The Pro sports blog
The material provided here is general information and individual advice should be obtained with an evaluation or assessment by an appropriate physical therapist
Angelene Belle Dimaano, SPT
Low back pain is the most prevalent musculoskeletal disorder both globally and in the US. Unfortunately, over 70% of all adults will experience it in their lifetime. There are many elements that contribute to a person’s experience of low back pain; the major players we focus on clinically are nociceptive pain, neuropathic pain, and nonorganic pain. Nociceptive pain is pain that is alerted by tissue damage, neuropathic pain is pain associated with nerves, and nonorganic pain is pain that cannot be traced to any biological structure.
It should be noted that while low back pain can include all three elements, the neuropathic component is often underrecognized and undertreated. In fact, an analysis of a US claims database reveals a neuropathic component in 90% of chronic low back pain cases. While the neuropathic portion is underrecognized, in the two last decades, there has been an exponential growth in the body of evidence supporting its contribution. In neuropathic low back pain, there are a number of nerves, nervous tissue, as well as surrounding nerve structures that can contribute. Some structures include peripheral nerves such as the sciatic or femoral nerves and individual spinal nerve roots. Although it is not present in every patient, one must also consider contributions from the central nervous system in a patient’s experience of neuropathic low back pain.
Nerves and nervous tissue contribute to the perception of low back pain in one of two ways. One course is peripheral nerves, like muscles, can become injured from being over worked, being compressed, or mechanical trauma. In this case, pain is a normal and natural reaction that serves as an alert system to signify damage. The other course occurs when the central nervous system becomes heightened and therefore responds to non-painful stimuli or disproportionately to painful stimuli.
Physical therapy addresses neuropathic low back pain in three themes: (1) the body is resilient (2) movement does not equal pain and (3) nervous tissues have neuroplasticity: the ability to learn. Treatments that have been shown in the evidence to improve neuropathic low back pain include manual therapy for pain modulation, directional preference for centralization, neuromuscular re-education for proper muscle activation, cognitive behavioral principles of graded exposure to reintroduce activity, and neuromobilization of nerves and the surrounding structures to normalize pain response. The jury is still out on what the gold standard treatment for neuropathic low back pain is, but as the body of evidence supporting the neuropathic component of low back pain continues to grow, it is important to remember it can play a role and it can be treated.
We are pleased to be a part of the Scarsdale High School sports medicine team, providing care for Scarsdale athletes for over two decades. Tim and Brandon have collectively be on the sidelines for thousands of games and are excited to welcome new Athletic Trainer Jessica White to the team!
Brandon Schmitt DPT, ATC
One of the big questions following ACL reconstruction surgery is: when can I go back to play? A seemingly simple decision on the surface becomes much more challenging in light of the current research. Only 55% of athletes return to sport, even with full intent to do so, and despite good surgical outcomes. The reasons range from not trusting the surgical knee to poor self reported outcomes. Of those who return, they are 15 times more likely to sustain a (second) ACL tear. Performance can also suffer, with only 66% reaching preinjury level two years out from surgery.
There are three primary components that need to be considered when making a return to sport decision: biological, physical/functional, and psychological. From a biological standpoint, the graft needs time to heal and undergo a process called ligamentization in which the graft needs to revascularize and re-innervate. This process can take twelve months or more to occur based on animal and human studies.
The second consideration is the patient's functional performance. A series of biomechanical studies showed that some athletes who have had surgery showed specific biomechanical deficits, such as knees caving in and stiff knee landing, which were risk factors for future injury. From these findings a series of tests were designed to test jumping and landing mechanics as well as quadriceps strength. Hopping and landing mechanics are commonly assessed through a testing battery consisting of single leg hops for both distance and time and compared to the non-surgical leg. Generally a deficit of less than 10% is required before being cleared to return to sport. This limb symmetry index, as it's called, is better at ruling out those athletes not yet ready to return to sport versus ruling in those who are ready to return. While there are some tests designed to look specifically at movement quality, none to date that can be easily done in the clinical setting have been shown to have good predictive value for sustaining another injury.
The next measure to consider with regards to function is quadriceps strength. This is most commonly done with an isokinetic dynamometer or with a hand held dynamometer in order to get an object strength measure. The knee strength on the surgical side is compared to the non-surgical side and a limb-index measure is derived. Research has shown that for every one percent decrease in this deficit, there is a three percent reduced risk of reinjury to the knee. At PRO Sports PT we use a biodex unit, which gives the most accurate strength testing measurements.
The third component of return to sport is the psychological aspect. It is not uncommon for an athlete to have some degree of fear and apprehension following ACL surgery. At PRO Sports we use a special test called the Return to Sports Index (RSI) which measures a patient's emotions, confidence in performance, and and risk appraisal. This test has been shown to have good reliability, validity, and predictive value.
While there is no validated return to sport testing battery with regards to return to sport decision making following ACL reconstruction, we at PRO Sports PT use the most up to date research and our extensive experience, as well as collaborating with the patients and surgeons, in making the decision. While the decision is not always simple, science and experience can help make the best decision possible.
Emily Snee, SPT, CSCS
Squat Technique: What variables matter?
The squat at its core is a movement that most people perform on a daily basis. It is one of the most functional exercises that challenges the entire body. When the squat is assessed in the physical therapy setting, it is most likely chosen because it is one of the greatest tests of lower-extremity strength. The squat activates the quadriceps, gluteal muscles, hamstrings, hip adductors, hip abductors, and many other stabilizing muscles. But can we as physical therapists manipulate technique variables in order to increase the activation of specific muscles?
Increased quadriceps muscle strength and size are desired outcomes for various patients rehabbing from ACLR, anterior knee pain, etc. Studies have shown that to increase the activation of these muscles during the squat, the patient must perform the motion to at least parallel. When loading the squat, it has been shown that loading in a front rack position leads to increased quadriceps muscle activity as compared to the typical “back squat” position. Stance width does not have any effect on the activation of the quadriceps muscles.
If the desired outcome of the squat is to target the gluteus maximus, the only variables that need to be altered are depth and stance width. A patient must squat as deep as possible and with a wide stance (140-200% greater trochanter distance) in order to increase glute max activation. To ensure increased activation of the hip adductors, have the patient squat with a wide stance as well. Other factors in squat technique, such as degree of hip external rotation and heel height, did not influence the activation of any muscle.
Optimizing muscle activation by manipulating technique variables is a great way to make the squat a more useful intervention, however the simplest and most effective way to increase muscle activation is to increase the load. Studies have shown that utilizing 70-90% of a patient’s 1RM will activate the lower-extremity muscles to the greatest degree, while maintaining safe and correct technique.
Michael J. Hogan SPT
Sleep is an altered state of consciousness that individuals should spend one third of their lives in. Unfortunately, studies find that Americans only get 6.1-6.8 hours of sleep per night, which is below CDC recommendations for all age ranges. Eight hours of quality sleep is considered optimal for anyone over the age of twelve, but when life gets stressful with busy schedules, late nights, and work that just has to get done, sleep is often the first thing to go. Losing a couple hours of sleep often gets brushed off, but consistent sleep loss can have adverse effects on our bodies.
When recovering from an injury, sleep could be the catalyst for a smooth recovery and lack of sleep could elongate the healing process. Studies have shown that decreased sleep is associated with increased pain perception, decreased ability to recover, and decreased max vertical jump. While increasing sleep to optimal levels is associated with increased athletic performance, decreased reaction time, and improved subjective mood. Therefore, achieving optimal sleep could improve an individual’s ability to rehabilitate and improve their outcomes.
The safest and most effective way to increase sleep time and improve sleep quality is to establish healthy sleep hygiene. Sleep hygiene includes establishing a regular bedtime routine as well as consistently going to sleep and waking up around the same time. Bright lights from phones and TVs should be avoided at night, especially right before bed. The bedroom should be kept cool, dark, and comfortable. Caffeine, nicotine, and alcohol should all be avoided before bed. Finally, you should not spend excessive time in bed outside of sleeping hours. These recommendations can be used to guide individuals toward optimizing their sleep.
1. Bolin, D. J. (2019). Sleep deprivation and its contribution to mood and performance deterioration in college athletes. Current sports medicine reports, 18(8), 305-310.
2. Larson, R. A., & Carter, J. R. (2016). Total sleep deprivation and pain perception during cold noxious stimuli in humans. Scandinavian journal of pain, 13(1), 12-16.
3. Chase, J. D., Roberson, P. A., Saunders, M. J., Hargens, T. A., Womack, C. J., & Luden, N. D. (2017). One night of sleep restriction following heavy exercise impairs 3-km cycling time-trial performance in the morning. Applied Physiology, Nutrition, and Metabolism, 42(9), 909-915.
4. Mah, C. D., Sparks, A. J., Samaan, M. A., Souza, R. B., & Luke, A. (2019). Sleep restriction impairs maximal jump performance and joint coordination in elite athletes. Journal of sports sciences, 1-8.
5. Mah, C. D., Mah, K. E., Kezirian, E. J., & Dement, W. C. (2011). The effects of sleep extension on the athletic performance of collegiate basketball players. Sleep, 34(7), 943-950.
6. Kroshus, E., Wagner, J., Wyrick, D., Athey, A., Bell, L., Benjamin, H. J., ... & Watson, N. F. (2019). Wake up call for collegiate athlete sleep: narrative review and consensus recommendations from the NCAA Interassociation Task Force on Sleep and Wellness. British journal of sports medicine, 53(12), 731-736.
By Logan Chaffin ATC, SPT
Deep Vein Thrombosis, most commonly referred to as DVTs, are relatively common not only in the elderly but also young athletic populations. DVTs if identified and treated early on can be a minor setback, however, if left untreated can quickly develop into a very dangerous and potentially life-threatening situation. Your physical therapist is highly trained in not only rehabilitating the joint or muscle that brought you to them, but also to screen for dangerous disease processes like DVTs. Your physical therapist should educate you on the signs and symptoms of DVTs and will be able to answer any questions you may have about possible DVTs.
Unfortunately for some there are predictors of who will likely get DVTs, however, anyone can get a DVT and any DVT can progress into a life-threatening situation. Women are more likely than men, post-operative patients (most commonly total knee replacements), and the older you are the more likely you are to get a DVT. Considering this, the patient that comes to mind is a 75-year-old woman who just underwent a total knee replacement; however, recent studies have also shown that 1 in 40 young people who undergo an ACL reconstruction will experience a DVT. There are some predisposing factors that you can control such as smoking and being sedentary that both drastically increase your possibility of getting a DVT.
Some signs and symptoms to look for of a DVT are pain that gradually progresses it is most commonly in the posterior calf that is often described as a cramp or spasm. You should also keep an eye out for redness or warmth that is not present in your other lower extremity. Finally, one other thing to watch for is swelling or prominent deep veins that again are not present in the opposite lower extremity.
If you suspect that you may be experiencing a DVT consult your physical therapist who will examine you and your symptoms. Using what is known as the Wells clinical prediction rule, they should be able to identify if you are someone who needs to undergo further imaging for a DVT. With a possible DVT it is often better to be safe than sorry and with the ease and relative cheap and easily available doppler ultrasound when in doubt get it checked out.
By Dominic Violi CSCS, SPT
The major compound weightlifting movements, with emphasis on the squat and deadlift, are a staple in the world of physical therapy due to their mirroring of functional movements performed every day. For example, rising out of a low bed involves similar concentric quadriceps and gluteal activity to that of a front squat while the lifting of a bag from the floor involves similar extension and balance motor patterns to that of a single leg deadlift.
The squat and deadlift are both considered closed kinetic chain exercises, indicating the patient is weight bearing while moving a load. Closed kinetic chain exercises are found to significantly minimize the risk of Osteoporosis and age-related falls in the older adult,1 while maximal squat strength is specifically correlated with increased sprint speed and vertical jump heights in elite athletes.2 Due to the fact that 65% of females over the age of 75 report not being able to lift 10 pounds off the floor,3 the deadlift addresses a major functional deficit.
From a rehabilitation standpoint, both the squat and deadlift are strong tools in the return to premorbid level of function. In a Duke University systematic review, the single-limb deadlift and single-limb squat were found to be the most effective exercise in eliciting glute med and glute max contraction as a percent MVIC.4 The deadlift was also found to be associated with a lower VAS score after 11 physical therapy visits in patients with mechanical low back pain,5 while the maximally loaded barbell squat from 0-90° knee flexion was found to produce 0 Newtons of tensile force across the ACL.6
There is a plethora of benefits that can be attained from compound movements such as the squat and deadlift from both a functional and a rehabilitative perspective. These closed kinetic chain lifts are associated with significant improvements in performance in both athletics and ADL’s, while loading of ligamentous tissue and risk of injury is minimal when performed under the supervision of a skilled physical therapist.
1. Thabet AAE, Alshehri MA, Helal OF, Refaat B. The impact of closed versus open kinetic chain exercises on osteoporotic femur neck and risk of fall in postmenopausal women. J Phys Ther Sci. 2017;29(9):1612-1616.
2. Wisløff U, Castagna C, Helgerud J, et al Strong correlation of maximal squat strength with sprint performance and vertical jump height in elite soccer players British Journal of Sports Medicine 2004;38:285-288.
3. Jette AM, Branch LG. The Framingham Disability Study: II. Physical disability among the aging. Am J Public Health. 1981;71(11):1211-6.
4. Reiman, M. P., Bolgla, L. A., & Loudon, J. K. (2012). A literature review of studies evaluating gluteus maximus and gluteus medius activation during rehabilitation exercises. Physiotherapy theory and practice, 28(4), 257-268.
5. Aasa, B., Berglund, L., Michaelson, P., & Aasa, U. (2015). Individualized low-load motor control exercises and education versus a high-load lifting exercise and education to improve activity, pain intensity, and physical performance in patients with low back pain: a randomized controlled trial. journal of orthopaedic & sports physical therapy, 45(2), 77-85.
6. Escamilla, R. F., MacLeod, T. D., Wilk, K. E., Paulos, L., & Andrews, J. R. (2012). ACL Strain and Tensile Forces for Weight Bearing and Non—Weight-Bearing Exercises After ACL Reconstruction: A Guide to Exercise Selection. journal of orthopaedic & sports physical therapy, 42(3), 208-220
By Dominic Violi CSCS, SPT
By Patrick Knox, SPT
Low back pain is a highly prevalent and debilitating condition that accounts for a substantial amount of the cumulative annual healthcare expenditure. Due to its multifactorial nature, treatment measures for low back pain vary within the realm of physical therapy. Often, clinicians utilize tests and measures in order to stratify patients into subgroups that typically respond to specific interventions. One such classification group of low back pain patients is those with LSI (lumbar segmental instability).
The origins of lumbar stability research are deeply rooted in mathematical and biomechanical analysis given the inherent complexity of the spinal system. Pioneers in the field developed in vitro models that accounted for both passive (osteoligamentous system) and active (muscle stiffness and activation levels) restraints. Over time, these models were updated to include real-time data from research participants (including movement kinematics via video analysis and muscle recruitment patterns via EMG), which eventually resulted in recommendations for how to best treat patients that were predisposed to injury secondary to loss of osteoligamentous integrity, trunk neuromuscular control deficits, or a combination thereof. Particularly, stabilization programs should include the following: abdominal brace, abdominal curl-up, horizontal side-support (side planks), and quadruped extremity lifts (bird dogs).
Research has delineated which tests and measures (prone instability test, aberrant motions during AROM assessment, FABQ-PA value, and hypermobility in the lumbar spine) will best indicate the subgroup of low back pain patients who will positively respond to the aforementioned lumbar stabilization exercises, and has validated the use of such exercises on a longitudinal basis. Additionally, research suggests the addition of NMES to the lumbar paraspinals may be an effective adjunct to lumbar stabilization exercises.
The following presentation explains, in detail, the lineage of lumbar stabilization and provides pragmatic examples of how to optimize clinical practice. More research is needed to determine how these exercises should be adapted to different patient populations, and the magnitude to which NMES augments traditional stabilization programs.
Journal Club- Subacromial Decompression Yields a Better Clinical Outcome Than Therapy Alone; A Prospective Randomized Study of Patients With a Minimum 10-Year Follow-Up - AJSM 2018:46(6)
Jamie Ferraro, SPT, CSCS
Subacromial Impingement Syndrome (SAIS) is the most common pathology of the shoulder. The subacromial space of the shoulder joint is made up of the humeral head inferiorly, the acromion anteriorly, and both the coracoacromial ligament and acromioclavicular joint superiorly. The space between the humeral head and the acromion ranges from 1.0-1.5 centimeters, and is occupied by the tendons of the rotator cuff, long head of biceps tendon, a bursa, and the coracoacromial ligament. SAIS may occur when there is an abnormality leading to a disruption in the relationship of these structures.
SAIS can be categorized into three stages. Stage I is typically found in individuals under 25 years old, and it involves edema and hemorrhage of the bursa and the rotator cuff. Stage II is more often found in 25-40 year olds and involves irreversible changes of the rotator cuff, such as fibrosis and tendonitis. Stage III involves chronic changes of the rotator cuff, including partial or complete tears, and is more often found in individuals over 40 or those who have an occupation that involves increased arm abduction. Currently, the treatment for early stages of SAIS consists of conservative methods, such as physical therapy, NSAIDs, or cortisone injections. If these methods fail or the SAIS is more severe, a subacromial decompression operation may be performed. Originally this procedure was performed as an open acromioplasty, however since the 1980’s surgeons have transitioned to an arthroscopic technique.
This study hypothesized that individuals with Stage I and II SAIS who underwent either an open or arthroscopic subacromial decompression would demonstrate a better long-term outcome after a minimum of 10 years, and run a lower risk of developing rotator cuff ruptures and osteoarthritis compared to patients who only participated in physical therapy. The authors based this study off of a previously reported short-term study after a 2.5-year follow up. The results showed that patients in both surgical groups showed better clinical results than those in the physical therapy only group.
There are some limitations in this study that should be considered. The sample size and follow-up rate in this study was very low, and the outcome measurements were assessed by a different physical therapist than the one who gathered the baseline measurements. Secondly, the physical therapy group was supervised by five difference physical therapists. Although they were all following the same protocol, the rate of progression and instruction technique is unknown and may not have been standardized. Additionally, the only objective measurements of strength were taken in abduction, and the range of motion tested in all groups was limited to flexion and internal rotation.
For both physical therapists and patients with SAIS, it is important to consider all of the available literature before selecting to undergo a surgical treatment option. SAIS may present differently in every patient and further studies have shown conflicting evidence, stating sham surgery offers no benefits compared to both subacromial decompression surgeries and non-operative treatments. Therefore, it is important to follow up on all of the research to remain educated on all possibilities to make an informed decision.
Beard DJ, et. al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three- group, randomised surgical trial. Egyptian Journal of Medical Human Genetics. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32457- 1/fulltext. Published November 20, 2017.
Farfaras S, Sernert N, Rostgard L, Hallström EK, Kartus JT. Subacromial Decompression Yields a Better Clinical Outcome Than Therapy Alone: A Prospective Randomized Study of Patients With a Minimum 10-Year Follow-up. https://www.ncbi.nlm.nih.gov/pubmed/29543510. Published May 2018.
Umer M, Qadir I, Azam M. Subacromial impingement syndrome. Orthopedic Reviews. 2012;4(2):e18. doi:10.4081/or.2012.e18.