Philly.com Sports Doc
POSTED: TUESDAY, NOVEMBER 25, 2014

If you’re a power lifter or body builder, please stop reading. If you’re a high level athlete, please read with an open mind. Now for the rest of us… My patients ask me all of the time, “What can I do in the gym?” For me, it’s not what you can and can’t do but what you should or shouldn't do.

Why do I say that? Here are just a few of the injuries we've seen in the office from doing the wrong things in the gym: a middle aged women who tore her ACL doing jumping jacks onto a plyometric box, a 60 year old who tore his meniscus when he was forced into deep knee flexion during yoga, and a broken tibia from the bar hitting her leg during Olympic lifting. It’s not that some people can’t do these things; it’s just that most of us shouldn't be doing them.

Here are my top 5 things you should avoid at the gym.

1. Deep squats

I always have this debate with strength and conditioning coaches. Why do they have their athletes squat past 90 with resistance?  It’s not functional except for maybe wrestlers and football lineman, and even with them, is it worth the risk of injury? For the rest of us who are just trying to stay in shape it is a recipe for knee pain and meniscus tears. Deep squats put significant strain on the knee ligaments, significant pressure on your patellofemoral joint (knee cap), and it puts your meniscus at significant risk for tearing.

Let’s talk about the meniscus tear more specifically. As we squat down, the knee not only flexes but the femur glides posteriorly on the tibia. From about 90 degrees and beyond, we are putting almost all of the pressure on the posterior horn of the meniscus. Now just add a little rotation and pop, there goes your meniscus. And we know that our menisci start to degenerate over time (starting at about 35-40) placing us at even greater risk for a meniscus tear. Do the theoretical benefits of deep squatting out weigh the risks, absolutely not!  So let’s please stop at 90 degrees.

2. Dead lifts

This is another exercise where I also debate people on the risk/benefit of the exercise. Yes, it’s a great exercise to strengthen your hip extensors (glutes and hamstrings) but it’s an even better way to injure your back. Repetitive flexion activities have been shown to be a significant factor in back injuries, specifically bulging and herniated disks. Even if you perform the exercise with perfect mechanics, which none of us do all the time, you’re still setting yourself up for a problem. Just like the meniscus in the knee, the discs in the spine start to degenerate with age. Combine this with an exercise that puts significant strain on the posterior annulus of the disc and you’re in for a lifetime of intermittent back pain. Instead of dead lifts, let’s focus on exercises that will still strengthen your hip extensors with less risk of injury. Lunges, step ups, bridging, and squats above 90 can all accomplish this while limiting the risk of low back injury.

3. Overhead presses

Overhead military press, dumbbell shoulder press, etc., all put your rotator cuff at risk for injury. Every time we lift our arms over head we have the potential for some impingement of our rotator cuff under our acromion. Now add weight and we’re just tempting fate. There is also a common theme with all these problematic exercises I’m writing about: our tissue starts to wear down and degenerate with age.

This is once again true for the rotator cuff. So why do an exercise to strengthen our shoulders that puts our rotator cuff at significant risk for injury? If you want to strengthen your deltoid you just need to do some pushing and pulling exercises. Overhead exercises aren't functional and the risk of injury just isn't worth it. Don’t try to “isolate” your shoulders and instead strengthen them functionally with pushing and pulling exercises such as push-ups and incline pull-ups on the smith press or TRX.

4. Bench press to your chest

I don’t like the bench press because it’s not a functional exercise, but that’s another discussion. The risk with bench press is that when your elbows break the plane of your chest, you’re putting significant strain on the stabilizing structures of the shoulder, specifically the labrum and capsule. Now add heavy weight and it’s a labral tear waiting to happen. And like everything else, the labrum degenerates over time. Clicking in your shoulder? It’s probably a labral tear. If you have to bench, keep the weight reasonable and don’t let your elbows break the plane of your chest. Better yet, do a standing cable column press as it is a much more functional position; just don’t go too deep and your shoulders will thank you.

5. Anything with heavy weights

I’ll be the first to admit that I loved lifting heavy weights when I wrestled in college. It was always a competition of who could bench and squat more.  Looking back, bench pressing did nothing for me as a wrestler as I should have been doing more pulling exercises. After two shoulder surgeries, a hip labral tear which has likely progressed to arthritis (no MRI as I don’t want to know), focal arthritis in my knee as well numerous other chronic injuries, my joints wish I had focused on functional training and not weight lifting.

There is starting to be a paradigm shift in the strength and conditioning world. People are turning away from weight lifting and focusing on functional training and injury prevention. Stanford University’s director of football sports performance Shannon Turley is on the forefront of this movement. Instead of having freshman players hit the weight room when they get to school, they focus on regaining flexibility, improving core stability, and relearning correct movement patterns. He has had to write letters to NFL scouts about his program and why his players don’t have a record setting combine bench press but excel on the field and are injury free.

EXOS, formerly Athlete’s Performance, is the provider for strength and conditioning for the Men’s U.S. National Soccer team. Their approach to sports performance is to fix an athlete’s problems/weaknesses.  There is little return in trying to improve quad strength in soccer players who already have super strong quads. Instead, you’ll see more gains by focusing on correcting their weaknesses such as limited hip mobility and glute med weakness. Even though we’re not professional athletes, let’s take a page out of their training programs and try to fix our deficits such as flexibility, core strength, and movement patterns and leave the heavy weights on the rack.

As I’m writing this, I’m envisioning the comments that I’ll be getting. But as I always tell my patients, “Is it better to look good or to feel good?” Let’s move away from working out the way we always have and start thinking about our long term health, as many of the exercises we do are counterproductive to our overall goal of living a healthy, happy, and pain free life.

Philly.com Sports Doc
POSTED: WEDNESDAY, JULY 9, 2014

We've all heard of ACL and Tommy John surgeries. But, have you heard of “hip scope,” the newest surgery in sports? Chase Utley, Alex Rodriguez, Tim Thomas, Osi Umenyiora, Ed Reed: these are just a few of the big time athletes who have undergone hip arthroscopy.  So, what is a hip scope? What does it fix? And how are athletes recovering from it?

Hip scope is short for hip arthroscopy and it describes the way the surgery is performed and not actually what is done. Hip arthroscopy is a newer technique and has advanced significantly over the last 5-10 years. With hip arthroscopy, the surgeon makes small portals or holes and uses a camera and surgical tools instead of making a large open incision.

There are numerous procedures that can be done through the scope. The most common are femoral acetabular impingement (FAI) decompression and labral debridement/repair. FAI decompression involves shaving down bone where the neck of the ball (femoral neck) pinches on the socket (acetabulum). Bone can either be shaved down on the femoral neck, the acetabulum, or both. For a torn labrum, it can either be trimmed or repaired with sutures depending on the location of the tear and the quality of the tissue. Other procedures that can be done arthroscopically are synovectomy, removal of loose bodies, articular cartilage procedures, capsular release (loosening) or plication (tightening), psoas tendon release, IT band release, and repair of a hip rotator cuff tear.

In young, athletic patients we can expect a full return to activity and sports after the surgery. The time frame to return to full athletic participation is about 4-6 months. A 2011 American Journal of Sports Medicine study by Kelly et al looked at outcomes after the arthroscopic treatment of femoroacetabular impingement in a mixed group of high-level athletes. In that group, 78 percent of athletes were able to return to play by one year and 73 percent of athletes were able to play at a two-year follow-up. Another 2011 American Journal of Sports Medicine study by Byrd et al looked at arthroscopic management of femoroacetabular impingement in athletes.  In Byrd’s study, 95 percent of professional athletes and 85 percent of intercollegiate athletes were able to return to their previous level of competition. These articles show that in younger, high level athletes the outcomes are very successful.  What they don’t show are the results at 5 and 10 years. In patients over 35, the outcomes aren’t as good, as the problem is usually longer standing and has likely started to show some signs of early cartilage damage (i.e. arthritis). A 2014 study in Knee Surgery, Sports Traumatology, Arthroscopy by Krych et al looked at isolated arthroscopic labral debridement for hip labral tears in patients between the ages of 32 and 60. Of these patients, 45 percent had combined poor results when strictly defining failure as repeat surgery or abnormal hip rating. Untreated FAI and concomitant chondroplasty were risk factors for inferior outcome. As with most orthopedic problems, patients under 35 show good results, while patients over 35 show less favorable outcomes.

Postoperative rehabilitation is a very important factor in the outcome of hip arthroscopy. The key is to correct any underlying dysfunction that may have led to the surgery (ie flexibility, strength, alignment, etc). What we typically see with hip problems is a loss of internal rotation range of motion, gluteus medius weakness, and core weakness. It is important to see an athletic trainer or physical therapist that specializes in hip rehabilitation as the postoperative rehabilitation guidelines are still being developed and those without experience may do more harm than good. 

So the next time you see an athlete on the IR or DL following a hip scope, you might be wondering (as I always do) what they really had done. We know that following this procedure, the athlete should be back and playing at some point, but the question is when. Your fantasy draft may depend on it.