Brian Schiff’s Blog

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.

I just finished presenting at our our second ACL Symposium of the year at the Athletic Performance Center last Saturday.   Rehabbing and training female athletes has been a passion of mine for some time.  Over the years, I have also developed a love for research and reading it, particularly studies on the ACL.

In my practice, I have incorporated jump landing, single leg training and deceleration based training for some time.  While we all know females are 3-8 times more likely to suffer an ACL injury than males, we have not isolated the exact reason why. Researchers have offered some clues such as: wider pelvis, narrow femoral notch, smaller ACL, ligament dominance, limb dominance, natural laxity (hormonal factors), wider Q angles, and faulty muscle firing patterns to name a few.

Many of the structural factors are beyond our control.  So, as practitioners, we must focus on the training.  Consider the following study just published in the August 2011 edition of the American Journal of Sports Medicine that basically reveals females develop peak valgus moments during deceleration during a drop landing maneuver, whereas males develop peak valgus forces during acceleration on the way back up:

Click here for the abstract

Drop Landing

This article adds more evidence that females recruit and fire their muscles very differently than males.  More importantly, it reiterates that we as coaches, therapists and S & C professionals need to be working on deceleration mechanics.  I believe this starts with simple soft two legged drills such as:

1. Small squat jump and holds
2. Box drops and holds
3. Forward line jump, stick and hold
4. Lateral line jump, stick and hold
5. 90 degree jump turn, stick and hold

In addition, one of my favorite drills is a single leg forward leap (hop) and stick working on deceleration.  The athlete stands on the right leg and then pushes off forward landing on the left leg.  Coaching the athlete to land softly on a bent hip and knee while avoiding valgus is important.  I usually perform 2-3 sets of 5 reps on each side.  Cueing with a mirror, auditory corrections and tactile cues are useful in encouraging proper form.

SL Stick (start)

SL Stick (finish)

It is important to keep in mind that the majority of non-contact ACL tears occur between 0 and 30 degrees of knee flexion.  They also typically involve deceleration (landing, jump stop or change of direction), planting or cutting.  For this reason, deceleration training must also involve programming for agility and change of direction.

On Saturday, I led the break-out session on deceleration training and covered a few key exercises I use with my athletes.  These drills are layered on one another and the basic ones I begin with are:

1. Stops – I have athletes accelerate out and then decelerate to a controlled two legged stop after 10-20 yards.  Keep in mind allowing for a longer run will allow the athlete to gradually slow down, while decreasing the distance increases intensity and force on the knees.  I coach breaking down with small “pitter patter” steps versus a sudden hard stop.
2. 2 cone lateral shuffle stops – the athlete shuffles over 5-6 yards and then stops with good hip, knee and foot alignment working to keep the shoulders inside the knees (inside the box).  I progress to multiple cone shuffles to increase intensity and maximize repetitive deceleration.
3. Pro-agility drills – 3 cones are placed 5 yards apart and I combine linear and lateral movements between the cones layering #1 and #2 above in a continuous pattern to work on acceleration/deceleration combos and change of direction
4. Y drill (4 cones) – the athlete runs forward to a cone 5-15 yards out and then performs a 45 degree cut left/right.  The progression begins with directed and predictable movement and then advances to reactive cueing with auditory and visual cues.
5. Arrow drill (4 cones) – The athlete runs 5-15 yards forward and then performs a 135 degree cut left/right and runs past the cone that serves as the bottom edge of the arrow head.  This is much more demanding on the body (knee) and as such I only move to this after the Y drill has been mastered.  In addition, I teach a hip turn (from Lee Taft) to reposition the hips and minimize torsion on the lower leg.  I move from predictive to reactive agility as in the Y drill.

These exercises are a small sampling of my ACL prehab/rehab routine.  I also include an enormous amount of single leg PRE’s and balance training as well.  I believe the most important things we can currently do to reduce ACL risk in this population are:

• Screen our athletes to help identify risk (FMS, drop landing, dynamic strength,running/cutting analysis)
• Emphasize hamstring, gluteus medius and lateral rotator strengthening
• Teach landing mechanics and proper deceleration through neuromuscular exercise, biofeedback and repetitive cueing
• Refine proper cutting technique by teaching ideal angles and how to reposition the hips
• Empower coaches and athletes with simple yet effective body weight training routines that can be replicated on the field or court with the team

For now, the battle rages on.  I hope you will join me in the quest to prevent these catastrophic injuries.  I think as research evolves we will continue to see that the answer to promoting optimal stability at the knee will increasingly have more to do with addressing the hip and ankle.  For now, we need to teach soft bent knee landing/cutting that shifts the body’s center of mass forward, while eliminating valgus loading as much as possible in the danger zone.

This post is a follow-up post to one of my previous ones, A Closer Look at Push-ups & Modified Push-ups, based on some dialogue with a reader. Click the link to familiarize yourself with the background.  Some people simply do not agree with my assertion that modifying and or limiting end range of motion with certain exercises such as bench press, push-ups and flies is needed to preserve shoulder health long term.

So many people want to hitch their wagon to “simply strengthen the scapula” as a fix all solution.  While I agree 100% that scapular stabilizer and cuff strengthening goes a long way, we would be foolish to ignore joint biomechanics, physics and kinesiology when examining how loads affect joint structure and function over time.

I will start out by saying I ascribe to the idea that a healthy joint should be able to move through full range of motion.  My question to you is with how much load and how many times over and over again before destructive microtrauma sets in.  With that said, how many healthy shoulder joints do you think are working out in gyms across the world today?  Without an x-ray, it is impossible to know if you have a type I (normal), II (flat) or III (hook-shaped) acromion.  Your genetics do make a difference in your risk for developing shoulder problems, as types II and III are more prone to impingement (see photos below)

This is one risk factor that cannot be mitigated by prehab if you will.  I would also challenge you to consider that loading the shoulder repetitively with heavy loads in the furthest depths of shoulder horizontal abduction (bar touching the chest in bench press or lowering DB’s well below the plane of the body with flies) will eventually create atraumatic shoulder pathology.

Ever wonder about things like:

• Osteolysis of the distal clavicle
• Anterior shoulder laxity (over stretching the anterior capsule and joint structures over time)
• Creating impingement with repetitive motion in the presence of poor bony architecture, a thickened bursa or inadequate shoulder stability

While some may argue lifting does not create instability (it is known that bench press may lead to subtle posterior instability over time), I don’t think we can question the impact of weight lifting on clavicle destruction.  Men more commonly develop acromio-clavicular arthritis, and osteolysis of the clavicle is common with lifting exercises such as bench press, dips and upright rows.

Click here for an article discussing osteolysis of the clavicle. The authors specifically mention modifying or avoiding certain weight lifting techniques base on pain and radiographic findings.  I think we must as fitness professionals, strength coaches and educators look at the long term implications of lifting techniques on long term shoulder health and function.

Most would not hesitate to say they would do anything to avoid shoulder surgery if they knew their exercise habits might pose a risk for a future procedure to alleviate pain and restore function.  I firmly believe avid recreational weight lifters and bodybuilders should modify range of motion with many of these pressing and lifting motions to be safe.  This includes blocking full range bench press, modifying flies and push-ups, avoiding deep dips and generally minimizing how often they choose to do dips and upright rows. I also feel most people over age 35 or 40 should minimize the frequency of dips and upright rows as risk outweighs reward over time with repetitive loading of the clavicle (particularly if they have a long history of weight lifting already).

Take a look at the x-ray below showing osteolysis.  You can often see a widening at the AC joint.  Many times, these patients must undergo steroid injections, rest, activity modification and even a distal clavicle excision to resolve the pain.

Call me conservative or crazy, but  I know personally how limiting bench press/fly range of motion eliminated my cuff pain in less than 2 weeks years ago when I was in college.  Additionally, I currently have two patients in  my clinic with shoulder injuries:

1. A 19 y/o male hurt doing submax loads full range with a barbell
2. A 60 plus y/o male who had arthroscopic repair of a torn supraspinatus that occurred while doing dumbbell flies (submax loads) on a flat bench lowering the dumbbells far below the parallel

Two patients decades apart hurt by the same mechanism – a biomechanical mismatch and repetitive microtrauma.  So, my own body, years of clinical and training experience, and research studies have led me to conclude that modifications for those choosing to do resistance training 2-3 plus times per week for many years on end are necessary to have healthy shoulders for years to come.   If you value your shoulder health and that of your clients, consider restricting depth, reducing shoulder abduction angels with pressing and carefully selecting and or limiting certain exercises based on client medical history and functional goals.

I think it is safe to say most would agree that deadlifts are great for building maximal lower body strength. Elite Olympic weightlifters are generally able to lift more loads in this lift compared to other free weight exercises.  I know personally that I like to use it to develop lumbar extensor strength, as well as in place of the squat if I want to avoid spinal compression from the weight of the bar.

In the past I have heard some strength coaches say they don’t use a hex bar for deadlifts because it is not the same as lifting a straight bar.  While not always sure exactly what they mean by that, I found a recent article in the July 2011 Journal of Strength & Conditioning Research very insightful.  The researchers looked at the difference between straight and hexagonal bar deadlifts in submax loading situations.

The concern with deadlifting has always been stress on the spine.  The study notes:

“For world class athletes lifting extremely heavy loads, lumbar disk compression forces as large as 36,400 N have been reported.”

Lifters have long been encouraged to keep the barbell as close to them as possible to reduce the moment arm. The issue with the straight bar is that it can impinge on the body.  Thus, the trap bar or hex bar apparatus was developed.  The researchers hypothesized that the hex bar would reduce the joint movements and resistance moment arms.  In addition, they hypothesized that larger forces would be produced with the submax loads.

The study use 19 male powerlifters and was conducted 3 months after their most recent competition where most were at the end of a training cycle aimed at matching or exceeding their previous competition performance.  The subjects (following their own warm-up) performed HBD and SBD at 10, 20, 30, 40, 50, 60, 70 and 80% of his SBD 1RM.  Twelve markers were placed on the body for biomechanical analysis.

Continue reading…

Today I am going to share two pieces I have written for other publications as I think the exercises I discuss have real merit and broad application for competitive athletes and weekend warriors.  I am a columnist for PFP Magazine and Endurance Magazine and these articles come from those publications.

Single Leg Theraband Activation Squats

The idea behind this exercise is applying progressive gradients of resistance that encourage the faulty motion (pulling the leg into adduction and internal rotation) to facilitate increased activation of the gluteus medius/minimus and small lateral rotators to create an anti-adduction/internal rotation force.  Decreasing such moments at the knee will reduce IT Band issues, patellofemoral pain, ACL injury risk and overuse problems often seen in running.

Click here to see how to perform the exercise

Mobility Training for Endurance Athletes

It is no secret that endurance events require repetitive motion and often carry a higher risk of overuse injuries.   In light of this, poor thoracic extension and/or limited ankle dorsiflexion negatively impact proper running and riding mechanics and lead to faulty movement patterns.  Beyond physical stress, this reduces performance capacity as well.  There are two simple mobility exercises to help correct imbalances that may be hindering you.

Click here (go to page 16) to see how to sustain your body with these exercises