WNBA Injury Summary

Hey everyone!  Happy Fourth of July! Yesterday the Seattle Storm played their "Kid's Day" game, a tradition around the WNBA hosting games early in the day - always a rowdy event with lots of children attending games and singing along with what's going on in the arena.  Today was the first time I've ever head "Baby Shark" at a WNBA game.  I certainly hope it's the last.  If you don't know what that is, it's here for your viewing pleasure, but know that you have been warned: your day is about to be ruined. 

As the Storm Physical Therapist, I have the opportunity to work with some of the players who are injured while they rehab to get back to playing.  This season, the Storm seems to be battling a curse that started in the off-season when Breanna Stewart's ruptured Achilles which I wrote about here, followed by Sue Bird having a knee surgery that was written up in the Seattle Times here. And the list continues after that. There are articles here about Jordin Canada's injury, which she has returned from, and an article here about Jewell Loyd's ankle injury, and an article here, about Kaleena Mosqueda-Lewis injuring her ankle earlier today.  What a mess!  

But I'm not here to write about the Storm Players' injuries (affter all, there are laws against that).  Watching another player getting injured today made me reflective on the woes of the Storm this season and then start looking into the other teams to see how they're faring.  There is a site which lists WNBA injuries, here, which I used for the starting point of this research.  And so, without further ado, my research findings of injuries from around the WNBA.

ATLANTA: 

Angel McCoughtry, a 2x Olympian and WNBA All-Star tore her ACL in August 2018.  Based on typical rehab timelines, I'm not really sure why she hasn't made it back to the court by now - this article and this one from last week both say it's due to strength deficits, which would definitely be a reason to delay returning.  I previously wrote about Angel here when I saw a video of her rehab in the off-season that I found appalling.  I hope things have gotten better for her recovery since they filmed that session.  Earlier this season, Tiffany Hayes had an ankle injury that was written about by High Post Hoops here, but she's been playing through it for the past eleven games.

CHICAGO:

Katie Lou Samuelson has missed all but three games with a broken right wrist.  I recently read this article about her injury where she was working with my long-time friend and the Sky Strength and Conditioning Coach Ann Crosby about all the cardio "Lou" has been doing while she's been casted, hoping to stay in good shape for when she's cut out of the plaster and allowed to start dribbling again.  High Post Hoops also covered Katie Lou and her teammate Jamierra Faulkner who had a knee injury in this article. Faulkner tore her right ACL last July (her left ACL was injured in 2017), and like Angel in Atlanta, appears to have had some complications with her recovery delaying her return to the court.

CONNECTICUT:

Last week, Layshia Clarendon underwent surgery on her ankle, putting her on the injured list for several months.  The Sun, the team I worked for from 2007-2010, posted the news here.  If she recovers on the fastest timeline for her particular surgical procedure, she might be able to step on the court by the end of the WNBA playoffs.  But basically, she's going to be watching a lot of basketball and not playing, which is unfortunate, because she's fun to watch!  With Connecticut winning lots of games right now, if they can manage to stay healthy, I think they'll still be playing in September.  And they have one of the most experienced (and also long-time friend) Head Athletic Trainers in the WNBA, Rosemary Ragle.    

DALLAS: 

It bothers me a little bit that pregnancy is included on the injury list - but they also list players who are unavailable to their teams for overseas basketball commitment, so maybe the list should be called "players who won't dress" rather than being an injured list?  Anyways, Skylar Diggins-Smith had a baby boy in April and is set on returning to the court this season, but hasn't yet.  The team has had so many issues with players being unavailable (Skylar, Glory Johnson in the Eurobasket, and Tayler Hill about to have knee surgery - all listed here) that they were ultimately able to add NCAA WBB Player of the Year Megan Gustafson about three weeks ago.  Even USA today had a little blurb about Tayler Hill having surgery here- and they didn't have a single article during the WNBA Finals last year.  (At least they had no articles in print - maybe there were some online that I didn't see.) And Dallas has Isabelle Harrison back after suffering two concussions early in the season. 

INDIANA: 

Victoria Vivians is out with an ACL injury from overseas during the off-season and Natalie Achonwa missed a game or two with a finger injury, but otherwise, I haven't seen anything about Fever injuries. 

LAS VEGAS: 

Aces center Liz Cambage came in for the season with Achilles tendinitis but has returned to playing.  Point guard Sydney Colson also had a concussion in June but has since returned.  Another crew that's overwhelmingly staying healthier than most. 

LOS ANGELES: 

Team Super Star Candace Parker sat out the first several games of the season after a hamstring injury during a pre-season game, but has returned to the team. Alana Beard also missed about a month of the early portion of the season with a leg injury.  That's two key players missing the first month of the season - so now that they're getting back into the swing of things, it will be interesting to see if LA can turn some of their early season woes around.

MINNESOTA:

Things got so bad in Minnesota, they were approved TWO roster exemptions so they could add players because they are facing multiple season-ending injuries. Two new players on the roster after more than a third of the season is over is incredibly challenging to teach your basketball system and try to build chemistry.  They're having a lot of knee troubles.  Karima Christmas-Kelly hurt her knee and underwent surgery two days ago and is listed as out for the rest of the season. Jessica Shepard is also out for the season with an ACL injury and Seimone Augustus has not yet played in a game this season from a May knee surgery - but she is expected to return at some point.  Damiris Dantas is also out with a calf injury expected to return in about two weeks.  And we don't have to mention the absence of Maya Moore, who is not injured but is pursuing some personal ventures this season... (OK of course I had to mention her)  

NEW YORK:

The NY Liberty mostly has personnel issues due to several team members playing overseas, though they'll be returning shortly.  Rebecca Allan has a finger injury keeping her sidelined and she did not play against us in Seattle yesterday.  New York has had a lot of front office struggles in the news in past years which hopefully are improving now that they have new ownership - so maybe they deserve a break from the injury bug while they try to make positive changes in one of the few remaining cities to have an original WNBA team despite their move away from Madison Square Garden.

PHOENIX: 

In my opinion, the greatest basketball player of all time is Diana Taurasi.  She's also an exceptional human being.  Unfortunately, Diana has been sidelined all season so far following spine surgery, but is tentatively expected to return to the court this week.  Sophie Cunningham had back pain two weeks ago that limited her playing and DeWanna Bonner had an ankle injury last week, but both have returned.

WASHINGTON:

Kiara Leslie underwent a meniscus surgery at the end of May with expectations of about 3-4 months of rehab.  Kristi Toliver had an injury to her right quad and Aerial Powers had an injury to her left glute, but both have made it back to the court.  Superstar Elena Delle Donne has had some lingering issues with her knee since injuring it during the 2018 playoffs, but only missed the earliest games of the season. 

I'm sure I missed other injuries.. and the ones listed above are just the ones I found when google searching - which means these are the athletes that missed a game - or many.  Having been around teams for so long, it's easy to say that most WNBA players are battling nagging aches and pains and are getting regular treatment - either massage or chiropractic care or acupuncture or just spending time in prehab/rehab with the athletic trainer and strength and conditioning coach.  Or in the unlikely event, as I wrote about here, with their physical therapist.  

TAKE HOME MESSAGES:

1) The WNBA is experiencing a lot of injuries this season, and reviewing these articles, they're not just small injuries like ankle sprains removing athletes from 1-2 games.  These are surgical interventions and months-long rehabilitations including year-long recoveries when you consider the Achilles tear for Breanna Stewart and the ACL injuries of Angel McCoughtry and so many others.  

2) It's really hard to know if this rate of injuries and the number of "severe" injuries is more than previous years or not. It looks to me like it's definitely more, at least here in Seattle.  But, from what I've learned in the past two years having had discussions with league representatives about my interest in researching WNBA injuries is that the system by which the league collects injury data has not been monitored or really enforced in many of the previous seasons and there isn't anyone with access who can put this information together into a report. I don't have access.  Teams have to submit their injuries.  Some teams are really good about it.  Others are less diligent.  In my dream world, I'd be taking the data from all the WNBA seasons with injury information in the past and I'd be analyzing it to see what kinds of trends can be identified to try to help with injury prevention programs at the youth, high school, and collegiate levels, with particular focuse on female athletes, but it certainly would not hurt males.  I'd also be working to compare it to the NBA because their work conditions and medical equipment and support staff limitations are so different, it would be interesting to see if any correlations could be found.  Someday I'll figure out how to take this project on and develop meaningful data that can be used to help future WNBA players - and elevate the world of women's sports. Someday.  

3)  How awesome is it that there are so many more news sources reporting on the WNBA!?!?!?!  LOVE THIS!  CBS Sports even posted this article about the Connecticut Sun soaring while all the other teams are figuring out how to deal with their injuries. 

4) There are a lot of former UConn Huskies on this injury list... and while that probably isn't relevant, it is apparent.  Maybe that's because there are so many in the WNBA - or it could be several other reasons.  I won't try to suggest what it could be, but watching UConn basketball players getting injured in college and the WNBA is what drove me to go to PT School in the first place.  I'm feeling a little disheartened that there hasn't been enough progress in injury prevention in these athletes, and potentially we're doing worse in the WNBA.

5) When the Seattle Storm won the championship last season, many of the medical providers felt that the WNBA season is a marathon - not a sprint - and that the team with the least severe and least number of injuries during the season would be the last team standing.  This is part of the game in all sports.  But I'd prefer it if the last team standing, hoisting that awesome WNBA Championship trophy overhead, was the one who had the most talented basketball players with the best chemistry and showed us all how beautiful this game really can be. 

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

Ann Strother

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

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

Kevin Durant

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

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

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

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

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

"Just an Ankle Sprain..."

Let's talk about ankle sprains.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

"Long Term Cost of Quick Fixes"

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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!)

Concussion and the Brain

Happy October 1st! Fall is upon us and schools here in the Pacific Northwest has been up and running for about a month.  With the return of school comes the start of the local fall sports teams.  This year I've noticed several patients in the clinic coming in with a recent concussion.  For my caseload, they've all been girls and most of these have occurred with playing soccer.  This is of course not a rule - in the past I have worked with males who have experienced concussions and they've come from all sorts of mechanisms of injuries.  What comes to mind are falling off a bike, getting hit in the head playing softball, inner tubing, and trampoline parks.  Though football players statistically tend to have more concussions, I don't think I've treated any of those.

I personally have experienced two concussions myself!  My first one was in high school when a friend of mine and I were walking away from each other and she threw a basketball and it bounced off the back of my head.  I initially thought I was fine and later woke up on the bathroom floor.  I had a headache for a few days and saw a doctor for it but was ultimately fine.  My second concussion was getting hit in the face with a softball that broke my nose and I had a loss of consciousness for about 3 seconds.  Apparently that's what the glove is for... catching the ball.  I didn't see a doctor that time, which was not the smartest on my part.  With that one I also had headaches for a few days, dizziness, some nausea, and a lot of sensitivity to light.  My sleep was disrupted and I had trouble looking at my computer screen at work.  My glasses broke during the injury so I was wearing my prescription sunglasses at work which helped some.  I'm so fortunate that both of mine were years apart and that I recovered so quickly, and it helps me to relate to these patients since I've gone through it a little bit.  Plus this gives me a great opportunity to share the photos of my black eyes from when I had my last one!  Notice the softball stitches visibly imprinted into my face.

Concussions are a really interesting diagnosis because each person presents very differently.  I've previously written about the WNBA Concussion Protocol here following one of the Seattle Storm players experiencing a concussion this past season, but since I've been treating more of these patients in the clinic, I've been reviewing my previous Medbridge courses on concussion and refreshing my knowledge to better treat this patient population.  Here are some interesting things about concussions you should know.

1) Concussions are brain injuries.  Concussions get a reputation for being less significant than they are because people have used terms like "getting their bell rung" to describe what happened on the playing field when the injury occurred.  This is a problem because concussions are brain injuries.  Many of the kids who come in for concussion treatment have a variety of symptoms - headaches, dizziness, trouble with school from a variety of causes, difficulty sleeping... and they almost brush these off as normal because of a concussion.  But these are all symptoms of the brain going through a healing process!  You wouldn't act the same way if you had a fractured skull or a stroke - both also serious head injuries.  Let's start acknowledging how serious a concussion is so that kids who experience them take their recovery a little more seriously!

2) Concussions are not anatomical problems- they are physiological.  I'll simplify that.  Anatomy defined: the structure of something.  So with a concussion - we're not looking at the structure of the brain.  With an anatomical (structural) problem, when a doctor is trying to diagnose what is wrong, imaging is generally done.  Typically, a person who has experienced a concussion will not have anything wrong on XRAYS, CT Scan, or MRI.  These imaging studies are used to look at anatomy - again - like the skull fracture - to see if any structures have been damaged.  Imaging is helpful to rule out these other anatomical problems, but they don't tell us much about the concussion or the person experiencing it.  So - if the structure of the body isn't the problem - what is?  The function of these structures are what is affected in a concussion.  Physiology is how things work... so how the anatomical structure operates.  Example - your lungs are a structure which can be injured.  They also function to breathe.  Anatomy: lungs.  Physiology: breathing.  Concussion structure involved is the brain - but there is no anatomical problem.  The physiology of the brain is what has been injured.

This concept is important because it can impact expectations of recovery.  It's pretty easy for people to understand the idea of an anatomical injury and how that recovers.  A broken bone takes approximately 8 weeks to heal and can be seen on an XRAY broken and then healed later on.  Concussion recovery is much more complicated and you can't see a starting point or a finish line.  So what's actually happening?  Well.. that's what I'm working hard on learning to better understand. 

The brain is composed of about 100 billion neurons.  Neurons are the types of cells that make up nerves.  Neurons look a bit like this:

https://biology.stackexchange.com/questions/25967/nerves-neurons-axons-and-dendrites-by-example

These nerves interact with each other to send electrical signals throughout the brain and the body so you can do whatever task you want to do in life - and even the tasks you don't choose to do but that the body does for your survival, like breathe.  When a concussion occurs, these nerve structures can be stretched or twisted just enough that the way that the electrical signals are passed along is impacted and all different types of messages can be influenced.

If you fall on the ground and scrape your knee on the ground, your skin may experience an abrasion and bleed a little bit.  The skin cells near the surface will, over the next several days, heal.  Fortunately, with the type of injury that occurs to neurons (nerve cells) during a concussion, they can also generally heal.  Most concussions will heal spontaneously very quickly, but some take much longer to recover.  These patients with slower recovery concussions are the ones I generally work with in the clinic.  People whose neurons may have recovered from the initial concussion processes, but who are still experiencing symptoms.

3. Treatment varies for each person with a concussion. This is because every person who experiences a concussion will present differently.  Even better... a single person experiencing concussion symptoms can vary hour by hour or day by day with their own symptoms, particularly in the first few days after a concussion.  So I track symptoms (using a graded symptom checklist like this one) over time with these patients to see if they're trending towards improvement and I can't compare one person's recovery to any other.  Every time I have taken a course learning about symptoms with concussion, it has been important to recognize that the goal is not to be a 0 on all of these items.  Teenagers get headaches occasionally.  They also get emotional sometimes.  But the goal is to reduce the overall symptom total and get them to stay at a relatively consistent level that does not fluctuate in response to physical or mental stressors.

I will say that there are some common themes with treating these patients.  Just like I don't treat every patient who experiences an ankle sprain the same way - the components of treatment for those patients is usually similar.  With a person who has experienced a concussion, there is often a headache and neck pain which tends to come from the upper cervical spine more than the lower cervical spine.  Some have vision and vestibular symptoms that require completely different treatments.  Symptoms for concussion have been grouped together into four categories of concussions: 1) vestibular symptoms, 2) visual symptoms, 3) cognitive symptoms, and 4) migrainous/headache symptoms.  These can overlap, but the treatments tend to fall into the categories that match the symptoms.  If the person is experiencing headache symptoms alone, the treatment likely shouldn't target vestibular or vision problems.  This is important because a person experiencing vestibular symptoms likely won't recover from those without specific vestibular treatments and those should be addressed prior to the other considerations.

4. It is the law that you must be cleared by a medical provider to return to sport activities following a concussion.  Laws vary by state and Washington State was the first one to pass such a law in 2009.  However, if you are a coach, and you have an athlete who experiences a concussion, there are many states which require 1) That the athlete stop playing immediately and cannot return for a minimum of 24 hours and 2) that the athlete must be cleared by a healthcare provider to play.  Some states allow physical therapists to be the person who clears these athletes for return to activities - but at Seattle Children's Hospital, we leave that decision up to the diagnosing physician.  So any of these kids who I'm working with to get back to sports - they're not playing in a sport competition until the doctor says so.  And it's not just word of mouth.  Schools are supposed to require that the clearance comes in writing!  Here's why these rules are important.

First - let's say you hit your head in a game and show some mild signs of a concussion but then a few minutes later you think you're feeling ok and try to play again.  Concussion symptoms are not immediate to show up, but reaction time and coordination can be impacted by a concussion.  So now, you've just experienced a concussion and are re-entering your game at considerably higher risk for another injury.  This is dangerous.  No sporting event - championship or scrimmage - is ever important enough to risk a brain injury.  Second - there is actually a name for someone who experiences a concussion, and then experiences a second one before the first one has resolved.  It is called Second Impact Syndrome.  It has a name because it increases the risk of mortality by 50% and it increases morbidity by 100%.  That means that if you experience two concussions in close succession, you increase your risk of death by 50% and 100% of these people have significant delay in recovery.  Doesn't it just make more sense to recover fully from the first one to reduce the risk of these much more severe outcomes?

I'm really enjoying learning about this patient population because it is fairly complicated in comparison to some of the other things you treat, and once these patients start to feel better, their quality of life is significantly impacted for the better.  Concussions can affect tolerance to sitting through classes in school with reading or looking at the whiteboard, they can influence tolerance to lights and noises and participation in sports - which is huge for some of these kids.  They can make you dizzy which makes all activity terrible.  These are serious and I hope that writing this helps people better appreciate the need for them to be treated appropriately. 

Happy Fall Sports Season, everyone!  Let's try to play smart and safe!

Sleep Deprivation and Risk of Injuries

© creativecommonsstockphotos - ID 96494735 | Dreamstime Stock Photos

A few days ago, I wrote this post describing some recent air travel stories.  Included was the plight of the Las Vegas Aces WNBA team whose travel delays heading toward Washington D.C. to play the Mystics ended up with the Aces cancelling their game - and a twitter storm of discussion over whether or not that should have been allowed.   At the time of this writing, the WNBA has not yet presented its decision on what will be the outcome of the Aces canceling the game - since they did ultimately make it to D.C. in time to physically be present.  The delay in the outcome of this saga is a bit surprising... twitter has been buzzing waiting to see what will happen... and it has huge playoff implications for both teams. 
The Aces released this (abridged) statement:  "To all of our WNBA fans around the world: We are so sorry that the Aces were not able to take the court tonight against the Washington Mystics. We trust that you know this decision was not made lightly...Given the travel issues we faced over the past two days—25+ hours spent in airports and airplanes, in cramped quarters and having not slept in a bed since Wednesday night—and after consulting with Players Association leadership and medical professionals, we concluded that playing tonight’s game would put us at too great a risk for injury. Naturally, the issue of player safety is of paramount concern for all involved in the WNBA..."

As a WNBA fan - I was sad that the game didn't occur.  If I had tickets, I'm sure I would have been disappointed, especially since people travel to get to games, and they canceled only an hour and a half before tip off.  But as a physical therapist who works with a WNBA team (and would never play any role in making the decision of if we would be playing), I think this was the right decision.  I didn't have enough research to back it up before - so now I've gone searching.  Full disclosure - I'm biased.  I searched for research relating sleep deprivation and fatigue to injuries.  I'm sure I could potentially find papers that would state the opposite outcome... but this is one of the problems with practicing evidence-based medicine.  For every paper that has an outcome, there could be differently designed papers that have the opposite outcome.  So here's what I found, and we can take it with a grain of salt...

1) Durmer et al wrote in a a 2005 about the "Neurocognitive Consequences of Sleep Deprivation."  They wrote about increased risk of car crashes in sleep-deprived males with injury severity and frequency of accidents similar to those of alcohol-related incidents.  This paper focused more on the chronically sleep deprived - people who sleep less than 7 hours per night consistently - though it does mention other types of sleep deprivation such as short term sleep deprivation for less than 45 hours or long term for greater than 45 hours.  Changes in mood, confusion, anxiety, and depression are noted issues across types of sleep deprivation.  Of key importance is that there was a correlation with decreased response time and increased rate of errors with multitasking... which is essential for sports participation.

2) Milewski et al in 2014 also examined more chronic sleep deprivation and found increased risk of injury in adolescent athletes who slept less than 8 hours compared to those who slept more than 8 hours.  Higher grade level in school (older kids) also had increased risk of injury in this study. 

3) Of course I did a search for the relationship between ACL injuries and fatigue...because in the women's basketball world, a torn ACL is considered one of the worst things that could happen. Last month, this brief article was published summarizing increased risk of ACL injury when jump-landing mechanics were assessed following aerobic exercise (acute bout of fatigue) which corresponded with 20% of local muscular fatigue.  It's hard to compare this to 25 hours of travel like the Las Vegas Aces underwent - but in that case we're talking about more of a full-body fatigue with increased risk because of the above-mentioned cognitive factors - in addition to this localized muscle fatigue which would potentially also be present from sleep deficits.  In 2008, Borotikar et al published this paper looking at central and peripheral fatigue influence on ACL injury in females. Again, the fatigue factor was not induced by air travel... it was caused by repeated squatting or jumping tasks, so the correlation is difficult to make.  This study was interesting because it looked at muscular (peripheral) fatigue as well as decision making (cognition/central fatigue) in tandem where previous studies had only looked at the impact of either type of fatigue on ACL injury.  Based on the length of the Aces travel, it is likely that they were mentally fatigued and muscularly fatigued... so it is absolutely reasonable to extrapolate from this particular study that their risk of ACL injury would have been increased by playing under their conditions.

I know there are plenty of people who say they should have played.  I understand those reasons... it's better for the league not to miss games, it's essential for fans to see their favorite players - especially since the teams only would meet in DC twice this season and it's close to South Carolina where Aces superstar A'ja Wilson played in college... South Carolina fans would really have to go to either DC or Atlanta to get to see her, and I saw a few posts online with some devastated fans that they couldn't see her play.  But the statement released by the Aces was clear that there was concern for injury - and thruthfully, if someone tore their ACL in this game - win or lose - that's a huge loss for someone's career and for the team finishing out the season.  Taking a single loss might just have been the best protection for the health of their team.

I can't believe we don't know what the league will do about this yet... but I'll go ahead and guess that the Aces will take the forfeit, the Mystics will get a win, the game won't be made up, there will likely be some financial penalty the Aces will have to pay to the Mystics for imposed costs... and the league will continue to move forward.  Even better - the WNBA players union will open up conversations in a few weeks for their collective bargaining agreement, and travel expectations are bound to be part of their negotiations moving forward.

The end of the WNBA regular season is rapidly approaching - last day is August 19th and then straight into the playoffs.  The blog may be a little heavy on WNBA basketball right now... and then I'll go through my end-of-season mourning period and return to more writing about physical therapy topics... at least until college basketball starts.  Can't wait to see what the league decides for the Aces... it could set a major precedent moving forward.

2018 WNBA Season Update - A Race to Stay Healthy!

Throwback to my Connecticut Sun Days with Allison Hightower, Kelsey Griffin, and Tina Charles

The 2018 WNBA Season is heading into its second trimester.  How quickly time flies when you love watching your favorite teams and favorite athletes who play a short 34-game season (plus some pre-season and playoffs) with most teams around 11 games in.  This season is condensed with the upcoming FIBA World Cup being held in Spain starting September 21st, with a USA National Team that will take the greatest stars from all the WNBA Teams resulting in this abbreviated schedule.  The usual length season, which already felt like a whirlwind, is now a hectic schedule with games practically every other day. This week the Seattle Storm played three home games in six days, but recovering and preparation between games becomes a challenge under these scheduling circumstances. And above all that, if a team is influenced by injury, how does this affect ticket sales and the entertainment on the court?

I've spent many years on the WNBA sidelines, but now that I'm a healthcare provider, my perspective on the league is different.  When I started working for the Connecticut Sun in 2007 as their Travel Coordinator and Equipment Manager, I helped out in the athletic training room, but I was in charge of laundry and buses.  My biggest concern for players' health was if their sneakers were giving them blisters. I also needed to remember to pack uniforms for injured reserve players who generally were not listed on the line-up but could potentially play if someone else got hurt.  At that time, teams could keep a player available to fill an injured player's spot... that doesn't exist anymore.  

From a physical therapy perspective - this season's playoff contenders will likely be the teams that can stay healthy despite the crazy schedule.  Rookie players will need to learn how to take care of themselves in ways they didn't have to in college. When I was at UConn, we had meals as a team that offered nutritious options and salads pretty much daily.  It is easy to see that a new grad WNBA player might not know how to cook because they never had to before.  They also need to self regulate their recovery, figure out what works best for them, and start taking direction from new athletic trainers than the ones they've used for the past four years. It's a little bit of a relationship-building game in a really quick span of time, and it's been really interesting to watch how that develops year after year. 

Veteran players will also need to find ways to take the best care of themselves to recover between games.  There aren't many days off and the need to re-fuel, rest, and feel good through massage or chiropractic care or ice baths or foam rolling need to be well managed and consistently available.  The WNBA could not have picked a better season to get a league-wide partnership with Cortiva, a massage therapy training school, to have more massage therapists available in certain cities.  Recovery will be key this season.

Since I wrote my PT School thesis on women's basketball players' injuries at the college and WNBA level, I've been thinking about player injuries in this league for a long time.  Feel free to be the fourth person to ever read that paper in your spare time. I try to follow what's going on around the league with regard to injuries - and have several ways of doing so. This website and this website (and there are several others that are similar) list WNBA injuries and stay fairly current... but the first website lists injuries as a service for people who are betting (gambling) on women's basketball and the second one is a fantasy sports team database.  They generally seem to be getting their information from news articles so it's not certain how reputable any of the sites are.  There are currently injuries listed on 9 of the 12 teams, with several teams listing multiple injuries.  I also follow numerous writers on Twitter who write about the injured athletes for their local teams.  The schedule has been up for discussion quite a bit more this season than in the past. 

What I keep waiting for is a bigger entity to start organizing this information.  ESPN has an NBA Injury Report page, but no WNBA Injury Report page, CBS Sports has an NBA Injury Report Page but doesn't have one for the WNBA - nor does their header even include a link to the WNBA at all!  Research publications in the WNBA are limited, but this 2006 paper examined WNBA versus NBA injuries and acknowledges that, even at that time 12 years ago, the rates in the WNBA were higher.  So why isn't this information more readily available yet?  Part of the problem is that the NBA has an Athletic Trainer's Association (NBATA)  which reports and tracks their injuries whereas the WNBA Athletic Trainers report their injuries to the WNBA, and then nothing happens with that information (or at least it is not published and made available for public consumption).  This is something I, personally, am hoping to remedy in the future.  

I didn't look to the research for specific data on the impact of fatigue on injuries - but I learned in school that there is a likely correlation, particularly with postural muscles which would include the muscles of the calf and also with reaction time where the brain is slower to react when it is fatigued which could impact injuries.  Since ankle sprains are always considered the most frequent injury in basketball players, it's not really surprising that we're seeing a lot of ankle injuries already this season.  Here's to hoping that these injuries are low grade and the athletes will recover quickly and get back to playing - but there's a lot of basketball left to be played by fatigued athletes.

I'm already trying to prepare myself for the dark ages that will come between the end of the 2018 WNBA Season and the beginning of NCAA Women's College Basketball almost two months later... it's going to be rough.  Fortunately there is time to continue enjoying WNBA basketball right now while it's here.  Good luck to all the WNBA Athletes, Athletic Trainers, Strength Coaches, and team personnel this season.  And a friendly reminder - if you're part of the travel party - you need to take care of yourself too!  Hydrate and recover!

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.