New WNBA Injury Data Published!

Alert! Hot off the Presses! Physical Therapists working in Sports... Athletic Trainers... Strength and Conditioning Coaches... High School Basketball Coaches... Female Athlete Parents... Orthopedic Surgeons... WNBA Colleagues... Basketball Fans... Any one else who is interested in learning something today... Check this one out.

Presenting at Seattle Children's Sports Symposium

A new paper was published (April 16, 2020) in Arthroscopy, Sports Medicine, and Rehabilitation entitled "Injury in the WNBA from 2015-2019."  You can find the paper here. I jumped for joy to see this new release when it was in my inbox this morning.  Gotta love alerts that know what I'm interested in.  In case you don't know, women's basketball player injuries was the topic of my PT School Thesis paper, "College and Professional Women's Basketball Players' Lower Extremity Injuries: A Survey of Career Incidence" which you can read here.  In November 2019, I
had the opportunity to present on this topic to the Sports Medicine Department at Seattle Children's Hospital, updating my findings and making it more applicable to our department's work in pediatric sports medicine.  This topic is on my mind constantly, and since WNBA Physicals were supposed to be this week, now postponed until the coronavirus battle is under control, I'm thrilled to have basketball on my mind.  A new publication five years after my own with some similar findings from an entirely different approach was both gratifying and validating and this paper could not have come at a better time.

The new paper, written by Orthopedic Surgeons at the University of Chicago summarized injuries in the WNBA between 2015 and 2019 which were compiled from publicly accessible websites.  Interestingly, the findings were similar to my research with regard to ankle sprains being the most common injury and both papers explore ACL Injuries.  My study only looked at lower body injuries so it did not examine concussions, but this recent paper did and I've previously written about the WNBA Concussion Protocol here.

Here's why this paper is important, in my opinion.

PubMed is a search engine for research papers, kind of like Google, only your search will bring scientific information. A PubMed Search conducted today, April 20th, for "WNBA AND Basketball" will give you EIGHT results.  In comparison, A PubMed Search for "NBA AND Basketball" will give you 120.  This new paper doesn't appear in that search.  Neither does mine.  I'm not sure what you need to do for PubMed to determine you're worthy, but it's apparent that the topic isn't a common one found in this search engine.  PubMed is where I go first when I want to find research on a specific topic that impacts my patients. 

So how about a different search engine like Google Scholar.  There "WNBA and Basketball" has 5,120 (94 results since 2020), including this new paper and my own, and "NBA and Basketball has 55,000 (1140 since 2020).  Obviously I did not screen every title to see if they actually refer to basketball and the NBA which is why I wrote the search this way, but it's SO EASY to see the discrepancy.  In my opinion, a new publication looking at the WNBA is a HUGE win for the WNBA. 

The papers that are found on the Google Scholar search are on all sorts of topics.  There are publications about injuries, like the ones I'm talking about and, as a physical therapist, which I find most interesting.  But there are papers about basketball, about female athletes, about gender differences from various perspectives including pay and spectator attitudes, differences between draft selection and playing times, sexuality, fan experiences, race, television time, and the list goes on. 

The battle to improve opportunities for women in sports continues.  The battle for pay equity, though improved with the new WNBA Players Association negotiations for their collective bargaining agreement, continues.  The battle for sports media to increase awareness of women's competitions and to increase support of elite female athletes continues.  And this week, the battle for increased awareness of injury data - which ultimately can help contribute to injury prevention strategies, continues, but with a step forward.  I tip my hat to you, University of Chicago Orthopedics. 

Jack of All Trades...

Master of none?  Of some?  Of one?  Of a few?

One of the great things about being a physical therapist is the variety of things available to you.  Numerous settings are available to work in - schools, hospitals, nursing homes, clinics, sports teams.  You can work with a narrow age of ranges like birth to three years old or the geriatric patient or the whole spectrum of age, gender, and a variety of levels of ability, disability - both physical and intellectual.  In my office alone, there are physical therapists who primarily focus on sports/orthopedics, others who primarily focus on developmental rehabilitation, and a specialized physical therapist who works on infant feeding.  Variety is the spice of life, right?  

Some days, the list of diagnoses between all the patients on my schedule looks a lot like: knee pain, knee pain, ankle sprain, knee pain, knee surgery... repeat.  The mechanisms of these injuries for knee pain and ankle sprains might vary - soccer, soccer, gymnastics, jumping, soccer, soccer - or not that much maybe. Some days that’s just how it is.  Not a whole lot of variability in the body region where pain is occurring. Not a lot of variety in age groups.  I've had days where I've seen only girls between age 12-15.  And I generally see eleven patients in a day, so that's a lot of "luck" to have so much congruency between patients. 

Because of how sports seasons work, there’s a tendency to see clusters of athletes from the same sport at once - like soccer players when their season is starting, baseball players at a different time.  We don't see many football injuries in middle of December, and it's rare to see a skiing injury in August. Teammates bumping into one another at the clinic is not usually a good sign, particularly if they have the same type of overuse injury, but it definitely happens.  Last winter, when 3 swimmers from the same team showed up with shoulder pain, it seemed imperative to reach out to the coaching staff and see if we could help the whole crew.  

So while I really do love days like this because I’m a sports physical therapist and I love helping kids get back to playing their favorite sport, there are days that are also quite different.  Days where the diagnoses on my schedule look like this: chronic regional pain syndrome, post concussion syndrome, post-op meniscus repair, broken humerus, knee pain, scapular dyskinesia, ankle sprain, osteomyelitis of the shoulder post irrigation and debridement, post-illness deconditioning.  When this happens, there's also a much wider spectrum of mechanisms of injury - like for these - skateboarding, soccer, trampoline park, fell off jungle gym, marching band, swimming, "my brother tripped me down the stairs", insidious/unknown, cancer.  The injuries and conditions can be much more variable and require a lot more knowledge and skill to treat. I love this, too, but it makes me think a lot about my strengths and weaknesses as a PT.  At the end of the day, all of them are trying to get back to something, usually a sport or activity of some kind, which means guiding them through restored function in more important things like going up and down the stairs or getting off the toilet- but after that boring stuff (kidding), we get to play soccer or basketball or hop scotch in the clinic. 

I’ve been thinking a lot about this second type of day and had this blog post almost entirely drafted when Lenny Macrina, who I've previously written about here and here, posted this on his twitter: "Hey PTs, if you could treat one only type of patient presentation for the rest of your career, what would it be?" (Side note, I'm currently running for the office of President of the Lenny Macrina Fan Club).

In high school we took career placement testing that suggested I should become a farmer.  In my head I thought - that's the most regimented routine EVER.  Up at sunrise with the chickens, milk the cows, maybe some change with seasons but overwhelmingly very similar day to day.  No thanks! I never considered being a dentist because I didn't want to look at people's teeth all the time.  Gross. I definitely didn't want to be a podiatrist, because I really don't like feet. Gross times a million. I didn't want to do any sort of work that was repetitive in nature. So thankfully, I don't get stuck treating tons of ankle sprains, and when the occasional one does, I make sure they're good about washing before I get near them.  I always knew I needed variety, which is what this post was about in the first place... and had to respond to Lenny's tweet: "Why Lenny?!?! This week my upcoming blog post is about days where all the patients have similar body part ailments or conditions versus days where they're all over the board.  Variety is the spice of life! I'd go nuts with the same all day."

I really, really love the variety. but I also recognize that by seeing this variety, does this mean that I've become a jack of all trades, capable of doing something to help everyone but not being really good at helping anyone in particular?  Is this a problem for PT practice that we don't really have to specialize much beyond our setting of practice?  

For me, there are certain patient types and conditions that I'm really interested in.  I primarily focus my continuing education on those areas.  Some injuries and conditions are simple to evaluate, simple to treat, quick to get the patient back to their normal self.  Some just aren’t. And, as I think I’ve said before, though physical therapy is based on science, there is definitely an art to it.  There is an art to connecting with people, encouraging behavior change and convincing people to exercise who normally wouldn't.  But beyond the connections, there is a real need to have a good understanding of the human body, the relevant components to a person's injury and to the needs of their activities, and to how the body heals. 

There are basic skills any physical therapist would use to evaluate the majority of their patients. We would assess their range of motion and strength and probably palpate some body regions to assess irritability of the tissue and mobility of a joint, and then maybe some special tests to identify certain tissue structures that may be involved.  And then we have to be more specific, like I mentioned earlier, in further assessment techniques and treatment options based on the needs of that individual person. 

So... should every PT be treating a case load that has so much diversity in diagnoses and patient presentations?  Should I be?  I do... but... should I?  Is it OK that I'm a Jack of All Trades?  

I'm here to say that I think this makes us even better.  If I only treated post-op ACL reconstructed patients every single day - but their sport or daily life needs vastly differed - and their concomitant injuries included many other things like meniscus pathology or PCL injury or traumatic fracture, I don't think I'd be as good at rehabilitating that patient population as if I worked with patients with all kinds of hip, knee, ankle/foot injuries playing a variety of sports.  And truly, a patient with an ACL injury is one of my favorites - but it's because of the duration of recovery and connection to the patient that I like it, along with the ability to use a whole lot of different treatment tactics with them! If I only saw kids with concussions, my vestibular rehabilitation skills would definitely improve - without question - but at what cost?  What would be lost by specializing in a specific patient population?  

So, the next time I need a physical therapist for myself, I’m going to ask them what they like to study and learn more about.  Do they choose to do continuing education on hip pain, while I'm experiencing hip pain, that they may have seen the most recent evidence of what they should consider for my care?  And also, do they treat a variety of patients, or only people with hip pain.  But most importantly, do I like them?  Can we connect at all?  Because truthfully, a lot of the time, I don't think it matters quite so much what we know or study or who we've treated the most, but how we interact with our patients and empower them to move forward.

Jack of All Trades, Master of None?  Fine by me. 

Seattle Children's Youth Upper Extremities Injuries Conference

This past Saturday, March 23rd, the Seattle Children's Hospital Sports Physical Therapy Education Committee organized a full-day conference: Youth Upper Extremity Injuries: Medical and Rehabilitation Management for Return to Play. I had the pleasure of presenting Anatomy and Biomechanics of the Shoulder to a crowd of about 75 people.  There were PT students, many Athletic Trainers, a few Occupational Therapists and Physical Therapists in attendance and the other presenters were Seattle Children's Orthopedic Physicians and fellow Sports Physical Therapists.  It was fun learning from the doctors whose patients I have the opportunity to treat and from my fellow therapists. Here are some highlights from the day!

Dr. John Lockhart

We kicked off with a presentation from Dr. John Lockhart who presented Pediatric Cases of Common Upper Extremity Injuries.  He included shoulder, elbow, wrist, and hand cases through the lens of when it’s really imperative for athletes to be held from sport. Sometimes injuries won't get worse with playing in the championship game, or its acceptable to delay the rest period without a huge risk.  Other times there could be a potential for long term damage with continued participation.  For example, Little League Shoulder, medically known as proximal humeral epiphysitis, requires rest immediately.  It is not a condition that can be played through because it is essentially a stress fracture to a kid's growth plate.  These kids should not be allowed to play through their pain.  Same thing applies to little league elbow.  However, a shoulder impingement that is uncomfortable and acute may be able to continue playing while rehabilitating and working on throwing mechanics without worsening the condition. It feels terrible to be the one to tell a kid they need to stop playing the sport they love... but sometimes we have to be the "bad guy" for the greater good. Safety First.

Dr. Kyle Nagle

Then Dr. Kyle Nagle, Team Physician for Paralympic Nordic Skiing, highlighted the difference between Olympics, Special Olympics, and Paralympics in his presentation on Upper Extremity Injuries for Adaptive Athletes.  Last summer I volunteered at the Special Olympics and wrote about that experience here, but couldn't really have described the differences until now.

The Special Olympics focus on an athlete's ability, what they're able to do, and is for athletes with intellectual disabilities.  They try to level the playing field so that competitions are within 15% ability from those competing against each other as best they can, and it's meant to encourage inclusive participation with opportunities to compete for everyone.  Paralympics are primarily for physically disabled or visually impaired athletes.  Dr. Nagle has participated as a classifier for these athletes and, unfortunately, they look more through a lens of impairment - what the athlete cannot do - to try to categorize the athletes for participation.  Paralympics athletes have a physical impairment or a visual impairment, though they have previously had intellectual disabilities as an category and this is potentially going to return for more sports in the future.  

Dr. Nagle discussed the common shoulder injuries in adaptive athletes. Spoiler alert- they’re the same as any other athlete! But the impact on life function may be more impactful if, for example, they only have 1 arm and injure it, and the financial implications Dr. Nagle described for these athletes are much larger than I expected.

Dr. Michael Saper

The third physician to speak was Seattle Children's orthopedic surgeon Dr. Michael Saper.  He presented upper extremity surgerical procedures, why he likes arthroscopies more than open surgery, and a little about the protocols he has us follow for our rehab. 

He specifically commented on anterior shoulder dislocations and how in a youth athlete, a high number  (about 50% between age 15-20 years old) have repeated dislocation and should be considered for surgery, so he would want to see them as soon as possible following their injury to determine if this is necessary.  Oftentimes these athletes return to athletics without surgery, but the risk of long-term shoulder instability and repeated dislocation is very high if the first time dislocation occurs before age 40, according to the above linked article.

Image of an OATS procedure (kinda gross, sorry)

Dr. Saper also discussed Osteochondritis Dessicans (OCD) at the elbow, more commonly seen at the knee but we've treated both locations in the clinic recently.  With OCD the patient has degeneration of the cartilage that normally covers bone so there is less protection to the bone surface.  Sometimes the condition progresses so that there is damage occurring at the bone.  Patients who have this condition generally undergo surgery and there are various options - selection of procedure based on the size of the cartilage lesion.  So a small hole in the cartilage, less than 1 cm, could be repaired using a microfracture procedure in which the cartilage is "cleaned up" (debrided) and then the surface of the bone is poked with a needle to make it bleed, which should facilitate healing at that surface.  If the injury is larger, the OATS procedure is used.  OATS stands for OsteoArticular Transfer System where a graft is made using either the patient's own cells or a donor's cartilage made into plugs that are put into the damaged space.  Both are long, slow-healing procedures but tend to do well in the clinic with the OATS procedure looking like it has better long-term outcomes, particularly in higher level athletes.

Dr. Lockhart and Dr. Saper teamed up to demonstrate special tests they use when screening their patients. The recommendation was to fine tune the order of evaluation tests you do in the clinic so that you're thorough, systematic, efficient, and don't forget anything.

Dr. Lockhart assessing Dr. Saper's A-C joint

There were some key overarching themes between the physicians:

1) Taking a thorough medical history is essential to appropriate care of our patients.  It can help identify the problem, and even more importantly, the solution.

2) Being honest about expectations at the beginning of recovery from injury is essential.  We as physical therapists need to be discussing the process of rehabilitation and what the progression looks like so that there aren't surprises or questions about the duration of recovery. 

3) Anyone returning to sporting activity should follow appropriate recovery timelines, but they also need to be mentally ready before they get back into it.  An apprehensive or fearful athlete puts themself at risk for injury, even if they have physically achieved all the recovery milestones.

Following the discussions from the physicians, the physical therapists took over the show.  I kicked it off with my presentation on the anatomy and biomechanics of the shoulder.  Based on the amount of time allotted, I structured the presentation to overlap the anatomy with the biomechanics with occasional applications rather than the ways I have previously learned anatomy.  I thought it was successful, though I wasn't humerus...

Then came Steve Cisco, sports physical therapist at the Seattle Children's - Bellevue location, who presented about the mechanics of throwing a baseball.  I'm not sure anyone loves baseball as much as Steve does and his passion for the topic showed.  Chris Wong, another Bellevue physical therapist presented the upper extremity return to sports assessment battery of tests which a group of us had previously presented and I wrote about here.  And then there were some really excellent break-out sessions lead by PTs Steve (more throwing), Kaite Thompson (gymnastics), Brandon Tom (swimming), and Athletic Trainer Holly Runtzel (athletic training topics).  I attended Kaite and Brandon's talks and learned some fun new things to use in the clinic for those patient populations.

Overall - it was a fun day of learning, nice to head over to the main hospital and see my colleagues who work in different locations - and a great way to learn that I actually like presenting.  I'm looking forward to the chance to do so again in the future and am grateful to the Sports Physical Therapy Education Committee for giving me the opportunity and putting together a great course. 

Do No Harm.

This week on the social media interwebs, I saw a startling video of a rehab session of WNBA Player Angel McCoughtry. Angel is a two-time Olympic Gold Medalist and five-time WNBA All-Star who plays for the Atlanta Dream. She's a star on the basketball court.   The first time I saw her play in person was when her Louisville Cardinals lost to UConn in the 2009 NCAA Women's Basketball Championship in St. Louis but I've easily been watching her play since 2005 when Louisville entered the Big East Conference... she's a really fun player to watch, very dynamic and energetic.  I saw Kevin Garnett play in Boston for the first time after I had seen Angel play and thought he reminded me of her.  Unfortunately, Angel hurt her knee towards the end of this past WNBA Season and required surgery - information she posted on her social media pages.

Last week, Angel posted this video of her recent rehab session on her twitter and instagram accounts:

It’s easy to see the glits and glam of success , but this is what it looks like behind closed doors! pic.twitter.com/dtjy28QRmU

— Angel McCoughtry (@angel_35) February 14, 2019

I'm speechless watching this. It takes a lot to make me speechless... but this did the trick.

I'm not treating Angel's knee condition so I don't know what she's gone through to this point - or what the goal of this particular moment is - but I can make some educated guesses based on my work as a physical therapist and with women's basketball players.

Trying to bend a joint past what it is able to do is incredibly painful. The mobility is necessary, so it's possible that this rehab team has tried numerous other options before using this technique to try to get her knee to bend sufficiently. I'd have no way of knowing, but I do know that even if I had tried everything I could think of - this would not be in my list of treatment options.

There are many studies that show the need to have symmetrical knee mobility (both sides bend and straighten the same amount) to have normal walking pattern which would translate to normal running pattern.  However, this paper also examined the number of post-op ACL patients who don't get back their full mobility and found it to be 11% in a sample of 244 patients. This paper discusses the way that scar tissue build-up in a knee is classified and what is generally done if physical therapy intervention is insufficient.  Asymmetrical mobility increases risk of injury - and nobody wants that.  While I agree that she should have matching mobility on both knees, the method being used to achieve this seems inappropriate.  I have never done this in over four years as a physical therapist and, when I saw the video, I distributed it to several other physical therapists and athletic trainers, all of which agreed that there are numerous better ways to achieve the goal they're trying to achieve in the video.

It looks like someone is trying to make Angel's knee bend more than it currently does.  Knee flexion (bending) is a challenging thing to achieve sometimes, particularly after surgery, and sometimes it even requires an additional surgical treatment called a manipulation under anesthesia, in which a person is medicated so that they won't feel it when their knee is forcefully bent all the way to restore full motion.  These can be incredibly painful procedures and with the WNBA season starting in just about two months, nobody would want her to have another surgery when she;s starting to get back onto the basketball court to prepare for the season.

This research article from 2008 uses a similar position to try to get knee flexion but describes the need to hold the position for extended periods of time - at least 10 minutes - and notes that having a physical therapist apply this type of sustained hold is incredibly fatiguing to the therapist so it recommends using belts on a table to achieve long duration, low load stretching.  However, it also specifically states that the hold should be to the tolerance of the patient and may be a little uncomfortable.  I would argue that the session in this video is not to the patient's tolerance and is therefore harmful.

These papers: 1, 2, 3, 4, 5, are just a few which suggest alternative ways to achieve the same goal - or the last one talks about the lack of evidence to support what's going on in the video. A brief summary of each:
1) An alternative technique to use to try to gain knee flexion range of motion
2) Another alternative technique to use to try to gain knee range of motion
3) A list of manual therapy options with photos from a University of Kentucky physical therapist - none of which are what is used in this video.
4) This is from the PhysioPedia which includes videos that even include knee flexion in the prone (face down) position like the one in Angel's video, however you will notice joint mobilization is being used rather than just a cranking technique, and, if your sound is on, you will also notice an absence of apparent pain.
5) This is a much older paper from 1992 that looks at ways to change the length of connective tissue (like the ACL or capsule around the knee joint) which is composed primarily of collagen.  It describes that there is not sufficient understanding of how much force would need to be applied to make change in length of these tissues - but that if that force were measureable, it would require some amount of damage to the tissue.

So, if you're receiving physical therapy treatment and you're experiencing pain during the session that feels like it is harmful to you, tell your provider to STOP.  Sometimes treatment may be uncomfortable - and that's ok - but if you're yelling out, that's not ok.  You should ALWAYS feel like the treatments you are receiving are helpful.  You should ALWAYS know that you have the say of what is being done to your body.  And you should know that you ALWAYS have the right to ask why something is being done to you - and if there is another way it can be done.  Because in this case, I strongly believe there are alternative ways that are safer, more effective, and that do not look like torture.  Physical therapy gets a bad reputation because the abbreviation, PT, also is jokingly referred to as Pain and Torture.  This is wrong.  And if you feel like your PT session is more like pain and torture, please get another physical therapist.  We take an oath to Do No Harm.  The Hippocratic Oath of healthcare providers.  We should be living up to our oath.

Wishing a very speedy recovery to Angel McCoughtry.  I can't wait to see her back on the basketball court. And I hope her rehab is not painful in the future.

"Just an Ankle Sprain..."

Let's talk about ankle sprains.

I've recently had a few patients come through the clinic with ankle sprains that needed to be evaluated.  It's basketball season!  My first question to any new patient is usually "what brings you into physical therapy today?" Any of my fellow PTs also experience teenagers coming in and answering this question with "just an ankle sprain?" They usually shrug while they say it and sigh in exasperation, maybe even a hint of an eye roll.  It's a completely different presentation from the kid in a sling who broke their arm and tells you all about the huge tree they were climbing or the other kids who were on the monkey bars when they slipped and who got the teacher for help and whether or not they cried. It's a different presentation from someone who just tore their ACL and feels like the future of their sport seems impossible - or at best a million years way.  Those are real injuries, right?  A broken arm or a torn ACL are a big deal... but an ankle sprain is no big thing, they think.

From a physical therapist perspective, an ankle sprain is a bit of a double-edged sword.  On the one hand, they're pretty easy to evaluate and they overall recover fairly quickly - at least back to baseline function.  On the other hand, they usually feel really good long before they have made an effort to reduce the risk factors that contributed to their injury in the first place.  Said another way, sometimes these athletes feel like they're back to normal, but normal is at risk for getting injured again.  As a physical therapist, I sometimes have to convince these patients that just because they feel like they should be playing their sport without any restrictions, it doesn't mean physical therapy or strength training has ended.

So who says this?  Sometimes it's a young athlete who wants to look tough after an injury that shouldn't seem like a big deal. Sometimes it's an athlete who really didn't have that much pain a day or two after the injury but couldn't get into physical therapy so they're almost back to playing sports.  These athletes have already gone to practice but their coach won't let them play in a game until someone clears them, so they come in for their first visit hoping that I'll be the one to do that.  This very rarely happens, though I won't say never. Sometimes they've noticed that half of their teammates have had the same injury and it's really common.  When you're at physical therapy and your teammates are there with you, something could be very wrong with your team training program. 

Here's why it is, in fact, a big deal:

Ankle sprains are really common.  In my graduate thesis that surveyed 246 high-level women's basketball players about their injury history, 70% had experienced an ankle sprain.  So not only are they really common - but athletes also recover from them and get back to playing their sport at a high level.  You can sprain your ankle and recover in such a short period of time that it would be possible to experience the same injury repeatedly throughout a season or career, though with each subsequent injury, the recovery is generally longer and the tissue damage gets worse.

When someone sprains their ankle, about 40% of the time, the ankle becomes chronically unstable.  According to this 2017 paper by Miklovic et al, this chronic instability affects range of motion, strength, movement patterns, and postural control.  Basically your nervous system recognizes that something has occurred and tries to protect you by moving in different ways.  An unstable ankle can get better with strengthening and balance - though it doesn't generally go back to it's original state.  The other way an unstable ankle gets better is through surgery... which is what happened to me.

The BIGGEST RISK FACTOR for an injury is a previous injury.  (Sorry PTs who have heard this before!  The general population just doesn't know this is a fact!) So if 70% of athletes on your team are having ankle sprains, that means 70% of athletes on your team are at risk for another injury and next time it may be another ankle sprain, or it could potentially be something that takes them off the field or court for a much longer duration.

Here are three key concepts with regard to ankle sprains that are really important for you to know if you're an athlete or a parent of a youth athlete or a youth sports coach or a person with an ankle - because these happen to non-athletes, too!:

First: When an ankle sprain occurs, it can be classified into one of three grades. This grading system is used for all sprains and strains in the body, but we're talking specifically about the ankle today.  There are many references that outline this, so here's one:

Grade I: the ankle feels stable, you can probably walk on it, there likely isn't any bruising but maybe some swelling.  There may not be any damage or a few ligament fibers are injured, which is painful, but these generally recover very quickly in about 1-2 weeks and often they are not treated in physical therapy.  In my opinion, this is a mistake!  Get it checked, get a home exercise program, and reduce risk of re-injury particularly when you're only missing a short period of time from sports or activities.

Grade II: the ankle probably has a little bit of bruising and swelling, it's painful to walk on, and may or may not feel unstable.  Usually people with a grade II sprain are given crutches and sometimes a boot for a short period of time.  There is partial tearing of a ligament with this injury.  These take a little longer to recover, more like 4-6 weeks.  These are more frequently seen in the PT clinic, but still many people don't come get treated for these until they've had multiple episodes.  Again, I believe this is a mistake. 

Grade III: the ankle will have much more bruising, usually also going into the foot and lots of swelling.  Generally you won't be able to walk with this and there is full rupture of a ligament or more than one ligament.  Sometimes these are also accompanied by fractures to the ankle bones, so these people typicall need XRAYS to determine the severity of their injury. These are the injuries that get a boot and crutches for a longer period of time.  The ankle feels unstable, even after the extended period of immobilization.  Generally these do not require surgery but take closer to 6-12 weeks for full recovery and almost always are recommended to have physical therapy.

(Of course - recovery times vary and it depends on the anatomical structures involved in the injury.)

Second: It seems pretty obvious to some, but in case you haven't noticed, in a standing  sport, the foot is the first place that the body interacts with the environment. The foot strikes the ground and that interaction directs human movement.  When I treat patients in the clinic with pain in their low back - I must choose to treat them from the ground moving upwards or from their head moving downwards.  Sometimes the symptoms are driven from above- othertimes from below - and sometimes the symptoms are sandwiched between dysfunctions and you treat from both directions.  When it comes to the foot - there isn't really anything to consider below it because that's the ground.  I of course need to make sure the toes are all moving, but overwhelmingly, when you are looking at someone who experienced an ankle sprain, you're going to treat the ankle injury and give focus higher up the chain to the hip which controls the leg in space.

After an ankle sprain occurs, the most common deficits to the athlete following the injury are: Limited dorsiflexion ROM, decreased balance/proprioception, decreased strength which translates into decreased power to push off or jump.  This is a long list of things that are affected from "just an ankle sprain."  So if you play a sport in which you jump, after an ankle sprain you're likely jumping differently than beforehand.  And squatting differently.  And walking differently.  And rebounding differently. And pushing off of first base differently... got the idea?  Your movement changes after the injury - and physical therapy helps guide you to exercises that will improve this.  Moving differently may not be a problem - but it might contribute to your risk for another injury.

If you just treat these deficits and don't consider what could have been going on BEFORE the injury, you might entirely miss the need to assess and strengthen their hips and the way they move as a whole unit.  The body moves as a whole and needs to be treated as a whole.

Third: What you can do about it:
I've previously written about injury prevention programs.  Ideally everyone would do a better job of preventing ankle sprains from happening in the first place. Here's where I've written about those in the past for ACL injuries as well as this post using dynamic warm ups as a way to incoporate injury prevention into daily practices.  Start with a program for everyone on your team and find a physical therapist in your area to screen your athletes for risk factors and then get individualized exercises to add in for each person.  There is evidence available showing that injury prevention programs help reduce ankle sprains.

If you are a parent to an athlete who experiences an ankle sprain or a youth coach who has an athlete experience this injury, SEND THE KID TO PHYSICAL THERAPY!  Once the injury occurs, get them screened, get them a home exercise program that you incorporate for all your athletes.  They will probably benefit from some mobility work, some strengthening to their ankle, hips, and core, some training on how to move with control, and some balance exercises.  If I've said it before, I've said it a million times: Injury Prevention = Performance Enhancement. 

Don't end up like me, in the photo above, having had so many ankle sprains that I did nothing about and ultimately ending up in the operating room.  Prevent things from getting worse, and Get PT 1st.  It might even make you a better athlete!

Online Knee Seminar and Three Key Components to Patient Care

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I’m starting to look like a groupie of Champion Physical Therapy and Performance in Boston, MA- but that’s for good reason! I’ve previously written about this crew, particularly Mike Reinold and Lenny Macrina here and I just completed their Online Knee Seminar.  This class was awesome- and I’ll tell you about it - but I also want to share some of the underlying themes about patient care that were introduced that relate to how they (and I) practice physical therapy. This could be particularly helpful for the new grad PTs entering the work force after passing the NPTE exams in July but as a PT who is almost four years into my career, I still learned a ton from taking this class.

On my first orthopedic clinical rotation during PT School, I worked with Craig Katko - then the PT for the Connecticut Sun WNBA team and now the PT for the New England Black Wolves National Lacrosse League team. As far as clinical rotations go, Craig was the best instructor for my first time working in orthopedics.  I was very lucky to have that opportunity. As I prepare to take my first student, I'm reflecting on what my rotations were like and what helped me most.  What I remember from my time with Craig was mirrored in the introductory portion of the knee seminar, and I was grateful for the refresher:

First - Patient history and evaluation components are essential to guiding your treatment, but learning how to do an evaluation, and getting to be good at it, is challenging.  Craig recommended that I find an evaluation system that I trusted to use consistently until I was confident in recognizing patterns, and then to later on use as a fall-back plan.  He lent me his copy of Grey Cook's "Movement" book to read - and I learned the SFMA - which I used for my rotation with him. Lenny Macrina has mentioned the SFMA in a few of his courses, and every time he mentions it, I think to myself - he's not checking cervical range of motion in a patient with knee pain.  (Are you, Lenny?)  New grads - you may want to check out the SFMA principles if you haven't yet learned them - especially if you're not confident in your evaluation skills, yet. Now, four years out of school, I don't use the full SFMA for every patient... but I use many of the principles from it constantly. Specifically - I examine neighboring joints proximal and distal to the pain region and check mobility and stability in those regions - both key concepts in the SFMA.  These apply to the knee in numerous ways.  You must clear the spine with patients who have pain in their extremities, and for a patient with knee pain, you need to consider both the hips and feet.  When a patient doesn't fit a pattern that you've come to recognize, the SFMA is always there as an option to re-assess them.

Second - Don’t get too bogged down with diagnostics.  As the PT profession moved into Direct Access and patients started coming into the clinic without seeing a doctor first, I was excited to try to identify patient pathologies. What I came to realize was a specific diagnosis usually doesn't really matter! There are a lot of structures involved in the knee (or elsewhere) that need to be checked, but special tests don't have great reliability and use of palpation to diagnose an isolated structure being injured is about as good as guessing.  As I've learned more about the biopsychosocial model, and treated more patients, it has become apparent that sometimes specific tissue diagnoses do more harm than good, and they often don't help guide treatment. For example, as described in the Knee Seminar, a patient can have patellofemoral syndrome from numerous causes: foot mobility or control issues, strength deficits or imbalances of the hips, overuse, improper jump-landing mechanics, body alignment considerations... the list goes on.  If you tell a patient that their leg is lined up improperly - something that genetically they're unlikely to change - you can create a fearful situation that is unnecessary.  I've actually come to prefer referrals that list a diagnosis as "right knee pain" because I'm not treating a diagnosis... I'm treating the specific person sitting right in front of me with their unique presentation. While clinicians do need to be able to explain what's going on to patients, you can do it in a way that will empower the patient/client to embrace their personalized recovery strategy.  I work with kids.  It's really easy to tell them that I can see some reasons why their knee might be hurting... tell them they're strong... and then give them a home exercise program with some things they can do to make themselves move in new ways that should change the way their body is loaded.

Third - Use functional impairments to guide treatment. I use the slogan "find a problem, fix a problem" as my guide.  This might infuriate some of my PT colleagues because it isn't how their belief system works... but there are lots of patterns that can be applied to all body parts for rehab and progressing through these in a sensible manner to achieve optimal function leads to patients achieving goals.   For example... if I'm working with someone experiencing knee pain and they can't tolerate going down stairs (function), I can break that down to see why (impairments).  Following the progression of working to improve inflammatory processes, then to restoring range of motion, then increasing strength, and finally focusing on proprioception/motor control/higher level activities applies to all knee pathologies, though the timeline of progression varies by person.

So these three concepts were identified in the introductory portion of the Knee Seminar and reminded me of when I first started learning about patient care.  I found these concepts valuable to get my career started and have built on them and developed my habits with additional continuing education courses... which leads me back to the Knee Seminar.  If you're looking for a continuing education course specific to the knee - this is the most comprehensive one I've seen. 

The seminar is broken down into seven key components: 1) examination of the knee, 2) treatment of the knee, 3) ACL, 4) Patellofemoral Syndrome, 5) Meniscus, 6) Articular Cartilage, and 7) Osteoarthritis.  There are videos for each section along with some key selected articles.  Just like I experienced with their Shoulder Seminar - the articles they picked were really useful and I'm glad to have added them to my library for future reference.  The top three considerations that I'm looking forward to implementing in my own patient care were 1) The biomechanics of the knee, particularly with regard to the forces at the patella at different points in the knee range of motion, 2) better understanding of the meniscus anatomy, how it moves, when it is stressed, and considerations with rehabilitation for repair versus removal, and 3) treatment options with regard to articular cartilage pathologies.  There are new surgeries (at least new to me) being used to treat these conditions - such as the OATS (Osteochondral Allograft Transplantation Surgery) and the ACI (Autologous Chondrocyte Implantation) procedures.  If you're a new grad and you haven't seen these yet, this course helped me understand the procedure and the rehabilitation protocols, but better yet - when you would use these treatments and why the rehab is progressed so slowly.  This was a great continuing education course!

Good luck, new grad PTs!  I hope this is helpful.  And just remember, ask for help.  And teach us more seasoned PTs the things you're learning in school so we can all make the profession better!

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!

The Importance of Breathing

Breathing Exercises Are Challenging!

This past week, the Seattle Children's Hospital Sports Physical Therapists held their quarterly in-service meeting which included a presentation by three of our PTs who recently attended a PRI - Postural Restoration Institute Seminar.  The presentation was led by Natalie Johnson, DPT, Paul Moraski, DPT, CMP, and Jeremy Kirschner, DPT, ATC, CSCS and was a great introduction to the basics of breathing.  I was really excited about the topic because I have had the PRI courses on my "to-do" continuing education list for a really long time and it was a great introduction to how breathing can impact movement.  The PRI courses are definitely going to move up on my priority list from this experience.

I have previously encountered breathing as a continuing education component when I went through my FMS (Functional Movement Screen) and SFMA (Selective Functional Movement Assessment) certifications through FMS - Functional Movement Systems.  I read Gray Cook's book "Movement" on my first orthopedic clinical affiliation during school and used the system to evaluate patients frequently back then.  While I don't use the SFMA or FMS in my evaluations very often now, I do like having them available to me as a fall back or as I'm progressing patients back to return to sports activities.  I really like using rolling techniques which comes from these systems and, when those aren't successful, breathing is the primary regression that remains.  Oh how I wish I had paid better attention during my motor control and developmental stages during PT School - but at that time, I just couldn't understand how these things were relevant.

Key concepts I took from the in-service:
1) Breathing is at the foundation of all activities.  If you're not breathing - you're not moving.  And if you're not breathing "properly" this can contribute to dysfunctions.  To work with patients that have a breathing dysfunction by training at a much higher level, you may be able to guide them to fully restored function.  However, focused training for proper breathing is sometimes necessary.
2)

photo (and additional information below) from: http://novusfitnesstraining.com/zone-of-apposition/

The Zone of Apposition (ZOA) describes the positioning of the rib cage and how it influences the function of the diaphragm which directly impacts breathing.  This also directly relates to posture, as the skeleton on the right side has a loss of ZOA due to the bottom of the rib cage flaring and influencing the available excursion of the diaphragm.  While I have joined the bandwagon of "there is no bad posture, only positions that are sustained for too long or that you can't get out of," I still feel that there are optimal postures for various activities.  For example, a basketball player who attempts to dunk but has increased thoracic kyphosis limiting shoulder elevation and anterior weight shift while squatting that limits the stretch-shortening cycle of the posterior chain while jumping will have difficulty getting the ball over the rim unless they're 8 feet tall.  The current trend of saying there is no perfect posture relates more to static positioning throughout the day than postures for activity.
3) There are commonly seen breathing fault patterns.  Three that were described at the in-service were:
- an anterior internal chain dysfunction which presents with quad dominance and decreased extension through the hip that is more often a unilateral pattern.
- a brachial chain dysfunction more related to the upper body presenting with accessory musculature facilitating breathing and rib flare with shoulder flexion.
- a posterior external chain dysfunction which often presents as a forward head with increased thoracic kyphosis and lumbar lordosis and anterior pelvic tilt and more often a bilateral pattern.
4) Basic breathing techniques to improve apical expansion generally require focused training of the left internal obliques and improved ability to breathe into the right upper lungs region.  In the picture at the top of this post, I'm siting in a position that allows for the right side of my rib cage to open up and increase my ability to breathe into the right side of my lunges while I'm using my left arm to reach forward and increase activation of my left interior obliques while simultaneously using left hip adduction that integrates the pelvis and the lower portion of the internal obliques.

Overall, an awesome learning opportunity and good reminder of the importance of breathing.  I know that I have far more to learn on this topic and hope to get to a PRI Course at some point.  Feel free to check out the link with the Zone of Apposition photo because that blog had really interesting information about breathing - among several other topics!

Cyclops Lesion

Photo: http://www.kneeguru.co.uk/KNEEnotes/articles/general-articles/2016/cyclops-lesion-after-acl-reconstruction

I learned something new this week!  I was listening to an older episode of Mike Reinold's Podcast, "The Ask Mike Reinold Show," when Lenny Macrina mentioned a Cyclops Lesion, something I had never heard of before.

Of course I immediately googled to get a definition and then hit PubMed for a few articles.  A Cyclops Lesion, also discribed here, nicknamed the Cyclops Lesion for its appearance on imaging is also known as Localized Anterior Arthrofibrosis.  It is basically a build up of scar tissue in the intracondylar region of the femur.  It is a limiting factor in terminal knee extension (TKE) following ACL repair which is important because if TKE is not fully restored, future comorbidities are more likely later down the road.  According to this case study by Dhanda et al, 1-9.8% of patients who have had an ACL reconstruction may experience a cyclops lesion.  Most importantly from this article, "aggressive physical therapy does not improve extension loss associated with cyclops lesion."

I looked into this a little bit further and came across this study from Shelbourne which describes the importance of the relationship between surgeons and physical therapists as well as the key role in ROM symmetry in the knee.  They note that the surgical knee should be within 2* of hyperextension to the non surgical side and within 5* of flexion.  This is a case when symmetry matters, where so often in rehabilitation we allow for asymmetry because this is more natural.

After learning about the Cyclops Lesion, I went to PT Pub Night Seattle and met up with some fellow PTs and surveyed the crew... several had either not heard of or seen this in their practice despite mostly being in orthopedic practice.  I hope the new learning will benefit as much as I anticipate it will help me.  How could this affect my practice?

I definitely have a greater appreciation of the need for symmetry for post op ACL patients and I now know that this exists so that if I encounter issues with ROM, particularly achieving and sustaining terminal knee extension beyond around 8 weeks post op, I need to refer back to the surgeon with concerns.  Hopefully this will help others who may be unfamiliar with this condition.

About Me - Professional Abby

I guess I just jumped into trying to be a blogger without actually introducing myself sufficiently.  My apologies.

Hey there.  I'm Abby Gordon - a Physical Therapist living in the Seattle area for the past 3 years.  Job-wise, I'm currently working at Seattle Children's Hospital in their outpatient sports medicine Mill Creek (soon to be Everett, WA/North) clinic.  On the side, I consult with the Seattle Storm and recently have added on consultation for the Spectrum Dance Theater.

How did I get here? The personal basics: My undergraduate education was a BS in Exercise Science from the University of Connecticut in 2007.  While in college, I was also a manager for the University of Connecticut Women's Basketball Team for four seasons along with a season each of Women's Soccer and Softball.  After graduating, I worked for the Connecticut Sun Women's National Basketball Association team as their Travel Coordinator and Equipment Manager for four seasons before returning to UConn for my DPT in Physical Therapy which I completed in 2014.

While in graduate school I wrote a research project focusing on women's basketball lower extremity injuries.  My paper, if you're so inclined, was published in 2014, and you can feel free to be the only person, maybe ever, to read it: here.  The research process was incredibly beneficial in helping me grow as a physical therapist.  I have much more appreciation when I read scholarly writing now, because I know that it took several years for those papers to get to publication - along with blood, sweat, and tears of a group of investigators.  I have, on several occasions, considered further participation in research - but then feel like there's so much information to read - I should start there and get to the research at a later point in time.  This blog is a way for me to keep some of the research I'm reading organized and share key ideas that may help others.

So there's the basics of how I came to be AIG DPT... You'll see the basketball theme permeating the physical therapy career.  Basketball, somehow, is my favorite thing of all things.

Happy Thanksgiving everyone!

Abby