Women in Sports in the News!

I have several blog posts that I have started drafting that are in skeleton form.  Ideas pop into my head while I'm doing my continuing education work or reading things online that I think I'll want to learn more about in the future and I start up a draft for later.  I had plans for this week's blog because I just finished reading a book I really enjoyed... and then I hopped onto my Twitter and Facebook accounts and saw two really awesome articles about some amazing women in sports.  Change of plans! This week we're looking at some real trailblazers.

First: this awesome video from Gatorade Performance Partners about the Female Athletic Trainers serving in the NFL. Maybe someday, it won't matter that we identify them as females... but for now, this is important!  I came upon this post because the Head Team Physician and Orthopedic Surgeon for the Connecticut Sun, Dr. Katherine Coyner, tweeted it.  I recently connected with her and have been following her work at the University of Connecticut Health Center and with the Connecticut Sun from afar.  (To my knowledge, there are four WNBA teams that have head physicians who are women, two of which are orthopedic surgeons.  The Minnesota Lynx operate with surgeon Dr. Nancy Cummings, the New York Liberty work with Dr. Lisa Callahan, and the Phoenix Mercury work with Dr. Amy Jo Overlin.  These women are trailblazers and their career paths are inspiring!)  Back to the video... there are six female athletic trainers in the NFL out of 145.  But more than 50% of athletic trainers are females and more than half of the current students in athletic training programs are also females (according to the clip).  I'm sure these ATCs don't all want to work in the NFL - or potentially any of the professional men's sports... but opportunities for women in professional sports are limited.   Check it out!


I saw this video first thing this morning while I was perusing my social media over breakfast.  I then went to work... treated some kiddos at Seattle Children's Hospital... and came home to find this post:

<--Jenny Boucek, former Seattle Storm Head Coach, now Assistant to the Coaching Staff/Special Projects with the Dallas Mavericks

I first met Coach Jenny Boucek when I was an undergraduate at UConn and she came to watch practice before an upcoming WNBA draft.  I remember asking her if she wanted to draft a team manager... I already knew where I wanted to go after college.  We had a nice chat and our paths crossed numerous times over the years.  I loved that she was the Head Coach when I first came to Seattle to serve as the Storm Physical Therapist.  She's a wonderful person.  And now she's navigating uncharted waters as a pregnant coaching staff member for an NBA Team!  I can't wait to hear more about how her story unfolds, but this first article about her job prospects from a few NBA teams gives me hope. I truly believe that with ANY job... it should only matter that the best candidate is hired.  Based on this, it looks like employers are now starting to join in that belief and cross the gender boundaries that were so much more rigid in the past. Way to go, Mark Cuban.

Both of these news clips brought me joy.  The opportunities for women are growing right in front of my eyes, particularly in sports - and not just in women's sports.  We can still do better - but let's enjoy these moments and then get to work on making more progress.  This upcoming weekend is the WNBA All Star Game and I can't wait to watch while I'm on a quick visit home to the East Coast! 

Any other inspiring stories you've come across and want to share!?  Post a comment... and consider following the blog!

UConn Connection and Human versus Animal

Last week I had the pleasure of a lunch meeting with the University of Connecticut College of Agriculture, Health, and Natural Resources (CAHNR) Interim Dean of Students Dr. Cameron Faustman while he was visiting Seattle.  This was an unexpected meeting, but connecting with with the Physical Therapy program newly housed in CAHNR, I've felt limited connection between the University and the Physical Therapy Alumni which I was looking forward to discussing. There were several purposes to our meeting - but primarily it was an opportunity to discuss ways for CAHNR to connect with alumni, learn more about changes going on in Storrs, CT, and see if there are opportunities for collaboration and relationships with the school.  (As a side note, CAHNR just recently released a beautiful write up on my PT classmate and friend regarding her work with MS that you can read about here.  She's the reason I Climb to the Top for MS every year and wrote about here.  I can see that they're trying to get us involved, and I appreciate that).

The meeting started out discussing each other's backgrounds and some scholarly interests.  Dr. Faustman is a native of Wallingford, CT - which is basically next to my hometown of Cheshire, CT.  He went to UConn for his undergraduate schooling where he studied Agricultural Education and Natural Resources Conservation before ultimately continuing his studies at the University of Wisconsin where he studied Animal Science.  He told me that his current interests lie in working to improve food waste, but that his initial research involved looking at the color of meat - which directly relates to muscle tissue. He has previously published papers on several topics, but we discussed his work with myoglobin quite a bit.  Myoglobin is the protein found in muscle tissue that uses iron to bind oxygen which is needed for energy. I explained that I did all of my studies at the University of Connecticut with an undergraduate degree in Exercise Science and then later my Doctorate in Physical Therapy.  My undergraduate research interests were childhood obesity and muscle fiber typing and my graduate research was women's basketball lower extremity injuries, which you could be the fifth person to read that publication if you clicked here.  Common bond: we both studied muscles!

http://nosetotailapp.com/meat-cuts.php

We discussed a recent conversation I had with a local surgeon who told me about comparing meat cuts to human "cuts" where if you ever were stuck in a situation where you had to be a cannibal, the hamstring would not be the optimal choice of meat... (we never reached the point of determining what part of the human body you should eat if faced with these conditions).  I recalled the way the hamstrings felt if I treated them with manual therapy interventions in the clinic: fibrous, gristly, and tough.

I wanted to learn more about this, and found this article by Bret Contreras which summarized muscle fiber analysis of the hamstrings.  It states that while most research finds the hamstrings to be predominantly fast twitch muscle fibers (type II fibers that don't require as much oxygen and are used for short bursts of energy), the distribution of type I (aerobic oxygenated fiber which would have a higher blood supply and capillaries nearby also contributing to the color) to type II fibers varies between people and is not exactly known, but probably at least tilts more toward those type II fibers.  In simpler terms - most research says that the composition of the hamstrings is made up of about half of fibers that don't use much oxygen, but oxygenated fibers are the ones that look bright red (or dark in chicken) in meat sources.  This directly relates to the work Dr. Faustman does concerning the color of meat.  When you buy a chicken leg or thigh, the dark meat, these are muscles that the chicken is using constantly, running around, and as such they use more oxygen - compared to the breast muscles which would flap the chicken's wings occasionally - but they rarely leave the ground in their flight.  These concepts apply similarly to the cow and your beef cut - the leg muscles that are used most often or continuously look different and ultimately have a different texture and flavor.  Interestingly, I found this article which outlines how you should cook your meat based on the color because this can indicate the composition of what you're about to eat - and what type of method will optimize its moisture.

The conversation shifted onto fish.  Now, I personally do not consume red meat, but I do eat poultry and fish.  Considering which human pieces of meat would be optimal for consumption may have cemented my stance as a non-beef/pork/lamb eater... but until having this lunch meeting, I had never considered that when I ate fish, I was also eating muscle.  The few people I've discussed this meeting with in the past week have been pretty 50/50 split on whether they had previously considered this idea. It makes sense - I just hadn't thought of it.  Fish don't bear weight through their tiny bones and are suspended in water so their structure is different.  The muscle structure of a fish is called a myotome (which has a totally different meaning in the physical therapy world - though I would be willing to bet that the PT version is named after the fish structure). Where the other creatures previously discussed have muscles that are structured as fibers that are collected into bundles, like this:

https://en.wikipedia.org/wiki/Muscle#/media/File:1007_Muscle_Fibes_(large).jpg

the muscle structure of fish is layered.  Think of what it looks like when you flake apart your salmon and you can consider what each muscle layer looks like.  Or here is a picture of a tuna steak where you can sort-of see the layers.

http://star-gazypie.blogspot.com/2010/06/behold-power-of-tuna-recognize.html

Want to know what makes that tuna steak look red?  Myoglobin! The same stuff in humans that helps our muscles optimize oxygen use.  Tuna has more of it than some of the more white-colored fish because they swim faster and more extensively.  Salmon's pink flesh is not from myoglobin, though.  It comes from the food that salmon consumes, just like the flamingos.  So for the past several days I've been looking into animal muscle structures and tissues and gaining an understanding of similarities and differences between people and animals and it has been really interesting to think about the way the human body works from this different perspective.  How I failed to gain this understanding during my whole undergraduate course of Animal Physiology is beyond me!

So where I focus on human movement, including muscle tissue, Dr. Faustman focuses on animal muscle tissue which is food.  These are surprisingly very similar concepts and it was fun to think in a new way.  It helps to make sense of why the Physical Therapy program and the Department of Kinesiology would fit well into the College of Agriculture.

We concluded by discussing some of our current projects.  I knew there was a lot of wasted food in the US, but when looking further into it, I came upon Feeding America, which estimates that almost half of the food grown, processed, and transported in the US is wasted!  This is terrible.  It's not just food, either.  There's tons of fresh water used to produce food, so if the food is wasted, that's a lot of water waste, too.  Interestingly, I learned from Feeding America that unsold food at Starbucks at the end of the day is brought to food banks to reduce waste... so now I feel a little better about my occasional splurge of a $7 grilled cheese and $5 frappuccino at Starbucks if part of my purchase supports less food waste.

Thanks for lunch, UConn!

Concussion Protocol and the WNBA

This week the Seattle Storm played two home games - Tuesday versus the LA Sparks and Saturday versus the Dallas Wings.  Both games were hard fought battles.  As I've previously written about here, the 2018 WNBA season is shortened due to the upcoming World Championships in September,  so teams are cramming the same 34-games into a shorter length season.  I was concerned that the increased level of fatigue could correspond with increased injuries.

Unfortunately, one of the Storm players experienced a concussion this week - media release here.  I of course cannot blame the season schedule on the concussion - there's no way to determine cause and effect here - but there have been several injuries throughout the WNBA this year, and it seems like there are more than in previous seasons, though I don't have the data to be certain.  (This is one of my concerns about WNBA injury reporting - I wish this data was more readily available!)  Anyways, I thought this would be a great opportunity to discuss concussions a little bit from an acute response perspective - rather than what the longer term care looks like when I treat kids who've experienced a concussion at Seattle Children's Hospital. 

I think it is of key importance to mention that a concussion is a brain injury.  No two people experiencing a concussion have the same symptoms or present the same way.  This differs from your general ankle sprain patients where they mostly behave similarly and follow a similar trajectory for recovery.  Where there is a similarity: athletes at all levels who experience a concussion generally want to get right back into the game.  It makes sense - they're competitors.  But this is dangerous and as a sports medicine provider, it would be irresponsible to allow a symptomatic athlete to participate in activities that could be life-threatening.  I'll say it again - a concussion is a mild traumatic brain injury.

Every (major male) professional sports league has a concussion policy.  During WNBA training camp before the season gets underway, players complete a baseline testing on a computer for neurological and cognitive function.  If a concussion occurs in a game, a physician evaluates the athlete and then this same computer testing can be completed for comparison.  You can see the moment of injury at the Storm versus Sparks game at the 2:45 mark in this video - also included below.   

If a head injury occurs on the basketball court, the athlete needs to be evaluated in a quiet area without distractions.  This initial screening is conducted by an athletic trainer or team physician and includes a lot of questions such as any symptoms they may be experiencing: headache, dizziness, nausea, sensitivity to light or sound.  Then a physical exam including a screen of what the eyes are doing - if they can track a moving target or if they operate abnormally, an evaluation of the neck is conducted, the nervous system is assessed, and balance, memory, and comprehension are all considered.  Generally concussion symptoms don't always show up right away and it's best to wait several minutes to determine if anything comes on after a delay.  This is a complication for sports such as football where an athlete may take a hard hit and initially seem symptom-free, only to worsen a few minutes later where sideline assessment often occurs on the field where there isn't really a quiet place to conduct a thorough assessment. 

The NBA announced that they would initiate a concussion protocol in 2011 - following in the steps of many other professional sports leagues, particularly the NFL who was dealing with CTE (chronic traumatic encephalopathy - a neurological disease found in athletes and veterans likely related to repeated hits to the head and diagnosed post-mortem).  The WNBA Concussion Protocol wasn't easily accessible from my search - but it's based on the NBA's policies which are summarized here.  Basically the athlete will go through five stages of recovery including 1) asymptomatic at rest, 2) asymptomatic with bike riding, 3) asymptomatic with jogging, 4) asymptomatic with basketball drills without defense, and 5) asymptomatic in full practice.  The computerized testing will be conducted between stages to compare to baseline and determine that the athlete is not having increased symptoms.  These stages can be completed in as few as about 3 days, more typically a minimum of 5 days based on articles about players I've read about online - but the maximum duration varies based on the individual athlete's response to their progressively increasing activity level.

The stages for recovery are fairly similar to what is used at Seattle Children's - but the key difference is that physical therapy interventions on kids who have experienced a concussion generally only occur if the child has been experiencing post-concussion syndrome (sometimes referred to as delayed symptom resolution).  By definition - this means they've had symptoms for at least a month, but usually by the time I'm evaluating a kid for concussion in the clinic, they've generally been experiencing symptoms for more than 3 months. (At least 70% recover spontaneously in less than one month).  

This paper that examined concussions in multiple sports found that 4.7% of all injuries in women's basketball are concussions.  In general, only football, women's soccer, men's and women's ice hockey, and men's and women's lacrosse had more concussions than in women's basketball.  Across all sports, 5% of all sports injuries were concussion.  The paper also breaks down mechanisms of injury for concussion for each sport which interestingly showed that, in basketball, women tend to experience the injury while ball handling or playing defense whereas men tend to have it diving for a loose ball or rebounding.  Interestingly, the mechanism of injury you'll see in the video link above for the Storm injury was a loose ball retrieval effort.  In my personal opinion, as the level of play of the WNBA has gotten increasingly better year after year, the difference in mechanism of injury is likely to change.  WNBA athletes are incredibly athletic and are doing things on the basketball court that we didn't see in women's sports 15 years ago when this data was collected. 

If you or someone you know experiences a head injury, please get them examined by the appropriate healthcare provider. 

Special Olympics 2018

The Special Olympics just wrapped up in Seattle and, in case you missed it, there were some really awesome moments.  I don't have a TV so I didn't get to watch nearly enough - but there were highlights posted online that were heartwarming and inspirational and I had the opportunity to volunteer with them on Thursday.  Here's my favorite photo, thanks to the Seattle Times:

Virginia Wade, 17 year old gymnast from Seattle

This was the 50th Anniversary of the Special Olympics with athletes competing in 14 sports.  As a physical therapist, I was disappointed that I was not permitted to provide sideline coverage for any of the events, but I was still able to volunteer to help screen healthy athletes for risk of injury.  I supervised a great group of Physical Therapy Assistants students who were completing a series of balance tests for hundreds of athletes.  Other groups were screening flexibility, strength, and aerobic endurance.  Our four stations were a small part of the available resources for the athletes, all of which included collecting baseline data on these athletes and helping to provide education for them to improve in areas where they may be at risk for injury.  Competing athletes were also given the opportunity to have a dental examination, vision check, hearing assessment, health assessment for blood pressure and body mass index, and a podiatrist foot inspection.  By completing several of these stations - all for free - athletes could be provided new hearing aids, newly made glasses with proper prescriptions, dental care, referrals for physical therapy or other healthcare services and they were provided a free pair of sneakers.  All of these things were provided by sponsors which is really incredible. 

I met hundreds of athletes from at least 20 different states.  We know that about 2,000 athletes were screened during the week, and that all 50 states and Washington, D.C. were represented by athletes.  Several of the Washington (state) athletes were followed by cameras to their various stations which was cool to see them getting a little extra treatment.  Several athletes had finished their competitions and were wearing their medals.  Having personally seen Olympic Medals in the past, I was pleased at the caliber of the medals used at this event, as well.  Still so heavy!  Each athlete was also wearing a credential and usually a team jersey or Special Olympics shirt with their state listed on it.  States were trading pins with each other and collecting them.  When the Connecticut delegation came through, I was super excited to see people from my home state, and they gave me a 50th Anniversary Special Olympics Connecticut pin!

Who competes in the Special Olympics? These are athletes who have an intellectual disability which means that they have limitations in their cognitive functioning that could include delayed learning and development.  The games are an opportunity for these athletes to "demonstrate ability rather tahn disability" and, among numerous other benefits of participation, provides them with free access to healthcare, and this is one of the foundational purposes of the Special Olympics.  Washington Special Olympics will hold another Special Olympics event again in August in Everett and they'll be looking for volunteers then, too.  I encourage people to check out the Special Olympics website, find their local community page, volunteer for an event, and support this awesome group of athletes! 

Shoulder Care with Eric Cressey

Last weekend I jetted off to Denver for a visit with family and a continuing education course.  The family time was fantastic - a few hours of biking around Denver - far more than I'm used to doing as I'm not a fan of bike seats - some really delicious tacos - beautiful art and the backdrop of the Rocky Mountains!

The course was "Shoulder Assessment, Corrective Exercise, and Programming" presented by Eric Cressey of Cressey Sports Performance and it was hosted at Landow Performance in Centennial CO.  Loren Landow is the newly hired Strength and Conditioning Coach for the Denver Broncos and his facility is beautiful with state-of-the-art equipment and autographed jerseys all over the walls from numerous professional athletes.  His bio says he has trained WNBA athletes, too - so extra points in my book!  If you're not familiar with Eric's work, he's a Strength and Conditioning coach with facilities in Hudson, MA and Jupiter, FL and, though he is most well known for his work with professional baseball players, he also works with the general population and is considered to be an expert in the shoulder.  He's published tons of research and has a blog with articles posted starting in 2002 with regular high quality content.  I previously wrote about one of his older blog posts here.  Most importantly, Eric is a UConn grad, so I've followed his work since I first learned about him somewhere around 2005 when I was in a class with Dr. William Kraemer, one of Eric's mentors, and have been looking forward to meeting him and attending one of his seminars for a long time.

With Eric Cressey June 24, 2018

Why did I want to take this class?  Beyond wanting to hear Eric speak live and get the chance to ask him questions, I previously took a course with a strength and conditioning coach (Matthew Ibrahim) in conjunction with a physical therapist (Zak Gabor) which I wrote about here, and felt that learning from people with different backgrounds was really impactful for me.  The audience was primarily strength and conditioning coaches who work with baseball players... but there were also a handful of physical therapists, chiropractors, massage therapists, personal trainers, and baseball coaches.  People had traveled from Australia and Korea and all over the United States, some of which trained athletes from unique sports like Professional Disc Golf or MMA fighters. The variety of people present was really neat... but also, the content is applicable to so many other sports.

More importantly, I have been treating a lot of patients and athletes with shoulder injuries and recently completed Mike Reinold's shoulder seminar, but also wanted a live course to better observe how other providers evaluate and treat shoulder pathologies. Eric's approach to shoulder treatment does not look like Mike's.  They have different "favorite" screening tools and exercises that they use.  If you observe their social media, you could probably pick up on these differences and similarities.  I'd say the biggest overlap I observed was that both of them regularly use the prone low trap exercise for rotator cuff strengthening which Eric has a video for here.

When it comes to my work with the Seattle Storm, though, we also have to consider that we're working in an overhead sport with repetitive action.  Shooting a basketball is nothing like the motion of throwing a baseball, but it still requires significant mobility and stability - and very different from baseball, it requires the athlete to be reactive to opponent players slapping at their arms while they're doing it.  The arm care programs used by the Seattle Storm should not look like the arm care programs used by the Boston Red Sox - but the principles involved in developing them do match.

I learned a lot from this course which I'm still processing, but was able to immediately use some of the skills in the clinic. Here are my top 5 favorite Eric Cressey quotes and take-aways from the weekend.

1) The biggest key for the shoulder is "Keep the ball on the socket." Simple.  Having a better biomechanical understanding of the force vectors of the rotator cuff is vital. If the scapula is sitting in a depressed position, the lats may be over-active which will influence upward rotation when getting overhead.  Similarly, if the scapula is tilted anteriorly, could there be shoulder impingement with elevation or is there enough muscular balance to safely overhead press?

2) Rehab and training are the same thing!  I've previously written about physical therapists' role as strength coaches here - and this came up in the course.  Eric Cressey is not a physical therapist and he discloses this and discusses how he interacts with PTs all over the country.  So it surprised me to see the differences between what Mike Reinold and what Eric Cressey do considering this statement, but I would not expect Eric to be seeing athletes post-op day 1 following labrum repair.  So, I took this to mean that once the acute healing phase is completed, rehab and training are the same thing.  There is a need for progressive loading to tissues and a need to understand periodization, even if your PT treatment sessions are not written like a periodized training program.

3) Scapular winging is a garbage term. It does not describe what is going on with the scapula.  I document scapular winging all the time - so this will be a change I need to consider moving forward.  Is the scapula winging because it is anteriorly tilted?  Upwardly rotated?  Because there is a flat thoracic spine so the medial border is just more pronounced?  And is this inherently pathological?  Or just a finding that you're documenting.  I can't promise I'll stop using the term scapular winging entirely, but I can commit to adding at least one descriptor of the scapular position to better describe the situation moving forward.

4) Stop telling people to bring their shoulder blades down and back.  It would only be a slight exaggeration to say that Eric Cressey is begging people to stop using this cue.  Too many people use this resulting in patients pulling their elbows back with anterior humeral head translation and improper mechanics that we could be creating problems!  I asked him what cue he likes instead - and he said he manually puts people into the position he wants them to be in, using optimal muscle activation, until they can do it independently.

5) Push:Pull ratios are not accurate nor are they adequate.  It has been well ingrained into my training that for every push exercise, you should be doing at least 2, probably more like 3 pull exercises.  I've been trained to teach that focusing on the back musculature 2-3x more than the front helps combat many of the anterior shoulder issues that are seen in the clinic.  However, Eric points out two key points that make you think about this more carefully.  First, the push:pull ratio is almost always considered for front:back motion and ignores top:bottom... but both planes need to be considered.  I think John Rusin tries to deal with this by including upper body push, upper body pull, and carries into his 6 foundational movement patterns, but the balance needs to be considered for both planes.  Second: not all pushes can be considered alike.  The bench press is a push exercise that necessitates the scapulae being blocked on a bench... compared to the push up where they are moving freely on the body.  This is also an important consideration as you're not getting the benefit for scapular control through the pushing motion when doing a bench press - and Eric says he doesn't have his baseball players bench pressing.

I'd be lying if I said this even touched the surface of all the things I learned at the class... but these were big takeaways that made me think and will change how I operate to some degree.   Thanks for an awesome course, Eric!