Brian Schiff’s Blog
Injury Prevention, Sports Rehab & Performance Training Expert
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For those who know me well, it is safe to say I am an “ACL geek” of sorts. I love studying, reading and searching for the best way to rehab and prevent these injuries. As I have grown in the profession, I have become increasingly concerned with articular cartilage damage and the long term effects it has on our young athletes.
Perhaps I am getting more concerned as my knees aren’t getting any younger either (lol). Anyway, I truly believe we often underestimate how deleterious cartilage injuries can be long term. In addition, I feel we, as rehab and conditioning professionals, need to better understand how our training impacts the cartilage regardless of whether patients had a concomitant bone bruise with their ACL injury or not.
One of my favorite prehab exercises is a single leg hop and stick (see below)
I typically begin with an alternate leg approach (push off right and land on left) prior to initiating takeoff and landing on the same leg to teach proper landing mechanics. By now, we know increasing hip and knee flexion, as well as shifting center of mass forward reduces ACL strain and injury risk through a diminished extension moment.
However, what we may not know as much about is how an ACL reconstruction alters tibiofemoral joint mechanics at such a landing. I want to share some interesting information from a recent article in the September edition of The American Journal of Sports Medicine. The article by Deneweth et al. looked at tibiofemoral joint kinematics of the ACL reconstructed knee during a single-legged hop landing.
So, I am about 4 weeks into my new job at as a supervisor and sports physical therapist at the Athletic Performance Center (www.apcraleigh.com). So far, I am really enjoying it.
I have seen lots of different athletes ranging from youth to professionals. The one thing people often seek to eliminate with rehab is pain. Ironically, what most people fail to realize is that this pain is actually one of the biggest tools they need to rely on in the recovery process.
You see, most injuries I encounter are related to repetitive micro-trauma or overuse. Such injuries include tendonitis, bursitis, stress fractures, muscle strains, cervical and lumbar disc bulges, and so on.
It is critical that people learn to read their own pain as a marker of how well their body is holding up to the stress they are subjecting it to each day. If they simply learn to recognize and respect pain and what it tells them, they would be able to rehab and recover much faster.
Pain, while undesirable, is one of the most important tools we can use as therapists, strength coaches, ATC’s and fitness enthusiasts to judge how best to move forward or step back.
No pain, no gain is old school and best left in the past. To help athletes today and long term, it is best to educate them how best to recognize and react to pain when it occurs. Too many times they ignore it or fail to report it because they believe they will be held out of participation, or it is not a big deal.
Little do they know that this mentality often costs them more playing time long term or even may jeopardize their health in later years. So, as I tackle patella tendonitis, lateral epicondylitis, muscle strains and such, I teach my clients how to interpret pain in response to their daily life and sport.
Pain is not the enemy, but rather a warning signal our body sends us when it simply needs a break or is beginning to break down. Therefore, learn to listen more closely to your body and let pain guide your training, play and rehab process.
I advise people to consider the following:
- Soreness up to 3-4/10 on a 0-10 pain scale (10 being the worst) is acceptable provided it does not escalate with activity
- Any increased soreness after an activity should subside or return to baseline within 24 hours
- Pain that is at 5/10 or greater is a red flag and precursor to mechanical failure
Finally, keep in m ind that once pain subsides, that does not necessarily mean your body is done healing. Pain is a symptom and there is often a mechanical cause or disruption that leads to it. So, just remember to pay close attention to soreness and pain with activity as your body was programmed to let you know when tissue is starting to break down.
Most adult males are in search of that ever elusive six pack, right? Well, most intelligent trainers and strength coaches are well aware that there is so much more than just crunches to making the core functional.
With that said, I believe abs may be one of the most over trained sets of muscles today. Some people are doing ab work daily. Why? Our abs function daily to stabilize and resist force, as well as activate trunk movements.
In reality, the aesthetics of the midsection have far more to do with nutrition and body fat than the number of crunches one does. My aim today is not to discuss this, but instead to talk about an interesting article in the latest Strength and Conditioning Journal that discusses the effects of over training the rectus abdominis on weightlifting performance.
In this article, Ellyn Robinson discusses the best way to allow athletes to stabilize weight overhead during complex lifts such as snatches, cleans and jerks. She aptly points out that if an athlete cannot stabilize the weight overhead, he/she could miss the lift in front or behind the body.
I probably get more emails about shoulder problems than anything else. Most of the emails center on rotator cuff and SLAP tears, as well as whether or not to have surgery.
Let me be clear – I am not going to tell you TO or NOT TO have surgery in this post. That is for you and your MD to decide. However, I will give you my thoughts on key considerations with respect to this major decision.
Below are some major considerations to take into account if you are facing this dilemma.
Indications for having surgery:
- Unremitting pain (especially at night)
- Loss of daily function (dressing, bathing, self care activities)
- Marked loss of strength
- Bony impingement with failed rehab
- Moderate to massive tears with active jobs, healthy and < 50 y/0
- Isolated partial and full thickness tears with high probability of operative success after failed rehab
Now, some contraindications for surgery:
- Weakened tissue (including too much tissue retraction or shortening)
- Multiple tears in older population
- Failed previous rotator cuff repair
- High risk patients (includes those with cardiovascular and other medical issues)
- No rehab trial to date
- Partial or full thickness tears with good range of motion, negligible pain and sufficient strength to do most activities of daily living
These thoughts are mostly relative to rotator cuff pathology. SLAP tears are a much different animal in that they often do not do well conservatively with rehab, particularly in active patients. I approach SLAP tears in rehab much like I do a cuff problem, but the varying degrees of SLAP tears and associated involvement of biceps tendon pathology and/or rotator cuff damage make the treatment algorithm more challenging.
What I san say with confidence is that shoulder surgery is never quick and easy. The shoulder is such a complex and pain sensitive joint that whether or not you have arthroscopic or an open repair, the rehab and recovery process is often painful and laborious. This is not to deter you, but more so to make you aware that once you wake up from surgery your shoulder will not be back to normal, nor is there any guarantee your shoulder will be as good as new again. You understand that there is no problem surgery cannot make worse (quote from Dr. Jack Hughston).
Finding a skilled and competent shoulder surgeon will certainly lessen the complications and recovery window. So, when faced with the prospect of surgery, be certain to exhaust conservative measures first, seek multiple MD opinions, get an X-Ray/MRI, and weigh the current functional deficits with the desired functional level to determine the best course of action.
I was asked to comment on a thought provoking blog post on MyPhyscialTherapySpace.com. There is ongoing discussion with respect to the exact role a therapist should play in the continuum of care for patients. I enjoyed reading the posts on there and I have posted my reply on my blog for you to see (not to mention the fact the blog site would not let me post my entire repsonse in a single comment). To read the original post click the link below:
Now my comments…….
I would say as a cash based practitioner currently living in the sports performance and post-rehab fitness realm (I own a fitness training facility), I would say that many of my therapy colleagues do not truly understand how to push and/or fully rehabilitate people to a high enough level that meets the pre-injury functional capacity.
I often see referrals that have already failed traditional rehab or are getting inadequate therapy. Why? In many cases, PT’s are following basic protocols, not supervising exercise progression closely enough, moving too slowly or in some cases (ACL rehab) moving too fast. I also find clinicians are often hesitant or perhaps unwilling to change treatment progressions within the sessions, reps or sets even if the client’s response to the stimulus indicates such a change.
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