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Brian Schiff’s Blog

Injury Prevention, Sports Rehab & Performance Training Expert

Tag: return to play

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Every month there are new papers on ACL surgery and rehab appearing in the literature.  I do my best to stay up on them as this is one area of my practice I am extremely passionate about.  I am driven to understand as much as I can about both prevention and rehab, but find myself increasingly focused on preventing secondary ACL tears in my patients.

I feel poor movement patterns, muscle imbalances and inefficient neuromuscular control are major risk factors for athletes suffering a primary ACL tear.  We also know being female markedly increases injury risk.  Research also tells us that males are more likely to suffer a re-tear of the same side, whereas females are more likely to suffer a contralateral injury.

A study just published in the July issue of the American Journal of Sports Medicine looked at the incidence of second ACL injuries 2 years after a primary ACL reconstruction and return to sport.  In a nutshell, the findings were:

  • 24 months after ACLR and return to sport, patients are at greater risk (6x) to suffer a subsequent ACL tear compared to young athletes w/o a history of ACL injury
  • Female athletes in the ACLR group are 5x more likely to suffer a second injury
  • The contralateral limb of female athletes is at greatest risk

Click here to read the full abstract

This information is not surprising as I have seen it firsthand in 17 years as a physical therapist.  What we do not have much information about is how do the younger patients (e.g 15 and under) really recover from this injury.  When should they be cleared?  I worked with a young female soccer athlete who tore her ACL and medial meniscus at age 13.  She worked diligently with me in rehab 3x/week for about 6 months and then continued training with me at least 2x/week until she was about 1 year out from surgery.


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The FMS is a great tool to uncover asymmetry and movement dysfunction in fitness clients as well as patients in the clinic who are ready to transition back to sport.  I have been using this tool consistently for 2.5 years in my practice.  One of the questions I have asked myself about the screening tool is how reliable is it?

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Click here for an earlier post I wrote on this topic regarding what it tells us as practitioners.  One of the challenges with any screen or test is not only validity but reliability.  In the April edition of the Journal of Strength and Conditioning Research, we gain some new insight regarding intra and interrater reliability via 2 new articles.

The first article discusses a controlled laboratory study where repeated measures were used to investigate how experience using the FMS and clinical experience as an athletic trainer (AT) affects the intrarater reliability of FMS testing.  The raters (17 men and 21 women who were recruited from the university’s athletic training clinical staff and academic programs), with different levels of FMS and clinical experience (AT students, AT or AT with at least 6 months experience using the FMS) viewed each of the 3 videotaped models.

None of the AT students or AT members had seen or used the FMS previously compared to the AT group with at least 6 months of experience. Each group rated the models on each of the FMS exercises according to the script presented by the lead investigator.  A week later the raters watched the same videos again in a different randomized order and rated each model on each exercise.

The intersession scores were examined to establish intrarater reliability of all participants.  In addition, the intrarater reliability of different groups of participants (students and clinicians) was compared to infer differences about the influence of clinical experience as an AT along with previous experience using the FMS.

Results:

  1. Average FMS score was 13.68 +/- 0.98
  2. There was moderate intrarater reliability was observed when all participants were analyzed
  3. The AT group with experience had the strongest intrarater reliability followed by the AT group (no experience)
  4. The AT students demonstrated poor reliability with a large 95% confidence interval

Key takeaways:

  • Previous research by Minick et al. had established excellent agreement on all components of the FMS among expert and novice raters indicating strong interrater reliability, but authors point out that is first study to look at intrarater reliability
  • This helps establish reliability of assessment giving more credibility to using it as an effective assessment tool
  • All raters were either AT’s or AT senior undergraduate students - need to include other professionals in future studies to confidently apply the external validity of the results in this particular study
  • Primary limitation of this study is the fact that video was used as opposed to live assessment
  • Possessing clinical experience and experience with the FMS strengthens intrarater reliability so learning to use the tool with other experienced clinicians may be wise to improve validity

Click here to read the abstract on this article.


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One of my favorite quotes from a well known fitness professional, Alwyn Cosgrove, is: “Exercise is a drug.  If we give the right drug in the right dose – everything works.  But, if we give the wrong drug or even the right drug in the wrong dose, we cause more problems than provide solutions.”  In essence, dosage matters a whole lot.  This means that getting it just right is also not by accident, but by careful analysis and exacting prescription.

medication

After a thorough evaluation, exercise selection and progression must be predicated on the end goal for the athlete.  Where are they now?  How do I get him/her back to 100%  Understanding the injury itself, training and medical history as well as inflammation and healing time frames is important, but that is just one part of the equation.

For those with experience, you already know athletes heal differently and no two injuries are ever just alike.  Addressing the mental components outlined in my previous post, Return to Play: Part 1 (The Athlete’s Mindset), is the starting point.  Next, you must formulate a plan to physically mend, challenge and prepare the athlete’s body to return to its previous functional level.

Below are some BIG mistakes I have either made along the way or witnessed in my career:

  1. Prescribing exercise solely based on the diagnosis - while logical and not entirely off base, we must learn to think globally and make sure we assess the whole athlete as opposed to isolating one area.  In my early days, I tended to focus on the affected area where symptoms were prevalent.  Keep in mind the symptoms may simply be the result of another weak link in the chain.  The FMS, SFMA and myofascial chains have taught us the importance of kinetic linking
  2. Pushing too hard too fast - progressing sessions simply based on what the athlete tells me as opposed to properly moving through a sound functional progression with specific criteria needing to be met prior to moving on to the next phase of rehab can cause more harm than good.  While you may be able to go faster in some cases, do not get too greedy without satisfying set goals along the way.  You do not want to reinforce a poor movement pattern.  A misstep here may cause a recurrence of the injury, perpetuate inflammation or weaken healing tissue.
  3. Not pushing the athlete hard enough - it is paramount that we assess client response “in the moment” rep to rep and set to set as opposed to just session to session.  Observe form and fatigue, but do not let the athlete coast or get bored with the lack of progression.  Understanding and applying fundamental exercise physiology principles and recognizing periodization is necessary to ensure complete restoration.

Now, on the my next big point.  I strongly believe you need to know how HARD the exercises you suggest are in order to effectively prescribe them.  One of my primary philosophies is that I will not prescribe exercises I cannot do.  Not only is this critical for teaching proper form, it is a must to gage fatigue, workout demand, recovery needs and so on.

Possessing a solid grasp of volume and intensity is also essential.  For example, having an athlete who is 6 weeks post-op with a bone-tendon-bone ACL autograft reconstruction do too much eccentric quad loading will inevitably lead to anterior knee pain or patellar tendonitis.  Would you do 10 separate eccentric quad exercises (2-3 sets of 10-15 each) in one hour ?  I do not do this type of volume on my healthy knee, but I have seen rehab done this way.  We must always keep a watchful eye on load, time under tension and overall volume throughout the rehab process.  The proper balance is critical.


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I have spent the past 16 years helping athletes get back to their sport or desired activity following an injury. Whether dealing with muscle strains or ACL ruptures, every injured client shares the same goal of making a full recovery and getting back to their previous activity level. My purpose in writing a blog series on this topic is simply to share some pearls I have picked up along the way and to help others learn from my mistakes and successes.

Beyond the severity and nature of the injury itself, there are several considerations that play a significant role in the rehabilitation process including: the athlete’s emotions, goals, mental toughness, age, experience, previous medical history, relationships with parents/coaches/teammates, innate movement patterns, etc. I feel the first and perhaps most important step in the recovery process involves connecting with the athlete on an emotional level.

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Injured clients want to know that their medical team (MD, PT, ATC and strength coach) really care about their well being, that they truly understand the impact of the injury on his/her life, and that they can provide the skilled care necessary to restore the body to its prior level of function. Too many times, we as health care professionals speak first espousing all our expertise and often forget to LISTEN enough.  Our athletes want to feel special during this low point in their life.

Pearl #1 - Spend more time listening on the first meeting/visit to gain a thorough understanding of how the injured athlete “feels” and views their current injury. I spend the majority of my eval time interviewing the client to allow them to describe their physical symptoms, but more importantly fully elaborate on their goals, perceptions and thought processes surrounding the rehab timeline and expected outcome. Knowing how they feel (afraid, angry, depressed, etc) is essential in order to connect as well as properly motivate/coach throughout.

Many athletes (especially those who have been injured before) tend to want to dictate how things will go or pre-determine when they will be able to return to the playing field.   I will re-direct them, but it is wise to listen to them tell you what did not work for them in the past.  Mistakenly, they often compare their injuries to past experiences of their own or peers. While prior experience dealing with the same injury is helpful mentally preparing for the recovery process, it is critical to remind the athlete coach and family that no two injuries are exactly alike and that the recovery process will be guided by specific milestones and processes as opposed to “what happened in the past.”

Pearl #2 - Thoroughly educate the athlete on his/her condition, the anticipated timeline for return to sport and the implications for pushing too hard and fast in rehab. Never assume he/she does not want to know all the details. Emphasize that your goal is to return to sport as soon as possible but in a safe manner that ensures adequate recovery and minimizes the risk for re-injury. Telling your athletes the “why” behind each and every decision (exercise selection, reps, sets, practice limitations, etc) will help put the athlete at ease early on and foster trust and collaboration. This is an absolute must.  To ensure success, we need the athlete to honestly and openly communicate throughout.  I tell every athlete I work with that we are a team dedicated to the same goal - this achieves buy in from them up front as they see I am fully committed and invested in them.

In almost all cases, I find the athletes fear losing their starting position and/or letting down the coach far more than long term damage to their bodies. As such, I tell them it really is okay to rest and recover. They seemingly feel guilty about not contributing and their self-worth may markedly diminish. Recognizing this and encouraging them to be patient, stay the course and see the light at the end of the tunnel is very important. You see, the emotional and psychological healing is a HUGE part of the process during rehab. Being an advocate for the patient and not the sport provides security and emotional support for the injured client.

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Over the past several years, the trend in the health and fitness industry has been toward injury prevention and movement screening.  Gray Cook and Lee Burton have given us the FMS.  More recently, the Y-Balance test has emerged as another tool to assess asymmetry in the upper and lower quarter.

I am currently FMS certified and planning to attend the SFMA course next month in Durham.  I routinely incorporate the FMS in both our rehab and sports performance work at the APC.  I like many things about the screening exam.  It provides a consistent tool to assess baseline movement and record asymmetry on a simple 4 point scale scale.  It also has been shown to have good intra and inter-rater reliability.  Click here for a recent study published in the Journal or Orthopaedic & Sports Physical Therapy.

For those unfamiliar with the screen, it is 7 tests scored on a 0-3 scale as follows:

  • 0 = pain
  • 1 = unable to perform the movement pattern (or perform with marked dysfunction)
  • 2 = performs the movement with a mild compensation
  • 3 = performs the movement correctly

I would say on average, most of the athletes I screen score between a 12 and 15.  My highest score was a 19 (9 year old gymnast) and my lowest was a 9 (NFL lineman).  As screeners, we are charged with uncovering asymmetry and faulty movement patterns.  What do you see in the following picture?

hurdle-step

Clearly, the dowel is not level, thus we score it a 2.  She also had some ER in the right leg when stepping over the hurdle.  She was a symmetrical 2 on the hurdle step test.  This is a Division I soccer player who scored 17 on the exam.

Most of the movements seem straightforward.  However, many question what the rotary stability test measures with respect to the ideal 3 score (ipsilateral movement)?  It assesses an unnatural movement pattern to be sure.  This athlete failed miserably on the ipsilateral pattern but scored a solid 2 with the contralateral pattern.

rotary-stability

I have yet to test someone who can score a legitimate 3.  I have seen some get a 3 on one side and 2 on the other (asymmetrical and a red flag in FMS land).  As one who naturally questions things, I find myself questioning how many are truly capable of scoring a 3.


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