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Movers to Athletes to Specialists

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As their 13-year-old daughters played in their first soccer game of the spring season, the mothers discussed their dedication to their children, and their children’s dedication to the game. One mother spoke about her older daughter, a high-school sophomore, who missed the fall soccer season because of knee surgery. This caught my attention, and I scanned the field: Four of the 22 players – 12 and 13 years old – on the field wore bulky knee braces indicative of some form of injury.  Another mother mentioned the ankle injuries of an older sibling, and a father mentioned the concussions. Each parent appeared to try and top the others with stories of their children’s injuries and surgeries from their participation in soccer, as though being injured and returning to continue one’s career was a badge of honor. The players who were revered were not the ones who capably moved around the field, avoiding tackles, and skillfully playing the ball, but the ones who limped around the field, showing their toughness as they returned to soccer from an injury, probably far too quickly. Rene Wormhoudt, the strength and conditioning coach for the Netherlands Football Federation, said at the Seattle Sounders Sports Science Conference that children become good movers, good movers become good athletes, and good athletes become specialists, or skilled soccer players. These u14 girls appeared to have skipped the first two steps and moved directly toward the goal of becoming a skilled soccer player. The skill level was impressive for an early season game between 12 and 13 year olds. The players used tactics and skills that I never learned or tried in my 10 years of youth soccer. Players played the ball back to the goalie to avoid pressure rather than panicking with the ball in their defensive third. Goalies controlled the ball and juked on-rushing attackers rather than kicking the ball as quickly and as far as possible. Players used one-twos all over the field, and played the ball with their right and left feet. They kept their shape, talked to each other on the field, and showed a good understanding of the game. Despite their game understanding and technical skills, the majority were terrible soccer players. Their skills were no match for the few athletic players on the field. The vast majority of players moved so poorly that the mere act of playing soccer was likely a risk to their health. The injuries discussed by the parents were no surprise after watching 20 minutes of their younger daughters. Despite their sport-specific skills, they lacked good motor control. When they jumped to head or chest the ball, their arms flailed wildly. When they ran shoulder to shoulder with an opponent, one of the players inevitably went tumbling, unable to absorb any contact. When players landed from jumps, without jumping very high, their knees caved in (knee valgus), a common precursor to ACL ruptures. They struggled to decelerate or change directions to avoid collisions, and many fouls were symptoms of poor movement skills and body control. Rather than becoming good movers initially and progressing to sport-specific skills, these players appeared to strive for soccer success. These teams dutifully performed the FIFA11+ warmup (below), designed to reduce injuries by teaching and training basic movements, but there was no concentration or corrections on the warmup. The coach set up the next drill as the players performed their warmup, and the players quickly moved through the exercises in order to get to the important drills, the ones with the ball. The warmups with the ball were primarily linear; they dribbled in a straight line and passed to another player, or they dribbled at the goal and took a shot. Very few of the movements in warmups engaged the players or challenged their movement skills. Despite their soccer success, these girls were not good athletes. Based on the conversations of the parents, most played year-round soccer rather than compete in another sport. The year-round play may have helped with the early mastery of their sport-specific skills, but none of the girls had a long future in the sport unless they greatly enhanced their athleticism and movement skills. In all likelihood, more of those 22 players will miss a season in their four years of high school due to an injury suffered while playing soccer than will extend their soccer career beyond high school. Adolescent females who specialized in one sport were 1.5 times as likely as those who participated in multiple sports to suffer from patellofemoral pain (PFP; Hall et al., 2014), and girls’ soccer has the highest rate of ACL injuries, with 11.7 injuries for every 100,000 athlete exposures (an athlete exposure is one athlete participating in one practice or competition; Comstock et al., 2013). Furthermore, youth soccer players who practiced four or more days per week prior to age 12, as did some of these girls based on the sideline conversations, were more likely to suffer cam deformities to their hip than those who waited until after age 12 to practice four or more days per week (Tak et al., 2015). Rather than focus on more soccer and continuing to expand their soccer skills, these players would be served better by playing another sport, especially track and field. University of North Carolina head coach Anson Dorrance has said that he prefers to recruit sprinters because of the added speed on the field. These players are working backwards, as they originally skipped the correct progression of mover to athlete to player. Now, they must try to work backward from player to athlete to mover, and running track and field, and especially the sprints, would be one approach to learn better movement skills. Additionally, the players should concentrate in their movement warmup and expand upon this brief warmup with additional plyometics and strength exercises. Before trying to add another layer of skill, or another step-over dribbling move, they should master running, jumping, landing, and stopping. When I was a child, playing and training was less

Your Brain on Exercise

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We are all aware of the positive effects of regular exercise – weight control, aerobic fitness, the maintenance of muscular strength, blood pressure control, and the improvement of HDL (high-density lipoprotein). However, not nearly as obvious to most are the positive effects of exercise on brain function, especially as we age. What we have found out over time is that the brain is more “plastic” in function than we thought and our brain circuits are changing constantly depending on what we’re doing (or not doing) in the world. Dementia is the loss of the brain’s elasticity and it seems that the old adage “use it or lose it” applies to brain elasticity and circuitry. Exciting new research shows that exercise, both mental and physical, can help decrease the risk of dementia in adult life. Peter Elwood of the Cochrane Institute at Cardiff University in the United Kingdom did a study of 2235 men (aged 45-59 years) over 30 years. The results showed that: 1. Eating a healthy diet 2. Having a BMI (body mass index) between 18-25 3. Not Smoking 4. Limiting Alcohol Consumption reduced the risk of cognitive decline by 60%! BUT, better than all those well-known healthy habits was EXERCISE! Biking 10 miles a day, walking 2 miles a day, or other daily vigorous exercise produced the best results. Another study showed that walking at least 1 mile a day significantly enhanced the volume of several brain areas and a different study revealed that higher aerobic fitness levels were associated with larger right and left hippocampi and therefore better spatial memory performance. Dementia and Alzheimer’s (the most common form of dementia) are devastating illnesses. The latest research showing the benefits of exercise on brain health gives us one more reason to make exercise a daily habit.

Pain on the Outside of Your Knee?? IT Band Syndrome

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The IT band is a long, fibrous band that is the extension of the tensor fascia lata muscle (and slips from the gluteus maximus) that originates at the outside of the pelvis, and the “band” portion attaches just below the outside of the knee. The muscle moves the leg away from the body (abduction), bends the leg up (flexion), rotates the leg inward (internal rotation), and stabilizes the outside of the knee.   Wow.  It does so many things.  BUT, its work is affected by the BUTT (let’s call it “the hip” which is the joint that the BUTT muscles (now to be called “the gluteal muscles”) surround and operate).  Weak gluteal muscles / poor hip control can cause pain on the side of your knee called iliotibial band syndrome, or IT band syndrome. How?  And what can you do? In running, when the hip / gluteal muscles are weak or poorly activated, it can’t manage the very high rates of loading and force that running demands of it, so other, often-times smaller muscles that can do (some) of the same functions as the weak gluteals (like the TFL that becomes the IT band) are left to carry that load.  Then that muscle gets overused and often times, tight (because it’s being overused).  Because, as mentioned above, the TFL turns the leg inward (internal rotation), and the weak gluteal muscles can’t well counteract that internal rotation torque, the (tight) TFL and its IT band get stretched / stressed, and can experience greater friction against the bony prominence or fat pad of the femoral lateral epicondyle that lies just beneath the IT band near the knee.  This is (one) recipe for IT band pain at the outside of the knee. What to do… you need to activate the gluteal muscles (especially the “work-horse” gluteus maximus) so they can do their critical job to control the hip to stop the hip from rotating inward and creating strain on the IT band.  Also, stretch the TFL and foam roll or actively release the muscle and IT band with a tennis or lacrosse ball.  This will decrease the tightness and, along with the ever-so-critical hip strengthening, will decrease the strain on the IT band.  An additional, very critical element is learning how to activate your gluteal muscles when you run.  It’s not enough to strengthen without learning how to use those (now stronger) muscles.  This motor learning of a new, biomechanically optimal movement pattern is what research now plainly shows is critical for long-lasting rehabilitation results of orthopedic and musculoskeletal injuries. Think about it… if you strengthen and stretch and get manual work on your tissues, etc., but you don’t know how to use the muscles differently (it’s difficult since you’ve been using the same motor pattern for a very long time, not knowing of its potential ill-effects until the body reaches a threshold and the pain starts), you will continue with the motor pattern that your brain / nervous system knows and that got you into this mess in the first place. The IT band pain can unfortunately be a nagging, sometimes very long-lasting problem for runners and often-times sidelines them over and over again for months at a time.  If you’re having knee pain, come in for a PT evaluation of the problem. We will move you through a customized program based on your particular knee issue. There are numerous things to be done for IT band syndrome once the cause(s) of the pain are determined. The range of interventions includes: training adjustments (stop running through pain!), running analysis, modalities for pain, manual therapy, stretching, myofascial release, strengthening and movement re-training. Should weak hip muscles be a culprit, here is a great exercise: FIRE HYDRANT: We love the fire hydrant!  It does a beautiful job of activating the gluteus maximus (as seen on EMG in research and in the practice setting with surface EMG), the big boy in this scenario that MUST be working to abduct and externally rotate the hip during the landing / weight acceptance phase of running and support the TFL / IT band so it doesn’t get overloaded. Note: the leg is lifting up and out at a 45 degree angle.  Back is flat. You should feel this in the back of the hip / gluteus maximus.  Try 15 second holds, alternating sides, for 3 – 4 minutes daily.  Add a resistive band (of lowest resistance initially) to progress yourself.  If the exercise is painful, stop and come in for PT!

Rethinking Movement: Why You Should See A Physical Therapist Every Year

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Why is it that superbly fit athletes can find themselves in as much back, knee, or neck pain as their flabby fans, who sit at desks all day long then watch sports from overstuffed sofas? “When you do an activity over and over again, your body adapts to that activity,” warns Dr. Shirley Sahrmann, professor emerita of physical therapy at Washington University School of Medicine. “If you play tennis, your arm gets bigger on that side; if you do karate you get adaptations in your hip and leg. Even if you just sit, you lean, you slump, your neck goes forward.” Either your body fails to build up musculature to support itself, or it overbuilds certain muscles and throws off the symmetry your skeleton craves. That’s why Sahrmann wants to see an annual physical therapy exam become as routine as a dental checkup. “We go to the dentist twice a year and spend thousands to straighten our teeth, and all we do with them is eat and talk. Meanwhile the rest of our body’s just hanging out there.” People think of PT as something generic their doctor orders after an injury, she says. But by analyzing the way you walk, bend, sit, and carry yourself, physical therapists can prevent injuries and head off future surgeries and chronic pain. “Kids don’t sit correctly, they slump, so they wind up sitting on the middle of their back,” she says. “We have these little bones on our bottom where we are supposed to sit and keep our spine erect. When you slump, the muscles get stretched out, and they’re not going to function optimally.” A temporary phase? Maybe. But “bones adapt to the alignment that you keep them in,” Sahrmann points out, “and your spine becomes shaped like that.” Watching teenagers walk makes her crazy: “They are not using what we consider a normal gait. They walk without bending at the hip and knee and pushing off. They shuffle. And they sway back—their shoulders are behind their hips—so their gluteal muscles don’t work as much as they should. All of these little cultural changes in sitting posture, what’s considered cool—even the clothing.” For a while there, she says, “the new waistline was the gluteal fold! And how do you walk when your legs are strapped together with a belt? Their knees get caught in the crotch of their pants—it’s hysterical. But it’s also not good.” In years past, there was little appreciation of how lifestyle affected your health. “My family thought they just got diabetes or hypertension; it had nothing to do with the cans of Crisco my grandmother cooked with.” The way we move and align ourselves is just as important as what we eat, she says. “There is complexity to movement, and you can do it right or wrong.” I bring up ergonomics—surely that’s helped? “It’s not just whether the setup is right,” she points out. “It’s what you bring to that setup and what you do when you’re not there.” We’re designed to keep changing position, not sit frozen in the perfect chair. Even working out requires real knowledge, if you want to lift weights or do aerobic training without compromising the performance of all your other joints. Sahrmann’s one of the nation’s pioneers in pushing the concept of a movement system, emphasizing the subtle, necessary interconnections of muscles and bones and nerves but also heart, lungs, and the endocrine system. Her career has spanned more than half a century, and its twists and turns led her to see the body whole. She began work at the end of the polio era and spent nine years taking care of patients who’d suffered head injuries or strokes. In order to understand the disordered motor control of patients with central nervous system lesions, she left clinical practice to earn a Ph.D. in neurobiology. Then serendipity sent her a different kind of patient: athletes who had musculoskeletal pain.  “I started teaching them to move differently, and they got better for reasons I didn’t understand,” she says. “I’ve spent a good many years with my colleagues at Wash.U. working to analyze these relationships between movement and musculoskeletal pain.” She’s written two books and talked herself hoarse, urging people to see the body’s movement as systemic. Now that approach is finally catching hold, not just here but nationally and internationally. But she’ll know she’s really succeeded when PT evaluations are annual, and there are formal diagnoses based on movement patterns that consistently cause pain: flexion syndrome, when the back bows out; extension syndrome when it bows in and hunches you over; tibiofemoral rotation that can lead to knee problems. “We all move differently,” she says. “I’ve seen patients whose feet are so callused I don’t know how they put their shoes on, and I’ve seen marathon runners with no calluses at all. “You need to have an exam by a body expert at least once a year,” she finishes crisply. “Even if insurance doesn’t cover it, the cost is no more than you’d pay a personal trainer. I think we could substantially reduce the number of injuries and slow the process of osteoarthritis as people age.” She’s not saying arthritis can be eliminated altogether—but it can be delayed and its effects minimized. “There’s evidence that if a joint is lax, or you have injury, or your muscles are weak, you can get these arthritic changes.” Move right, and you lower the chance of injury—whether you’re an Olympian or a couch potato. By Jeannette Cooperman May 11, 2015 / St. Louis Magazine  

Parent Confessions… I Hurt My Little Leaguer’s Arm

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Little League baseball season is in full ‘swing’. Look out for overuse injuries in your child, and check this out from littleleague.org of one parent’s account of his child’s overuse and need for Tommy John surgery… he thought it could never happen to his child. If your baseball player is experiencing elbow pain, come in for a PT evaluation, see your pediatrician, orthopedist, or sports medicine doctor. We’re reaching epidemic proportions in the number of youth players requiring this surgery. Be aware, and prevent it from happening to your child. __________________________________________ Parent Confessions… I Hurt My Little Leaguer’s Arm I remember the day my wife gave me an article about kids having Tommy John surgery. I read it, and kind of blew it off. Not my kid I thought. He’ll just take it easy once in a while. He’ll be fine. Well, it ended up being my kid. All that talent… gone. I blamed others. My wife blamed me. She was right. As an 11-year-old, my son didn’t lose a game on the mound. He pitched two no-hitters. Even the high-school coach came to see him pitch. “Lots of talent, AND he’s a lefty!” he said after a game. I kept picturing my son sitting at a table, signing a Division 1 Letter of Intent. We started practicing for his final year of Little League the very next day after his last game as an 11-year-old. I convinced him basketball was taking up too much time, and that if he concentrated only on baseball, he might get a free ride somewhere. I know now that was a mistake. Throughout the fall and winter, he worked with a pitching coach, and he continued with his travel ball team. We live in North Carolina, so we play pretty much year round. He was the ace on the travel ball team. The manager pitched him… A LOT. My son won… A LOT. We concluded a travel ball tournament on a Friday night. He pitched five innings. Got the W. The next day was “Opening Day” for Little League. My son was so excited. His coach came up to me before the game, and asked if my son had been pitching a lot on his travel ball team. “Nah,” I said. He kind of just looked at me. “I don’t want to risk injuring his arm,” he said. “You need to tell me if he’s pitching too much on the other team.” “He’s fine,” I told him. “Opening day, Coach. Gotta go with your number one, right?” He did. We won. Me and my son’s Little League coach had the same type of conversation one more time during the year. He had those talks with my son, too. My son, like me, said his arm was fine. Like most kids, he wasn’t going to say if he felt something a little weird in his elbow. My son was 3-0. He was scheduled to start against the best team in the league. He was excited. I was excited, until that is, another kid took the mound in his place. I poked my head in the dugout. “I’m shutting him down,” said the manager. I asked why. “His arm is dead! I told you to tell if he’s pitching a lot with other teams!” I ended up resting him a little. That season, he only pitched one more time for his Little League team. I rested him some more. He played 50/70, and continued travel ball. His travel ball coach pitched him. I shouldn’t have let him. His arm felt good one day, tired the next. We rested, iced it, and heated it. Sometimes he threw like his old self. Most times, he didn’t. At 14, we went to the doctor. And at only 15, my son had Tommy John. He will never be the same, and that Letter of Intent that I was so intent on will never come.

When Exercise Isn’t Enough

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FRIDAY, OCTOBER 10, 2014 By: ERIN BERESINI Face it, most of us aren’t complete athletes. We lack the strength to make us fit, and we follow cultlike exercise programs. But there is a cure: Listen to renegade coach Mark Rippetoe, grab a barbell, and get back to basics. Mark Rippetoe believes the $27 billion fitness industry is confusing you. Worst of all, they’re doing it on purpose to nab your cash. The man doesn’t have a degree in exercise physiology or a PhD after his name. Instead, the owner of Wichita Falls Athletic Club in Texas has more than 35 years of experience training weight lifters and their coaches. In 2009, he cut ties with CrossFit after developing the company’s barbell program and became the first coach to give up his National Strength and Conditioning Association credential—which is why you’ve likely heard his name. The reason he left is surprisingly simple and immediately appealing: Strength is the core of fitness. Without it, you won’t be a fast roadie, confident MTBer, or strong skier. The problem with most exercise programs, Rippetoe says, is they’re cultlike and single-minded. Sure, the community vibe helps keep you training (and a happy customer), but it’s not going to make you a stronger all-around athlete. “If I’m a yoga instructor, I’ll tell you the most important thing about fitness is flexibility,” Rippetoe says. “If I’m an aerobics instructor, I’ll say it’s cardio. And if I’m CrossFit, I’ll say it’s everything. My position is strength is the basis for all physical interaction in the environment. If you’re not strong, it doesn’t matter how conditioned your heart and lungs are if you can’t get up off the pot.” The way to get strong is simple, Rippetoe says. All it takes is five barbell moves and progressive loading of weight over time. The moves: squats, presses, dead lifts, bench presses, and power cleans. Those exercises will allow the body to move anatomically while making every muscle stronger, even if they’re the only moves you ever do. “One of my pet peeves with the modern approaches to fitness is they vary exercises,” Rippetoe says. “They confuse the whole concept of training and exercise.” Exercise, Rippetoe says, is physical activity. “We do it for the effect if produces today.” Training, on the other hand, is a “process of acquiring physical adaptations that satisfy your physical requirements in the future.” It’s the difference between a daily jogger and someone training for a marathon. The daily jogger has no other goal than feeling good today; the marathoner’s daily runs are targeted toward performing her best on race day. “For most people, exercise is just fine,” Rippetoe says. “But when you decide you want more out of the process, the process must be planned. Each workout becomes important because it fits into the process.” At first, Rippetoe’s distinctions might seem pedantic. And his list of moves are more powerlifter than Outside athlete, but he’s on to something. Few of us are complete athletes. We’re strong on the bike but can’t do a pushup. Or we’re the master of the WOD but can’t run more than a mile. And even fewer of us train for specific events or goals. That combo, then, is what makes his ideas so compelling. Knowing the difference between training and exercise is the key to staying healthy (making exercise a part of your lifestyle), peaking to perform (training with a purpose), and avoiding the injury-causing and money-wasting fitness fads. “Rise above the platitudes of the fitness industry,” Rippetoe says. “Think about what you want and plan to acquire what you want so you can spend your time and money more efficiently.”  

Runner’s Gait Analysis

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Gait Analysis: The Serious Runner’s Salvation A Tool to Precisely Spot Stride Problems and Stop Joint Pain and Injury By MATTHEW FUTTERMAN Sept. 22, 2014 7:21 p.m. ET People who lace up their running shoes and pound the pavement have a roughly 50% chance of sustaining an injury that interrupts their training. Among marathon runners, studies have placed the injury incidence rate significantly higher, in some cases as high as 90%. It isn’t running itself that’s doing the damage, a growing number of physicians, physical therapists and exercise scientists say. It’s the way people run. Too many runners stride too far out in front of their bodies, or land with their legs at awkward angles. Increasingly the runner’s road to healthy joints starts with gait analysis. Medical boots, cortisone shots or even surgeries never solved runners’ problems the way 20 minutes of being filmed on a treadmill can, experts say. Gait analysis seeks to identify the root of an injury, or a bad habit that may lead to one. It usually starts with an evaluation of strength and flexibility that includes some manipulation on an examination table and a series of exercises. A running session on a treadmill in front of a video camera follows. These examinations take place at a handful of hospitals and sports performance centers, and typically last one to two hours, including an initial review of what the medical professionals see. Patients usually get a written evaluation detailing how they might run pain-free. Anne-Michelle Barrett, a personal trainer and triathlon coach who lives in Sausalito, Calif., suffered a stress fracture in her left shin in 2010, then one in her right shin at the beginning of 2013. She says she wasn’t overtraining. She rested and wore an orthopedic boot for six weeks in 2010 and four weeks in 2013. “I coach running, personal training and triathlon, and even I was still struggling,” says Ms. Barrett, 37. Desperate to figure out what was causing the injuries, she signed up for a gait analysis at New York City’s Hospital for Special Surgery with Michael Silverman, a physical therapist and the coordinator at the hospital’s Tisch Performance Center. Mr. Silverman’s initial examination revealed Ms. Barrett had hyper-mobile hips, which can produce an unstable stride. Then Mr. Silverman had Ms. Barrett perform a series of leg squats. He also watched as she stepped slowly off a platform. During each motion her knees bent inward as her legs moved forward. Next, Mr. Silverman filmed Ms. Barrett running on a treadmill from several angles. When he slowed down the video and measured the angles of her legs during her stride, the likely source of the pain became obvious—big strides and landing on the inside half of her feet. William Roberts teaches at the University of Minnesota Medical School and has served as medical director for the Twin Cities Marathon. He says gait analysis has become a more accepted part of sports medicine as traditionally trained orthopedists and surgeons have started to embrace the holistic approach of chiropractors, osteopaths and physical therapists. Dr. Roberts sees it as especially fruitful for runners who keep getting injured even though they are otherwise healthy. “If you are mechanically correct and there is still pain, then a gait analysis can really help,” he says, since running shouldn’t lead to joint injuries. The main causes of such injuries are obesity, genetics and traumas, such as a torn knee ligament on a leg twisted in a soccer game. Many doctors held for decades that distance running hurts joints and bones as much as it helps the heart. But beginning roughly five years ago, a series of studies have revealed that runners’ joints and bones are actually healthier than average. Runners and others who exercise vigorously are actually significantly less likely to experience arthritis or require a major joint replacement than people who don’t. James Fries, an emeritus professor of immunology and rheumatology at Stanford University, co-wrote the definitive study debunking the links between running and debilitating injuries in a 2008 report published in Archives of Internal Medicine (a publication since renamed JAMA Internal Medicine). He studied about 1,000 people 50 and over from 1984 to 2005. He calls running “the greatest intervention to postpone aging that’s ever been reported.” On average, his study showed running or another form of vigorous exercise postponed disability by 16 years and death by seven to nine years. Looking at a subset of study subjects found more joint replacements in the non-runners. “With osteoarthritis we used to worry about the wear and tear. Now we just worry about the tear,” says Dr. Fries, who plans to publish updated results next year. The healthiest runners’ legs move straight and forward. With each stride, Ms. Barrett’s legs were bending inward at the knees. That caused her to land on the inside half of her feet. Her feet hit the ground directly beneath the center of her body, putting intense pressure on her lower shins, a problem exacerbated by Ms. Barrett’s overstriding. Straighten out the knees and shorten the stride and the pain just might go away, Mr. Silverman said. Ms. Barrett soon started running on a treadmill in front of a mirror so she could focus on running as if on narrow railroad tracks. She strengthened her gluteal muscles so she could better control her knees, shortened her stride and speeded up her cadence. She has completed two more triathlons and a trail race since the analysis, and the 200-mile relay race from San Francisco to Calistoga, Calif. Dr. Fries, the Stanford physician, cautions that it’s too early for gait analysis to be deemed a panacea. The practice has been going on for more than a decade but has only become popular in recent years. “They don’t have the 30-year studies of outcomes,” he says. Mr. Silverman agrees. But he and other medical professionals say there is a high degree of correlation between certain running patterns and certain injuries. For instance, a bouncy running motion