Ways to Move This Summer

Earlier this week, I had a unique opportunity to do some work with a small child, maybe about 3 years old? She wasn't my patient... it was a special circumstance...  and, though she was very, very cute, this was entirely out of my comfort zone.  Though I do work at Seattle Children's, my patient population is between ages 5-21, with the majority of them between ages 9-15.  That's right, I spend most of my day with teenagers. It's awesome.  The younger kids will still talk about Disney princesses or super heroes and the older ones can discuss books I read when I was a kid, sports, movies... nothing deep, nothing life shattering.  It is a rare occasion that an older patient comes in and discusses politics or religion or their job - though several of the younger kids talk about their church camps or youth organizations or really interesting volunteer projects they work on and some of the teenagers do work.  It's entirely different from the conversations I used to have when I worked with adults who had stress from jobs, older parents or younger children, money woes, car break downs, or deeper interests that required me to think.  A 3 year old was uncharted waters.

One does not simply sit and have a conversation with a child of this age.  This particular child didn't even really sit at all. She was constantly on the move, excited to explore the world around her, touch everything colorful in the Seattle Children's Rehab space.  I'm not sure how parents do it!?!  I'm not sure how my coworkers who do work with children this little do it!?!

Anyways, I was tasked with finding things for this little girl to do for about twenty minutes.  Fortunately, I had just read a new Community Education flyer from the Seattle Children's Sports Medicine Department entitled "35 Ways to Move Your Body This Summer."  My awesome colleagues - a rock star physician and three incredibly talented physical therapists (also team #StrongWomen) - collaborated on this project to provide families with ideas to keep moving.  (Message me or comment with email address and I'll send you the whole PDF!)  This list came in handy when trying to identify things to use with a small child - but could easily be applied to all ages - kids through adults - to find ways to stay active during the summer time - and beyond!  Here are some of my favorite suggestions from the list, and some that I used to survive working with a tiny kiddo!

1) Make an obstacle course: in the clinic we have access to lots of cool things to climb over, jump on and off of, balance on, and even a tunnel to crawl through. This is an easy thing for children to help build and then use to keep moving, and then rearranged.  Or, perhaps you're going to the playground and using the items there to make an obstacle course.  Either way - so much delight from that little girls face with crawling through the tunnel and jumping onto colorful circle dots.

https://www.amazon.com/Discovery-Kids-Adventure-Removable-Lightweight/dp/B07BR83L6J/ref=sr_1_55_sspa?keywords=crawl+tunnel&qid=1563483750&s=gateway&sr=8-55-spons&psc=1

2) Water Play: this could be in a pool or at the beach or running through the sprinkler in your back yard.  At the beach, you can bring various toys to play with - like a beach ball or shovels and pails to build a sand castle with a moat.  If the water isn't too cold where you are, and you're going in to swim - you can also play water games, swim races, hand stands in the water, or see how long you can balance on one foot while in the water.  For me, water play is kayaking.  In fact, I wish I was in my kayak right this minute.  But there are so many other options good for kids!  In Seattle, you can rent Canoes near UW, link  or rent kayaks or paddle boards at Green Lake or multiple places on Lake Union.  Tons of the teenagers coming into the clinic have been trying out paddle boarding this summer because it's so popular here.  Endless options to get outside and keep on moving.

3) Boot Camp or 4) Circuit Training and 5) Stretching: Attached to the "35 Activities" is a list of exercises and a list of stretches. But these additional lists can be organized in tons of different ways.  For example, boot camp directs you to choose a few exercises such as jumping jacks, push ups, sit ups, running in place and you do as many as you can for a minute, and repeat the routine a few times.  This idea is similar to circuit training, a technique I commonly use in the clinic, though the intensity is a bit different.  Using a variety of stretches, you could create your own home yoga class!  Even more fun, lay a towel out in the yard and do it outside!  I've previously written about my affinity for yoga here and strongly feel that though the intent is usually stretching, several stretches require you to work hard and also improve your strength and overall fitness. The list goes on with many ideas for games using these exercises such as assigning each one a letter, and then spelling out your name or a word.

So many great suggestions, and I've only touched the surface of the list from my coworkers!  This resource is really great - I can't wait to share it.  Don't forget about the tons of ways you can make walking fun: go somewhere different to explore a new neighborhood, make a list of objects to find (scavenger hunt) and see how many you find, walk your dog, go with friends, do it in the woods or at the beach, or make a game out of it like dancing every time you see a car drive by you.  Ride your bike or a skateboard or a scooter.  Also, a pack of sidewalk chalk makes your driveway into an endless number of games - like four square or hop scotch or into a race track.  My niece and nephew used to make a race track in their driveway with lava areas they had to avoid or stop signs or change of direction arrows that they drew before riding scooters or bikes or skates on it.

All these suggestions are a great follow up to my post last week about the negative impact of early sport specialization.  That post discussed concerns with athletes starting to play only one sport too young.  Though there is varying information, it is recommended that kids should play multiple sports until at least finishing middle school, probably somewhere around age 14.  This 3 year old had NO problem with wanting to climb on things, jump on things, stack cones, hop, skip, jump, squat, throw, kick... you name it, there was a TON of variety.  I don't think you need to be participating in multiple organized sports - you just need to move in more ways.  For example, strength training in an organized manner rather than playing your sport year-round could be a great way to improve your fitness and make a more skilled athlete.  Or, have a dance party with your friends... it's certain to look different than your usual sports.

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. 

"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!

Warm Up Like You Mean It

Photo Credit: Seattle Pediatric Sports Medicine
I'm front-right, and I need to work on my landing.

High school and college basketball season is here!!!!!! (YAY!) I'm so fortunate to have many friends who coach or work in high school and intercollegiate athletics.  This post is for all of you.  It's tinted towards basketball, but it could apply to any sport. 

Working in pediatric sports medicine, I notice clusters of injuries which coincide with the change in sports seasons.  This is, of course, a generalization, but it seems that there are patterns. Some examples: shoulder overuse injuries in swim and baseball season, concussions as football gets underway, "shin splints" in cross country runners who may have ramped up too quickly, and ankle sprains with soccer and basketball.

So now that the sports seasons are changing and I'm expecting to start seeing basketball players in the clinic, I thought it was time to hop on my soap box suggesting the use of a dynamic warm-up as an injury prevention tool. It has recently come to my attention that some of the local high schools are so overbooked on their gym time that the athletes are expected to warm-up on their own before they're allowed access to the court.  The team does not warm up together unless the captain organizes the group beforehand.  To me, that means it isn't mandatory.  It isn't a priority.  If teams only get 2 hours of on-court time per day, they'll use the time to focus on sport-specific activities, no time wasted on preparing their bodies.  I get it, but I don't approve.  I think you might end up with a team that knows a few extra plays, but you also might have a few more injured players on the bench.  Is it worth it?  There's quite a lot of research on the benefit of ACL injury prevention programs, including the 2018 National Athletic Trainer's Association Position Statement written by an awesome group including my mentor, Dr. Lindsay DiStefano, which can be found here.  (That paper includes the components you should include in your injury prevention program... no worries ... they're going to be briefly summarized below.)

I've previously mentioned that an injury prevention program is the same thing as a performance enhancement program here.  Most of these programs are targeting prevention of ACL injuries, but there is no reason to believe they couldn't help prevent other injuries, as well.  The Seattle Pediatric Sports Medicine Group's ACL Injury Prevention Program and the FIFA 11+ programs were both designed to be used as a dynamic warm-up.  Note that I'm using three different names for the same thing: Dynamic warm-up, if used properly, is the same thing as an injury prevention program, which is the same thing as performance enhancement.  (There are many other programs out there, but these are the two I'm most familiar with and have seen teams use most frequently. Ignore that they're set on a soccer field... it doesn't matter!). 

Let's back up for a moment.  What is a dynamic warm-up?  A dynamic warm-up is a progressive increase in the intensity of exercise placed at the beginning of a training session to prepare the body for the work it will do.  It targets increasing the cardiovascular system and getting the blood flowing as well as progressively increasing the use of the musculo-skeletal system and the nervous system to optimize the body for movement.  There are numerous publications that recommend doing this for a variety of reasons.  Like this article for injury prevention, and this one to optimize power. You've probably learned that you shouldn't skip meals leading up to Thanksgiving Dinner (though many people wrongly think this means more room for extra desserts, you're better off having some breakfast earlier in the day and regular eating the day before.  You're welcome.)  Why would you go from sitting in school all day long to sprinting up and down the basketball court without preparing your body?

Great, so now that we've determined that you're going to include a warm-up in your teams' practices and before games, why not decide how to design the warm-up for optimal performance?  This really can't be just about going through the motions.  It needs to be intentional.  It needs to be focused.  This is a great opportunity to develop a plan that team captains can lead early in the season so you can help teach individuals who might need more help with some of the movement patterns.

No more sitting in a circle stretching and chatting about last night's episode of Grey's Anatomy. Focused, purposeful movement.  There are SO MANY activities you can include if you're not able or willing to use one of the programs already designed for you due to the amount of time they may take.  I urge you to consider one of those programs, but alternatively, take the components from those programs and use them interchangeably.  If you structure your practices so you know what things you're going to work on, you can also structure your warm-ups so you know what you're going to work on in that time. What good is running a play for your shooter if they're not yet getting off the floor with their jumps?  What good is spending an hour teaching your team how to get a pass into the post if your center doesn't understand the benefit of getting low (in their squat pattern) to back down their defender and take it to the hole.  I'll say it one more time for the people in the back, injury prevention IS performance enhancement and a dynamic warm-up is an easy way to fit this into your daily routine.  If you help develop your athletes into just that - better athletes - they'll have more skills available to them to apply to whatever sport they're playing.

Components you should consider using in your warm-up.
1) mobility/flexibility (walking stretches)
2) strength (of the hips and core as well as the upper body) which can be done using:
3) movement patterns (squat, lunge)
4) jumping (plyometrics)
5) balance
6) agility (cutting/change of direction)
According to the NATA position statement, you should be using at least 3 of the above categories.  The prepared programs use all of them.

I don't have data to support this claim, but in general, I would say that most of the injured teenage girl athletes I see in the clinic do not jump or land in an "optimal fashion".  They're generally strong, but need to be stronger for the demands of the sport they're playing.  They often can't squat without falling over and I don't think I've seen any who can control a single leg squat.  As a coach, if you don't know how to teach these things to your players or why they're important, you could ask a local physical therapist to come in and screen your athletes and give you some pointers.  Or call me and we can chat about them!  Seriously... any time.  If this post prevents one high school basketball player from injury, I'll be happy.  Or if this post changes the way a coach organizes their practice to include more of the above components, I'll be elated.

As a reminder -
Every jump shot is, in fact, a jump and a landing.
Most rebounds are, in fact, a jump and a landing.
Jump-landings are, in fact, related to the squat.  If you do it on one leg, it's more related to a single-leg squat.
Defensive stance and the "triple threat" position are, in fact, related to the squat.
If you are standing on one leg for any reason - landing from a rebound, trying to save a ball from going out of bounds - you need to be able to balance.  Most teenagers can easily stand on one foot on a firm surface and balance steadily without a problem.  But if they have had an ankle sprain, it gets much more difficult.  If they're turning their head - like they would for an outlet pass or to avoid a defender - it gets much more difficult.

I'll go back to the discussion of getting the high school girls into the weight room another day, but for now, strength training could be as simple as a few sets of squats and a few lengths of the court with walking lunges and a few side planks - all with body weight - to focus on movement patterns and strengthening.  That could easily be a huge part of their warm-up before playing basketball.  (If you're preparing for a strength training workout, the dynamic warm-up should more closely mimic the motions of the exercises to be completed, but for a sports practice, there's a ton of variety available that will be relevant and beneficial). 

Last thought on these warm-ups.  Something that makes my mind go nutty is watching a team practice where they spend a good 15 minutes warming up, and then the coach has them circle up and stand still to discuss the upcoming practice, ultimately cooling them back down.  Prepare your team's mindset before the warm-up so you can transition right from the warm-up into business.  You can't avoid it during games when you substitute a player from the bench and they've been sitting for the whole first half.  That player is cold and has to use the game to warm up. Hopefully the energy of the game has kept the blood pumping a bit.  Hopefully they do some jumping up and down on the sidelines when your team makes a great play, to keep them warmer.  But on a daily practice routine, you can keep them warm and ready to go.

Any questions?  Let me know if I can help.
Here's to a great basketball season with zero injuries for your team.  And lots of offensive rebounds.  Those are my favorite.

(Go Cheshire Rams! Go UConn Huskies!)

Women's Basketball Summit

I'm participating in the Women's Basketball Summit!  This event is like attending a conference from the comfort of your couch.  You can wear sweats, make some popcorn, put your feet up, and watch interviews over a four day span from people of all different backgrounds talking about basketball!  The target audience is for young female athletes, their parents, and their coaches - to gain new perspectives about ways to improve performance both on and off the court.  The panel includes college basketball coaches and administrators, strength and conditioning coaches, physical therapists, injury prevention specialists, personal trainers, communication experts, and more!

Today I was able to record my discussion with host Jen Brickey. Jen is a strength and conditioning coach in Massachusetts who played Division I College basketball at Hofstra University in NY.  I've been fortunate enough to meet several of the other presenters throughout my career working in women's basketball - and I can tell you they're really bright people with unique and interesting backgrounds.  Right now, if you want to register to watch, you can have access to all the videos for only $5 when they go live in September!  Prices will go up in about a week!

We had the opportunity to talk about my responsibilities with the Seattle Storm, work I do in the clinic at Seattle Children's Hospital as a Sports Physical Therapist, common injuries in women's basketball, and recommendations for youth athletes.

Check out the website.  Sign up here! Mark your calendars. And then let me know what you think!

What Do Physical Therapists Do? Installment #4: We Return Athletes to Sports Participation

Welcome to the fourth installment of "What Do Physical Therapists Do?" I chose to use this as a recurring segment because there are several common misconceptions about what we actually do, probably because we do so many different things! This 2006 paper noted that over 1/3rd of participants surveyed (college-aged potential physical therapy students) were unaware of PTs' ability to help decrease pain and promote health. That same paper mentions the lack of knowledge of the general public regarding the amount of education required to be a physical therapist and what that training would include. 

Overall, the key underlying action of a physical therapist is guiding our patients or clients back to their optimal function - whatever that function may be.  I often feel like people think our primary purpose is to help people get out of pain, despite the report from the previously mentioned 2006 paper.  While pain relief is a consideration, it's really more about the activities. So this recurring segment looks at various ways we help people get back to their chosen functional activities.  In the past, I've discussed that we strength train (#3) here, we listen to the needs of our patients (#2) here, and we examine body mechanics with different movement patterns (#1) here. 

One of the most common questions I'm asked by patients and their family members is "When can I get back to X activity?"  In this scenario, X can be anything.  Some are obvious functions or activities that aren't surprising... when can I run or exercise, when can I lift my toddler, when can I go back to work, when can I walk without crutches, when will I be able to reach the top shelf of my closet... an endless list.  Some activities have been less obvious (or less sensible)... when can I get back to head-banging at concerts was a surprising question I've been asked by a gentleman recovering from neck pain after a car accident.  It surprised me - but that's what he wanted to do.  And why a teenager who had a severe injury on a trampoline would ever want to get back onto a trampoline shocked me... but they ask! (Side note - if I ever have my own children, I hope to find a way to ban them from trampolines.  SO MANY injuries.)

The activities are frequently sports-related so it is a responsibility of a physical therapist to clear athletes to return to sports. This week, I was fortunate enough to present the new Upper Extremity Return To Sports Assessment that will be implemented at Seattle Children's Hospital to the Sports Medicine Team of Physical Therapists and Athletic Trainers.  The program we developed has not yet been thoroughly tested despite being based on published research, so it's still a work in progress.  It includes a group of tests to assess athletes who have had upper body injuries and/or surgeries as criteria to get back on the field/court.

Seattle Children's Hospital already has protocols for returning kids to sports after ankle and knee injuries, so we had a template to use of what has been helpful in the past.  I like using the lower extremity assessments because they make it easy for a kid and their family to understand that they can go back to their sports when they pass all their tests. There are benchmark goals that help them progress in activity as you go along so having a series of tests at the end fits into the way things progress along the way.  Using tests and goals motivates patients.  For example, with consideration for surgical protocols and healing timelines, I tell kids that they can stop walking with crutches when they can stand on their injured leg for 30 seconds with steady balance and when they can complete 10 straight leg raises without any bend in their knee.  Those are usually components of their home exercise programs and they often know if they're getting better and coming closer to meeting the goal. The goals help motivate them to work on their home exercises and they're measurable.

Did you know that if you are a healthcare provider - of any kind - and you clear an athlete to return to sports prematurely, you can be held liable if they get re-injured?  You can.  Did you know that a physician who clears an athlete back to their sports usually bases this on a tissue healing timeline whereas a physical therapist who clears an athlete back to their sports bases the decision on movement mechanics and other test criteria - such as the tests in this protocol - to make the decision?  Something I find interesting about myself as a healthcare provider is that I rarely tell a patient to stop participating in an activity if they're tolerating it enough - but when it becomes my responsibility to allow them to return to a sport that a physician has discontinued their activity from, I'm much more confident in my decision if they have to complete tests showing they're ready in a controlled environment.

A basic summary of the categories of tests included in the protocol for upper extremity injured athletes returning to sport are as follows:
1) Range of motion comparison between shoulders with consideration for the total arc of motion for internal and external rotation.
2) Strength testing comparison for shoulder internal and external rotation as well as for grip.
3) Endurance testing observing how many push ups can be done with proper form.  There are published normal values for this test by age and gender and, in the USA, this is part of the physical fitness testing conducted.
4) Upper body stability testing including the upper quarter Y Balance Test and the Closed Kinetic Chain Upper Extremity Stability Test
5) Power assessment using a seated shotput test.
6) Biodex testing as available.

Using numerous published papers on each of these tests, criteria were developed and the sports medicine crew at Seattle Children's will start to use the tests to determine if kids are ready to go back to their activities.  There is still not enough published evidence for returning athletes to sport from any injury, so developing a protocol like this is not only challenging, but needs to be supported by clinical judgment.  If you or someone you know is being treated by a physical therapist to get back to playing sports, you should ask them what criteria they use to determine if you are ready.  Feeling good and being pain-free isn't enough and we want to prevent future injury as much as possible.

ACL Injuries No Longer a Career - Ender

This post originally appeared on the TD Athletes Edge blog on January 24, 2018 - my first guest post!  Special thanks to Tim DiFrancesco for the invitation and the learning opportunity.  

When it comes to scientific research, anecdotal evidence is lowest on the hierarchy of resources.  As a clinician, it is vital to review higher levels of evidence, but sometimes it’s impossible to ignore what you witness.  There are numerous publications reporting higher incidence of ACL injury in females compared to males, and there are also studies that outline the outcomes to these athletes.

When I was the manager for the Cheshire High School (Connecticut - GO RAMS!) Girls’ Basketball Team, my friend tore her ACL going for a breakaway layup and landing in a heap on the floor.  A few years later, as a team manager for UConn Women’s Basketball (Go Huskies!), I was standing three feet away from a player when she changed directions during a drill and dropped to the floor with a yelp…torn ACL. After an ankle sprain you're back to playing in a week or two… but with these injuries mean you're out for almost a year. 

Rosemary Ragle was the Athletic Trainer for UConn Women’s Basketball for 18 seasons.  She was kind enough to share with me that in her tenure, 6 athletes (average of 1 every 3 seasons) tore their ACL and she also treated several others, at least 6 more, who had the injury prior to arriving on campus needing rehab.  Of the six that were injured at UConn, all of them returned to the team roster and most moved on to play professionally. 

James Doran, the current Men’s Basketball Athletic Trainer at UConn has been there for 12 seasons.  He confirmed what I had read in this Hartford Courant Article that he had worked with two athletes (average of 1 every six seasons) who tore their ACL in a Husky jersey. AJ Price, later played eight years in the NBA and Terry Larrier is currently the team’s 2nd leading scorer.

After UConn, I spent four seasons with the Connecticut Sun WNBA team.  During that time, four Sun players (average 1 per season) tore their ACL either in a Sun jersey or while playing overseas.  All four recovered and played again at an elite level including one winning a 2016 Olympic Medal.  I asked Tim DiFrancesco how many Lakers guys had torn their ACL in his six seasons in the NBA: Zero! Basically – there’s a boatload of anecdotal evidence with a small sample size that demonstrates females are injured more often than males. At the end of the day, though, most of these injured athletes ultimately made it back to their previous level of competition.

My graduate research studied lower extremity injuries in the WNBA and (former) Big East Conference Women's Basketball Teams. Previous studies showed that ACL injury was uncommon: 3-5% of basketball players, but that was because it was looking at how many athletes were injured in a season.  From that perspective, sure, it's rare to tear an ACL. But my research looked at a large sample of women’s basketball players (246) over their whole career and showed that almost 25% of these athletes had experienced the injury, some of them multiple times.  25% doesn't sound so rare to me. These athletes were all currently playing in Division I College Basketball or in the WNBA at the time of their participation having overcome an ACL injury. 

To my knowledge, a study of this type has never been conducted in the NBA, but based on this 2006 article, the WNBA experiences more ACL tears than the NBA. A CBS Sports7 report from 2013 outlined that in each NBA season, up to 5 players (out of 491 roster spots) tear an ACL which is about 1% of all the players in the league. At that time, this was an increase to previous NBA seasons. If a set of teammates don't both experience the injury, 25 teams out of 30 will go through the season unharmed. I wish I had the access and approval to do my study in the NBA to see how many of these guys have ever torn their ACL in their whole career – and then made it back.  My suspicion is significantly less players have been injured in the NBA than in the 25% in the WNBA, and the majority have made it back to playing.

Twenty years ago, and sometimes still today, an ACL tear was considered a career-ending injury. It’s still devastating because of the time lost from sports and school for the injured athletes, lost work time for parents, costs, extensive rehabilitation, pain and potential long term physical and mental consequences.  Though it is easy to see the gender disparity, these injured athletes mostly return to basketball and are able to excel at a high level of competition.  Why these outcomes have improved is largely speculative, but since we started out anecdotally, why not suggest reasons for the improvement?

Perhaps surgical techniques such as physeal sparing in the youth population and the trend towards more bone-patellar tendon-bone grafts over hamstring grafts or allografts is a contributor to better outcomes.  When there is not additional internal derangement to the meniscus, it is likely that more accelerated protocols for early range of motion and weight bearing in rehabilitation are getting these athletes back into shape quicker.  There is research on return to sport protocols which have improved the process of assessing injured athletes to make sure they’re ready for return, hopefully preventing recurrence of injury.  There have been studies examining mechanical faults during ACL injuries as well as muscular imbalances that increase risk of injury which can be treated by physical therapy.  The development of more ACL Injury Prevention programs has been increasing and groups are working hard to get them disbursed that this may be improving outcomes.

Why does any of this matter?  It matters because even though these injured athletes make it back to their sports, there are a large percentage of them that could be preventable.  There is now ample research showing that ACL injury prevention programs reduce the risk of injury.  Newly released in January 2018 is the National Athletic Trainer’s Association Position Statement on ACL Injury Prevention which is the most up-to-date data on evaluating the levels of evidence that support the importance of participation in these programs.  It outlines that participation in an ACL injury prevention program can reduce the risk of ACL injury 52-61% but it can also reduce risk of other injuries, too. If your child, particularly middle-school or high-school aged is participating in a sport, ask their coaches if they’re doing a program with their team.  If they’re not, have your child independently examined by a physical therapist, a skilled strength and conditioning team such as at TD Athletes Edge, or consider some of the following resources which may be helpful:

1) Seattle Pediatric Sports Medicine ACL Injury Prevention Program: http://seattlepediatricsportsmedicine.com/injury-prevention/injury-prevention-warm-up-program/injury-prevention-routine/

2) FIFA 11 ACL Injury Prevention Program: https://www.kort.com/uploadedFiles/KORT/Content/Services/Sports_Medicine/Concussion_Management/FIFA-the-11-Booklet.pdf

3) Cincinnati’s Sportsmetrics ACL Injury Prevention Program: http://sportsmetrics.org/

4) As a parent or coach, watching an ACL Injury Prevention Program and trying to implement it with your child/team is not enough.  A skilled clinician should be implementing it or checking the movement patterns.  This is imperative.  Ask a local physical therapist or skilled strength coach to watch your child’s movement to assess their risk for injury and to develop a program tailored to their needs to decrease their risk.

References 

1)      Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: Summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42(2):311–319. PubMed

2)      Deitch JR, Starkey C, Walters SL, Moseley JB. Injury risk in professional basketball players. A comparison of women’s national basketball association and national basketball association athletes. Am J Sports Med. 2006;34(7):1077–1083. PubMed doi:10.1177/0363546505285383 7. https://www.ncbi.nlm.nih.gov/pubmed/16493173

3)      Renstrom P, Ljungqvist A, Arendt E, Beynnon B, Fukubayashi T, Garrett W, et al. Non-contact ACL injuries in female athletes: An international Olympic Committee current concepts statement. Br J Sports Med. 2008;42:394–412. PubMed doi:10.1136/bjsm.2008.048934 http://bjsm.bmj.com/content/42/6/394

4)      Gordon AI, DiStefano LJ, Denegar CR, Ragle RB, Norman JR. College and Professional Women’s Basketball Players’ Lower Extremity Injuries: A Survey of Career Incidence. IJATT. 19:5 (22-35). September 2014.  http://journals.humankinetics.com/doi/pdf/10.1123/ijatt.2014-0020

5)      Padua DA, DiStefano LJ, Hewett TE, Garrett WE, Marshall SW, Golden GM, Shultz, SJ, Sigward SM, National Athletic Trainers’ Association Position Statement: Prevention of Anterior Cruciate Ligament Injury. Journal of Athletic Training. 2018; 53(1).

6)      Hartford Courant Article: Dom Amore. UConn Men’s Insider: Doran is a trainer with patience, but too many patients. January 31, 2017.  Accessed January 9, 2018. http://www.courant.com/sports/uconn-mens-basketball/hc-uconn-men-insider-james-doran-0201-20170130-story.html

7)      CBS Sports Article: Ken Berger. ACL Injuries Once Were Rare Occurrences in the NBA But No More: October 4, 2013. Accessed January 12, 2018. https://www.cbssports.com/nba/news/acl-injuries-once-were-rare-occurrences-in-nba-but-no-more/