Assessment of dysfunction

I saw an athlete today complaining of ongoing hamstring tightness and strains that I have seen in the past. Based on the exam I noticed he had very tight hamstrings and restricted movement. He also displayed a quad dominant squat pattern with patellofemoral overload and some instability with single leg squats. 

Based on his presentation we discussed a multi faceted program to improve his mobility and decrease his constant strains. We started doing 1 leg drops for movement and stability ball curls for hip and hamstring strength. We reviewed squatting and single leg squatting to engage his glute muscles to alleviate knee pain and we perform multi directional lunges for hip mobility. As an added bonus we worked on planks to strengthen his core and ensure that he can maintain adequate alignment. 

Since his hamstring is the main link between the pelvis and lower body it is easy to get tight and strained. In order to combat this we need to build a strong stable base for the pelvis and core muscles. When these are stronger the hamstring his not under the same amount of tension trying to provide stability. 

We will recheck his progress but this program should improve his strength and improve his motion leading to less recurrent strains. 

Physical therapy vs. physical training

During a conversation with some colleagues yesterday, we were discussing the true benefits of physical therapy. Personally, I am lucky to work and collaborate with some very talented physical therapists. Still, the reason that people go to physical therapy are different than those who work with strength coaches, personal trainers, and so on. The main goal of PT is to decrease pain, improve range of motion and mobility and restore function. This is not the same as improving function or functional performance, which is a different goal.

Physical Therapy is great for soft tissue therapy and release of adhesions, improving flexibility and joint mobility and improving postural stability and neuromuscular control. They work with patients to regain some pain free motion, firing patterns and control after an injury or a surgery. All too often, however, the patients use physical therapy as a fitness program or a fitness consultant, which is an improper use of their expertise. In an ideal world (one where insurance does not determine treatment decisions) patients would work with a therapist on their specific injury and work with a  qualified fitness professional on maintaining their global health while they recover from their injury. I stress qualified because this changes with the specific injuries and diseases that patients have. A qualified strength coach may not be the best choice for a diabetic with heart disease. This population has specific guidelines and needs that need to be properly understood.

When the therapist and the fitness professional work together to help individuals return to, and improve, their physical capabilities, the patient wins. They are now able to have improved use of their injured limb and maintain and increase their global strength, endurance and capacity for exercise. I personally believe that it is time for treatment programs to focus on the holistic health of the patient and develop programs that help them address and improve all facets of their health. By focusing on one small area, we do patients a disservice. The key with therapy is to address and correct the causes leading to their pain and dysfunction while still exercising around their injury so they are maintaining their fitness and improving other aspects of their physical well-being.

Balancing for ankle strength

A new research study was published that showed the benefits of balancing for treating chronic ankle instability. If you have ever injured your ankle, rehabilitation is of vital importance. The simple act of balancing on your foot can help strengthen the muscles that support your ankle and decrease feelings of instability.

Incorporating a balance routine into your exercise program can help keep your ankles strong and decrease the chances of suffering an ankle sprain. To make it harder, add in different exercises to change the stimulation.

ACL rehabilitation and return to play

Athletes who tear their ACL and want to return to their sport usually opt for surgical reconstruction. This is primarily done with either using the patient’s patella tendon or hamstring tendon to graft a new ACL. After surgery, patient’s need to perform rehabilitation in order to regain their range of motion, strength and function. Some reviews have been performed that can help guide the rehab and return to sport process. Interestingly, even though there has been a lot of research performed on ACL’s in general, there is not a lot of information on return to sport criteria.

 

For rehabiliation, the following has been recommended:

1.      Forgo the brace. Post operative bracing is not effective for improving pain, range of motion or preventing a potential re injury and is not necessary.

2.      An accelerate rehab is safe for patients and they can begin early weight bearing exercise, range of motion from 0-90 degrees and close chain strengthening exercising. Adding in eccentric quad strengthening after 3 weeks was also beneficial in recovery.

3.      Focus on strength and range of motion. Adding neuromuscular strengthening is somewhat helpful, but the focus for rehabilitation should be on improving strength and range of motion. Once this is restored, neuromuscular training can be helpful to relearn movement patterns.

4.      Single leg cycling can be performed in order to maintain cardiovascular fitness.

 

Returning to sports?

1.       Many athletes do not return to their previous level of sport participation, in fact, only 50% may return.

2.       The decsion to return is multifactoral, but there is a general lack of evidence to determine the best testing criteria to signal return to play. In general, the decision to return is based on the following;

a.       Higher quadricep strength

b.       Less swelling

c.        Less pain

d.       Fewer episodes of instability

e.        Low kinesiophobia (fear of moving)

f.        Higher athletic confidence

g.        Higher motivation

3.       Part of the challenge is the psychological componenet of returning to sport. The fear of moving (kinesiophobia) may prevent some patients from returning. Patient’s that have more confidence have a greater chance of returning to their sport.

 

The current research shows plenty of gaps in following a standard program for rehabilitation and return to play, but patient’s and their providers can use what we do know to customize a plan.

 

Patient’s should start moving as tolerated shortly after surgery. They can walk as they are able and perform range of motion exercises and strengthening as tolerated progressing the intensity as they heal.

 

When their graft is healed and they have regained strength and motion they can add in neuromuscular training to improve movement patterns. This is also a good time to work on building up their confidnce in a controlled setting. Allowing them to get into a position  can improve their confidence as the speed and force of the movement is increased.

 

Consistently working on the psychological aspect of rehab should not be ignored. Rehab is a chance to control the environment so that patient’s can gradually tolerate the load. As they improve, their rehab should adjust to mimic the functional tasks they will need to perform in life and on the field. Once they have reached their healing, they should re-integrate into their sport (once again in a controlled setting) and progressively increase their activity.

 

While there is a lot of flexibility in these guidelines, this can serve as a framework for the rehabilitation and reintegration process. Discussing the steps with the patients, their support groups and providers can help to get everyone on the same page and understand the steps required to resume their active lifestyle.

 

Czuppon, S., Racette, B., Klein, S. & Harris-Hayes, M. (2014). Variables associated with return to sport following anterior cruciate ligament reconstruction: a systematic review. British Journal of Sports Medicine, 48 (5). 356-364.

Kruse, L., Gray, B. & Wright, R. (2012). Rehabilitation after anterior cruciate ligament reconstruction. Journal of Bone Joint Surgery, 94 (19). 1737-1748.