Brian Schiff’s Blog

Seldom do I use my blog as a platform to rant, boast or anything in between.  I generally like to share evidenced based information that helps improve your health and performance.  But, every once in a while I feel the need to share my opinions on things I feel strongly about.  Today, I want to offer you my suggestions and theory on professional excellence within the fields of health and fitness.

Let me preface this post by simply saying I would never think of writing this or publishing it online for the whole world to read without having several years (15 now) of professional experience under my belt and a proven track record of getting RESULTS for my clients.  In my mind, the very reasons for my success include: being blessed with above average intelligence, a strong work ethic, a desire to help and serve others, unquenchable PASSION to be the very best I can be in my field, and an uncanny knack for seeing things others do not and using that information to make impactful exercise and treatment decisions for my patients and clients.

Where am I going with this?  Well, unfortunately, not all trainers, coaches and physical therapists share this same passion or possess this knack that I speak of.  Some are content after college (or certification) to be good enough and may not read literature, go above and beyond with continuing education, surround themselves with the best in the business or strive to be better each day.  Others may simply not have an innate ability to problem solve and synthesize given data to construct the right plan for the client.  Often trainers and clinicians default to what is easy or “what they know” as opposed to viewing each client in a different light.  In other words, they lack artistry.  They will never be revered like Picasso (pictured below).

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I thought a fitting way to kick off the new year would be to share the top 10 things I learned or embraced that have most shpaed and impacted my training and rehab this past year.  In no particular order I will rattle these things off.  I hope at least one of these little pearls has a positive impact on your training and/or rehab as well.

1. Often times it appears necessary to perform a biceps tenodesis or tenotomy in active adults undergoing a SLAP repair to ensure more predictable pain relief.  I heard this at a sports medicine conference last May and I can tell you those patients having this done alongside their shoulder surgeries seem to recover quicker with less pain relief.  With that said, keep in mind that SLAP tears are difficult to define and operate on as surgeons still do not have great agreement across the board on defining the extent of injuries and how to deal with them (operative vs. non-operative).
2. Performance on the Functional Movement Screen (FMS) has little to no correlation with athletic performance.  I screened an NBA player and an NFL player this year who both failed the screen.  However, they obviously have mad athleticism and genetic ability.  Keep in mind the FMS is a valuable tool used to assess movement and expose injury risk patterns based on the 7 tests.
3. Soft tissue therapy is undervalued and misunderstood by most lay people.  Assessing tissue restrictions and educating our clients to perform self myofascial release techniques is essential if they want to compete and remain healthy day in and day out.  Specific problem areas I have increased my focus on this year have been the psoas, soleus and posterior rotator cuff/joint capsule.  Click here for my soleus blog post.
4. Core training is probably as much about not moving as it is about generating force with movement.  I read work from Stuart McGill and other smart people in the field, and the concepts of anti-rotation and anti-extension are sound concepts to explore and look more closely at.  Many times, performance in sport and life require us to resist movement and maintain position so strengthening the core to resist potentially harmful and stressful motions is and should be an important part of training and rehab programs.  Understanding how to facilitate and activate core musculature in the training to protect the spine and improve mobility/strength is key.  Click here for more on my core training.
5. Hip dissociation is an important element to train as the lack of it can impact function and performance in a negative way.  We assess it on the active SLR in FMS and I see the lack of it show up on clinical exams all the time.  Whether it is HS tightness, hip flexor weakness or simply poor neuromuscular control, clients who are unable to effectively dissociate the hips are more prone to injury and limited performance.
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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:

Partial (left) vs. Full (right)

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)

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.

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.