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. 

Conflicted

Hey everyone.  This past week I've been conflicted with something I use in my patient care.  Conflicted enough that I've brought up this conversation with my coworkers and a close PT friend and it's still weighing heavily on my mind. So now it's here for others to read and comment on. Please send your thoughts, fellow PTs.

There is a physiotherapist out of the UK named Adam Meakins who posts regularly about various physical therapy topics including issues with the profession, our techniques, and our shortcomings. He goes by "The Sports Physio" and has a very respectable social media following: 54.4K twitter followers and 76,000 followers on his blog... compared to my 270 twitter followers and 9 blog followers (plus my mom).  I present these numbers for the sole purpose of demonstrating that he's a well-known PT.  I have followed him and read his materials for about a year and have come to find that he challenges my thought processes, which is essential for my growth, though sometimes is hard to swallow.

ID 2530204

© Chrisharvey

| Dreamstime.com

In the past week, two physical therapists who I respect - but also occasionally differ in opinion with - have mentioned Adam Meakins. One of them linked to a video Adam posted on Facebook which he further discussed in this recent blog post and he was also interviewed on this podcast about a different subject - so he's just come up a lot more this week than usual and his messages have been on my mind.

This post is not meant to be an attack on Adam.  He works hard to improve healthcare and physical therapy practices - noble efforts with messages I often agree with.  He expresses his perspectives confidently in an unapologetic abrasive manner that has a certain appeal for getting his message across.  (AKA - there's no bullshit.  He tells it like he sees it.  I love this about him.) He's a physio and he's trying to help people live healthier lives doing the things they love to do... so I respect him. I have never met him in person (yet), but I do pay attention to what he's posting because I think his perspective is really valuable, even if mine differs, like it does right now.  I wonder what it would be like to shadow him treating patients for a day.

The blog (and video) he posted discuss the use of palpation (evaluative touch) and how we present our findings to patients.  

Adam listed multiple studies as his references, many of which I have now read, which report that either more research is needed or that palpation techniques are not reliable. To my knowledge, there are not many papers that say the opposite, and my skills of critically appraising research are certainly inferior to Adam's, but this paper contradicts the research presented in Adam's blog post.  I had to search to find that one.  I searched because I have found multiple occasions where someone has told me to do something with patients because they read an article about it - and I was able to find multiple publications that stated the opposite information.  So when I read his post and immediately felt like it didn't sit right with me, I had to do some searching. Maybe I don't understand his message properly.  Maybe I'm too biased to see through my own thought processes.  Regardless, I am conflicted.

Adam points out that physical therapists are not good at palpating things like "knots" or "trigger points" or "tight bands" or "joint play at the spine" and that we are not consistent between providers or even consistent with our own practices.  In non-medical terms - if you smell pizza in the morning and identify that it is, in fact, pizza - but in the afternoon smell the same exact thing and identify it as a cheeseburger, you're not being consistent with your own findings.  And to tell someone that you have a cheeseburger when it's actually a pizza could be confusing or problematic.  Scientific research says that physical therapists touch patients to evaluate them but report different findings. The research also says that we cannot identify if parts of the spine moves abnormally or identify which level of the spine we're touching with consistent results.

Now... when I palpate a patient and feel like a segment of their lumbar spine feels hypomobile, I agree with Adam that it makes no sense for me to state the specific level of the spine to the patient, because I don't have XRAY vision to know I'm 100% accurate and, working with kids, it probably doesn't have much meaning to them anyways.  I worked with a patient with neck pain today and, as I've previously mentioned, I currently have a student.  So when I palpated a segment that I thought was hypomobile (and reproduced the patient's symptoms), I relayed to my student that she should look around where C3 would likely be because I can't actually be certain that it is C3.  I think it is, I'll document it as such, but the reality is - I don't actually care exactly what level it is.  I feel something, it reproduces my patient's symptoms, it's where I want to treat.  I don't know how I could have better directed my student to what I found for her to feel it herself, but the patient felt relief with mobilizations at this region.  Adam's post suggests that this confirms my bias to this being a useful technique.

Maybe it's more about the way the care is interpreted and explained to the patient than the actual identification of specific structures and the interventions that are applied that Adam has a problem with.  I agree with him that we really need to STOP TELLING PEOPLE their L5 is rotated or their back is out. What does it mean for you to throw your back out?  That is not medical terminology.  Can your back ever be in?

But... when I palpate, particularly at the spine, I do feel "something." Of course I'm biased on my opinion of my own patient care...it would be wrong of me to use interventions that I did not believe were helpful and, since I also manipulate the spine on occasion, I feel it is essential for me to use palpation to identify hypomobile segments of the spine.  I feel hypomobility in some regions compared to other regions in the same person.  While I don't generally compare spinal mobility person to person because I don't find that useful, I do correlate certain patient responses with what I'm feeling in soft tissues in my hands and compare that to what I've felt with others.  If a person laying on the table in front of me presents with a neck that is tender to palpation and their cervical and thoracic spine feel stiff compared to their lumbar spine, I want to treat this issue.  Maybe with manual therapy.  Maybe with exercise.  Maybe with both.

I used to do things very differently.  I no longer say to my patients, "Wow your neck is really stiff," or "Your 1st rib is stuck"- though I do sometimes feel a stiff neck and a hypomobile first rib... which I treat.  I don't say these things any more because it freaked out the patients.  They'd worry about their rib being a problem.

I used to look at the pelvis and tell patients that they had one leg longer than the other. All the time.  Guilty. I didn't know better, then! I used long axis distraction of a leg to distract the hip while simultaneously re-aligning the SI Joint.  That's what I truly believed.  I'm telling you that I used to regularly yank on people's legs. Maybe as often as daily. Wanna know why I did it so much?  Because sometimes IT ACTUALLY WORKED.  And they felt better.  And that's a bit of what Adam Meakins is saying... that we can be convinced that the care we're providing is beneficial, even when it is not supported by research. I eventually learned that it didn't work as much as I thought it did.  It didn't help enough people.  It could have been harmful to the patients and I constantly felt like I was doing something to patients to try to fix them rather than guiding them towards ways to fix themselves.

Humans can't be symmetrical if we have hand dominance and we move to get in and out of a car in the same way all the time but less frequently on the other side of the car. Our heart is not centered in our chest cavity.  There is only one spleen and one liver and they're not in the middle perfectly symmetrical....  So while Adam Meakins is practically pleading with physical therapists (and hopefully chiropractors and physicians) to STOP telling our patients that they have anatomical problems that are probably not actually problems, and I agree with that message... I still feel "something" when I palpate the spine.

If patients ask, I now use an explanation about the nervous system having a reason to try to protect that particular region of the body and that by using load management strategies, it may calm down. I explain that "hurt does not equal harm"... that the tissues of the body may hurt even though damage is not occurring.  The body uses pain to protect itself.  And then I give a home exercise program to guide them on restoring motion, strength, or function based on what I determine the patient needs... which I did by using palpation.

I remember sitting in PT school and being taught how to palpate the multifius and the transverse abdominus musculature to assess if they're contracting.  I could never feel the multifidi.  Never.  And then the PTs at my first job out of PT school encouraged me to focus on assessing the multifidi in various positions and using abdominal bracing and using electric stimulation in conjunction with abdominal bracing on my patients.  I tried to use that.  But I could not feel it.  This is what Adam seems to be describing but relevant to palpating the spine.  Is it possible that we have different skills with regard to palpation?  Is it possible that while I cannot feel the multifidi, I could feel hypomobility at the spine?  Is it possible that the issue is not about what we identify, but more in how we express it to our patients?  We are definitely impacting the beliefs of the patients we see.

The podcast interview goes a bit more into the discussion of the narratives that physical therapists (and healthcare providers) present to their patients and how this can negatively impact them.  I like that Adam states in the podcast that removal of pain is the wrong way for PT to be going as a profession.  We need to be empowering patients, give them realistic expectations, and help them operate within the constraints that their individual bodies allow.  The goal should be developing resilience and tolerance - not elimination of pain.  I agree with Adam on all these points.

I also agree that we are over-treating patients.  Too many visits.  Too many referrals from person to person rather than really understanding what's going on.
I also agree that the medical system doesn't operate in an ideal fashion.  Insurance companies limiting treatment influence the care that patients get.  This is wrong.
I also agree that sometimes the best treatment for a patient is NO TREATMENT.  I recently was working with a patient who was seeing so many different providers that I just sat her down and told her - I think you're trying to find too many solutions to a small number of problems and can't follow a single path to your recovery.  I recommended that she sit down and write a list of all the people she had been seeking answers from, and pick the one that she wanted to commit to.  Who do you believe is helping you?  Follow that person.  Get rid of the rest of us.  Everyone telling you different things is confusing and ineffective.   I don't actually care if physical therapy is her solution.  The best solution for every patient is the one they buy into and helps them find a way to get back to their function.  Period.

Even as I write this, I'm feeling my thought processes shift about what I say, but I"m not ready to throw away palpation yet.  I like that I'm trained to provide spine manipulations and have had some really great results using it. I use it selectively and in conjunction with movement.  And so, I'm unwilling to throw away a tool from my toolbox that I sometimes find essential.  At least for now.

Take Home Message: There are lots of really good physical therapists out there, many of which are creating content that is easily accessible and easy to apply.  The messages differ between them.  But patient populations differ and you have to believe in what you're selling to your patients.  I believe in a little Mike Reinold and a little Lenny Macrina and a little Lorimer Moseley and a little Adam Meakins and then I add some strength and conditioning with Eric Cressey and a little breathing from yoga practices and a little mental health... and I'm my own unique clinical provider because of all those influences... which is why I keep writing about all of them!  So use a variety of backgrounds and consider opposing opinions, try out different techniques, challenge your own beliefs and welcome growth along with failure.  Feel free to tell me if I'm wrong... I may not like that, but I'd like to think I'll be respectful and consider the alternatives.

Above all else - Do No Harm.

2018 Year in Review

The last blog post of 2018! Since I started writing in November 2017, Abby's World has had 14,000 visitors.  I still don't like the title... Some posts were really popular... four posts had over 400 readers, others had less interest... and that's ok.  I think it's safe to say that I'm still figuring things out a bit to narrow down the scope, but I'm enjoying the variety of topics right now.  Thank you, so much, to everyone who has stopped by! I hope you've learned something and that I've been helpful to you in some way.

Today's post will serve as recap of 2018 - both personally and professionally - and a look back at some of my favorite posts of 2018.  As for 2019, I don't think I'm going to write a plan or set goals - other than to keep writing.

The Seattle Storm and UConn Connection

My 2018 biggest moments:
I'll start with the Seattle Storm winning the WNBA Championship, which I wrote about here.  I was so fortunate to be able to attend WNBA Finals Game 3 in Washington, D.C. with my brother, and still love basketball despite my poor skills at playing the game. I'm already looking forward to next season and it's still several months away.

Dear Evan Hansen, New York City, July 2018

As great as the championship was, my family celebrated a huge milestone this year.  In May, my niece and nephew became B'nai Mitzvah, which is a Jewish coming-of-age or right of passage.  They're thirteen years old, now!  The actual events for the B'Nai Mitzvah were incredible and I'm so proud of them for their accomplishment and hard work, but more special was the opportunity to celebrate them each in their own individual way.  I asked them a few months before-hand what they would want most, and I love how different they are and what they chose.  I celebrated my niece by taking her, my sister, and my mom to see the musical Dear Evan Hansen in New York City.  If you haven't heard much about this story, I encourage you to check it out, particularly if you have teenagers in the house. I'm so glad we could do that together, and that it was what she wanted to do - with her aunt, mom, and grandma.  I celebrated my nephew at the Denver Broncos versus Seattle Seahawks game in Denver, CO.  He's been a Broncos fan since birth because he liked the color orange and had always wanted to see their stadium.  As a sports fan myself, I really loved watching him experience something he had wanted to so much... and the rivalry of rooting for opposite teams but in a mature manner.  It was a chance to spend time with my favorite people as they head into teenage-hood and, soon, adulthood.  Next year they'll both attend Cheshire High School, the same school I graduated from fifteen years ago.  I remember holding them when they were born and all of these events were a flood of pride and emotions.   Because of them, I spent more quality time with my family in 2018 than I had since I moved to Seattle.  That was the best part of 2018.

Seattle Seahawks @ Denver Broncos, September 2018

Some of my other favorite things from 2018 that have nothing to do with Physical Therapy:
I saw the Goo Goo Dolls perform their 20th Anniversary celebration of Dizzy Up The Girls.
I rode in a helicopter for the first time. Total trip time was about 3 minutes.  It was awesome.
I read the first five books of the Harry Potter Series and watched the first three movies... my first time for all of that.  Don't worry, book six is in progress and I'll finish all of it in 2019.
I read a lot of books in 2018, actually.  Some really deep, sciency stuff.  Some much lighter and more relaxing.  I have come to embrace the audio book for commutes. I read The Origin of Species which I wrote about here and definitely do not recommend others read, but feel like I can read anything if I could get through that.
I got addicted to yoga.  And then dropped out of yoga.  I miss yoga.

My 2018 Physical Therapy Continuing Education was primarily focused on three areas.
1) Orthopedics from Mike Reinold, Lenny Macrina, and Eric Cressey.  I took Mike's shoulder seminar, which I wrote about here, Lenny's knee seminar which I wrote about here (and his elbow course), and Eric's shoulder course which I wrote about here.  I'm so grateful that there are mentors willing to share their expertise and knowledge online, and who also have made trips out to the West Coast for me to learn from in person.

2) Chronic Pain, primarily from Lorimer Moseley and Adriaan Louw.  I've written about those experiences here - from reading Explain Pain, and here from reading Explain Pain Supercharged and from meeting Lorimer Moseley at his presentation at the University of Washington.  Starting in two weeks, I'll be working with the Seattle Children's Pain Clinic as part of a collaborative team to help kids experiencing chronic pain.  I'm looking forward to putting all that learning to good use.

3) Strength and Conditioning.  I passed the CSCS (Certified Strength and Conditioning Specialist) exam in 2018, which I wrote about here and took a Medbridge Education Course instructed by Sue Falsone on this topic as well.  This has definitely made an impact on how I treat patients, specifically by loading them more and manipulating rep/set schemes a little bit more than I did in the past.  A few PTs have asked me if I thought this process was worth it, and for my patient population and side gigs, I feel that it is definitely useful.  I work in Pediatric Sports Medicine so my patient population is mostly athletic and getting back to sports.  They've generally never worked with a strength and conditioning coach or a physical therapist and don't understand any of the key basics of movement or how the body works.  I love having this background knowledge to educate them!

I feel like I spent a lot of time working towards growing as a physical therapist in 2018, but when I look back, it wasn't even close to what was most important.

Looking forward to 2019:  I'd be lying if I pretended that 2018 was perfect. Social media sometimes has that impact...  nobody posts their tears and struggles on Facebook and Instagram.  I certainly only post the happy times and the beauty I see around me. In truth, 2018 was a hard year.  I'm not sure 2019 will be easier... but there will be more family time and more hard work and growth.  And for all that, I'm grateful.

Happy New Year!

Shoulder Care with Eric Cressey

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

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

With Eric Cressey June 24, 2018

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

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

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

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

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

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

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

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

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

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

SNF Side Hustle

I've been working my way through Eric Cressey's older blog articles (as well as a collaboration he did with Mike Reinold called Optimal Shoulder Performance) and came across this post written in 2005 in which he debunks weightlifting myths.  In the post Eric recalls: "Dr. Jeff Anderson, Director of Sports Medicine at the University of Connecticut, said to me once: 'If you live your life the right way, you'll likely find yourself in an orthopedist's office at some point. If you live it the wrong way, you'll likely end up in cardiologist's office instead.'"  "Doc A" unfortunately passed away last year, but he was a great physician and all-around nice guy.  Reading his quote reminded me of my experience observing this in real life.


When I first graduated from PT School, alongside my job in outpatient orthopedics, I also worked as a per diem PT in a skilled nursing facility (SNF).  (#sidehustle). I was mostly scheduled to evaluate patients who arrived to the facility on a Friday and, because of insurance mandates, needed a weekend evaluation for admission. I regularly observed Dr. Anderson's statement, but it is only now, reading the quote, that it seems so much more simplified and realistic.  A day at the SNF would have a patient schedule of about six patients, an hour to 90 minutes for each one, often looking like this: 

1) Frail lady with osteoporosis, 82 years old, who fell and broke her hip.  Many of these patients would also present with a urinary tract infection and confusion. (primarily orthopedics)
2) Type II diabetic, obese, sedentary man in his 60's who just had a total knee replacement (orthopedics with cardiology risk factors/co-morbidities).
3) Man, 76 years old, life-long smoker, worked a manual labor job for his whole life, who recently had a stroke or a heart attack. (cardiology or neurology)
4) Younger woman, early 20's, detoxing from drug overdose. (could fall under several categories - I'm not exaggerating, here.  I really did see a lot of patients who were either detoxing or recovering from an overdose or had an accident that involved drugs or alcohol.  The first time I saw track marks left an impression.)
5) Overweight woman, 55, using supplemental oxygen with debilitating back pain and depression. (orthopedics with cardiology and psychological co-morbidities)
6) Homeless person who is malnourished and recovering from pneumonia. (also a variety of categories)

If the patient had been newly admitted to the facility, they may not have been out of bed for several days.  This 2007 paper outlines the effects of bed rest on the cardiovascular system, the muscular system, and the skeletal system but a basic summary is that everything gets worse when you stay in bed for too long.  What the paper doesn't explore is how self aware people are when they have been on bed rest.  These patients had frequently walked themselves into a hospital or were brought via ambulance within the past two weeks.  They sometimes have lost a little bit of sense of time, but they were able to walk not too long ago, so of course they can stand and walk.  I'd estimate about 25% ultimately weren't able to hold up their weight requiring me to hold them up when they got lightheaded from orthostatic hypotension or when their knees buckled from disuse of their quads.  Want to know another awesome benefit of standing and getting out of bed for the first time in several days?  The gravitational effect on your gastrointestinal tract! That's right, many of these patients would stand for the first time in several days and take a few steps and would need to be at the commode in under 14 seconds.  I was pooped on 1 out of every 2 shifts I worked. 

I would finish my day, exhausted from lifting people to help them transfer in and out of bed and onto the commode.  More than physical exhaustion, I would be a wreck from the intense emotional drain of trying to motivate people suffering from pain and limited endurance to go for walks and exercise.   This type of work really got to me.  The gains were small from day to day and I was only there once or twice a month so I never got to see the patients improve.  I had only worked there for a few months when I found myself finishing my day, sitting in my car, unable to get going because I was too busy wondering what the end of my life could possibly look like. 

According to the CDC, heart disease was the #1 cause of death in the USA in 2015 accounting for 23.4% of deaths that year.  When broken down by age, unintentional injuries/accidents was the most common cause of death in people younger than age 45.  This includes a fall as a cause of injury in addition to numerous non-orthopedic accidents such as drowning or smoke inhalation.  I don't think Doc A was referring to death in his conversation to Eric, but that's how my brain got here, and I like the idea that if you use your body so much that you develop orthopedic issues, you could be preventing some of the co-morbidities associated with cardiovascular pathology. 

The world really isn't so black-and-white and these outcomes aren't so dichotomous.  There are very active people running on a regular basis, who die unexpectedly from a cardiac event.  Can you lead a lifestyle that decreases your risk of cardiovascular pathology?  Yes, and it doesn't inherently mean a future of orthopedic issues is coming your way.  Can you take good care of your body with exercise and prevent arthritis/bodily breakdown?  Yes and it doesn't dictate you're going to have a stroke.  What does this mean?  It means try to eat a healthy diet and exercise regularly because in the end, we only get one life to live and one body to use, so we should make the best of it! 

I Failed The 28 Day Challenge - and Built Up my Anti-Library

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In early February, I wrote this blog post stating that I was planning to participate in the "28 Day Challenge" of reading a journal article every day for the month.  I failed.  Big time.

Here's what happened:  I started the challenge two days late and managed to catch up on day three.  I managed to stay on track through day 7.   (4 days... not so strong). And then the weekend came, and I had plans with friends and a job to go to with patients to treat and.... all of a sudden I had six more articles in my "to read" folder on my computer and I just couldn't get myself out of that hole. I think I got through 12 of the articles in total in the month. 

I find that I have been collecting papers to read later on because there's so much to read and so little time.  I have a file of them on my work email all about concussion research, a growing collection of journal articles about shoulders/throwing injuries and anything at all related to ACL injuries at home.  I follow several PTs online and when they recommend an article to read, I add it to the stack.  And so, my list of papers to read keeps growing.  It's the same with books.  My "to-read" shelf on Goodreads is now more than 600 books.  I don't have the space (or funds) to accumulate all those books - but if I did, my house would be overflowing with books.  My continuing education plan for the year is written out and developed and I work my way through it but other things I'm interested in keep coming in my path and leading me off course.

This week I was listening to "The Movement Fix" Podcast Episode #60 with guest Brett Bartholomew, author of Conscious Coaching (which happens to be on order and should be one of the next books I'll be reading). Ryan DeBell (founder of The Movement Fix, headquartered nearby in Lynwood, WA) asks Brett about how much he reads, and Brett presents the point that it's not about how much you read, but about taking the time to digest new learning so you can apply it.  Some days I feel like I'm bombarding my brain with loads of new knowledge, taking in whatever tidbits I can grasp.  Other days I can't shove anything into it no matter how hard I try.  And some days, I can read and take in so much information it's like I'm in the desert and was just given a tall glass of water.

That's right - in addition to journal articles and books, I also have a list of podcasts to work my way through and a list of blogs to read.  The approach I've been taking has been listening/reading from the oldest posts to the newest from the same authors until I've gotten through all of them and can just read or listen to the newest ones as they come out.  A few examples: I'm currently reading through all of Eric Cressey's old blog posts starting in 2002 when he wrote for "T-Nation." He posts several times per month so I need to get through more than he's currently posting to catch up.  I'm doing a better job now of skimming the topic and seeing if it is at all relevant to my practice - but most of the time, I read the whole article and keep track of my progress.  Hopefully in a few months, I'll catch up and then any time he posts something new, I'll have the background knowledge of his prior posts.  Similarly, I listened to all of "The Ask Mike Reinold Show" so now any time a new one is posted, I'm caught up and it's just the new one to listen to.

Sometimes, as I'm working my way through my plan, something with a deadline comes along and pushes me off my track.  I requested the book "Explain Pain Supercharged" from the work library and only have until April 7th to get through it or the Seattle Children's Library Overlords will come take it away from me.  So this is delaying my progress in reading everything Eric Cressey has ever written.

We're in an era of information overload and my colleagues and friends keep getting smarter and smarter and can cite literature easily - which is a struggle for me.  It's hard to keep up when you have so many interests and aren't a fast reader (or even worse, a fast comprehender).  I shouldn't compare myself to them or care - but of course I do. 

Then I came across  this article and the embedded six minute YouTube video that describes the concepts of the "Anti-Library" and the "Black Swan."  An Anti-library is a collection of resources to help you find an answer to a question on a topic you are aware of but that you are not fully educated on.  Because of the internet, we have a virtual anti-library at our fingertips constantly.  The anti-library is where you go to look into "known unknowns." For example, I treat patients who have experienced concussions, but I'm not skilled with vestibular rehabilitation.  I know that my list of saved concussion papers includes some research regarding this area, so if I face a patient who needs this knowledge, I can quickly access it and get better informed.  But right now, this isn't in my case load and to spend time focusing on that learning when I can't apply it doesn't make much sense for me.  In contrast, the Black Swan is the "unknown unknowns."  These are the topics that I know nothing about, where I would need to start from scratch to even start educating myself.  A possible example of this could be a patient coming in with a brand new surgical procedure that I've never heard of or a rare disease with unique complications where I have no knowledge and would need to hit the books and don't even have a list of resources to go through on my mind.

Surrounding myself with knowledge so that I can access it if I need it shows that I am aware that I have so much to learn and that I want to surround myself with ways to gain new knowledge.  The article made me feel better about having a growing anti-library.  Now I just need to figure out a more efficient organizational system to keep track of everything.  Any suggestions?

Year in Review - The best things I did in 2017 to become a better Physical Therapist

December flew by!  I love the end of the year as a time for reflection of the prior year and to make plans for what’s ahead.  I'm a planner.  Here are the top three things I did to help myself become a better physical therapist in 2017 as well as my plan for how I’ll get even better in 2018.

1) I’m three years out of PT School and have worked hard to build a professional support network with particular focus on having great mentors. It was a priority to me coming out of school to find a clinic that would provide this opportunity for me. I also had great mentors in school who guided me in my research plans and in determining my path. These mentors are always available to me and happy (I hope!) to give their input when needed - but they’ve been around for 3-6 years. The absolute best thing I did in 2017 was add a new mentor to my crew.  I have access to new perspectives, resources, a bigger network of professionals - all with different experiences and knowledge.  My original mentors haven’t lost any value- they’re huge influences on me both personally and professionally and I’m immensely grateful to them. But doing this has reinvigorated me to grow as a physical therapist and has provided me with new content to read, classes to consider, different ways to prioritize my continuing education towards certifications, and career and employment advice that ultimately doesn’t impact him. I highly recommend finding mentors that will take the time to put your best interests to heart and help you along the pathway and keep growing your professional network.

2) The second best thing I did in 2017 was to find myself a personal health coach that helped me get on track with work-life balance and develop my own routine.  She's like having a professional closet organizer come in and give me guidance towards organizing my life.  Even coaches need coaching- in lots of ways.  It's not just about a coach for the weight room. She's here to help me get balance and keep me accountable while I'm getting my diet and training into a regular routine as well as helping me with my mental focus.

I’m a huge fan of the idea that people should be doing training programs- not arbitrary workouts. This is something I have been guilty of for years.  I know enough to write a workout but never spent the time to write myself a program with consideration for microcycles or macrocycles working towards a longer term focus with targeted goals. Thus- my past was full of workouts - a habit that yielded plateaus, imperfect compliance, and failure to achieve the goals I have set for myself.  And I got bored with them!  Now, I have a plan and a timeline with an end date and know that as I reach its end, I will either get a coach to plan my next cycle or write a new one myself - but either way - my routine is planned and I know what I'm doing for the next several weeks of training.

So- that’s a glance into my current routine... but how does this help with patient care?  By working on my own training, I’ve seen how longer term planning and focus during sessions has impacted my own body and have started to implement this with patients. For example: I see lots of kids with ankle sprains. In the past, I might have done a session with strengthening, balance, mobility, and plyometrics all together. Now, especially if I’m not sharing the patient and plan to see them several sessions in a row, I might focus a whole session on balance in several ways and the next whole session might be a core training or core and strength focus. I think overall this will help me become more efficient and I’m looking forward to seeing how it impacts my patient outcomes.   Additionally, I've given a lot more thought to the dynamic warm up component of my own workouts and the rehab sessions... that's a post for another day, though!

3) In 2017, I dramatically increased my "reading," particularly because I discovered the world of audiobooks and podcasts. I know- a little late to the party. The experts in the field say you should be devoting an hour daily to learning/reading and many days that just wasn’t possible for me - but with a new longer commute after my job change, I can get an hour of audio time at least 3 days per week. Thus, I've been working my way through all of the existing episodes of “The Ask Mike Reinold Show” and have found that reading shorter blog posts during the day adds up to my hour when I can't sit down and read longer pieces.  Just like my workouts, I wrote myself a reading plan and am reading all the archived blog posts from Tim DiFrancesco (awesome variety of quick reads with the occasional basketball flare) and Lenny Macrina (new blog - with literature reviews! So good!), rather than just arbitrarily reading whatever comes into my inbox - and I have a plan for the next round of podcasts and blogs once these are completed.  Here are some of the great books I read in 2017 (and yes, I do also read novels - because I need to be able to talk to my patients about something, too!).

1. Sports biographies: Sum it up (Pat Summitt - Tennessee Women's Basketball),  Forward: A Memoir (Abby Wambach - USA Women's Soccer), Shoe Dog (Phil Knight - Founder of NIKE), Tuff Juice (Caron Butler - UConn and NBA Basketballer)
2. Unique in sports- Born to Run: a hidden tribe of super athletes and the greatest race the world has ever seen by Christopher McDougall
3. World Biography: Born a Crime (Trevor Noah), I am Malala (Malala Yousafzai)
4. Breathing: Science of Breath
5. Women in science: Headstrong: 52 women who changed Science and the World
6. Currently reading: Deep Nutrition by Dr. Catherine Shanahan (coming soon: blog post for book review!)

Looking ahead to 2018: what do I have planned?

1) I’ve got some shadowing/observation time that I'm arranging with various different practitioners including surgery observation, time with a chiropractor who values exercise, quality time with some experienced and up-and-coming strength coaches, and some amazing physical therapists with various specialties.

2) In addition to the blogs/podcast archives I'm finishing up, I have several new blogs planned to get through - particularly the works of Eric Cressey - which is a whole lot of reading because he's been writing for so long. Also, more books planned:

1. Nutrition: The Omnivores Dilemma by Michael Pollan and In Defense of Food by Michael Pollan
2. Evolution: The Origin of Species by Charles Darwin
3. Coaching: Conscious Coaching by Bret Bartholomew
4. Pain Science: Explain Pain: Supercharged by David Butler
5. Sports Biographies: Pre (Steve Prefontaine), In My Skin - My Life On and Off the Basketball Court (Brittney Griner),They Call Me Coach (John Wooden), From the outside. My Journey Through Life and the Game I Love. Ray Allen. 
6. Women's Basketball: Bird at the Buzzer by Jeff Goldberg

(Purposeful inclusion of UConn Basketball reads - and Eric Cressey is also UConn educated!)

3) Even bigger focus on sports periodization planned for my own training program to begin in March 2018 once my current program is completed.  I'm banking on this getting better from reading so much of Eric's work

4) More blogging.  Because I'm starting to really enjoy my visits to the local coffee shop where I'm becoming a Thursday morning regular and am loving their ginger peach pot of tea.