WNBA Finals Despite the Injuries!

Yesterday was Game 3 of the WNBA Finals. If you're not familiar with this league, the Finals are a best-of-five series which means you need to win three games (out of five) to be crowned champion. Last year, the Seattle Storm swept the Washington Mystics 3-0.  It was glorious!  Right now, the Washington Mystics are 2-1 ahead of the Connecticut Sun, with Game 4 being held tomorrow night at Mohegan Sun Arena in Connecticut.

Why is this important to me?  First, as the physical therapist for the Seattle Storm, I wish the Storm were playing in the Finals and that I was there to watch.  I love basketball and this really is some of the best basketball you can watch.  Haven't been to a WNBA game?  What are you waiting for?!?! Second, despite being dedicated to the team I work with, I'm also a supporter of the league as a whole and have a long history with the teams currently competing.  The current Head Athletic Trainer for the Sun, Rosemary Ragle, was the UConn Women's Basketball Athletic Trainer while I was in college - and also worked with me on my Grad School thesis.  The current Washington Mystics Head Coach, Mike Thibault, hired me to work for the Connecticut Sun when I was graduating from UConn in 2007.  I worked for him - and the Sun - for four seasons before PT School.  Their assistant coaches include his son, Eric Thibault, and former UConn and Connecticut Sun standout and Olympic Gold Medalist Asjha Jones who were both with the Sun when I worked there.  I can't possibly root for one team over the other - though I have a lot more Connecticut Sun t-shirts in my closet than Mystics attire. 

So I'm following the WNBA Finals, watching teams compete for the highest position in Women's Basketball - perhaps falling only behind the glory of an Olympic Gold Medal or World Championship - and the headlines are riddled with descriptions of injuries these players are experiencing.

Like these tweets:

Alyssa Thomas has a torn labrum in BOTH of her shoulders.

Instead of missing games to have surgery, she modified her shot and played through the pain. 👏#WNBAFinals pic.twitter.com/cVkqss0cQz

— espnW (@espnW) October 2, 2019

The @ConnecticutSun say they'll prepare as if @De11eDonne will play Sunday. The @WashMystics have to prepare as if she won't. The MVP's status for Game 3 of @WNBA Finals expected to be announced Saturday. https://t.co/0Vuwyd1R5m

— Mechelle Voepel (@MechelleV) October 4, 2019

Or this article today in The Guardian:

Elena Delle Donne plays through injury to move Mystics one win from WNBA title

• Washington beat Connecticut Sun 91-81, lead series 2-1
• League MVP has a herniated disk pinching nerve in her back

Associated Press

Sun 6 Oct 2019 18.22 EDT

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 Elena Delle Donne drives the ball to the basket during Sunday’s game. Photograph: David Butler II/USA Today Sports

"Elena Delle Donne put forth a gutsy effort, playing through a back injury, and Washington beat the Connecticut Sun 94-81 on Sunday to move within a victory of winning the franchise’s first title. The league’s MVP has a herniated disk that is pinching a nerve in her back and was questionable to play in Game 3. She finished with 13 points, hitting five of her six shots and played 26 minutes."

I can't help but thinking - what message does this send to the fans, particularly the young ones?  Is this helpful?  What does it all mean, anyways?

First and foremost, a disclaimer. I am not working with either of these athletes.  I do not know what care they are receiving - but I would bet it's excellent from my years interacting with both organizations.  I care about the health practices around the WNBA and have been trying to help improve their standards for several years - so from the research I've done, I can say with confidence that it is highly likely that these basketball players are being well taken care of. 

Additionally, I absolutely 100% believe that the above-mentioned athletes with injuries are experiencing pain.  I read one account that said that Elena Delle Donne could not sit down because it was too painful, so the medical staff and coaching staff had devised a plan to bring her into their locker room when she was subbed out of the game to keep her moving and stretching and to avoid extended periods of sitting time.   This sounds like EXCELLENT collaboration between a medical and coaching staff and is something other teams should take notice of!  (The Storm is good at this, too, in my opinion!)  If an athlete is reporting pain, I believe that they have it.  All pain is real.  Pain is a personal experience that is influenced by many things.  But pain is also a protector and it doesn't necessarily mean these athletes can't be playing.  Here are my thoughts with what I've read and, more importantly, some thoughts on comments from fans who have opinions on the matter.

1) There are HUGE numbers of people with imaging showing torn labrums in their shoulders and disc herniations that DO NOT have pain.  This paper discusses the labrum tears and found that 55-72% of people without shoulder pain had a labrum tear. (The population was a little older than Alyssa Thomas, aged 45-60, but she is an overhead athlete so this presentation for her is not really that surprising).  Want something more specific to athletes?  This blog post from fellow UConn Graduate and well-known strength and conditioning coach with Major League Baseball players, Eric Cressey, presented the research on the same topic.  He quotes: " Miniaci et al. found that 79% of asymptomatic professional pitchers (28/40) had "abnormal labrum" features and noted that "magnetic resonance imaging of the shoulder in asymptomatic high performance throwing athletes reveals abnormalities that may encompass a spectrum of 'nonclinical' findings." This paper looked at a large sample (3110 subjects) without back pain and found on MRI that 30% of 20-year-olds have disc herniations and that the number increases over time.  This is why sometimes people have surgery but it does nothing to correct their pain... because the MRI findings and the surgical correction does not always fit with the pain.  

2) These are elite level athletes so it concerns me when I read that suggest they're "skipping surgery and playing through pain."  Tissue damage DOES NOT correlate with pain, so unless ESPNw was given reports from the teams stating that they had pre-participation MRIs that were normal and then started having pain the correlated with tissue damage (which goes against a lot of the evidence) a surgery may not even come close to fixing these problems.  Another way of looking at this is - why does their body adapt to present with the MRI findings that they have.  For example (hypothetically) is Alyssa Thomas' upper back too stiff for her to get her arms all the way overhead to shoot and rebound?  Because if that's happening, she's effectively cranking on her labrum to get her arms over head and then a shoulder surgery may fix her labrum, but it doesn't actually fix the initial cause of the problem.  She'll still have a stiff upper back, so it'll only be a matter of time until the labrum is reinjured unless the real underlying cause is addressed.  Why does everyone want people to rush straight to surgery, anyways?  That's painful!  As a physical therapist, my number one goal is to help athletes avoid having any surgery at all.  Sure - if it's necessary, such as in the case of Breanna Stewart having an entirely ruptured Achilles tendon, we're talking about something different.  But what if we just let these athletes recover after a grueling season (next week!).  

3) Can we acknowledge the additional stressors of playing in the WNBA Championships?  It is well known that emotional stress contributes to our experience of pain.  Elena Delle Donne was injured during Game 2 of the WNBA Finals.  Anybody else ever get injured at work and need to finish the shift or wake up with a super stiff neck or spasm in their low back and still have to go to their job the next day?  She has a job to do and it's far more in the spotlight than most people's work.  She'll get her symptoms managed and her pain will likely have a bigger impact on her job than on many other peoples' jobs, but she'll also participate in the conversation of whether or not she plays.  Or at least she'll have her agent do it.  Someone will be advocating on behalf of these players to protect their health. 

Many of the comments online were about how she was forced to play.  We don't really know that!  Any chance these commenters considered that she chose to play once the medical providers told her she would be allowed to?  The reality of this situation is that in less than one week the WNBA season ends, the physical and emotional stresses of the season will be reduced, and a period of relative rest (which means  they don't just curl up in a ball in bed) can begin.  What if they have some injuries, but they're also sleep deprived with elevated cortisol levels from their increased stress, not eating as healthy as usual with their family entourage visiting for the Finals and wanting to eat out?  It's so much more complicated than just "an MRI showed some damage." There will be time to stay away from the basketball court coming soon, time to reduce the amount of stress on their bodies and their minds with decreased physical activity including, less jumping, decreased torsion and load on injured anatomy, maybe some extra napping, some gentle swimming or yoga, and globally allowing the nervous system to calm down.  The Playoffs are three straight weeks of sympathetic Fight or Flight Mode... how about a nice parasympathetic Thanksgiving style dinner that puts you into rest and digest recovery mode?  Maybe we'll see that no surgeries will be needed for any of them!  

4) There are definitely circumstances where an injury to an athlete means they should not play their sport because it puts them at risk for further injury.  For example, after experiencing a concussion, it is dangerous to the athlete's health to compete before all symptoms have entirely resolved.  For example, if an athlete has a broken bone, not only could it be extremely painful to compete, but the athlete is at much worse damage with a subsequent injury.  For example, if an athlete cannot control their bowel or bladder or they have muscle weakness or numbness/tingling into their legs or arms - these can suggest a much bigger problem with the spinal cord. 

But there are many circumstances where an injury to an athlete means they will have pain while they do the things they love, but they may be OK to play with certain precautions.  For example, someone who recently sprained their ankle may be able to play while wearing an ankle brace.  The brace can protect from further injury while they are completing their healing.  For example, in many states it is approved for someone wearing a cast with a broken bone to pad the cast and play sports anyways.  The cast will protect the injured athlete from worse injury and the padding protects opponents from being hurt.  A torn labrum of the shoulder may be associated with a lot of pain for Alyssa Thomas, but is she at risk for any sort of red flag event by playing through it?  No.  And, without knowing the details of Elena Delle Donne's injury, I suspect she's experiencing a lot of back pain without the neurological symptoms into her legs that suggest spinal cord problems and that her medical team has determined it is safe to be playing.  She would not be on the court otherwise.

At the end of the day, tomorrow night could be the final game of the 2019 WNBA Season.  If it is, the Mystics go home with a Championship.  If not, they will play one more game.  I personally want to see all the best players on the court at the top of their performance.  So I'll send up some prayers for these two incredible athletes and role models and to all the other WNBA players currently having pain.  And I'll be rooting for the Sun and Mystics medical providers who will soon get a nice rest break, too. 

Wishing Stewie a Speedy Recovery!

My heart hurts to write this week’s blog post. 

A few days ago, WNBA Most Valuable Player – and Seattle Storm superstar – and former University of Connecticut standout – and all-around philanthropic and kind person - Breanna Stewart - ruptured her Achilles tendon playing basketball overseas.  Since my social media feeds are filled with a combination of women’s basketball gurus and physical therapists/strength and conditioning coaches, there were A LOT of posts on my feed about her injury and the political implications of it.  If you're not squeamish, you can watch this video of her injury:

breanna stewart landed on brittney griners foot during the euroleague title game and looked in serious pain

not clear if it was ankle or knee but she was helped off the floor and put no weight on it pic.twitter.com/AO8ecTLtgJ

— dynamo kursk fan account (@WEREONLIVE) April 14, 2019

(Note: she injures the other leg - not the one that lands on Brittney Griner.  And it has now been publically announced that she has ruptured her Achilles on multiple news outlets, by the Seattle Storm, and by Breanna Stewart herself.)

So many people have focused on the fact that her income in the WNBA requires her to play overseas and that if the pay scale was more equitable to what the NBA players make she wouldn’t need to play overseas for more income (meaning WNBA players should earn the same percentage of league income as NBA players – not that they would have equal salaries to the men). I get it. I understand the value of that conversation.  I understand many of the challenges the WNBA faces limiting their ability to increase the salaries of their players.  I should also mention that I serve as the Seattle Storm team physical therapist, a role I have served in a volunteer capacity for the past four seasons.  I would have taken a pay cut to make it so Stewie could have avoided this injury, because in my professional opinion, it's the worst, but alas, I have no funds to defer to even share with her.  Instead of looking at the political implications for the WNBA players and their finances, I’m going to look at her injury from the physical therapist perspective to share why this injury means she's not going to be seen in a Storm jersey this season. 

Just a few days ago, Dr. Tim Hewett at the Mayo Clinic posted this video of an Achilles tendon rupture. 

How does a Human Achilles Tendon Rupture ...? Here's how ... check it out @MayoClinic Materials & Structural Testing Core @mayoclinicsport ! pic.twitter.com/qM9ZoXJ2Oq

— Tim Hewett (@Hewett1Tim) September 22, 2017

In real-time, it happens much faster with a high force while the foot is plantarflexed (toes below the heel, as occurs when jumping off the ground) and is generally described as feeling like you were shot in the back of your heel.  The video of Stewie's injury certainly looks like it matches the usual description.  When I wrote my thesis for PT School, a survey of WNBA and NCAA (Former) Big East Women's Basketball Players, only two people playing in the WNBA had recovered from Achilles Tendon Ruptures.  That's good news because it shows that people recover from this severe injury which is so much less common in elite athletes than the ACL tear we more frequently see.

Some additional elite-level women's basketball players who returned from Achilles tendon ruptures (I'm sure not an exhaustive list):
1) Nykesha Sales who tore hers in her senior year at UConn in 1998 and then returned to play nine WNBA seasons including six WNBA All Star Game appearances
2) Tamika Catchings - who tore hers in the 2007 WNBA playoffs and returned to play for the Indiana Fever in 2008 as well as in the 2008 Olympic Games
3) Liz Cambage - tore in the Australia vs USA exhibition game leading up to the World Championships in 2014 and ultimately returned to her national team and WNBA
4) Riquna Williams - ruptured abroad in Dubai in 2016 and returned to play for the LA Sparks
5) Brittany Boyd - tore hers in 2017 and returned to the New York Liberty
6) Chiney Ogumwike tore her Achilles in 2016 in China and returned to the Connecticut Sun Lineup in 2018
7) And of course, there are NBA players too.  Kobe Bryant tore his Achilles and made it back to the NBA, for about 1.5 more seasons.  Fellow Uconn Husky Rudy Gay (weird - he's the 3rd Husky on this list!) made it back with decreased minutes.   DeMarcus Cousins tore his last summer and a whole article was written on all the players who had injured their Achilles tendon and how many had made it back to the NBA.  The odds were ok... not great... but none of those dudes were Stewie.

For rehabilitation from a surgery, there are often protocols used by physical therapists as guidelines to progress someone recovering from an injury.  Protocols are helpful ways to communicate between a surgeon and a physical therapist because the surgeon was actually able to see the extent of damage done and how complicated the repair or procedure was.  So, for someone who is young and healthy like Breanna Stewart, her protocol may allow for a faster progression than perhaps the 65 year old dentist I rehabbed from an Achilles repair two years ago because her tissue quality should be better than his.  If, however, Stewie had been having aches and pains in her Achilles for years prior to this injury and her tendon quality was not in good shape, it's possible the surgeon would recommend a slower return to activities because of the health of the materials he was working with.  Regardless, there are standard healing times for different types of tissues that will need to be followed.

Numerous protocols exist online as guidelines to rehab from an Achilles Tendon Repair, but truthfully, they should all take into account the basic properties of healing and the input of the surgeon based on their findings.  For example, this protocol from the University of Wisconsin has the START of running (in a straight line) at 4 months post surgery.  That does not mean jumping, cutting, hopping on one foot, turn around jumpers, or doing any sort of awesome acrobatics that Breanna Stewart customarily performs in basketball games.

This protocol from Mass General Hospital starts with two weeks in a cast, then about twelve more weeks in a walking boot, before transitioning to a shoe.  Then, it allows for start of run/walk intervals at about five months post op with jumping and sport activities from six to eight months after surgery.  There's quite a bit of variability between these programs - but in my experience, nobody is getting back to sports, especially at an elite level like Stewie, in less than six months.  Tendon just needs that much time to heel and an annoyingly slow progression  in loading it to get back to previous level of activity.

Stewie posted a few things on social media heading into surgery today.  I'm sure she knows the road ahead is long, but that she's got a lot of good things on her side, most notably her age and support system.  That and she's a fighter.  Wishing Stewie a speedy recovery and can't wait to see her on the Storm Sidelines this season as she works her way back to the court for 2020.

UConn and the Storm: Me, Breanna Stewart, Kaleena Mosqueda-Lewis, Coach Auriemma, Sue Bird, Coach Dailey

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. 

To Dynamic Valgus - Or Not to Dynamic Valgus? That is the Question

Ann Strother

I was recently watching a Medbridge video on knee injuries when this image appeared on the screen.  HEY!  That's Ann Strother!  Hey girl!  A UConn Women's Basketball star overlapping with two of my years there as team manager, professional basketball player in the WNBA for a few teams while I was working for the Connecticut Sun, on my list for top 10 most beautiful three-point shots, and for sure one of the kindest people on Planet Earth - I was so excited to see her on the screen - except that it was with regard to knee injuries. 

The video was discussing her inverted "V" position called knee valgus which, according to several research articles (like this 2005 paper, and this 2003 paper, and this 2018 paper) may be one of many factors that increase risk of ACL injury in female athletes.  Medbridge had used this image demonstrating her continuing to exhibit this "faulty pattern" after already having had torn and rehabilitated from tearing her ACL. Ann tore her ACL during her sopomore year of high school.  Despite the injury, she was the 2002 Gatorade High School Basketball Player of the Year (her high school senior year) before heading to UConn where she was ultimately a two-time NCAA National Champion.

Kevin Durant

Anyways - seeing her on my computer made me think back to a few weeks earlier when I headed to California to see the Golden State Warriors play against the Los Angeles Lakers only for LeBron James to be out for the night.  I wrote about that here, but while watching the game, I observed that same knee posture repeatedly demonstrated by Kevin Durant of the Golden State Warriors.  See how he's standing at the free throw line about to shoot with his knees almost touching and his feet wider than his shoulders?  He does this a lot.  It's the same position.  While sitting at the game, I snapped this shot and sent it to all my favorite physical therapists and my current student in the clinic... because this knee position is repeatedly considered to be a big problem.

So... is it really a problem?  According to a lot of research, as I've previously mentioned, yes it is because of it's increased risk for injury.  But... is it a problem for Kevin Durant?  Should we be correcting this position in all of our patients who exhibit it?  Is it still a problem for Ann Strother, who I'm pretty sure is not currently playing basketball... but is still running around chasing after her two young children?  What I'm saying is - does every person who shows up in the PT clinic with this presentation need to have it "corrected" or do only some of them need to change it?  Or should we not be correcting it at all?  ACL injury prevention programs constantly work to strengthen the body to prevent exhibiting this type of movement and in PT school we're trained to squat "perfectly" without showing this pattern.  I'm constantly telling my patients to keep their knees out...but half of the time I'm wondering if it really matters. This is the movement pattern I see DAILY in my patients at Seattle Children's Hospital, most frequently in teenage girls who have knee pain, but certainly in boys and in all ages and with varying conditions.  I can tell you from experience that changing the squat position so that they don't do this inverted V is usually much less painful in many of these patients.  I can't tell you that training them to move without the V will prevent them from having an injury later on in life.

So what do we do about it?  As Robert Frost says, "Two roads diverged in a wood..." There appear to be different approaches to dealing with this presentation.  On the one hand, you can work to strengthen and reinforce a more "sturdy" pattern with the knees more straight above the feet rather than angled inward.  Glute strengthening, squatting, and training "proper" jump and landing form tend to be the typical components of a rehab program that works on this pathway.  Repeatedly trying to target a better posture and moving away from this dynamic valgus presentation is a common treatment approach. 

But Kevin Durant is paid about $30 Million per year... do you think he's going to let me change his free throw shot form?  Or anyone on his sports medicine staff for that manner?  Is he actually stable in this position?  Does he train in this position?   So the other option, that some people are now advocating for, is to train into these "suboptimal" positions on purpose.  There are recommendations to purposefully train ankle mobility and control into the position that is common for ankle sprains, particularly in those patients who have already sprained an ankle.  the thought process here seems to be that you can purposefully move into these patterns and try to develop control there so that you're less likely to injure yourself if you end up in that position.  In my search for literature on this approach, I came up empty-handed for scientific papers.  I know that when I injured my ankle years ago, putting it into the position of injury was painful and I wouldn't want to put myself there... years later I still don't purposefully do that motion... but if I play sports and accidentally end up there, I could see how I might be risking injury because I haven't trained my body to tolerate the position.  I did find some non-scientific articles that suggest doing this approach, like this one that discusses the idea of purposefully training into the movement patterns that you were injured in.  There are some people that suggest that if you don't train the injury pattern, you won't be resilient enough if life or your sport puts you into that position and you'll suffer another injury. 

And so...to dynamic valgus or not to dynamic valgus... that is the question. I'm here to tell you that I don't know the answer.  There's not enough evidence to support one way or the other - though there is definitely evidence showing that this position increases risk of injury - so the two approaches both suggest we need to be able to either avoid the position or control the position - not just ignore that position.  I think it might be a combination of both approaches.  I'm certainly not about to go give my patients who squat with dynamic valgus heavy load and have them repeatedly use that pattern - because that seems harmful, and as I've already written - we should Do No Harm.  But I'm also not afraid to consider putting people into and out of positions like this inverted V to see what they tolerate and show them that the human body can do some fascinating things.  What do you all think?

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!

"Long Term Cost of Quick Fixes"

Earlier this week, I attended the Seattle Pediatric Sports Medicine quarterly symposium entitled "Long Term Costs of Quick Fixes." I've previously written about that group with regard to their ACL Injury Prevention program here and here. This symposium was a panel of 4 elite athletes discussing their careers and injuries and some of their interactions with healthcare providers.  It made me think of all the sports movies, like Varsity Blues, with scenes of an injured athlete with a needle about to enter their body to get them back on the field right away. For me, the highlight was seeing Seattle Storm co-owner and Rowing Olympian Ginny Gilder! It's always fun attending networking and educational events and learning of the connections between people you know and the people you meet.

Ginny Gilder, Kerry Carter, Seth Orza, and Peter Shmock

Here's a little bit about each of the elite athletes who were included along with some insight to injuries they sustained and some quotes they said which stood out to me.

1) Ginny Gilder -  An Olympic Silver Medalist in Rowing in the 1984 Summer Olympics and also qualified for the 1980 games that were boycotted.  She attended Yale University, has launched multiple companies, all civic-minding and many empowering young women.  She is currently one of the owners of the Seattle Storm - so I was super excited to run into her, and she wrote a book called Course Correction: A Story of Rowing and Resilience in the Wake of Title IX reviewed as "Wild meets Boys in the Boat, a memoir about the quest for Olympic gold and the triumph of love over fear."  Guess what's now on the top of my reading list for 2019!?!

Injuries: Ginny told about her experience breaking a rib and having a cortisone injection to the intercostals to calm things down and being told by the physician to take some time off from rowing, only to be on the Charles River in Boston on a beautiful sunny day and knowing she just had to be on the water, getting into her boat for a casual row, and ultimately feeling a pop in her ribs that she knew was because of not listening to the advice she had been given.   She also commented on back pain that has been chronic and requires continued care today.  The common theme throughout the presentation was that at the elite level, athletes do whatever it takes to compete, sometimes ignoring advice for the long term.

Quotes:
- "Young athletes depend on competent adults to make decisions for them.  As a parent, you may not know how to deal with your kids injuries.  Parents just don't have the knowledge/experience to make all these decisions."
- "Ask parents why they encourage their kids to do sports?  What role sport is playing in setting up their child for success."

The controversial Goldman's Dilemma was also referred to, though not by name.  This was a study done in the 1970's where athletes were asked if they had the option to take a drug that would promise them the highest level of success, would they take it even if they knew it would kill them in five years.  It was a component of the anti-doping legislation that would later come out because at that time, the surveyed athletes would frequently respond that they would take the drug for the success.  Later editions of the study found different results, but some of the commentary focuses on the differences of how an elite level athlete thinks and operates compared to the general population.

2) Kerry Carter - played fullback for the Seattle Seahawks in 2003-2004 and the Washington Redskins in 2006 as well as in the Canadian football league. (I didn't actually know that Canada had a professional football league!)  He currently works as the Vice President for Football Operations for a company called Atavus Rugby and Football - whose CEO is Karen Bryant, former President/CEO for the Seattle Storm.  Kerry's responsibilities at Atavus include teaching football coaches how to teach football players proper tackling and they use scientific metrics to try to prevent injuries.  When asked about the other sports he played, he said volleyball - which is a rare combination for a football player.

Injuries: Kerry described an ACL tear, a shoulder labrum tear, a shoulder AC joint injury, and others that were not as severe, but that he went through multiple surgeries and worked hard each time to get back to the field.  He also discussed some of his lingering aches from those past injuries, and could describe some of the tactics his teammates used including one who had a pharmacy in his locker and would pop tons of pills daily to be able to tolerate the rigors of football.

Quote: "The thing I wish I knew when I was hurt was if there were other options available.  But to be honest, I may not have chosen any alternative that would have taken me longer to get back on the field."

3) Seth Orza - a principal ballerina for Pacific Northwest Ballet and a 20-year professional dancer.  Seth discussed that he also runs and conditions and lifts weights in addition to a 90 minute daily warm-up routine with the dance company and about six hours of rehearsals per day.

Injury: Multiple episodes of back pain.  He said "my back exploded at age 14" and he actually didn't receive healthcare for it, though he's not entirely sure why.  He spent some time in bed and then was able to return.  Since that time he has had additional back injuries and multiple PRP treatments to his knees, and he gave considerable credit to his PT, (my former coworker) Boyd Bender.

Quote:When discussing elite level sport or performing arts: "You're going to get injured, but it's a matter of how you deal with it, who you trust and surround yourself with, and whose advice you take to get through it."

What struck me with Seth's input was the words he used to describe his back injury - because this has come up in presentations that focus on the biopsychosocial model and how much impact words have.  Seth is in his mid 30's and the imagery of his back exploding at age 14 has been reinforced into him for 20 years... but maybe it doesn't impact him!

4) Peter Shmock - An Olympian Shot-Putter who competed in the 1976 games and also qualified for the boycotted 1980 games and now works in Seattle as a high performance coach.  In the late 1990's, he was the weight training coach for the Seattle Mariners and Pacific Northwest Ballet and has trained a long list of elite-level athletes.

Injuries:  Peter was the only one of the group who reported that he hadn't had any major injuries because of the innovation of legendary track and field coach at the University of Oregon and for the USA team, Bill Bowerman, who believed in recovery and a more holistic approach.  If his body didn't feel right, his training or competing was modified and he felt this was essential to his performance.

Quotes:
- In consideration for those he trains - "What is enough for you today?"
- In consideration for athletes who tell him they think they need to just keep doing more, rather than modify their training - "Do you want to do mindless work? Or do you want to improve?"
- "Train or rehab with intent and at a sustainable rate."
- "Be an advocate for the kid you're working with.  The problem with parents/coaches is that they often don't know how to advocate.  They only know go hard or go home."

As a healthcare provider for children and young athletes as well as for elite athletes, I took many important pieces from this presentation and had a great time.  Looking forward to seeing what the group puts together in 2019!