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Brian Schiff’s Blog

Injury Prevention, Sports Rehab & Performance Training Expert

Archive for 'medicine'

I have been a bit behind on blogging as of late.  I try to aim for one per week, but I also strive to deliver sound and relevant content.  Additionally, I do not seek outside contributors so finding time to write can be tricky with work and family life too.  So, forgive me for any apparent inconsistency in posting.  Just know that I will always try to provide valuable content.  Today’s post centers around an article in the July 2012 edition of AJSM.

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My work at the Athletic Performance Center has provided me an increased opportunity to work with FAI and athletic hip injuries.  This is an area of evolution and growth in our field, so I find it particularly interesting to see rationale and thought processes centering around the timing, contribution and selection of hip exercises for active patients/athletes.

This article comes from the Steadman Philippon Research Institute in Vail, CO.  The purpose of the study was to measure the highest activation of the piriformis and pectineus muscle during various exercises.  The hypothesis was that highest pectineus activation would occur with hip flexion and moderate activity with internal rotation, whereas the highest activation with the piriformis would be with external rotation and/or abduction.

anterior_hip_muscles250px-posterior_hip_muscles_1

Methods: 10 healthy volunteers completed the following 13 exercises:

  1. Standing stool hip rotation
  2. Supine double leg bridge
  3. Supine single leg bridge
  4. Supine hip flexion
  5. Side-lying hip ABD with external rotation
  6. Side-lying hip ABD with internal rotation
  7. Side-lying hip ABD against a wall
  8. Hip clam exercise with hips in 45 degrees of flexion
  9. Hip clam exercise with hips in neutral
  10. Prone heel squeeze
  11. Prone resisted terminal knee extension
  12. Prone resisted knee flexion
  13. Prone resisted hip extension

All of these exercises have been reported to be used in hip rehab following arthroscopy or recovery from injury.  The exercises were executed slowly and methodically with a metronome to reduce EMG amplitude variations.


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Disclaimer: This post is a small rant from me.  I normally don’t use this blog as a medium for that purpose. However, I feel so strongly about this topic that I decided to share my thoughts on it.

diploma

I had an interesting email exchange with a health care practitioner (HCP) this past week.  She had some questions about one of my products and asked specifically if I had done a clinical trial comparing my treatment method to leading national PT organizations.  My answer was no.

I explained to her I am not a researcher, nor do I have the time (or money for that matter) for such things as I am in the trenches every day treating patients and training athletes.  Her response was very interesting.  According to her I was defensive, and she suggested I check out a DPT program so I could in essence become a better clinician.

Hmmm………  Suffice it to say I completely disagree with her on this one.  I graduated from PT school at the Ohio State University in 1996.  Their program was very well respected at the time (over 500 applied and they took 60 in my class) and two of my professors (Lynn Colby and Carolyn Kisner) wrote the text on Therapeutic Exercise that is still used in many curriculums today.  On top of that, I worked at the top outpatient ortho clinic in the city as an aide my junior and senior year in college.

At the time of my admission, OSU only offered a B.S. degree, so I never had a choice for more at that point.  The university quickly adopted a Master’s program shortly after I finished and later became one of the first institutions to offer the full DPT program.

Upon graduation, I went to work at the same top ortho clinic and spent 5 years working side-by-side with some of the brightest PT’s and next door to what was considered by many to be the best surgical group in town.  I saw surgeries, sat in on MD appointments with my patients, participated in journal clubs and worked at a feverish pace.  Let’s just say I saw lots of patients and gained what felt like a fellowship experience for 5 more years.

Now, as I reflect upon this email from said HCP, I can honestly say that I believe experience and results matter more than just those three letters behind a name.  That is in no way meant as a slam or any disrespect to the DPTs out there, clinical research trials or the doctorate degree itself.  Students today have no choice but to take the DPT route.  To be honest, they really only have (1) more year of structured curriculum than I had in my program.  They leave school with a lot more debt, and afterward they still have no clinical (real world) experience when they first start out.  You simply can’t buy experience in school.


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Rotator cuff tears are common injuries, especially among active middle age men.  As researchers and scientists seek for better ways to promote healing and more optimal surgical outcomes,  PRP continues to get lots of attention.  If you want  a basic primer on PRP, click here to read one of my earlier posts on it.

In a recent study in the October 2011 American Journal of Sports Medicine, researchers looked at the effects of PRP on patients undergoing surgery for full thickness rotator cuff tears.  This is the first prospective cohort-control study to investigate the effect of PRP gel augmentation during arthroscopic rotator cuff repair. Forty two patients were included in the study (average age of 60), with 19 undergoing arthroscopic repair with PRP and 23 without.

Outcomes were assessed preoperatively and at 3, 6, 12, and finally at a minimum of 16 months after surgery (at an average of 19.7 +/- 1.9 months) with respect to pain, range of motion, strength, and overall satisfaction, and with respect to functional scores as determined using multiple assessment tools.  At a minimum of 9 months after surgery, repaired tendon structural integrities were assessed by magnetic resonance imaging.

Below are images defining a full thickness rotator cuff tear:

full-thickness-tears

Partial (left) vs. Full (right)

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Full Thickness Tear on MRI


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In my practice, I take care of many athletes ranging in age from 10 and up. Many of the injuries I see are related to over training and overuse. Common things I see in the clinic on a daily basis include but are not limited to:

  • Tendonitis
  • Shin splints
  • IT Band Syndrome
  • Patellofemoral pain
  • AC joint pain/arthritis

The list can go on and on.  There are many factors (inherent and training related) that contribute to such problems.  I personally believe many problems can be prevented with better education, smarter training, coaching predicated on individuality and physical response, and of course adding in more recovery.  Cross training is also a must - just look at what sport specialization at an early age has done to current injury rates.

You need not look any further than the declining age of patients walking through the door with what I term “repetitive microtrauma” injuries.  I saw a 14 year old cross country female runner a few weeks ago who had her second stress reaction injury inside of 12 months.  In addition, the rise in the number of Tommy John surgeries performed in the past decade with respect to those having them at an earlier age may serve as a harsh warning sign about doing too much too soon or doing too much of the same thing year round.

I say all this simply to say we must not be oblivious to the rise in these types of mechanical injuries.  Throwing, swimming, and running are all activities that become dangerous if done in excess, and they also produce predictable injury patterns.   So, if you are curious about some risk factors and how to better balance your training and manage these types of injuries, then check out a webinar I just did for Raleigh Orthopaedic Clinic last week (click on the screen shot below to view the webinar)

screen-shot-overuse-injuries

This presentation is ideal for athletes, parents, weekend warriors and sports coaches looking for practical, straightforward information on this topic with some foundational guidelines that can be applied objectively and immediately to injury management and recovery.  If this information helps just one person avoid an injury or accelerate their recovery then I will be thrilled!  Please feel free to forward this post to friends, share it on FB or tweet it!

One of the greatest things about medicine is that it continues to evolve and change.  Sports medicine is at the forefront and athletes are always looking for faster ways to recover and get back in the game.  If you are not familiar with platelet rich plasma (PRP) therapy, click here to read my earlier post on it.

It has been used increasingly to treat muscle strains and chronic tendinitis in the heel, knee and elbow.  While some early responses have been favorable, there has not been much follow-up data or research available to assess its efficacy.  In the August edition of the American Journal of Sports Medicine reports on one-year follow-up for the use of PRP in chronic Achilles tendinopathy.

achillestendonitis

The study was a double blind randomized placebo-controlled study using 54 patients (age 18-70) who had chronic tendinopathy 2-7 cm proximal to the Achilles tendon insertion (minimum of 2 months).  They were randomized and given PRP or a saline injection in addition to an eccentric training program.  Keep in mind recent research has indicated the efficacy of eccentric training to treat chronic tendon problems.

In this intervention, patients were given the injection with ultrasonagraphic guidance.  After the injection, theyw ere told to avoid sports for 4 weeks.  In week 2, they preformed a stretching program.  Then all participants began a 12 week eccentric exercise program.  Follow-up was done at 6, 12 and 24 weeks by one researcher, while another blinded researcher did the one-year follow-up.  Clinical and ultrasonagraphic follow-up was done at each interval.

Results

At the 1 year follow-up, there was no clinical or sonagraphic benefit of PRP. This matches the findings at 6 months as well.  One other radnomized studly looking at tennis elbow did find a statistical significance when they compared PRP to a corticosteroid injection at 1 year, instead of a placebo injection.  Another key factor or difference is one area is load bearing and the other is not.

In reviewing this study, it should be noted that not only was pain reduction not statistically greater, nor was there any added positive tendon structure changes noted using the PRP.  With that said, the looming issue with this treatment intervention is that variables like platelet count, injected volume. number of injections, preactivation and the presence of leukocytes are not always the same across studies, and they were not determined within this study either.

The takeaway here is that there appears to be no added benefit from PRP with chronic Achilles tendinits.  However, there is no known negative side effect associated with trying it either.  I think the hardest part is scaling back activity and being patient enough to overcome these injuries.  In my experience, they often require soft tissue massage, rolling, stretching, eccentric loading, relative rest, and a very specific return-to-activity plan based 100% on the tissue and pain response of the patient.

Time and future research will continue to tell us more about PRP.  I think we may find that different growth factors and treatment options may evolve that do in fact speed regeneration and healing.