – she said she couldn’t really think of why it initially started – “maybe running form or my shoes?”. I asked her when she started Orange Theory – lightbulb went off. BINGO again.  Let me be clear – there’s nothing wrong with her doing both running and Orange Theory. There is when your body is not prepared for the demand of these tasks. This was and is a volume issue, and if you’re reading this, think back to a previous non-contact injury and see if you can attribute any other factors playing into that specific injury – moreso volume in this case. Now, mobility, biomechanics, strength, etc., all play roles into whether we are operating as optimally as possible from a performance standpoint. For this patient, we did work on strength in certain areas and tweaked some things from a running standpoint, but the big component of her rehab was starting at a volume she could tolerate without pain or just a little, and progress forward from there. Training volume falls under the umbrella of Load Management (coming in Part 2) and is a big reason why injuries occur. Some common methods of measuring training volume include counting the number of sets to failure, the volume load (sets x reps x weight), distance, number of sprints, etc. Here are some terms to understand: Maintenance Volume (MV) – How much volume you need to maintain your gains Minimum Effective Dose (MED) – Smallest amount of stimulus needed to drive positive adaptation. If we are below this threshold, then there will be no adaptation. Maximum Adaptive Volume (MAV) – Here we are training at our optimal range of volume that we can adapt to and recover appropriately to drive optimal performance Maximum Recoverable Volume (MRV) – This is the absolute maximum volume that your body can handle and recovery from. Sometimes it’s necessary to pass this threshold from time to time, called overreaching, in order to elicit greater adaptations. Important point here is to make sure it is not often and that deloads are accompanying this high accumulation of volume to allow for supercompensation (the point of overreaching to get the training effect you want – improved strength, power, speed, etc.). When this is not appropriately monitored or constantly overreached without recovery, you open the door for injuries to occur and performance to suffer. (credit to Mike Israetel of Renaissance Periodization for this concept)  The way this is laid out is that you start with your MED, progress to MAV, then MRV to overreach. However, notice that you don’t dance with MRV often, nor do you want to.
Overtime, your MRV will increase, meaning you’ll get stronger and develop more work capacity, as long as you intelligently handle your training volume. A good rule of thumb is The 10% Rule - While there can be some variability here, staying within a 10% increase from the previous week tends to work well for a lot of people. It pushes that threshold in a progressive manner and allows appropriate recovery from the increased demand on the body. Next week, in Part 2, we’ll take a deeper dive into load management and training volume, explore exactly what this concept means, and how to practically apply it to yourself or athletes you work with. Cheers, Dr. Ravi Patel, PT, DPT, CSCS 
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.  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  Why is this topic so important to me? It’s because I’ve personally been through this process. Twice. And it’s one of the hardest things I’ve had to do in my life. Successful return to sport after anterior cruciate ligament (ACL) reconstruction requires optimal physical AND psychological recovery. The psychological component is quite often overlooked. Fear, emotion, and poor self-esteem can have profound effects on patients' compliance, athletic identity, and readiness to return to sport. An athlete can be physically prepared for return to sport, but if there is fear or anxiety associated, then this process should be prolonged. If you’re a clinician, parent, or athlete reading this, here are four key areas to consider: 1. Psychological Distress:
 This is where education and setting the expectations is huge. When working with an athlete, it’s important to consider this as a part of rehab. Who wouldn’t have anxiety or emotions when they can no longer play their sport and get their knee operated on. It’s completely normal. Rather than hiding it, have a conversation with your athlete. Educate them on what to expect before, during and after the procedure and for rehab. Assure them that everything will be okay and that they will get back to their sport. When an athlete knows what to expect, there’s less psychological distress associated with the process, which can significantly impact the success of the rehab and return-to-play process. 2. Self-Efficacy:
3. Locus of Control:
4. Athletic Identity:
 In addition to the 4 areas above, an objective measure can be very beneficial to quantify where the athlete stands from not only a physical perspective, but psychological. That’s where the ACL-Return to Sport after Injury scale (ACL-RSI) can be helpful. The ACL-RSI is a great outcome measures to assess athletes' emotions, confidence in performance, and risk appraisal in relation to return to sport.
Recognizing positive and negative psychological responses to injury is the first step in initiating treatment and potentially modifying beliefs through psychological interventions. It is important to identify patients who are at risk for poor outcomes because targeted psychological interventions may be successful. If you know of an athlete going through this injury and recovery process, don’t forget that there’s more to it than just what you can see. Cheers, Dr. Ravi, DPT Sources: - Christino MA, Fantry AJ, Vopat BG. Psychological Aspects of Recovery Following Anterior Cruciate Ligament Reconstruction. J Am Acad Orthop Surg. 2015;23(8):501-9. - Sadeqi M, Klouche S, Bohu Y, Herman S, Lefevre N, Gerometta A. Progression of the Psychological ACL-RSI Score and Return to Sport After Anterior Cruciate Ligament Reconstruction: A Prospective 2-Year Follow-up Study From the French Prospective Anterior Cruciate Ligament Reconstruction Cohort Study (FAST). Orthop J Sports Med. 2018;6(12):2325967118812819. - Ardern CL. Anterior Cruciate Ligament Reconstruction-Not Exactly a One-Way Ticket Back to the Preinjury Level: A Review of Contextual Factors Affecting Return to Sport After Surgery. Sports Health. 2015;7(3):224-30. -Schub D, Saluan P: Anterior cruciate ligament injuries in the young athlete: Evaluation and treatment. Sports Med Arthrosc 2011;19(1):34-43. Melissa A. Christino, MD, et al  Here’s what we know:
That last bullet point is a HUGE problem. How do we know when an athlete is ready? Traditional return-to-sport criteria are mainly focused on the time after ACLR and knee-specific impairments, while the return-to-sport decision-making process is only made at the hypothetical “end” of the rehabilitation period. When is this “end” point? When the patient runs out of insurance-covered visits? When the ortho clears them based on a 5-minute exam? When there’s no longer a government shutdown? This “end” point is completely made up and very subjective. That is why we need more concrete, objective measures to allow these athletes return to sport at a high level with the lowest risk of re-injury.  Dingenen et al. proposes: “an optimized criterion-based continuous and multifactorial return-to-sport approach based on shared decision making, with a focus on a broad spectrum of individual sensorimotor and biomechanical outcomes, within a biopsychosocial framework.” I could not agree more.  This means that we need to get away from time- and isolated-based assessments and look at this from a holistic 360 degree view, taking into account not only the biological factors of the athlete, but psychosocial factors as well. Since there are many individuals involved in this process, it takes a team to make the outcome truly successful. This team consists of the individual, their family, physical therapist, athletic trainer, orthopedic surgeon, sport coach, strength coach, etc.
Remember – A single component alone (i.e. time) is not enough to determine whether someone is ready. All of the components below could have the box checked except the last one and this athlete would still not be ready. I hope this provides some insight to you if you are going through this process as an athlete, parent, or clinician looking to return to sport.
Cheers, Dr. Ravi Source: Dingenen B, Gokeler A. Optimization of the Return-to-Sport Paradigm After Anterior Cruciate Ligament Reconstruction: A Critical Step Back to Move Forward. Sports Med. 2017;47(8):1487-1500.  Have you ever been in the middle of a workout and feel an ache or pain? It’s completely normal if it’s something small and goes away. It’s another story if it continues to bother you or increase in pain. Sometimes we just do too much (or too little) and it pisses off some part of our body. You may start to realize it’s impacting the way you move and you may even avoid a particular movement that causes the pain altogether. Often times, people see this as a sign to take some time off and rest. This may be the case in some instances, but it’s not always the best solution. Some people go to a healthcare professional to find out what’s going on. Quite frequently, they’re told to stop that activity or exercise. We hear it all the time from new patients. “Squats are bad for your knees.” “Running will wreck your body.” “Stop doing CrossFit. You’ll get hurt.”  [Credit: Barbell Physio] But, what if you’re an Olympic weightlifter who has a competition coming up? What if you’re a runner who loves a good 5k? What if you have a stressful job and CrossFit is your outlet to relieve that stress? Come on, healthcare - we can do better. If these are your goals, we want to help you get there. Here’s 5 different ways to train around pain and decrease stress on that painful area:
MAIN GOAL: MAKE THE LEAST CHANGES POSSIBLE TO THE MOVEMENT Now, let’s break down each one of these using knee pain with front squats as an example.
 [Credit: EricCressey.com]
 [Credit: Barbell Rehab]
Here are a few other examples for you:
Here’s the overall concept: Pain comes on --> scale back movement slightly --> train movement --> adapt --> progress difficulty --> adapt --> back to prior level --> continue training pain-free --> hit PR  [Credit: kcbi.org] I believe that any great coach or physical therapist should be able to modify and progress/regress any movement or activity. If you have given these methods a shot and pain continues to impact your life, then find a healthcare professional who understands your goals and doesn’t tell you to stop.
Cheers, Dr. Ravi, DPT Whether you are looking to PR your squat, want to squat without pain or are just sick of nagging lower extremity pain—this is where the change needs to begin. This week I posted a picture on social media of a patient who started the session with a squat that deviated to the right and then after some mobility she was centered. This started a lot of conversation from athletes asking for help with this exact issue. First, check out your mobility. Remember: symmetry is important in a squat so be sure to check both sides and compare! Pain and dysfunction in the back, hip and lower extremity can absolutely be caused by a laundry list of issues, but sometimes we make it more complicated than it needs to be. The best way to begin to decrease pain and improve function is to find the low hanging fruit and start there. At Athletes’ Potential we use a group of movements to screen every patient with lower extremity complaints. The last movement is always a body weight squat. Not because every patient we treat is a weightlifter and wants to improve their squat, but because it is a foundational movement that everyone should have the requisite mobility and strength to perform. The first two places to look for a mobility restriction are the ankle and the hip. A few indicators of ankle restriction during the squat often comes in two forms: the people that feel like they will fall backwards if their chest is up any higher (pic 1) OR those who look like they have a solid squat but on closer look, their ankles are collapsed and spin outward (pic 2&3).    Ankle dorsiflexion is essential to have a deep squat with an upright torso. The best way to check your own ankle mobility: place your foot a hand width from a wall (in a lunge position), with the foot in that position drive your knee toward the wall making sure that your heel stays down. Can it touch the wall? If yes, move on to checking hip mobility. If no, your ankles are limiting your squat!   Our favorite ankle mobility drill uses a band to distract the ankle and then move it through range. Check it out-- Ankle distraction and dorsiflexion Ankles can be a frustrating joint to mobilize because they are slower to change. It is important to work ankle mobility into your warm up and/or cool down as much as possible! As you begin to chip away at ankle restrictions, check out this older blog post about the best way for you to modify a squat until your mobility is improved: Is squatting bad for my knees? Part II To self-check hip mobility there are a two hip movements that are important to check- hip flexion and hip internal rotation. When you are missing hip flexion and/or internal rotation, there may be a pinching sensation at the front of the hip during a squat or you have a “butt wink” at the bottom. To check hip flexion, lay on your back and pull your knee towards your chest. Ideally, you will be able to get your knee about a fists width from your chest. As you apply overpressure with your hand, you might notice your pelvis start to lift off of the floor. This is actually lumbar flexion, which is synonymous with a ‘butt wink’. The athlete below is experiencing this a bit, I think he was trying to show off for the camera. ☺  When checking internal rotation, sit on a table or box so that your feet are not in contact with the ground. Internal rotation is the motion when your foot moves outward from your body when your hips and knees are bent. We like to see 40-45 degrees, as in the picture below. Be sure that as you rotate your hip, you don’t bring your booty off the table and lean to make it go further!  Lacking hip flexion? Here is a great sequence to work through-- Hip Flexion Mobility
Is your internal rotation less than ideal? Is one side much less than the other? Give this a try-- Anterior Hip Opener with Internal Rotation Maybe you check all of these areas and you have the ideal mobility. What else could it be?? Really bendy athletes are on an opposite end of the spectrum from more immobile athletes. In fact, banded mobility and banded distractions won’t help you at all! If this is you—stay tuned for Part II that covers the limiting factor of the squat for flexible folks. Thanks for reading, Dr. Jackie  Let’s recap from last week: Your ankles drive the squat bus and your knees are along for the ride. Unfortunately, the hip is often overlooked when pain or dysfunction with squats occurs. Strengthening targeted to the hip will improve knee position during the squat. If it hurts your knees to squat, it is likely a faulty movement pattern causing the issue. When there is pain, do not push through. Jane Fonda might have said “no pain, no gain” during her abs, buns & thighs workout but this does not apply. The feeling of an ice pick jabbed in your knee cap is not normal. Pain with a back squat does not mean you can’t squat at all! Try these first:
I eluded to different flavors of squats in the last post. Is high bar back squat bothering the knees today? Try a low bar position, front rack or squat to a box. There are so many options! It is nearly as exciting as picking a flavor of ice cream. Check out Noel showing us some variations of squats! Pay attention to her ankle and shin positions. High Bar Back Squat a.k.a Traditional Back Squat The bar rests across the top of the upper trap, on the shoulders. Throughout the movement, the torso remains upright. With this set up, the knees tend to move more forward than in other squat variations so adequate ankle mobility is essential!  Remember, those with significant ankle mobility issues will have trouble maintaining the upright torso and may try to sidestep the issue by turning the toes out wide. Another squat flavor will allow you to move in less compromising patterns while still gaining strength. Don’t forget to work on ankle mobility every day! Front Squat The bar rests across the front of your shoulder, elbows are high and in front. The torso is the most upright in this squat flavor to keep the barbell over the midfoot. Again, ankle mobility is key here!  For those who do not have glaring mobility restrictions, the front squat is a great exercise to carry over for the clean. Low Bar Back Squat The feet are in a wider stance than for the traditional squat. The bar rests lower across your shoulders, elbows are back and high to help create a shelf for the barbell. The torso maintains more of a forward inclination to keep the barbell over the midfoot.  This flavor of squat decreases the torque at the knees by allowing the tibia, or the shin, to remain more vertical. (Go back and look at her shin-to-foot angle in the traditional squat and compare!) More torque is placed at the hip, so the hammies and glutes are targeted. If you feel a pinching at the front of the hip, vary your squat width and work on that hip flexion mobility! Box Squat The feet are in a wider stance, similar to the low bar set up. The bar rests across your back in either high bar or low bar position. A sturdy box is behind the lower legs. The hips are allowed to travel further posteriorly during this movement which allows the tibia to remain vertical.  The box squat is great for all athletes to include in their workouts. It is helpful when just learning how to squat or trying different foot positions. After a knee or ankle injury, it is a good way to decrease torque at the knee and demand on the ankle joint. Box squats are also used for power athletes as it has been shown to increase the rate of force development, or explosive strength, more than other squat flavors.
Each of the squat flavors has something different to offer for your health and athletic development. If you are recovering from an injury or lack mobility in the hips or ankles, there is still a flavor for you! Grab an empty barbell and try each of the variations. Don’t be afraid to vary your stance width. Start with a taller box and gradually work your way down as you get comfortable. Taking a video of yourself moving is the cheapest and quickest way to find faults and underlying mobility issues. Once you work through each squat flavor, you will have a better idea of which mobility drills to introduce daily. Get your squat moving correctly and cut out that knee pain! After all, it’s not your knees’ fault! Thanks for reading! -Dr. Jackie References: Swinton P, Lloyd R, Koegh J, Agouris I, Stewart A. The biomechanical comparison of the traditional squat, powerlifting squat, and box squat Journal of Strength and Conditioning Research. 2012;26(7):1805-1816.  Hi, I’m Dr. Danny Matta DPT. I’m a Physical Therapist/Strength Coach and I’m the founder of Athletes’ Potential. Our company helps people just like you live higher quality, higher performance lives. That could be running your first 10K, competing in the CrossFit Games or getting rid of that lingering back pain so you can start getting back in shape! Dry needling is a technique we use frequently. I hope you have a better understanding of what it is after this article. Please email us if you have any other questions and we’d be glad to answer them for you. When I was in the Army as a Physical Therapist, I remember first hearing about dry needling and thinking how crazy it sounded. I remember thinking PTs that were doing dry needling were searching for some kind of voodoo treatment that only had placebo effects. I actively stayed away from learning it because at the time I was a new graduate that thought I knew everything and was going to set the world on fire by getting everyone better. Well, things changed one morning when I wrecked my back after a ruck march training session. I hurt my back so bad I could barely drive home and had to cancel all my patients that day. I threw everything at it that I knew and even enlisted the help of a few of my colleagues. Six months later, my back still hurt to pull weight from the ground, back squat or run (that was literally 80% of my training at the time!). About that same time, a new physical therapist named Dr. Emmanuel Easterling moved to where I was stationed. Dr. E, as we called him, was a certified dry needling ninja. I reluctantly let him perform his voodoo on my back and I'm so glad that I did! Within 2 days of Dr. E dry needling my back for the first time, I was running with no back pain. After the second time he did it, about a week later, I was squatting and deadlifting again. That was it- I was hooked and not only did I drink the Kool-Aid but I chugged it! I dove into dry needling head first and learned as much about it as possible.  So what does this technique do and why is it so effective? That’s a great question and the answer is we don’t fully know. Frankly, medicine is constantly evolving and we are always using our best evidence/knowledge at that time. Dry needling is the same way so as I answer this, understand there is probably way more to this than we even know. First, dry needling involves placing small needles into strategic spots in the muscles. These spots were recognized and mapped out by a physician named Dr. Janet Travell, MD. She was an incredibly smart lady and was even John F. Kennedy’s personal physician during his presidency. Did you know he had chronic back pain? Yep, and what did she use to alleviate the back pain? You got it- dry needling! The points Dr. Travell mapped were called trigger points. This trigger points in the muscle actually refer pain, not just where the “knots” in the muscle are, but to other areas of the body. Here’s an example of a trigger point in the upper trap. The X is where the trigger points are typically found. The dotted red areas are where the trigger points refer pain. Have pain on the inside of your shoulder blade? It could be just an irritated trigger point in your upper trap that dry needling would help fix really fast!  So how does a needle in a muscle cause pain to resolve quickly? There are a few theories on why this happens and I like to explain it in terms most of us understand: Think of a trigger point like a glitch in your computer. Something isn’t working right and it’s causing other things to have issues as well. What fixes most computer problems? You got it- the restart!
Dry needling is like the restart for the musculoskeletal system. If we have a irritated trigger point and we put a needle in it, it resets. This reset occurs at the muscle with what’s called the wash out effect. This basically means that a needle in a muscle causes increased blood flow to the area. Increased blood flow causes increased oxygen/healthy blood to shunt to the area. Local inflammation/stagnant fluid gets “washed out” by this effect. There has also been evidence to support the theory that dry needling has a strong effect on the nervous system. Basically, placing a needle in a trigger point causes local opioids (our bodies own natural painkillers) to be released. This also causes a positive pain relieving effect on the spinal cord. This means we can get a local and central pain relieving effect from this technique. Yes, most people are sore for a day. It feels like you worked out hard and the muscle is fatigued. In addition, you have to perform self-treatment work to really get the best benefit from dry needling. Picking the right home exercises and doing the right technique is where the magic is.
If you’ve been struggling with an injury or pain that’s stopping you from the activities you love, this might be a very effective treatment option for you. You have a choice. You don’t have to wake up every morning and hope that this is the day your shoulder/back/neck or whatever areas stops hurting. It’s sad how many people are in pain daily. It stops them from playing with their kids, walking 18 holes in golf, staying in shape and living overall happier lives. If you’re in the Atlanta area and you’d like to talk with one of our Doctors of Physical Therapy to find out if our approach is right for you, contact us. We’ll set up a free 10-minute phone consultation at your convenience. Thanks for reading. -Danny  “Give a man a fish and he eats for a day, teach a man to fish and he eats for a lifetime.” -Unknown or was it Jin? I recently had a patient that drove in from Orlando to work with me for two hours. He’s had lower back pain for about 5 years and it started while he was in the Army as a medic. He didn’t sustain any type of combat trauma that caused the back pain. It literally started while he was doing a workout one morning. The workout involved kettlebell swings and he felt a pop in his back toward the end of the workout. Fast forward 5 years later, and he still has back pain. He’s tried physical therapy, chiropractic, acupuncture and even took up yoga in the quest to fix his back pain. None of these things worked so he made the 7 hour drive to Atlanta to see me (ironically driving was one of the activities that aggravated his back). He showed up with a pretty classic presentation for back pain. Poor hip mobility, underactive posterior chain and really bad posture. We completed our evaluation and decided on a plan. First, we’d do some dry needling to the lower back and hips. This is a great technique for pain reduction. This allows us to work on things that would otherwise be painful to help regain strength and mobility.  Following a short bout of dry needling, we spent the rest of the time putting together a plan of what this individual needed to do everyday in order to fix his back pain permanently. We literally spent over an hour piecing together 5 exercises that I wanted him to do religiously. So how did he do? Well I just got an email from him about a week ago that said he was able to sleep through the night and is virtually pain-free consistently for the first time in 5 years. We get a chance to help individuals like this all the time and in many cases help them get out of chronic pain permanently. So why did this guy have to drive from Orlando to Atlanta to see another physical therapist? The answer is that no one was teaching him, they were all just trying to fix him. There are 168 hours in a week. Even if you went to see a physical therapist 3 times per week (the standard physical therapy prescription in many cases) that’s still 165 hours of the week that you are on your own. What are you doing in those 165 hours? Are you prioritizing sleep correctly to help with healing? Are you eating the right things and staying hydrated? Are you doing corrective exercises and mobility work? Are you getting out of bad positions as much as possible during the work day? Are you rounding your back every time you pick anything up off the ground?  Resolving long lasting and chronic problems comes down to compliance from you! It’s my job to teach you what you need to know and persuade you well enough to actually do it. If you’re dealing with a chronic issue and are sick of being in pain or avoiding certain activities, it doesn’t have to be that way. We see patients from all over the southeast just like you and they get better. They run 10k races again (the Peachtree race if you’re in Atlanta), they play with their kids without throwing their back out, they compete in local CrossFit competitions and they wake up in the morning without feeling like they have been hit by a truck.
At Athletes’ Potential we may be physical therapists but more than anything we are teachers. You have to learn how to take care of yourself. You have to be empowered with the right information to make huge long lasting changes. If you’re in Atlanta or the southeast, for that matter we’d love to help you. Give us a call at 470-355-2106 or fill out the contact request below and we’ll talk on the phone to see if you are a good fit for what we do. |
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