Sep 30, 2013

HEP for the HIP: Self Hip IR mobilization!

This is a quick video that I shot in the Athletic Training clinic the other day when working with a basketball player. This is a self-hip internal rotation mobilization that I have my patients perform on their own.

This helps to maintain the benefits gained from treatment and manual therapy when working with me in the clinic.  Ideally, this would be done about once an hour for a single set of 10-20 reps but it can be hard to have a student-athlete comply with this and fit it into their busy schedules.  I also have some of them do this before practice and lifting weights for temporary mobility gains.

This is done by the athlete applying an active-assisted hip internal movement while simultaneously providing slight distraction/traction. Check it out!

I have this athlete using an Edge Mobility Band in this video but they could also do this without the band. However, I feel that using the band is more efficacious due to the better hand-hold and compression provided by it.

In other news, I found an old but good video about pain by Lorimer Moseley on "Why Things Hurt". It is actually a pretty funny video and I am sad that I have only just now found this video. For some of you this will be old but for some of you it may be new. This guy's book is on my current to-read list.

Enjoy and Happy Monday!

Sep 24, 2013

Tuesday Morning's Interesting Finds!


Head on over to Yelling Stop to see Tucker Goodrich's post on the ketogenic diet of a top endurance athlete.


Like breaking down and analyzing the gait of others? Head over to see Pete Larson's latest post and RunBlogger to analyze some elites in SloMo.


Check out Mike Reinold's latest post on what GIRD is and is not.

Do you train CrossFit or treat people that do? Are you aware of the risk for Exertional Rhabdomyolysis? Get educated on this risk right here.

Sep 18, 2013

Bilateral Femoral Acetabular Impingement In a Collegiate Soccer Player

Today's case comes to us from one of my colleagues and classmates, Kathryn Deterding, ATC. Kathryn consulted with me about this case and then went on to implement a treatment protocol based off our discussion.

A Case of Bilateral Femoral Acetabular Impingement(FAI) and Labral Tears in a Collegiate Soccer Player. 


History: This was a 21 year old male collegiate soccer player. In the fall of 2011 he began to experience hip pain that he played through. In the upcoming spring of 2012 he was diagnosed with bilateral FAI and tried to rehabilitate his injury to prepare for the fall season of 2012. The fall season was just as painful as the previous season. This athlete then underwent two different surgical procedures in the winter of 2012. One for each hip, in attempt to lessen his FAI and correct additional labral tears of the hip. The athlete had minimal rehab for a month or so after his surgeries and refrained from heavy activity for a few months. 

Upon increasing activity to prepare for the fall 2013 season of soccer the athlete began to experience the same pain and symptoms. He consulted with an orthopaedic surgeon during the preseason and the physician told him that he may not see any improvements and that this was something that he most likely was going to have to live with.

It was at this point that Kathryn and I discussed the athlete's case together and came up with a plan of care.  The first thing that I did was discuss thought viruses with the athlete and talked about how current neuroscience is teaching us that pain is not necessarily patho-anatomically based but is a construct of the central nervous system. The athlete admitted to thinking that all of this discussion was a load of hogwash and didn't buy into any of what I said. Nevertheless, we continued on with our plan of care.

Sep 16, 2013

Case of The Week: Persistant Postural Headache

Today's case is hot off the press. Hot as in I just saw and treated this patient today.

History: This was a 22 year old collegiate softball player this plays catcher. She has a previous history of occasional headaches that weren't associated with general medical illness. Four days prior to seeing my this patient began suffering from an unusually strong headache. The pain was focal behind her eyebrows and began while she was busy studying and reading in the evening. The patient took ibuprofen but found no relief from it.

Day 2: The patient awoke the next morning with the headache again. This lingered throughout the day and ibuprofen still provided no relief. The headache was severe enough to cause nausea and dizziness as a result. The patient then tried Excedrin which provided minor relief enough to allow her to fall asleep that night.

Day 3: The patient awoke with the same searing headache and once again took Excedrin. This time it only provided minor relief for an hour or two at most. As the day went on the pain increased and induced nausea once again. This night the patient was unable to find sleep at all.

Day 4: A repeat of the previous day began with daybreak and this student-athlete had a lot of reading and studying to do for school. These activities only exacerbated her symptoms even more. Over-the-counter medications now provided no relief and her symptoms continued into the next day when she consulted with me.

Observation: On day 5 of this the patient presented me with her history and symptoms. Upon inspection she had a forward head posture, Bilaterally elevated and protracted shoulders, and an excessively forward slouching posture. I like Jay Dicharry's acronym for this postural presentation "F.A.T.S." aka female adolescent texting syndrome.

Treatment:  I began her treatment much like I do most of my treatments and that was with some light instrument assisted soft tissue mobilization (IASTM). I did IASTM along a cervical pattern and a little bit of her upper traps as well.

Next, I had her do some foam rolling rolling of her thoracic spine to help with increasing thoracic extension and to promote better posture. After this, I had the patient lie supine on the treatment table and had her perform 15-20 cervical retractions into the table. While she would hold the retraction into the table I would apply a light bilateral - posterior to anterior force with the pads of my index fingers just lateral to her C2 spinous process.

The next technique I applied was passive cervical retraction using my right shoulder to her forehead with manual traction/distraction by gripping the occiput with my right hand. I held this for about 20 seconds and did a few repeated retractions as well.

I then instructed the patient on how to perform repeated cervical retractions to cervical extension with manual overpressure. I had her do this for a set of twenty and instructed her that this would be her home exercise program to repeat. Here is a quick video on how these look.

After completion of this I asked the patient how she felt. She told me that her headache was completely abolished and that she an indescribable sensation of clarity. She felt as if she could see further and think more clearly...Funny how pain can cloud our judgement sometimes?

I educated the patient on proper posture and ergonomics for reading and studying. I also lectured her on the necessity to repeat her HEP because of the transient benefits from my treatment.  I told her that she should be able to self-medicate without medication and all that she needed was some quality movement.

I feel that this case highlights a few important things, some are repeat themes to my blog so far:
  • Pain can be debilitating even if it from seemingly common and minor issues such as headaches or migraines.
  • A rapid onset of pain can usually be rapidly reduced
  • Sometimes the best medicine is movement
    • This patient wasn't ill and her body wasn't short on OTC meds like ibuprofen or acetaminophen. These drugs aren't helping to fix your pain, just mask it.
  • Posture can be paramount but it is not as simple just remembering to sit up straight.
  • Patient education and empowerment 
    • Patients shouldn't have to rely on my hands or treatments. We should teach them how to carry on the benefits that we provide them and how to treat themselves in the future.

*Case Update*
I just consulted with the patient again and it is the day after my treatment session with her. Her headache did not return later that evening even after heavy exertion at softball practice.  She still feels great and not even a slight migraine to complain about.

Sep 8, 2013

Empathy: Better to Have too Much or too Little?

This is a short post today that I am typing up on my cell phone.  I'm on the team bus riding back from a football game where I just had to tell a college freshman that their first season of collegiate athletics was over after playing only one game.

This athlete most likely completely ruptured their ACL today and will probably need season ending surgery. This wasn't the first patient that I have delivered this news to and I'm sure it won't be the last. They took the news very well compared to others and didn't visibly weep.

Despite the athlete taking it so well I found myself trying to decide how empathetic I should be towards him. The mother of the athlete was openly weeping and so I tried to answer any questions that I could for the family and athlete.  I also tried to be as positive when discussing the future.

Seeing that this athlete is a freshman I have only known them for less than a month at this point. I don't have a lot of history with them and I don't know their personality very well yet. This will change as they will be forced to spend the next six months at least rehabilitating this injury after surgery.

I am writing this post because I find myself wondering if I was too cold, too invested or neither. Actually, I'm wondering if it's better to be one or the other? Maybe it's better for the patient to be overly empathetic and better for my own psyche to be a little desensitized.

The true answer probably lies somewhere in the middle and depends on the situation, the athlete's personality, and the severity of injury. I'm curious how others deal with these types of situations and thought processes. This isn't something that is explicitly taught or discussed in school. Perhaps this is related to why there is such a high rate of burnout in health care professions?

Thoughts or comments? I'd love to hear what y'all think.

Sep 6, 2013

A Few Friday Finds!


Earlier this week Mark Sisson discussed or should I say ranted about the haters of people choosing to go or live a gluten free life. His thoughts on this topic parallel very well with my own. Although, haters gonna hate.


Dr. Gangemi aka the "Soc Doc" did a Q&A over at the Natural Running Center. Questions ranged in topics from NSAIDs to orthotics to minimalist shoes. Check it out here.


I have been seeing a lot of patients and athletes lately with chronic issues and chronic pain. These are often accompanied by mindsets that Dr. Erson Religioso, DPT calls "Thought Viruses".  I have had some success in addressing this with some people and other times I've failed to explain it properly and end up offending the patient. Here is Dr. E's latest post on his to five most commonly encountered thought viruses and the way he goes about addressing them. 

Have a happy Friday! 

Sep 2, 2013

Case of The Week: Bilateral Plantar Fasciosis

Today's post is centered around a patient that I have been working with lately. This athlete is a sophomore collegiate runner that competes in middle distance running events.


This patient is now a 19 year old male that began running in 4th grade. He was in a running club affiliated with his grade school and was soon running around 160miles a year. He began to suffer minor injuries during middle school and somebody had prescribed him orthotics. He struggled with stress fractures, hip pain, and plantar fascia pain all through middle school. Despite these issues, he still managed to run a 4:43 Mile as an 8th grader.

Throughout high school he continued to struggle with injuries such as hamstring strains/tendonosis, spinal stenosis and low back pain, chronic ankle instability and piriformis issues. He also struggled with plantar fasciitis/osis during this time as well.

Once this athlete got to college he tried to transition to minimalist footwear in attempt to "correct" his heel strike. He did not suffer at all until halfway through his first cross-country season when he had a week long flare up of pain that was similar to his previous plantar fasciitis/osis. He was fine again until the beginning of his first indoor track season. The pain became unrelenting despite being prescribed new orthotics and undergoing an expensive shockwave therapy procedure. The patient decided to just cross train and rest for the remainder of his freshman year as a collegiate runner. 

This is where I entered the picture and had a few small conversations with this athlete regarding his plantar pain and I gave him a few exercises to perform on his own such as a self-mulligan mobilization with movement technique for ankle dorsiflexion and repeated end-range plantar flexion prior to runs. The patient used these few exercises all summer long until he returned for his sophomore year with good results but was not completely pain free.

I heard that he was still struggling with his plantar pain and offered to help him with a proper evaluation and treatment plan.


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