Brian Schiff’s Blog

Today’s blog post is about an observation and fundamental tenet of my practice today as a sports physical therapist and fitness professional. Having been in the business of rehabbing and training the human body for 15 years, I feel qualified to say I know a thing or two about training and exercise.

Perhaps one of the greatest pearls I can pass along as it relates to being a health and fitness professional involves the art of teaching. You see, I have witnessed firsthand the desire people have to attain knowledge when it comes to their bodies. Just look at how quickly and often people take the web in search of answers from the latest ab workout to the source of and remedy to their every ache and pain.

We live in a society of information overload. Unfortunately, the web, YouTube, FB, Twitter and so on give just about anyone a stage to philosophize and sound off as an “expert.” Many people who claim to know how to “train” you for this and that have little to no real world experience doing it, nor do they possess enough pre-requesite knowledge to truly be considered an expert.

I find many people mistakenly look for what they perceive to be the most “in” or “intense” training they can find, as they believe this is the way to finally meet their goals. In reality, what they should be seeking is someone interested in teaching them how to better understand their own body and how to apply the proper training principles to it in order to bring about the desired result they are so desperately seeking.

Training typically involves putting together drills, workouts or routines to challenge clients physically. Teaching, on the other hand, is centered on educating clients how to listen to their bodies and use that feedback to appropriately adjust physical loads and exercise programming to avoid injury and make positive physical adaptations.

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Wow!  It has been a busy two weeks for me.  I have been putting the final touches on a DVD and writing a ton of articles lately.  I just returned from speaking for Power Systems at a Total Training Seminar in Missouri in late March.  It is always interesting speaking and hearing other presenters.

There is usually no shortage of controversy and conflicting opinions either when it comes to fitness and training.  One speaker mentioned that it is perfectly okay to allow the knee to go over the toe with exercise.  In fact, this presenter said it was desirable to maximize training.   My talk (later on) was on bodyweight training for a healthier knee.

Naturally, I was asked what I thought about the earlier comment.  My answer was “it is complicated.”  I am not sure that is what the audience wanted me to say.  Pressed again later on, I acknowledged that in a repetitve training environment, lunging and squatting with the knee over the toe is not something I recommend.  However, if I am retraining a client to be able to descend stairs one foot over the other, the knee does in fact move beyond the toes.

So, there are times in life, where we need to think outside absolutes and adjust our thoughts and training to meet the needs of people at a current time and space so to speak.  The real trick is knowing the client, their medical condition, their needs and measuring the response from the body.  I hate protocols because no two people are the same, nor do their bodies heal and react the same way.

But, let’s get back to the knee.  I talked about assessing the knee and then integrating the “right exercises” to not only correct dysfunction but also to improve fitness and performance.  If you think body weight training is useless or for sissies, you may want to think again particularly if you like to run and have any issues with patellofemoral pain (most women do have PF pain or early arthritis).

Consider the research from the Journal of Orthopaedic and Sports Physical Therapy in 2003 where Powers et al. determined that PF joint forces are significantly  greater with external loading versus bodyweight only in flexion angles begining at 45 degrees during eccentric loading (lowering down while peaking at 90 degrees) and concentric loading (rising up) at 90 and 75 degrees.   What does this mean for you?

Essentially, if you are a runner and suffer from PF pain, you may want to limit deeper range of motion with squatting and/or consider limiting the amount of external loading as well.  Even better, you should be doing single leg training keeping this same information in mind.  Training is an exact science and most people get it wrong all the time.  That is why I am currently working on a Fit Knees DVD series to give trainers and consumers relevant and science based information to direct their training for optimal health and performance.

I just finished volume three in this series and it is ready for official release this Friday.  If you are a runner and want a blueprint to train for injury prevention and peak performance, this DVD is for you.  Or, if you are a runner who is currently injured or has been plagued by overuse injuries, it is still for you as I have a complete progressive rehab series on the DVD to get you back up and running again. 

As a runner myself, I have put these strategies to good use with much success.  I thought it was fitting to relase the DVD this week as I prepare to run my 4th half marathon in Charlotte this weekend.  Below you will see the product display. 

As a blog subscriber or reader, I am offering you $10 off the normal price of $34.95 through midnight Saturday.  Simply visit www.fitknees.com and use the copuon code BFITRUN (all caps) at checkout.  I am confident you will find it valuable as it covers training from A-Z with warm-up prep, foam rolling, balance training, strength and power exercises, rehab and stretching.  It is 65 minutes of power packed content.  Here’s to healthier knees and happy running!

Wow, it has been a while since I posted.  After battling what may have been H1N1 for nearly 2 weeks I am back at it.  I just returned from the Sports Physical Therapy Section Meeting in Las Vegas held last weekend.  All the brightest minds in the industry were there covering the latest research with an emphasis on knees and shoulders this year.

I must say I came away most impressed with Dr. Scott Dye.  He is an orthopedic surgeon at the University of San Francisco, CA.  He spoke on several topics but continued to highlight this concept of respecting the “envelope of function” in regard to activity and healing.  It really resonated with me as it sounded a lot like my concept of threshold training.

He believes we have a set envelope of function, if you will, that predetermines how much stress our body will absorb before breaking down.  There is the natural envelope and then an area he termed “supra physiologic load.”  Once we break this barrier of supra physiologic load, then mechanical tissue failure ensues.

He preached using bone scans as a diagnostic tool for measuring whether your body was really at tissue homeostasis as opposed to still being inflamed.  His assertion is that often we push people back to full activity too soon based upon subjective reports of no pain and clinical tests as opposed to measuring the joint itself with a scan to see if it is still reactive.

He raised a few eyebrows when he suggested that he does not let athletes return to play after ACL reconstruction until somewhere near 18 months.  While that may seem crazy, he had some interesting research he has done to show how his post-op patients do not get early arthritis at follow-up as far out as 15 years after surgery. 

In essence, he explained that we as practitioners must progress rehab and training in a very sequential and client specific way based upon this envelope of function theory.  While I am not sure I bought  his rehab time lines lock, stock and barrel, I do believe he is right on track with this envelope of function idea.

I have been saying for years that pain is not a good sign during training or rehab.  My critics have often said you can push through some pain with frozen shoulder, rotator cuff pain and the likes with training in order to move forward.  I have always countered that your body has a threshold to activity.  The only surefire way to progress without re-injury is to adequately gage and understand the threshold level, while adding stress to the system only as able while staying within the threshold.

How do I measure the threshold?  I have included my basic definition below:

With a proper training threshold, the athlete or client learns how to grade and evaluate the stress on his/her body during every practice/training session, while gaining an understanding of the exact threshold itself.  The threshold (activity tolerance level) should increase or progress with subsequent training, and the use of pain or soreness in response ot said stress should be the guiding factor in adding more load or volume.

Key parameters to track include:

• Pain at rest or before activity
• Pain during activity
• Pain after activity
• Length of time for pain (if present) to resolve or return to baseline

Teaching athletes and clients to track and understand this concept is critical to long term health.  First, you must get them to honestly report their symptoms.  Then, you must earn their trust by reassuring them your goal is to return them to full activity as soon as possible but as safely as possible.  Finally, you must implement the system and relate it to the exercises for them to understand how to measure their body’s response.

As I work with elite level athletes and everyday folks struggling with SLAP tears, rotator cuff impingement and knee arthritis to name a few, I become more convinced that accurately gaging their threshold or envelope of function is the key component when it comes to successful exercise program design and progression.

I am often asked when is it safe to go back to play after an injury.  In most cases, I am dealing with lower body or back injuries with my athletes, so for the purposes of this post, I will address a lower body functional return to play paradigm.

The tricky part about this question is that no two injuries are created equal.  Sure, I will be the first to acknowledge that I have general approaches to certain injuries and have a sense of how long it should take most of the time.  But, over the past 13 years I have seen enough irregularity and differences to say that everyone heals and recovers differently.

For example, I have had athletes with a simple grade 1 ankle sprain not go back to sport for 6 weeks, whereas those with much more severe grade 2 or even grade 3 sprains go back in much less time.  Why?  There may be several reasons including compliance, body structure, previous medical history, fitness, pain tolerance, and the quality of the rehab to name a few.

In the end, rehab professionals and strength coaches must have sound knowledge of pathophysiology, tissue healing, and program design that ensures maximal progression with optimal tissue loading.  Messing up the stress gradient (too little or too much) will slow the return to play process.  Below are some major milestones my athletes must clear in order before we even get to what I term “functional rehab” or preparatory movement prior to controlled practice:

1. Full active range of motion
2. Normal strength on muscle testing
3. Normal walking gait
4. Symmetrical squat and lunge patterns
5. Single leg squat (back, hip or knee injury) and/or calf raise (ankle injury) within normal limits compared to uninvolved side
6. Single leg hops in place x 10 equal to uninvolved side with no pain or instability
7. Normal running gait on treadmill x 5′ without pain or instability
8. Lateral gait cycle within normal limits (shuffle, carioca and cross stepping)
9. Planned and predictive controlled agility without pain or instability
10. Low level plyometrics in 3 planes without pain or instability

After moving through this fundamental progression (may take days or weeks), the athlete may then begin to perform more demanding neuromuscular work.  This would involve more rotational work, full intensity sprints an cutting, and gradually the transition to reactive agility and speed drills.  Once the athlete completes this process, he or she is ready for controlled practice.

This is an area where I see student athletes get in trouble. They get “cleared” so to speak by the MD and go back to practice.  Cleared to a coach means full go, right?  The athlete should ease back into practice even after a carefully prescribed rehab plan like the one I just laid out.  However, too often, I see athletes rushed back to full practice too soon.  In the case of soft tissue and stress reaction injuries, this often sends them back to the training room or sideline much sooner than the coach or athlete would like.

What is the answer?  Controlled practice progressions with the idea of first increasing volume (total minutes) prior to restoring maximal intensity.  Athletes know what is hard and what hurts.  We just need to communicate with them.  Allow them to do the easier drills and fill up time with those prior to ramping up the intensity for the entire practice.

Let’s take soccer as an example.  Dribbling, passing and light shooting are lower level drills.  In contrast, set pieces and small sided games are much more demanding.  Athletes and coaches must use discretion when returning form play to avoid re-aggravating an injury.  Measuring pain before, during and for 24 hours afterward is crucial in determining how the body is absorbing the force and responding to the training stress. 

If soreness is lingering for more than 24 hours, this is a red flag that the volume and/or intensity is too much.  I educate all my parents, coaches and athletes to follow this simple 24 hour rule.  I have found if you do, you end up with predictable results in terms of recovery and return to play.  So, if you have suffered an injury, be sure to consider moving through a set functional progression and be sure to used a controlled return to play approach to ensure you make a full recovery.  Have questions?  Leave a comment or shoot me an email.