Philly.com
Sports Doc
Posted: Tuesday, September 15th, 2015

It’s that time of year. Fall sports are in full swing. Hopefully you had a productive pre-season that prepared you for the fall. Here are some tips to keep players safe and injury free this fall.

Fitness: If you weren’t in shape going into pre-season, hopefully you survived it without any injuries. If you did sustain an injury in pre-season, make sure you address it now as it will only linger and will likely get worse during the season. Next summer, make sure you get in shape prior to pre-season in order to avoid the same problems.

Overuse Injuries: Stress fractures, shin splints, tendonitis, etc These all occur because of ramping up intensity too quickly. Two and three a day practices on hard fields or indoor courts after a summer off is a recipe for disaster for overuse injuries. If you sustained an injury during pre-season, you need to be evaluated by your athletic trainer as playing through it never works and almost always makes the injury worse and prolongs recovery.

Heat Illness: This is hot topic. The myth of hydrating is finally being dispelled. You should drink when you are thirsty and not be forced to drink excessive fluids. But, you also need to be allowed to drink freely and coaches cannot restrict fluid intake either. And sports drinks, they’re not really needed. Water is the best along with meals that include some salty food to replace the electrolytes lost during training. For players with cramping, sweat testing can be done to assess the cause and how to replace fluids and electrolytes appropriately. The Heat Institute at West Chester University is a local facility that can perform sweat testing with the appropriate replenishment recommendations.

Concussions: I don’t think we need to talk too much about concussions as we all know the significance of these injuries. Any concussion should be taken seriously and needs to be evaluated by your team’s athletic trainer and a physician who specializes in concussion evaluation and management. The current medical guidelines from the most recent consensus statement say “no return to play on the day of concussive injury should occur.” And the “athlete would take approximately 1 week to proceed through the full rehabilitation protocol once they are asymptomatic at rest and with provocative exercise.”  Please take concussions seriously as athletes can suffer lifelong post-concussive symptoms if not managed appropriately. 

Best of luck to all of the athletes and their teams this fall. Hopefully we only see you in the newspaper and not in the athletic training room or physician’s office.

Philly.com Sports Doc
Posted: Friday, February 27, 2015, 5:30 AM
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If you’ve joined a gym recently, you were probably offered a free fitness assessment. There are numerous different assessments available to exercise professionals. One of the more popular screening tools is the Functional Movement Screen (FMS). The FMS was developed as a tool to identify movement asymmetries or major limitations in movement patterns. The underlying principal of the FMS is that movement quality is essential to reducing injury and optimizing performance. It is used to identify limitations or asymmetries in 7 fundamental movement patterns. The screening places an individual in extreme positions where weaknesses and imbalances become noticeable if appropriate mobility and motor control is not utilized. The focus of the FMS is movement quality and to identify any movement deficiencies or limitations. Individuals must not have current pain or musculoskeletal injury.

The Functional Movement Screen consists of 7 specific tests and 3 clearing exams. The 7 tests are the hurdle step, in-line lunge, shoulder mobility, active straight leg raise, trunk stability push up, and rotational stability. The scoring system used is a 0-3 scale with 0 being a painful test and 3 being the highest score possible. 5 of the 7 tests are performed bilaterally looking for side-to-side differences as well as a combined score for the test. 

The 3 clearing tests are the active impingement, spinal extension, and spinal flexion tests which are scored positive or negative for pain. 

The FMS is used to assess an individual’s movement quality and asymmetries to help better design exercise or training programs which should allow a safe progression to higher level exercises/training. The theory is that by addressing any dysfunctions noted on the FMS, one can reduce their risk of injury and improve their performance in sports. Let’s look at the published research on the FMS and see what it says. 

Reliability
There are numerous studies looking at the reliability of the FMS screen with varying results. Overall, the studies show good to excellent intrarater reliability (the same assessor) for both experienced and novice assessors. There is generally fair to good interrater reliability (between assessors) in most published studies as well.

Movement Dysfunction
A study by Frost in the Journal of Strength and Conditioning Research from 2013 questions the ability of the FMS to assess dysfunction. They looked at 21 firefighters who initially performed a standard screen followed by a repeat screen 5 minutes later. The participants were provided with a verbal description of the grading criteria immediately before performing each task during the second screen. All firefighters improved their scores within minutes of being told what movement patterns were required. The authors conclude that it may be inappropriate to assume that movement patterns are the direct result of a specific “dysfunction” or “impairment” that could be rectified via “corrective” exercise. 

Injury risk
Keisel has published two studies involving NFL players showing that a total score of less than 14 or an asymmetry on any of the bilateral tests place players at a higher risk of injury. Players’ having both a total score of less than 14 and one or more asymmetries are at an even greater risk of injury. Lisman published in the journal Medicine & Science in Sports & Exercise in 2013 that military recruits who had a 3 mile run time less than 20.5 minutes and scored less than 14 on the FMS were 4.2 times more likely to experience an injury. These two studies support an overall score of 14 as the cut off for increased injury risk.

However, a study by Warren in the Journal of Sports Rehabilitation in 2014 showed a poor correlation with scores and asymmetries for both contact and non-contact injuries. In another article by Dossa in Journal of the Canadian Chiropractic Association in 2014, they concluded that the FMS couldn’t be recommended as a pre-season screening tool for injury prevention in major junior hockey players.  Lastly, McCall gave a recommendation of “D” for the FMS as a screening test to identify professional football players (soccer) at risk of injury in the British Journal of Sports Medicine 2015.

Sports performance
A 2011 study by Parchmann in the Journal of Strength and Conditioning Research found that there were no significant correlations between the FMS and on the field sports performance tests whereas the 1 rep max back squat showed a significant correlation to these field tests. Lockie in the Journal of Strength and Conditioning Research in 2015 found few significant correlations between FMS scores and multidirectional speed and jumping tests. Lastly, Okada published in the Journal of Strength and Conditioning Research in 2011 that core stability and the FMS are not strong predictors of sports performance.

All this research shows that the FMS is a reliable screen able to score movement patterns and assess for side-to-side asymmetries. It may not truly assess movement dysfunction and may just be showing unfamiliarity with the activity, which may be easily improved with verbal cuing and repeat performance. The research shows conflicting studies on whether or not it can predict injury risk in a variety of sports. Lastly, the research shows little correlation with specific sports performance tests and FMS results.

So, what does this all mean? Does the FMS truly screen for movement flaws or is there a spectrum of what constitutes “normal” movement? The FMS still shows potential for assessing an individual’s risk of injury but it should not be the only criteria as risk is multi-factorial and the FMS may not be specific enough to detect all of the underlying components. Although research doesn’t show any significant relationship between the FMS and specific sports performance tests, there may still be a correlation between FMS scores and how well and individual does in a specific sport. Sports performance tests, such as the 40-yard dash, do not show a high correlation to specific indicators of success in sports (ie batting average, points per game, touchdowns scored, etc).

My personal experience with the Functional Movement Screen is that it is a great tool to quickly assess “healthy” athletes for “abnormal” movement patterns that may be secondary to limitations with mobility and stability. However, it should not be the only assessment used and should not take the place of a more detailed individual assessment looking at specific areas such as joint ROM and mobility, specific muscle strength testing, on-the-field testing (ie pro agility), and fitness testing (ie beep test).

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: Monday, May 12, 2014, 9:37 AM

Unlike other collegiate sports, there have been no studies published on track and field injuries using the NCAA injury surveillance system. Therefore, we will look at the few studies that analyze injury prevalence in track and field.

A 2005 article published by Zemper in the journal Medicine and Sports Science suggested that 70-80 percent of all track and field injuries are the result of running events. 75 percent of all injuries are to the lower extremity and the overwhelming majority of injuries occur during practice. A 2011 article by Jacobsson et al in the American Journal of Sports Medicine showed a strong dominance of overuse-related conditions such as tendinopathies and stress fractures in track and field athletes.

These overuse injuries account from 60-90 percent of injuries in various published papers. An article by Alonso et al in 2012’s British Journal of Sports Medicine looked at track and field injuries during the period of the Daegu 2011 IAAF World Championships. Sprint events accounted for 27.7% of all injuries followed by long distance at 17.3%, and jump events at 14.1%.

Let’s look at the some of the different events and the injuries that go along with them.

Sprints and Relays

The most common injury in sprint events is muscle strain, specifically hamstring strain. The mechanism of hamstring injuries is still being debated.  These include neuromuscular inhibition, eccentric overload, over-striding, and decreased muscular endurance to name a few. To simplify hamstring injuries, these can be broken down into acute and chronic injuries.

Acute hamstring injuries are the result of a distinct injury such as a sprinter pulling out of a race. These usually involved a tear of the hamstring muscle. These can be minor or more serve where bruising, swelling, and a defect are noted. Hamstring injuries can result in significant time away from training and competition, and early return frequently results in re-injury. Treatment involves management of pain in the acute phase of injury followed by rehabilitation to regain ROM, strength, and eccentric control prior to initiating a running program.

Chronic hamstring pain can be due to a variety of underlying causes. These include incomplete rehabilitation from a previous hamstring injury, overuse injury, and referred pain from other areas such as the lumbar spine. A thorough evaluation from an athletic trainer or physical therapist is needed to determine the underlying cause and to develop an appropriate rehab program.

Middle Distance

Middle distance injuries are a combination of sprint injuries and distance injuries. The event distance and the training methods will dictate which type of injury is more likely to occur. As with any injury, the athlete should be evaluated by the team’s athletic trainer in order to develop an appropriate rehab program.

Long distance

Unlike sprints, long distance injuries are primarily overuse and repetitive stress injuries. These include sprains, strains, and tendinopathies as well as stress fractures, shin splints, and exertional compartment syndrome. Treatment should not only focus on resolving the symptoms but also include a thorough biomechanical evaluation to correct the underlying cause. This should include assessment of footwear, lower extremity alignment, and lower extremity flexibility and strength. This may also include modification of the athletes training program with decreases in frequency, intensity, and/or duration.

Hurdles and Steeple Chase

Hurdles and steeple chase have injuries similar to the above running events but also include more traumatic injuries. With hurdles, injuries can occur from hitting the hurdle or from catching a hurdle resulting in a fall or awkward landing. Steeple chase injuries can occur from stepping onto the obstacle, not clearing the obstacle, or landing from/over the obstacle.

Traumatic injuries can include contusions, ligament sprains, knee internal derangements (meniscus tear, ACL injury) and fractures. These injuries should be evaluated by the team’s athletic trainer and treated accordingly or referred to a sports medicine physician for more serious injuries. These more serious injuries usually require significant time away from training and competition.

Long jump and triple jump

Long jump and triple jump are horizontal jumping events with specific associated injuries. These injuries can be broken down into overuse and traumatic. Overuse injures include tendinopathies and repetitive stress injuries as seen in other events and should be treated as noted previously. Traumatic injuries occur either at takeoff or landing and can include fractures, acute muscle tears, dislocations, serious ligament sprains (such as ankle sprains), tendon ruptures, and knee internal derangements. These more serious injuries should be evaluated by your team’s athletic trainer and referred to a sports medicine physician for appropriate care. These more serious injuries usually require significant time away from training and competition.

High Jump and Pole Vault

High jump and pole vault are vertical jumping events with similar injuries to horizontal jumping events. These injuries can also be broken down into overuse and traumatic. Besides the traumatic injuries noted for long and triple jump, pole vault accounts for almost all of the catastrophic injuries (fatal, non-fatal but causing permanent severe functional disability) and serious (no permanent disability, but a severe injury). These more serious injuries should be evaluated by your athletic trainer and referred to a sports medicine physician for appropriate care. These injuries usually require significant time away from training and competition.

Javelin, shot put, hammer, and discus

Throwing events account for the vast majority of upper extremity injuries in track and field. These include injuries to the rotator cuff and shoulder labrum as well as abdominal injuries from the rotational throws, and lower extremity injuries from planting during a throw. One injury specific to the javelin is an ulnar collateral ligament tear (Tommy John injury).

UCL injuries in javelin are due to the throwing motion and the stress incurred at the elbow, similar to baseball. Throwing injuries need to be evaluated by the team’s athletic trainer and either treated conservatively through rest and rehabilitation or referred to a sports medicine physician when more a more serious injury occurs such as an ulnar collateral ligament tear.

Exertional heat illness

Lastly, environmental factors can cause heat related illness in track and field athletes. Athletes, coaches, and medical staff need to be aware of the environmental conditions (heat and humidity) and monitor athletes for any signs or symptoms of heat illness. Heat illness is an urgent and sometimes emergent issue and needs to be address by the event’s medical staff. Signs and symptoms can include finding it hard or impossible to keep playing, loss of coordination, dizziness or fainting, profuse sweating or pale skin, headache, nausea, vomiting or diarrhea, and stomach/intestinal cramps or persistent muscle cramps.

To truly evaluate an athlete for heat related injury, an accurate core body temperature needs to be assessed by a trained medical professional such as an athletic trainer. Cooling measures should be implemented with the best method being ice immersion. For those athletes with a core temperature over 104° and showing signs or symptoms of heat illness, immediate cooling should be implemented and emergency response should be initiated as heat stroke is likely.

The National Athletic Trainers Association has an excellent web page on How to recognize, prevent, & treat exertional heat illness: http://www.nata.org/nr072606

As you can see, not only do we see lower extremity injuries in track and field, we also see upper extremity injuries and environment injuries such as exertional heat illness. Although most of the injuries are minor, there are urgent and emergent injuries in track and field and these are best managed by the team’s athletic trainer and medical staff.