Brian Schiff’s Blog
Injury Prevention, Sports Rehab & Performance Training Expert
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I am currently working to attain my transitional doctorate in physical therapy (tDPT) at Northeastern University. As I continue to work full time as a clinician, it has been really cool to apply the learning with my current caseload. At this time, I am in a motor control class that is both fascinating and challenging. In week three, we examined pain and the impact it has on neuroplasticity (the brain’s ability to adapt or change).
In the sports medicine realm, I generally think many practitioners solely focus on the musculoskeletal system or physical impairment. As such, interventions are developed around tissue constraints, ROM deficits, weakness, etc. Too often, we look past the power and impact of the brain and how it plays a vital role in healing and return to play. For some patients, there is a maladaptive response to injury/surgery and a hypersensitivity of the central nervous system or central sensitization that occurs. Pelletier (2015) notes that structural and functional changes can occur. (1)
Two critical concepts to consider here are:
- Sensory amplification – sensory and motor representations change resulting in perceptual changes in body image, motor control changes, and even a persistence or amplification of pain
- Experience dependent plasticity – patient’s response to pain is related to prior experience and may experience maladatpive imprinting where the pain outlasts the physical insult
Kleim (2008) gives a great lesson on experience dependent plasticity and states that learning is essential for the brain to adapt to damage self taught behavioral changes can be maladaptive or positive and specific forms of neural plasticity and associated behavioral changes are dependent on specific kinds of experience (2). While one would assume that chronic pain is rare in athletes, I would counter and say it is probably just overlooked as we tend to expect athletes to “push through the pain” because of the driven culture we live in. Coaches, parents and even teammates can affect the mindset around injury and recovery.
Over the years, I have been fortunate to work with lots of athletes ranging from youth to professionals. Regardless of age or skill level, I have observed that each one approaches the recovery in their own way. Some are eager to tackle therapy, while others are apprehensive and fearful.
To be clear, the mindset of the patient is as important, if not more important than the physical part of the process as it relates to success. With ACL rehab, I pay close attention at post-op visit number one to determine if the patient is a coper, non-coper or somewhere in between. Having this awareness is crucial as I look to encourage the client and position him/her for success in the fist phase of rehab. The mindset of a patient recovering from their second or third ACL tear may differ greatly than that of a first timer.
With that said, assessing the state of mind of any athlete in the PT clinic is a must. An athlete’s identity, confidence and self-worth is often tied to his/her sport. Injuries separate the athletes from their teams and take away something very important to them. This can lead to depression, anxiety, anger, fear and loneliness to name a few.
It is imperative to connect with an athlete in the first 1-2 visits of rehab. I aim to bond with them and ensure they know I will do everything in my power to get them back to their prior level of performance. Fear of loss is powerful, and I want to partner with them to prevent the loss of playing time as quickly and safely I can though proper rehab.
One of the great things about being a columnist for PFP Magazine is that I often get to test out the latest fitness equipment on the market. While there are certainly some very gimmicky things out there, I have some ‘go to’ selections in my toolbox, such as the BOSU®NexGen™Pro Balance Trainer. It is the latest version of this training tool.
In my clinic, I rehab lots of athletes suffering from gluteus medius weakness, poor pillar stability and decreased hip stability. Many of my clientele are working to make it back from ACL reconstruction. One of my preferred strengthening exercises to target the shoulder, torso and hips is split squats. Once the client masters proper form on the ground, I move to an unstable setting using the BOSU®.
It is essential to challenge athletes to avoid valgus collapse. The BOSU® introduces instability at the ankle forcing the body to adapt during the split squat movement. Avoiding dynamic valgus and trunk dominance during training will help with injury reduction efforts for the client.
In the video below I produced for my PFP online column, you will see how to use this exercise effectively to improve strength, stability and proprioception.
Have you ever experienced a significant injury? If so, do you remember wondering if you would ever be whole again? Pain, fear and the inability to do your sport or physical activity can cripple the human spirit.
Over my 21 years as a physical therapist and fitness professional, I have witnessed how powerful the mind is and how critical it is to have the right mindset to overcome physical obstacles. Some people are mentally stronger than others – period. With that said, adversity and pain has a way of testing the spirit and will of an individual.
In any given week, I see at least 5-10 patients rehabbing an ACL injury. The injury, surgery and rehab is physically and mentally grueling. The injury itself takes the athlete away from his/her passion or sport immediately, while presenting them with a long path back to full health. Many suffer an identity crisis as they become isolated and away from their peers. Physical therapy that fully restores function is a must in this group of patients. For more on what complete ACL rehab looks like, click here to read one of my previous posts.
Fear of reinjury and persistent knee symptoms are common reasons for a lack of return to play after ACL reconstruction. Click here to read an abstract regarding kinesiophobia in this group of patients.
With any injury, it is only natural to worry about the outcome. Clients often wonder quietly whether they will be able to return to their previous level of play. In this post, I want to talk about the elephant in the room for patients coming back from an injury, and that is a legitimate fear of reinjury.
Many people suffer from chronic hamstring pain. The question is what is the root source the pain? As a seasoned clinician, I see many patients who present with pain in the upper hamstring/ischial region. Referral sources can include the low back, hip, SI joint, proximal hamstrings, gluteals, piriformis, and ischial bursitis to name a few. In some cases, the pain can be multi-factorial as I see some runners with low level discogenic (nerve) pain and proximal hamstring tendinopathy. The sciatic nerve and its proximity with the hamstrings necessitates thoroughly vetting the symptoms and its pattern in each client. Assessing SLR, slump test, reflexes, myotomes and dermatomes is a must.
Determining what the exact source of can be difficult and requires a good subjective exam and objective testing. For the purposes of this particular post, I am focusing on the proximal hamstrings themselves as the primary source of the pain, as I see so many who struggle with proximal tendinopathy who have seen many providers with little relief.
I treat many runners and middle aged adults who experience this high hamstring or buttock pain that is often worse with:
- Sitting
- Forward bending
- Walking or running uphill
As with traditional hamstring strains, eccentric strengthening is a must for this population. However, we must consider the myofascial component and contributions to this pain as well. In many cases, these patients have ischial tuberosity tenderness. Consider the referral pattern of the medial HS illustrated below:
I typically like to consider using hip and core strengthening, dry needling, IASTM, stretching and eccentric strengthening to address the pain. If I feel the problem may include a sciatic nerve component and there is an extension bias, I will utilize some PA glides and extension exercises too. In addressing this pain pattern, we must be thorough.
A 2014 case study published in JOSPT looked at a case study with two runners (71 and 69 y/o men) who were treated with eccentric exercises, trigger point dry needling and lumbopelvic stability exercises. The rehab was phase based and the results are as follows:
Patient 1 was treated in physical therapy for 9 visits over 8 weeks. At discharge, he had achieved his goal of running 8 to 10 km 5 times each week pain free. An e-mail received 6 months following discharge noted that he had remained symptom free with all activity and that he completed a triathlon symptom free.
Patient 2 was seen in physical therapy for 8 visits over the course of 10 weeks and discharge were performed by the same therapist who performed the initial evaluations and oversaw each treatment. He was discharged after running 30 km without symptoms and reporting significant decrease in hamstring pain. The patient was seen 6 months later in physical therapy for unrelated right shoulder subacromial impingement but reported no hamstring symptoms and that he had participated pain free in a marathon.
In my practice, I have found dry needling, heat and soft tissue work to be very helpful along with stretching and strengthening. I like to use eccentric PREs and hip stability work to resolve proximal hamstring pain. Specifically, I have used the following two exercises with very good results:
Single leg RDL
Supine reverse hamstring curls using gliding discs
Both of these exercises are effective in promoting eccentric hamstring strength, hip stability, and improved hamstring mobility. Furthermore, they can be effectively used in rehab, rehab and training situations. I routinely use them in all of the above. For a more detailed explanation of the reverse curls, be sure to check out my upcoming Functionally Fit column at www.fit-pro.com.
Keep in mind that hamstring pain can be caused by one or multiple sources. It is best to seek a medical evaluation to determine the exact source of pain and address it safely and effectively. Exercises such as the ones demonstrated in this post represent a few options for addressing hamstring strains/tendinopathy. Others may include Nordic hamstring curls, prone eccentric hamstring curls and hamstring walkouts. Using manual interventions along with exercise is often effective in accelerating and optimizing full recovery.
Reference
Jayaseelan DJ, Moats N, Ricardo C. Rehabilitation of Proximal Hamstring Tendinopathy Utilizing Eccentric Training, Lumbopelvic Stabilization, and Trigger Point Dry Needling: 2 Case Reports. J Orhtop Sports Phys Ther 2014 (44)3:198-205.
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