Femoroacetabular Impingement (FAI) series, Part 1: Pathophysiology

Femoroacetabular impingement (FAI) is a common condition among sports where athletes utilize rotational forces or high levels of impact during hip flexion. FAI has been shown to lead to secondary breakdown of the acetabular cartilage within the hip joint overtime. Eventually, the athlete will likely develop osteoarthritis, sooner than their less athletic counterparts. Many times, FAI begins as non-descript groin pain and is treated as such with temporary relief, but as the athlete continues to participate in high risk sports (golf, baseball, hockey etc…) the pain will increase. As athletes continue their careers, increased breakdown occurs which can lead to increased joint damage, ultimately lowering the threshold for deterioration. This causes lower than normal loads to negatively impact the joint.

There are 2 types of impingement: pincer and cam. Pincer impingement is when there is an overgrowth or increased prominence of the anterolateral acetabular rim. The site of the impingement is usually anteriorly and occurs when the hip is brought into a flexed/adducted/internally rotated position. Normally the acetabulum sits and faces slightly anteriorly/laterally with differences between males and females.  It can also be caused by an os acetabulum – a separate piece of bone along the anterolateral rim of the acetabulum. With hip flexion, the rim of the acetabulum begins to “crush” the labrum and with repeated motions, the labrum will start to fail leading to the typical anterior groin pain.

Cam impingements happen when there is a non-spherical femoral head rotating inside the acetabulum. Often times cam impingements are a sequela to Slipped Capital Femoral Epiphysis (SCFE) and can result in significant deficits into hip internal rotation. With hip flexion, the non-spherical shape of the femoral head eventually leads to increased deterioration of the cartilage inside the socket due to the shear forces placed on the surface – resulting in early onset arthritis. One theory on the cause of cam impingements, which has not be proven, is that there is early closing of the growth plate resulting in the non-spherical shape of the femoral head. Intense athletic activity may precipitate the premature closing of the capital physis, but it is unclear whether it causes the impingement.

As with all pathology, there is a chance for having both cam and pincer lesions present.

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Differential diagnosis will be touched on in the next post covering assessments of athletes with FAI. However, I would like to mention that there are a number of diagnoses that can cause anterior groin pain in the subjective history including athletic pubalgia (sports hernia) and muscle trigger points in the iliopsoas, QL, rectus femoris, and obliques. As mentioned above, many times FAI is treated locally and symptoms will subside with rest/time, but it will be imperative to treat movement dysfunction that the athlete will present with in order to help them return to sport with decreased risk of re-injury/minimal flare up.

Stay tuned for follow up posts in this series that will cover in-depth assessments in athletes for FAI (including at risk sports) as well as treatment interventions.

Sports Physio as part of a Professional Sports Team: My Experience in the CWHL

For anyone who’s been wondering why this blog has not be updated as regularly as it had been when it first started, I wanted to first apologize as I know a lot of viewers look forward to the posts, but I’m here to clear this up. For the past 6 months I have been working full time in the clinic seeing clients as well as operating as the head Physical Therapist and Emergency Medical Responder (EMR) for the Boston Blades, a professional women’s ice hockey team that plays in the Canadian Women’s Hockey League (CWHL). Now, as physical therapist, in order to practice on the sidelines the way I did, I had to obtain my first responder (EMR) certification – a course that focuses on medical management in emergency situations. I am not an Athletic Trainer (ATC), nor did I provide athletic training services – I was a first responder during the event, and a PT before and after. I covered both practices (before, during, and after) and games (home and away).

The Boston Blades play in the CWHL, and so all of our opponents operate out of Canada – Toronto, Brampton, Montreal, and Calgary – and therefore required a lot of travel; thankfully one of the perks of working with the team meant all travel and lodging was covered. Practices were every Tuesday and Thursday night and games were Saturday/Sunday (always back to back scheduling for games).

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First game of the season against the Toronto Fury in Toronto, CA at the MasterCard Center

Our roster consisted of girls who went to school in Boston and now live in the city (many BU, BC, and Northeastern alums) as well as girls who commuted from different states – most notably our two goalies Jetta Rackleff and Lauren Dahm who live in Rochester, NY and Syracuse, NY respectively as well as one of our defenders Maggie DiMasi who lives in Vermont – just to play hockey. The players are NOT paid during the season (only travel and lodging are covered for these girls, while staff are given a minimal stipend on top of travel expenses). Unfortunately there isn’t enough sponsorship or a big enough fan base to pay all of the players consistently. This experience has opened my eyes to just how differently women’s sports are treated compared to their male counterparts. It’s one thing to read about it, but to see and experience it first hand was shocking to say the least. I remember asking our GM at the beginning of the season why some of these players would travel so far just to play hockey and not get compensated for it, and her response was “Because they love the game”. These athletes play at the highest level possible for ice hockey, facing teams that have several Hockey Canada members and Multi-Olympians/Gold Medalists, including our captain Tara Watchorn, a 2014 Sochi Gold Medalist. Yet there still isn’t enough interest or money to pay these athletes a salary; besides our captain, every athlete on the Blades roster holds a full time professional job or is in graduate school full time. So they play internationally in Canada, get home at 4am on Monday morning and have to report to work or class in 5 hours – on a regular basis. All for the love of the game.

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Hometown hero Tara Watchorn’s Jersey inside The Old Newcastle House following Canada’s win in the 2014 Sochi Olympics

The overall experience working with the Boston Blades was truly amazing. I had never ice skated before the start of the season, let alone played high level hockey, but have treated hockey players in the past. I learned on the job, analyzed every player’s movement on the ice and posture at rest. I was fortunate enough to have gone through a PT program where I took a Sports PT elective taught by Dr. Melissa Baudo – who served on the Women’s Tennis Association tour for several years and has a wealth of experience with sideline coverage and therapeutic taping – and was able to apply EVERY BIT OF KNOWLEDGE that she taught me (for which I am FOREVER grateful), and then some.

In order to be successful as a sports physio working with a sports team (youth or professional) you have to be able to adapt on the fly. I never once had a treatment table available at the rink – practice or games – which made traditional manual therapy technique positions as well as taping positions unusable; you have to be creative and figure out new, innovative ways to treat on the go, including during 10 hour bus rides. You also have a budget for the season for medical supplies including tape (which can be expensive), so you have to have strategies to conserve the materials that you do have.

I remember a moment during the team’s training camp in September, my order of tape had not yet come in, and I had minimal tape that was left over from the previous season, yet I had to tape a player for patellar support and a valgus/varus knee block combo without Elastikon and minimal Leukotape and Lightplast. I had to think on the fly and modify my taping technique to make sure that player could skate and perform during tryouts. Now, this player arguably needs Physical Therapy/rehab and movement re-education – which I have referred her to. However, as a sports physio, you have to realize that during the season your job is to make sure that the player(s) make it through the season. Rehab is a long term solution, but it is not efficient or effective to shut a player down for 3 months to rehab shoulder impingement if it’s not serious. Athlete education is huge and I always make it clear to the athletes that more serious rehab would be warranted after the season ended but for now I would prescribe ther-ex and on the spot manual therapy to decrease the progression of their dysfunction. You have to step out of the “Rehab” mindset. Unless the player is unable to play due to fracture/concussion, it is unlikely they will sit out. Strains and localized pain from bone bruises or pulled muscles are not going to bench an athlete, and definitely not a hockey player.

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The Boston Blades pond hockey fundraising event at Gillette Stadium

Make sure they don’t compromise their physical fitness and make sure the condition isn’t progressing. You need to earn the athlete’s trust, they need to know that a strain is not going to make you go to the coach and bench them, because if they don’t trust you they won’t report an even more serious injury (concussion being the big one). It all comes down to education of the athlete, letting them understand the risks of continuing while injured. Concussions are not to be messed around with but a pulled groin will heal with time and taping/wrapping techniques can significantly help them play during the healing process.

I’m so thankful for this experience and have met such incredible, passionate, hardworking individuals along the way. This season was a huge learning curve for me – and I appreciate all of the players and staff members who’ve been patient and helped me along the way. Thank you for trusting me with your care this season, it was definitely an unforgettable one!

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The above collage represents, in my opinion, the highlights of the season. Top L: This is our third line, who all required treatment before each practice and game: such wonderful and amazing players who always put a smile on my face and made me laugh. Top R: Me with Tara ‘Watchy’ Watchorn and her 2014 Gold Medal during the final weekend of the Blades season when Watchy’s family hosted the team for dinner – such great hospitality and support from the Watchorn clan throughout the season, Thank You! Bottom L: My first time on ice skates during the Blades final practice. A side note, I won that faceoff with Nicole ‘Gino’ Giannino – Maybe next time I’ll strap on Dahm’s goalie pads and stand between the pipes! Bottom middle: This was an emotional game as it was the last of the season for the Blades in Watchy’s home town – the game itself was a nail biter and I felt that our team played some of it’s best hockey in that one game, truly unforgettable. Middle: This is probably my favorite of the season. It is on a road trip to St. Georges when we played Montreal Les Canadiennes at Marie-Philip Poulin’s home town in front of 1000+ screaming and excited hockey fans with standing room only. The atmosphere was unreal and I think it shows the potential of Women’s Ice Hockey. The future is bright for this sport and I can’t wait to see it continue to grow.

 

 

 

 

 

Featured Professional: Matthew Ibrahim

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First post of 2017, and it’s a good one! I recently had the opportunity to interview Matthew Ibrahim, CSCS, LMT – a hybrid strength coach and therapist at Boston Physical Therapy and Wellness (Medford, MA) and Boston Underground Strength Training (Waltham, MA). He has an impressive resume and loads of experience in both the strength/training and rehab fields. He is the founder of “Movement Resilience” and co-leads the Hip Hinge 101 Workshops with Dr. Zak Gabor, PT, DPT. You can follow him on social media at the following links: Facebook, Twitter, Instagram, Youtube.

JC: How did you get started in the rehab/fitness field?

MI: I’ve worked in both the Strength & Conditioning and Sports Rehabilitation fields since 2008. I started out by going to UMass Boston for my undergraduate degree in Exercise & Health Sciences. However, my academics were not stellar and I didn’t really know what I wanted to do. While at UMass, I was fortunate to have had an internship at the world-renowned Mike Boyle’s Strength & Conditioning facility in Woburn, MA. It was a good blessing in disguise, really, because at the time I didn’t know what I was doing. I was under the direction of Nicole Rodriguez, and she really kicked my butt – in a good way. Overall, that experience sparked my interest into applying to PT schools. For the next 3 years I worked as a PT Rehab Aide at Bay State Physical Therapy (Arlington, MA), as I was also taking some pre-requisite courses applying to local PT schools. While I worked my way through school, I was observing treatments and evaluations. I was fortunate enough to have learned a lot under the direction of the PT’s there.

I also worked as a Strength Coach / Personal Trainer at few local Strength & Conditioning training facilities during that time. I was trying to prepare myself for PT school, and read up on a lot of books regarding movement and performance. Long story short, I applied to 5 PT schools for 2 years in a row, but never got accepted. I wasn’t ready to give up, so I tried to boost my resume and get some certifications. I wanted to show PT schools my commitment to helping the community and started what I branded as “Mobility 101” at the time as an educational resource. The goal was to make some content and videos and share what I had learned from my experience as well as learn from others. I never thought it would get to the point that it is now. I continued to network and meet other rehab professionals who, later, were connections that allowed me to write several articles here and there for various well-know fitness and rehab websites. I applied a third time, and yet again, was denied into PT school. At this point, I had considered other options such as PTA (PT Assistant) school – which I got into and turned down – just to have credentials to work with the rehab population. However, I had gained so much experience just from working and networking over the years that going back to PTA school just to have the letters seemed like a waste of time to me. Ultimately, I decided to go to Massage Therapy School (LMT) to gain hands-on experience for manual therapy and soft tissue skills, and utilize my knowledge and experience as both a Strength Coach and PT Rehab Aide.

Just prior to LMT school, I gained employment at Boston Physical Therapy & Wellness in Medford, MA, and began working as a Strength Coach and PT Rehab Aide – training all of their clients and also assisting the staff PT’s during rehabilitation of patients.

JC: Tell me a little more about your brand.

MI: As I mentioned before, I first created Mobility 101 as an attempt to boost my applications for PT school – I wanted to demonstrate to the admissions committee that I was committed to promoting better movement and wellness on the community level. I published content based on my experiences as well as things that I had learned along the way. I wanted to keep things simple – so to me, Mobility was a hot topic word at the time, and “101” to me has connotations of “introductory” and “entry level”. I started to build a large following on social media, including Facebook and Instagram – something that I had never expected when I first started. People started to see me as being knowledgeable in the field, so much so that about a year ago, I rebranded to “Movement Resilience”. I did not want any confusion with the public with my first brand of Mobility 101. I was getting emails at the time from professionals all over who were asking me for my advice and opinion on things that I was not qualified to answer, and instead were truly intended for physical therapists. I wanted to create clarity for my mission and ways in which I could help people – albeit, through in-person training or treatment, live workshops, or even via social media educational content.

JC: How do you feel like your unique background strengthens your rapport with your clients?

MI: I work out of 2 locations – Boston Physical Therapy & Wellness (Medford, MA) and Boston Underground Strength Training (Waltham, MA) – with mostly clients who are looking to increase their fitness and enhance their training. I picked up powerlifting as hobby of mine and to create focus in my own training. I wanted to compete and challenge myself. This background helped me to speak the same language as my clients, which gives them more confidence in me in terms of being able to help them. Walking the walk, to me, is something my clients look for, so it’s important to me to continue doing this. However, if someone were to have a more serious injury, I am not able to diagnose per my licensure and credentials; therefore, I use my team of physical therapists at Boston Physical Therapy & Wellness to refer a client to. In this sense, I am the “bridge” in the gap of training and rehab – acting as a liaison between the two. I’m very fortunate to work alongside intelligent and hard working professionals at both Boston Physical Therapy & Wellness and Boston Underground Strength Training.

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Matt during a powerlifting competition

JC: What is a typical treatment session like with you?

MI: What I offer now is treatment and training. I still work at Boston Physical Therapy & Wellness, working with athletes of all skill levels and ages. I utilize manual therapy techniques, soft tissue skills, IASTM, and also active cupping from the Modern Manual Therapy (Dr. Erson Religioso). I consult with our PT staff here and refer patients to them who I believe are out of my scope of practice. In my treatment sessions, I combine soft tissue mobilizations, movement education, and specific corrective exercises. The goal is to use the window of opportunity gained from the manual therapy to retrain and reload the area and improve their movement.

A normal session has what I call the “four pillars”. I want to see what’s going on. This process is similar to a PT treatment session – however, I am not diagnosing, and it’s important that I respect the scope that I’m in. Again, I refer out (aka walk into the next room to speak with our PT’s) when needed.

Here’s the breakdown of my treatment process, based on my four pillars:

Assessment – I’ll review the intake form and then perform a quick assessment to see what’s going on. I use my sports rehab experience and knowledge in assessment tools such as FMS, SFMA, and PRI to break things down a bit more. From these findings, I’ll tell my client the game plan for this specific treatment session.

Manual Therapy – I use specific hands-on treatment techniques to restore function and treat the specific condition. Some of the skills I use are based in manual therapy, soft tissue skills, IASTM, and also active cupping. My goal is to address the dysfunction found from my assessment and integrate localized manual therapy treatment where I see fit.

Movement – I’ll carefully select a few specific corrective exercises for my client to incorporate into their training to help address the problematic area and/or pattern. This process includes exercise instruction, lifting technique and form, pain-free movement, and recovery strategies.

Education – This is the most important aspect of my treatment approach, since my goal is to make sure that the positive changes we made during the treatment session continues into their daily life and activities. It is my goal to not only help clients get out of pain, but also teach them how to move well and build strength. I often find that helping them get into better positions during their training, and avoiding poor positions, typically gets them to train again, pain-free.

JC: Tell me a little bit about your new ‘Hip Hinge 101 Workshop’

MI: I started the Hip Hinge 101 Workshop with Dr. Zak Gabor (PT, DPT, CSCS, USAW), a dear friend and colleague of mine from Boston Physical Therapy & Wellness. There aren’t too many workshops with both a strong rehab and strong training background from the instructors. We both love the topic of low back pain and hip hinging (deadlifting), and saw a lack of understanding/efficiency in these areas, not only among the public, but also among both rehab and fitness professionals. The workshop focuses on creating spinal rigidity and maintaining a strong core that is necessary for hip hinge-based exercises and deadlifting. We break down the entire assessment and screen process, the research and pain science behind it all, demonstrate all of our progressions and regressions, and then get the attendees on the training floor as we provide hands-on coaching through their deadlifting.

We started in May 2016, and have had 6 workshops since then, each one averaging 15 attendees each time. After receiving positive feedback and requests for the 2017 year, we ended up booking 5 more workshops. For 2017, we want to spend more time on anecdotal evidence from the clinic/patients as well as evidence from the literature to support the how and why of breaking down the assessment/screen as well as various forms of cueing for proper movement. The 5 workshops booked for 2017 will be in an 8-hour full day format with CEU’s through NSCA. We want to teach people how to properly hip hinge and deadlift for long term resilience and training. Our goal is to make it open, educational, and easily applicable – all the while having fun.

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Matt with Dr. Zak Gabor during one of their workshops

JC: You’ve also been active on social media promoting education on low back and hip health.

MI: Yes, I have started the “30 Days of Low Back & Hip Health” series. I have had Dr. Zak Gabor as a guest on 3 of the days to lecture his thoughts on low back and pain science. I’ve created 30 one-minute exercise tutorial videos to explain the how and why behind the proper execution of certain exercises related to the low back and hips. I’ve also covered safe and effective ways to train hard and recovery intelligently. Since it’s hard to put it all together when the videos are all separate, there will be an article coming out on http://www.STACK.com at the end of the month that will summarize the whole 30 days in one spot!

JC: What are some tips/pieces of advice you’d give to someone looking to get into the rehab/fitness field?

MI: There are a few tips I’d give. We’re here to help people – people miss that point. We are here to change how they move within their bodies. We have the power to help make their movement efficient and get to a healthier place for long-term resilience.

  1. While it is important to do well in school and crush your academics, I think a lot can be learned at seminars and networking with those in the field, shadowing/visiting, and reading up on topics in the field. Have an entrepreneurial spirit. Form your own opinion. Keep your mind open and blend all of these aspects together. Above all, never stop learning. Apply what is useful and help your clients get stronger and healthier.
  2. Work on improving your interpersonal, intrapersonal, and social skills to enhance your level of communication with others – meet patients and clients half way, and help them get to where they want to be. Listen, understand and simplify the approach. At the end of the day, I always check in with myself to ensure that what I’m doing is simple, digestible, and easily applicable for the people I am working with.

 

Year in Review: 2016

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Rather than start a new topic series on the last day of the year, I’ve decided to close out 2016 by reflecting on what I’ve been able accomplish in 2016. While many regard this past year as a terrible year (i.e. deaths of some of my favorite, and very prominent, celebrities including Carrie Fisher and Prince), 2016 did have its moments. For starters, the #NotYourAveragePhysio was brought to you all in 2016, and I was given the opportunity to work with the Boston Blades as their head Physical Therapist (the season’s not over yet, if you’re in the Boston area and would like to catch a game, please email me or message me on FB). 

I’d like to take this time and reflect on my top 5 posts from the past year:

  1. Lateral Ankle Sprain series, Part 3: Manual Interventions – This post garnered a lot of attention over the summer and I was very excited about this post because while in school I didn’t know how to treat an ankle sprain with manual techniques very well. I was very excited to share a few manual techniques that I like to use and have achieved good clinical results. Give them a try in the new year, 2017!
  2. Overhead Athlete series, Part 4: Treatment Interventions – This was another post I was very excited about. One of my clinical interests is treating the overhead athlete and often times I find that therapists and other healthcare professionals forget that the shoulder is, more times than not, the site of pain but NOT the cause of pain. The treatment interventions in this post demonstrate how important the Thoracic spine and Scapulothoracic connection is (obviously there’s aspects involved like the C-spine and AC/SC joints, but there wasn’t room to fit EVERYTHING in one post –> maybe another time I will tie it all together).
  3. Breaking Down the Initial Evaluation, Part 3: Static Postural Assessment – LE – Going along the lines of finding the cause of pain, this post (and series) does just that! Never accept that the site of pain is the source of pain without having evaluated and assessed other contributing factors clinically (though more times than not, you’ll find that the source of pain is NOT the site of pain). There are times where I do treat the site of pain but more on that another time. 99% of the time, I find the source of pain and treat there rather than focusing on where my client says they are in pain. We have to start treating more holistically in 2017!
  4. Featured Professional: Ramez Antoun, PT, DPT, SFMA, PNF – This was an interview I did with Dr. Antoun who is owner of Neuropedics in Boston, MA. I had so much fun conducting this interview and picking his brain – the entire interview was 3 hours long, I only included a snippet of it. There are some definite clinical pearls in this interview and I love his treatment philosophy!
  5. Concussion series, Part 1: Pathophysiology – Last but not least, this post allowed me to articulate all of the training I had underwent through Complete Concussion Management Institute  (CCMI) in Canada for treatment/management/diagnosis of concussions. It’s the hot topic buzzword in sports these days, and PT school definitely does not go over all of the intricacies and details of a concussion.

I’d like to also announce that in 2017, I will be adding a new segment to the blog answering YOUR questions. So please, FB message/email me any questions you may have regarding sports physical therapy, treatment, evaluation, or even a tough case you may have in the clinic!

May 2017 bring more professional development and topic series to you all!

Happy New Year!

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Screening for the Elite Hockey Player

Many of you know that this year I’ve been fortunate enough to be working with the Boston Blades in the Canadian Women’s Hockey League (CWHL) – a professional women’s hockey team/league – as their primary therapist for the season. It’s been a very exciting season so far, and it’s very rewarding to utilize some skills with the team (i.e. lots of taping) that I wouldn’t have the luxury of using in the clinic as much. I’ve also learned so much on the job just from observing. I can’t stress enough how crucial it is to be able to refine your observation skills as a physical therapist – even more so as a SPORTS PHYSICAL THERAPIST. It is paramount in our field to be able to pick up on the nuances and subtle movement patterns and be able to hone in on what is causing an athlete’s dysfunction, fast! It’s even more critical when you’re not as familiar with the sport at hand – which was my case starting the season.

My specialty area for treatment when it comes to sports and athletes – while I do treat athletes of all sports, my true expertise lies in overhead athletes such as baseball/softball players and volleyball players. Having gone to undergrad in Maine, I’m familiar with hockey (attending many Bowdoin v. Colby hockey games back in the day), but I’ve never ice skated before, let alone play hockey. However, through plenty of observation and research, I’ve come to understand movement/strength patterns necessary for the elite hockey player to be successful.

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Hockey players are always in a hip hinged position that requires plenty of control from their core. Without a strong core, their posture will become compromised and the athlete will end up loading in a flexed spinal position that can lead to low back pain. For anyone who knows me, you’ll know that I consider the glutes as an important part of supporting the deep core muscles. Glutes are important for stability in the frontal plane as well as required for push off while skating (posterolateral movement – hip abduction with extension). This allows the athlete to project themselves forward on the ice. However, often times, the athlete will become quad dominant and will compensate with knee extension more than hip extension – staying in the hip hinged position and increasing stress on the low back while keeping the glutes in a lengthened state.

Hockey players don’t only develop LE dysfunction, but they can also develop increased UE (bilateral) dysfunction as well. They are constantly in a rounded and protracted position of the scapula. Depending on which hand they shoot with – their top UE is excessively internally rotated and their bottom hand is excessively protracted relative to neutral. This creates muscular imbalances when compared side to side (dominant Latissimus dorsi and Serratus Anterior, under-active RTC, rhomboids, and lower trap). Goalies are a separate category all on their own due to the demands of their position – this post serves as a general guide for screening hockey players.

A screen I really like, and am a bit biased towards, is the Selective Functional Movement Assessment (SFMA). It really does capture everything in one screen! What I’ve found through screening the hockey players is that most have poor scapular control (sometimes accompanied by cervical ROM deficits) with excessive winging in the Medial Rotation Extension (MRE) pattern and Dysfunctional Non-painful (DN) in LRF. Muscular imbalances arise from the upper traps (hyperactive due to overuse during bracing), increased pec major/minor and lat activation, and under-active lower traps and RTC – often leading to impingement patterns. Of course, T spine is always involved with scapular control issues. In lower extremities, players often have decreased glute recruitment overtime, decreased SLS balance, decreased hip mobility into IR/ER/flexion, and DN of overhead deep squat (ODS).

As I mentioned in the series on treating the competitive volleyball player, it’s not enough to just correct these dysfunctional patterns or tell the athlete to avoid those positions – you have to understand the demands on the sport and why the athlete has now assumed these postures and developed painful or high risk movement. As this was very surface presentation of screening a hockey player – it should help point you in some areas that need to be assessed – performing your own assessment and drawing your own conclusions is just as important because every athlete is different. I hope this post can help any therapist unfamiliar with the sport of hockey and guide them towards problem areas as a starting point.

 

Concussion series, Part 3: Post Concussive Syndrome, Second Impact Syndrome, and Treatment Strategies

Parts 1 and 2 discussed the pathophysiology and return to play guidelines for a concussed athlete. But what happens if the athlete’s symptoms don’t go away, and it’s been a month or more? The ICD-10 definition of Post Concussive Syndrome (PCS) states that in order to be diagnosed with PCS, the athlete must experience at least 2 or more symptoms for a span of at least 4 weeks (i.e. headaches, dizziness, nausea etc…).

Post concussive syndrome can be tricky because most often times, you will need to not just treat the physical symptoms of the athlete, but you have to address the psychosocial aspect as well. While many studies have shown that while physically an athlete can show no signs or symptoms as soon as a week (some recover as fast as 8 -15days), through magnetic resonance spectroscopy we’ve found that metabolically, it could take up to 30 days to fully recover. In many cases the athlete will have been told by someone, prior to seeing you, that they should rest until they are symptom free because it could further damage their brain. In Part 2, you’ll remember that in return to play/work/life guidelines, step 1 is brain rest and step 2 is light activity. Under most usual circumstances you need to be in a stage for 24 hours symptom free before progressing. However I did place an asterisk  next to step 1 because you do not want your athlete in this stage of more than 3-4 days, though sometimes up to 14 days max.

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If an athlete comes to your clinic 3-4 weeks out from their concussion still symptomatic, and they’ve been on brain rest for this entire time, you’ll want to start them on some light activity to increase their hear rate.Aerobic exercise via bike and treadmill have been proven to help PCS athletes and non-athletes recover and become symptom free. Prolonged rest for an athlete can lead to deconditioning and metabolic deficits: which from Part 1 you’ll remember that a concussion is ultimately a mismatch in energy and is a metabolic syndrome of the brain. You do not want your athlete to become anxious and fear that looking at a screen will cause more damage (especially since they are a few weeks out from the initial injury) – fear avoidance behavior should be avoidedConsistently reassure the athlete and provide a timeline of how they’re improving towards their goals. Utilize positive language. If you haven’t please check out my interview with Dr. Ramez Antoun, PT, DPT who explains why language is so important and why it is often overlooked.

It is also interesting that studies have shown that if you exercise too soon (within the first week of recovery) you run the risk of doing more harm than good, but aerobic exercise starting between 14-21 days after injury has shown to improve cognitive function.

Aside from the physical symptoms similar to whiplash (suboccipital/upper trap/levator/SCM tightness, hypomobility in cervical spine etc…) you will want to also address any visual tracking/vestibular deficits they may still have. Think back to your Neurorehabilitation courses in PT school (shout out to all of the wonderful neuro inpatient rehab therapists out there). You will want to assess for any nystagmus and saccadic eye movement, re-train smooth pursuit, as well as use X1 and X2 activities to retrain the VOR. Dix-Hall pike and CRT roll maneuvers are examples of great for assessing and treating any vestibular deficits that made still be lingering (assess properly for specific vestibular deficits so that you can pick the correct treatment approach). Many outpatient PTs will often forget about the vestibular/visual tracking systems due to focus on manual therapy any joint/soft tissue restrictions, but these systems can ALSO contribute to any lingering symptoms.

Another very important topic, when discussing concussions, is Second Impact Syndrome. Second impact syndrome is when an athlete, prior to full metabolic AND physical recovery of a previous concussion, sustains a second concussion. In an athlete recovering from a concussion, there is metabolic deficits in the brain, disruption of the blood brain barrier, as well as diffuse axonal injuries that contribute to their symptoms. However, if an athlete recovers physically (but has not fully healed metabolically), they will run the risk of serious damage if a second hit is sustained. There will be an additive effect in second impact syndrome and can lead to increased intracranial pressure and decrease cerebral perfusion, leading to increased edema and swelling of the white matter.

Many athletes will argue they feel better and unless you have objective tests to run, you will have nothing prevent the athlete from going back in. This is why baseline testing is so crucial and important in contact sports. Having objective data to compare before and after injury will allow you as the clinician/therapist to make a better judgement on whether or not the athlete should be allowed to return to play. Asymmetries or cognitive scores lower than their baseline could indicate delayed metabolic healing. However, it’s better to be on the conservative side if you are unsure – athletes have died in the past due to Second Impact Syndrome (google Rowan’s Law, an athlete in Canada who died after sustaining a second hit prior to full recovery. Now, in Canada, you must be cleared by a trained medical professional in order to return to play to prevent Second Impact Syndrome).

While sometimes I think that the media can go a bit crazy and over report certain things, concussions are to be taken very seriously. This is not to say that you have to suspect that every little hit is a concussion, but you need to be vigilant if you’re covering a sport on the sidelines as well as if an athlete comes to your clinic. There is not enough education to the public at this moment about the severity of concussions and parents and athletes need to be informed. Concussions should not be brushed off as something minor, they are a form of brain injury and you only get 1 brain – make sure to take care of it!

'I don't think it's a concussion . . . although the smoke has me concerned.'

References:

http://www.mayoclinic.org/diseases-conditions/post-concussion-syndrome/basics/definition/con-20032705

Leddy, J. J., MD et al Rehabilitation of concussion and post concussion syndrome. Sports Health. 4(2) 2012

 

 

 

 

Concussion series, Part 2: Management and Return to Play

**Disclaimer**: I am not a representative of Complete Concussion Management Institute (CCMI), nor am I endorsed by them. I am a Certified Complete Concussion Management Practitioner (CCCMP) through CCMI, but am not paid to present this material. The following post is of my own, and does not represent opinions of anyone but myself.

Now that we have the basic physiology of concussions out of the way, lets talk management and return to play. This topic will be split into 2 parts; A and B. So an athlete comes off the field and tells you they don’t feel good, with c/o headache, dizziness, blurred vision, and nausea. They say they took a hit a few plays back but didn’t lose consciousness. Now what?

Until about 2012, the NFL had been using guidelines from the American Academy of Neurology’s 1997 Practice Parameters, which allowed an athlete to return to play if their symptoms resolved in 15 min. It also graded concussion severity based on loss of consciousness (or not) which we know, now, is not true. They also used to take the players and put them in a dark room to “help alleviate” symptoms – but we know that that also does not work, nor is it evidence based. There used to be a protocol where following a hit, in order to determine if they can return to play that day following resolution of symptoms, the athlete would be asked to do squats (bodyweight) and pushups and some battery of exertional movements. Increased body temperature has been shown to increase glutamate levels in the body – and from what we know about glutamate in Part 1 of this series, increased glutamate increases Ca+2 into the cells which is the main problem with concussions.

However, thankfully the 2012 Zurich Consensus happened and now there are rules against same day return to play if the athlete has either a clear MOI and/or exhibits signs and symptoms of having sustained a concussion.

So the athlete comes to you with c/o symptoms that appear to be from a concussion with an MOI. If the athlete is conscious (the play did not just happen leaving them on the ground and you do not need to activate EMS, and/or you’ve already ruled out the possibly of a spinal cord injury) you’d take them to the side and ask them some orientation questions and go through a sideline assessment such as the SCAT3. You’d continue to monitor their symptoms over the course of the next few hours – DO NOT let the athlete sleep for at least 3 hours. And when they do sleep have someone (or do it yourself if you’re traveling with the team) wake them up every 2-3 hours. The point is that while rest would be nice, you want to monitor their symptoms and make sure they don’t get worse. Make sure you rule out a hemorrhage – send to the ER for imaging if necessary or suspected.

If the athlete is coming to you a day or so after the hit, and you are performing the initial evaluation – make sure to do a full cranial nerve screen and neuro exam. Again, we want to rule out other serious pathology as well as make sure that their symptoms have not gotten worse. Education and reassurance is key in treating athletes with concussions – especially with the media giving it so much attention. There is a large psychological component of concussions and you need to address that at each and ever visit, starting with the eval.

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Many of you are familiar with the above chart for return to play. In order to progress from one stage to the next, the athlete needs to have no symptoms for at least 24 hours. If they get symptoms in the next stage, you regress them back one step until asymptomatic. The first step is brain rest. This gets tricky and needs to be handled with care otherwise you will be feeding into the psychological aspect of concussions. You want rest, but not for more than 3-4 days. Max, 14 days is the point at which you need to start encouraging them to perform light physical activity (stage 2). Many physicians will tell the athlete to rest until they have no symptoms – a month may go by and they are still having symptoms (Now, Post Concussive Syndrome). This can increase their anxiety levels and increase their risk of depression as well as decreased overall physical conditioning.  14 days is our turning point, at which, rest can become detrimental to the athlete. Exercise is the most important rehab intervention and has the following effects: increase brain derived neurotropic factor, increase blood flow, increased sense of control (for the patient), improving neurocognition, decreasing inflammation to name a few. So the idea is that you want them to exercise and progress to stage 2 as soon as possible, after an initial resting phase.

One point I’d like to stress is that most athletes will recover from their physical symptoms around 8 days, however research shows that METABOLIC RECOVERY can take up to 30 days in some cases. Therefore, I find the above RTP guidelines too simplistic in some cases because it does not TEST physical capabilities nor does it apply to work/school scenarios. Rather it is based on a reactionary scheme – if they do not have symptoms, progress, if they do then regress. But there is no mention on how to TEST the athlete to know if they can progress/regress.

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Physical exertion is required to stress the body and see how the athlete reacts – do they get onset of symptoms with a treadmill test or a bike test? At CCMI their RTP guidelines are a little more detailed and has 3 more steps. For example, in their RTP guidelines step 3 allows an athlete to return to a half day of school/work with restrictions. It is important to not only stress return to sport, but also return to daily life, which the general guidelines do not make much mention of.

Stay tuned for follow up posts that will discuss Post Concussion Syndrome, Second Impact Syndrome, and Physical Therapy interventions for the concussed athlete.

References:

Thomas, D. G. MD, MPH et al Benefits of strict rest after an acute concussion: A Randomized Trial. PEDIATRICS 135(2); 2015

McCulloch, K. L. et al Development of Clinical Recommendations for Progressive Return to Activity After Military Mild Traumatic Brain Injury: Guidance for Rehabilitation Providers. J. Head Trauma Rehabil 30(1); 56-67

Concussion series, Part 1: Pathophysiology

Over the past few years concussions have become quite the “buzz word” in sports. Many years ago, no one really cared about concussions, and then all of a sudden, we’ve gone to the other extreme – everyone who gets hit has a concussion.

Concussions are a very serious topic. It is a mild traumatic brain injury (mTBI). Back in the day, the scale of brain injury would be: concussion, mild TBI, moderate TBI, severe TBI. Now concussions and mTBI should be, and are, interchangeable. That is because concussions ARE a form of brain injury. Many people believe that in order to sustain a concussion you need to have Loss of Consciousness or be hit in the head. In the above video, the hit was clean shoulder to shoulder, and Toews was conscious. But Toews sustained a concussion in that play. Loss of consciousness is also not a predictor of how severe the concussion is, nor will it dictate the length of recovery for the athlete.

It is not just a physical syndrome (headaches, nausea, vomiting, dizziness etc…) but is it a metabolic syndrome as well – it is an energy mismatch in the brain, leading to a large ATP deficit. The old theory/hypothesis of why concussions happened is the “coupe/contrecoupe” theorem shown below.

concussion1.png In this hypothesis, it states that the brain impacts the front of the skull and then impacts the back of the skull, creating two sites of injury. However, it has actually been shown that concussions are more widespread throughout the brain that just that. The new hypothesis is that concussions are “acceleration/deceleration” injuries that create shearing of the neuronal axons.

concussion2

In the above image, shearing causes damage to the axons and also results in the energy mismatch that the literature has shown. When an athlete (really, any one in general too) experiences a concussion, action potentials are firing constantly at first (excitatory phase) and then when all of the ATP is used up, they become fatigued and lethargic (spreading depression phase).

If we all think back to physiology 101 (It been a long time since I’ve taken that class, and it was a memory I’d like to forget, haha), the concentration gradient inside a resting cell is as follows: K+ high inside, Na+ and Ca+2 high outside the cell. When there is shearing of the neuronal axons, there is also an resultant deformation of the cell membrane, leading to opening of ion channels and the ions flow down their respective gradients. This creates action potentials and causes the release and increase of Excitatory Amino Acids (EAAs): most notably, Glutamate. In order to restore the ion concentration balance to its resting state, we need activation of the Na+/K+ pumps – requires a lot of ATP. The release of glutamate triggers the activation of N-methyl-D-aspartate (NMDA) leading to an influx of calcium into the cell. Ca+2, however, has an affinity for the mitochrondria and when there is a large influx of it into the cell, it creates dysfunction within the electron transport chain – reduces the cell’s ability to create ATP, furthering the energy crisis.screen-shot-2016-09-27-at-9-12-58-am

In the above image, you can see the influx of calcium as well as NMDA in the middle of the cell body. An interesting point that has been made in the literature is that Mg+2 fits into one of the NMDA receptors like a plug. It’s been hypothesized that if you are sufficient in your body’s Mg+2 levels, then it can control how much calcium influxes into the cell and may decrease your recovery time. Many of the physical signs and symptoms can be derived from the underlying pathophysiology described above (headaches, fatigue, dizziness, inability to focus etc..).

That was a lot of physiology in one post. Take some time to wrap your head around the information. One of the big points I will be making in this series is that you have to recover physically AND metabolically to be considered 100% recovered from a concussion. However, many will not show signs and symptoms around day 8-10, but research has shown they are still not metabolically recovered – you will still be at risk for second impact syndrome and return to play at this point may further delay your recovery.

References:

Giza, C., Hoda, D. The neurometabolic cascade of concussion. J of Athletic Training. 2001;36(3):228–235

Giza, C., Hoda, D. The new neurometabolic cascade of concussion. Congress of Neurological Surgeons. 2014;75(4):524-533

Signoretti, S. et al The Pathophysiology of concussion. American Academy of Physical Medicine and Rehabilitation. 2011;3: S359-S368

Clinical Anecdotes: Treating Complaints of Chest Pain

PLEASE READ BELOW:

***This post will mark the start of a new segment – Clinical Anecdotes. While research is very important, it takes years and years to generate good research. It is always going to be somewhat behind – I say this meaning that since it takes a long time to generate good and reliable data for literature, by the time something has been validated, many times it is only confirming something that has been going on in the clinic for the past few years. For example, I see “new” research out quite a bit that states exercise is good for your heart health, exercise can help in the diabetic population etc…. But I would argue that this is nothing new. I’m not starting or engaging in an argument about this. This segment is meant to focus on clinical pearls of treatment to help guide your practice. ***

Recently in the clinic I had two athletes come in, both with c/o chest pain, what has helped them took a few visits to figure out but both have now greatly reduced pain levels.

Case 1:

28 year old male with primary c/o chest pain with dips at the gym. Pt presents with thoracogenic scoliosis (R sided convexity). Pin point pain with dips only (bench press was ok) and c/o pain at bottom of dip and pain that lingered – 8/10 at worst. No pain at rest.

Case 2:

18 year old female with c/o thoracic pain that was constant, referred into her neck, and when she retracted her shoulder blades, she had pain in her back as well as her chest that would cause her to cough, pain was 7/10 at worst. Pt’s posture is poor (severe forward head posture with poor stability and control in cervical spine). PMHx of high school rower and track and field sprinter.

The above only describes a limited background. In Case 2, she was cleared by her pediatrician of all other internal medical conditions as well as cleared chest X rays, no co-morbidities identified.

Both had improvement with Graston Technique for soft tissue mobilization. Both had poor posture and, therefore, started on posture correction and neuromuscular re-education for that. Both had complained of pain in a general bilateral chest pain that was also tender to palpation over the anterior shoulder. However, 2 muscles (on top of many others, i.e. pecs had already been addressed through multiple sessions with minimal improvement) were key in their treatment; Serratus Anterior and Latissimus Dorsi. In both cases, when the Lats and SA were released with Graston and soft tissue manual release techniques, both had significant pain reduction: Case 1 had an in session reduction to 1/10 pain with dips 3 sets of 5, and Case 2 had verbal reports of being able to sleep through the night and 4/10 pain with no pain in her neck anymore on her next visit. 

With both you can see how they might be experiencing general chest pain on the lateral and anterior sides due to the muscles’ pain referral pattern. I will also note that these were not the only symptoms seen in these patients, only a snapshot.

While their pain and symptom reduction was not due to SA and Lat release alone (both had a few sessions of NMR and postural retraining without the focus on SA and Lats), they have continued to improve and are able to tolerate increased activity with lower pain levels as well as improved their overall mobility.

Treating the competitive volleyball player series, Part 3: Lower Body Assessment

It’s fairly obvious that the shoulder is one of the more commonly injured joints, but just as obvious should be that the knees of a volleyball player are just as beat up. The impact alone, overtime, is enough to wear down a volleyball player’s knees. Both overuse and traumatic injuries can occur in volleyball to the lower extremities.

In volleyball, it is common for a blocker to land on the opposing hitter’s foot as seen below:

The rule is that you cannot land with a whole foot on the side of the dividing line. However, there is a bit of “no man’s land” where if part of your foot goes under the net, it is not called as a fault. This can be dangerous because having even part of your foot under the net can create a hazardous situation and lead to ankle sprains. I have an entire topic series devoted to lateral ankle sprains, here.

ACL injuries also occur often, more common in the women’s game. Mostly due to weakness in hips and decreased balance/proprioception. Biomechanically, many girls often land on 1 leg after an approach, and with decreased stability from their core and hips, there is an increased valgus moment at the knees:

As I mentioned in the first part of this series, many things are out of the athlete’s control, as in the above vide (first 30 seconds shows the ACL injury occurring). The set was pushed too far out and the hitter was reaching behind her, attempting to adjust to the set, resulting in her landing on 1 foot. Now, am I advocating for landing on 2 feet, always? Not necessarily. It is always better to land on 2 feet than 1. However it happens quite often due to the set location, and in the men’s game it is seen quite a bit as well – In the 2016 Olympics, #2 Aaron Russell an outside hitter for the United States often landed on 1 leg following a hit. The difference is neuromuscular control and overall strength. When treating athletes, don’t be quick to judge biomechanics (especially elite level athletes). Recognize that there are many situations that the athlete cannot control in game settings. It is our job, as rehab professionals, to make sure that their bodies are ready to adapt to any situation during matches. Once you have accounted for all aspects out of the control of the athlete, identify what their deficits are and improve their neuromuscular control/asymmetrical strength pattern so that they are able to adapt during a game safely.

When it comes to overuse injuries, many seen in volleyball are forms of tendonitis/tendonopathy, most notably patellar tendonitis/tendonopathy – also known as jumper’s knee. And it’s named rightfully so, first described and seen in athletes who engage in high repetitions of eccentric quad loading. It’s part of the biomechanics of landing from a jump – eccentric quad contraction to decelerate knee flexion; you’d never want to land straight legged and “jam” the tibiofemoral joint. With patellar tendonitis, it has been shown that it is the proximal end of the patella that becomes irritated and thickened when seen under imaging.

When examining these athletes, knowing what movements reproduce their pain will be key in providing the most effective and efficient treatment. Pain can be reproduced in patellar tendinopathy with resisted knee extension (more so in short sitting). Ascending and descending stairs may be painful, sitting for long periods of time and then standing up, as well as hopping/jumping can all lead to reproduction of symptoms.

Initially, depending on the severity and acuity of the patient’s symptoms, you will want to limit and even completely avoid all activities that require jumping and running. This will decrease the amount of impact on the athlete’s joints and allow for some much needed rest. During this phase, you will want to focus on strengthening of the patient’s hip and core (including eccentric quad control), improve joint mobility around the hip and tibiofemoral joints, as well as manual therapy to the patellar tendon (I prefer Graston or any type of IASTM).

It will also be crucial to note the athlete’s feet and observe whether or not their arches collapse. This can alter their biomechanics up the chain, leading to increased medial valgus stress on the tibiofemoral joint. Orthotics and instrinsic strengthening of the foot can help mediate this situation.

At some point in your rehab (I say this because depending on the athlete’s level of fitness and acuity of injury, I sometimes introduce squat progressions early on or later in the plan of care), you will want to re-train the athlete how to squat again – this is very important for return to sport due to the squat jump required during blocking. I will have a post detailing the importance of the squat and form in a later post – for now, I want to share a progression for the overhead squat that I like to use with my athletes.

The above progression starts with the client in quadruped, rocking back and forth working on maintaining spinal neutral – especially in lumbar spine. Then the client is progressed to tall kneeling, working on core and hip stability – all while maintaining lumbar neutral (make sure their lower lumbar spine does not go into flexion). Finally the exercise is progressed into standing with TRX suspension for external feedback and increased lower trap activation overhead. In all 3 parts of the progression, TheraBand can be tied around the client’s knees so that they are required to push against the resistance.

References:

Rath, E. et al. Clinical signs and anatomical correlation of patellar tendinitis. Indian J Orthop. 2010 Oct-Dec; 44(4): 435–437

Rutland, M. et al. Evidence Supported Rehabilitation of Patellar Tendinopathy. NAJSPT. 2010 Sep; 5(3): 166–178.