Brian Schiff’s Blog

So, I just returned from the Combined Sections Meeting for the APTA that was held in Indianapolis.  There was lots of great networking and presentations to be sure.   I attended sessions on ACL rehab/prevention, femoroacetabular impingement, elbow injuries in throwers, running gait analysis, and shoulder plyometric training with the legendary George Davies.  I thought I would give you my top 10 list of helpful nuggets I picked up over the weekend in no particular order of importance.

1. Performing upper body plyometrics has no effect on untrained subjects so don’t waste time putting it into the rehab program, where as it does benefit trained overhead athletes.  The one caveat is it also increases passive horizontal external rotation so keep this in mind when working with athletes who have shoulder instability.

2. A new study  coming out in 2015 in AJSM revealed no major differences in throwing kinematics between those following UCL reconstruction (Tommy John) and age-matched controls.  This is good news for those worried about pitching mechanics after the procedure.

3.  According to Dr. Reiman at Duke, the orthopedic hip exam does a better job of telling us they do not have a labral tear than it does telling us they do have an intra-articular problem.  The tests have poor specificity.  In fact, he goes on to say that the “special tests are not that special.”  That brought a chuckle from the crowd including me.  Bottom line – we are not really able to conclusively say “yes you have a labral tear based on my exam today.

4. Reiman also feels we must consider look for mechanical symptoms during the lowering portion of the Thomas test, while considering the fact that fat pad impingement may cause anterior hip pain as opposed to joint pain.  Again, things are not always as they appear in the “FAI” crowd so we need to take a great history, look at the classic tests and also see how squatting and loading affects the hip.

5. More experienced pitchers do not drop the glove side arm, but instead tend to move their body toward the glove to conserve angular momentum and overcome small moments of inertia.  Less experienced pitchers rotate their trunk sooner in pitching cycles whereas pitchers who threw at higher levels rotated later and produced less torque at the shoulder.  Consequently, many players with higher elbow valgus torque and distraction force at the shoulder rotate too early.

Continue reading…

It is no secret that running is synonymous with overuse injuries. Despite the best intentions, human nature craves more and more, while the competitive nature in us all to push a little harder also tends to get the best of us at times. One of the most rewarding parts of my job and profession is putting together plans that restore health and maximize performance.

The following story highlights both in an endurance athlete who I had an opportunity to work with last year. Normally I write about research, training and exercise on this blog. This post allows me to share the insight and perspective of one of my clients. I know that many of my readers have battled injuries. I am confident that this story of recovery and learning how to use the RIGHT training will resonate with you.

Click here to read about Anthony’s journey back to running

Every year I like to look back and reflect on things I have learned, things I have changed my mind about and of course clinical pearls that stand out.  Over the past year, I have been sharpening my IASTM skills, begun to practice dry needling techniques, and scrutinizing my hip and core exercises that I routinely use in rehab.

I look forward to sharing more about my clinical experiences with dry needling in 2014, but I feel the most critical and recurring theme of 2013 has been the overwhelming impact I have seen poor ankle dorsiflexion have on my patients.  I treat scores or runners, triathletes and clients with knee pain.  The most common issues in this group of clientele tends to be IT band friction syndrome or patellofemoral pain.

When I assess this group of patients, I routinely find the following:

1. Poor dorsiflexion
2. TFL dominance
3. Glute weakness

Any time I evaluate a runner, I assess closed chain dorsiflexion (DF) mobility.  This can be assessed in half kneeling on the floor or standing at a wall.  I suggest removing the shoes during the assessment to eliminate any rise from the heel in the shoe that may bias the movement.  In addition, I hold the ankle in subtalar neutral to get a true assessment without allowing pronation.

The image below simply demonstrates the assessment position as well as the corrective exercise that can be used to facilitate better motion.

Clients should be able to attain about 5 inches of clearance beyond the toes without lifting the heel or relying on pronation to get there. I routinely see limited mobility, and more importantly almost 100% of the time I find asymmetry on the side of the affected knee.

I recently evaluated a 29 y/o active female client who does Crossfit 3x/week and likes to run.  She has not been running much due to chronic right lateral knee pain and medial calf pain.  Her goal is to get back to running half-marathons.  Upon evaluation, her overhead squat assessment revealed pronation and external rotation bilaterally, right greater then left.  Her standing wall DF assessment revealed nearly a 1 inch deficit on the right side (about 3 inches), while her left side was 4 inches.

Below is how she looked on the treadmill video analysis I performed:

You can see the highlighted areas in the photo above.  She has a marked amount of pronation in mid stance as well as left pelvic drop due to poor gluteal activation.  The poor hip stability and activation on the right side also plays directly into TFL dominance with the repetitive femoral internal rotation and adducted position of her right hip..

This poor biomechanical chain is set into motion by poor dorsiflexion mobility.  Runners can get away with this for shorter distances (3-4 miles) in many cases, but increased mileage leads to shin splints, calf strains, IT friction syndrome and patellofemroal pain.  You can see how this poor kinetic chain movement leads to ongoing microtrauma and eventually debilitating pain and dysfunction.  No matter how much one rests, going back to higher mileage will yield the same result.

In my client’s case, she also had a trigger point in her medial soleus – another issue connected with the ankle mobility problem. Her primary treatment plan will focus on soft tissue mobilization for the gastroc/soleus complex, TFL/ITB and glutes/piriformis, ankle dorsiflexion mobility exercises, IASTM to her gastroc/soleus/Achilles, single leg balance and strengthening and hip/core activation and stability work.

I am confident all of this will effectively resolve her pain.  However, it all begins with restoring ankle mobility.  They say a picture is worth a thousand words.  I strongly believe the picture I included of my client on the treadmill speaks volumes as to how poor ankle mobility can lead to unwanted compensatory motion, gluteal inhibition and overuse injuries.  The take home message here is be sure to assess ankle mobility in the presence of any lower extremity pain or dysfunction as it is often a critical piece of the puzzle in the face or recurring injury and chronic pain.

I returned from a Disney vacation with my family last week.  While there, I saw all the runners who had just finished the marathon.  Several of them had compression socks and I was inspired to write today’s blog.

In 2009, I wrote a blog post on soleus strains, the Anatomy of a Soleus Injury. It is a widely read post about a commonly misdiagnosed issue and brings many inquiries as to how to solve this condition that plagues runners.  One question I often get is will compression socks help?  Over the past few years, I have seen a proliferation in the use of compression socks in the recreational running community.

But what exactly do these garments do?  Some of the proposed benefits are:

• Improved oxygen delivery to muscles
• Faster lactic acid resolution
• Prevention of muscle cramping
• Better stabilization of the lower leg leading to improved muscle efficiency
• Enhanced venous return to the heart through a more efficient calf muscle pump, leading to increased endurance capacity
• Diminished muscle fatigue resulting from more compact muscles, leading to improved balance and proprioception

What does science have to say about compression garments. I performed a literature search for relevant articles pertaining primarily to runners and endurance activity.  Below are some links to recent research abstracts:

– Physiological effects of wearing graduated compression stockings during running

– Compression stockings in male runners

– Impact on high intensity exercise in hot conditions

– Effect on 400 m sprint performance

– Impact on endurance running performance

– Effect of graduated compression stockings on running performance

– Calf compression sleeves and impact on oxygen saturation/running performance

In summary, much of the research we have no seems to tell us the following things:

1. Compression garments do not yield any measurable performance advantages
2. Runners prefer low compression socks over mod/high levels for comfort
3. Recovery does appear to be aided with compression in terms of improved venous flow and O2 saturation
4. No specific studies on gastroc/soleus muscle strains/rehab strategies using the socks

There is no conclusive evidence that these garments will prevent muscle strains, but research does indicate that perceived exertion is lower and the psychological impact of wearing the garment may aid runners.  I have not tried these myself, but some of my clients swear by them.  The idea of supporting/compressing soft tissue is certainly not new and many find some comfort in it.  We need more studies specific to injured populations to accurately evaluate the impact on those recovering from gastroc/soleus strains.

With that said, I am in favor of any modality that may allow athletes to train and compete with more confidence and less perceived exertion even if there is no direct measurable performance gain.  While I will stop short of endorsing these compression socks, I do see some potential benefits for those coming back from an injury in terms of recovery that warrant some consideration until they resume their prior levels of activity pain free.  For runners suffering from muscle injuries, utilizing soft tissue mobilization, stretching, strengthening, and proper running progression is still a an absolute must.

I wanted to make everyone aware of two courses that I am presenting in the next 2 weeks in conjunction with Allied Health Education:

The first is a (2) hour webinar on Current Concepts in the Recognition and Treatment of Femoroacetabular Impingement tonight, August 23 from 8-10 PM. The course is intended for PT’s, PTA’s and ATC’s looking for an in-depth presentation on the condition and its management. Click here for more information.

In addition, I am scheduled to present two (1) day seminars on “Fit Knees” in Greensboro, NC on Sept. 7 and Richmond, VA on Sept. 8. This lecture/workshop event will feature my evidence based approach to injury prevention and rehabilitation for knee osteoarthritis, running injuries and ACL injuries.

The material presented in this seminar is intended to help identify knee dysfunction and implement safe and effective rehab, corrective exercise and training strategies tailored to meet the needs of each client. Attendees will learn how the presenter utilizes the FMS, Y-Balance test and other screening tools to determine limb asymmetry and imbalances. Additionally, participants will learn how to use assessment and current research to create effective training programs, facilitate the rehab process and guide post-rehab decision making.  Click here for more information.

If you have further questions, feel free to post them on the blog.