Are Your Shoulders Ready for Brazilian Jiu Jitsu?

I have been keeping busy down here in Miami, Florida. I am about a quarter of the way through my first semester as a PhD student and I have been kept busy with teaching my first class (Introduction to Athletic and Sport Injuries) and by being a research assistant for my adviser as well. I have also had the opportunity to keep myself busy yet physically active by taking back up a long-lost but much loved hobby of mine: Brazilian Jiu Jitsu (BJJ).

BJJ took a backseat for me after training regularly during my bachelor's degree. It stayed on the back burner as I worked on my master's degree but my schedule has normalized enough to allow me to resume training. My sports medicine breadth of knowledge has grown and advanced while my BJJ was placed on hold, and because of that I feel that I have a expanded view on the biomechanics of the sport that I didn't necessarily have previously.

Specifically, I am going to touch briefly on a bit of injury prevention for anyone out there that may be into BJJ or for those of you that may treat people that participate in BJJ (actually this stuff applies to everybody not just BJJ guys). Nevertheless, this post is definitely geared more for the BJJ practitioner and not the clinicians out there...this may not even be new information for those who have visited this blog before.

While I am not somebody that you should go to for submission or any BJJ advice for that matter...I feel that I can give some good insight to help you stay on the mats. Specifically, when I was training I often saw a lot of people struggle with shoulder injuries. In fact, traumatic shoulder dislocations and subluxations were more prevalent than one might assume. Perhaps one wouldn't be surprised considering this is a sport where people enjoy catching each other in joint locks and submission-holds that work by forcibly placing one another's joints at their respective end ranges of motion. So when it comes to a sport where we are already pushing the limits with our body (within reason) then we need to ensure that we are not already at risk of damaging ourselves or our training partners.

I'm no Kenobi.

Having strong, mobile, and stable shoulders is just as important for your ability to submit as well as your ability to not get submitted. The status of your shoulders can also have repercussions up and down the kinetic chain. This is evident when a shoulder issue can manifest itself as a grip strength (I won't be touching on it in this post but proper grip strength can also play a huge role on proper shoulder stability) problem. Not to mention proper shoulder function, especially based upon the tests that I am about to show you, is entirely interdependent on proper function of the elbow joint, glenohumeral (shoulder) joint, the scapula (shoulder blade), the thoracic spine, and arguably the neck or cervical spine as well.

You can bet this guy needs some help, even if he doesn't have symptoms...yet.

So what is a quick an easy way to check for potential shoulder dysfunction? If you know me by now you know I am a fan of the Selective Functional Movement Assessment (SFMA) and think its a great way for everybody to look at movement despite the fact that we may all treat movement in many different ways. So that is where these tests originate!

1) Upper Extremity Pattern #1

What does this shoulder position look like?

This test requires adequate motor control and mobility of many different segments including: Shoulder internal rotation, shoulder extension, and horizontal adduction of the shoulder. Additionally it requires elbow flexion and thoracic spine extension/rotation. Any issues found here indicate a potential stability and/or mobility problem. One must not assume that it is a mobility/flexibility issue that needs stretching or cranking on.

Looks a lot like our test above...If you can't easily put your own arm here, how do you expect it to feel when does it for you?

What is a passing test? The ability for the finger tips to reach the inferior angle of the contralateral scapula without excessive scapular winging of the moving arm, without excessive effort, no deviations in starting posture, and a symmetrical result when compared to the other side. A failing test would require a local biomechanical assessment and to break down of the components of the movement to search for the weakest link. This is a normal range of motion to be able to move through. Deficiency here can lead to increased strain, tension and shearing forces through your upper extremity and its soft tissues.

#2) Upper Extremity Pattern #2

For this test you need adequate shoulder external rotation, shoulder abduction, shoulder flexion, and elbow flexion on top of thoracic extension/rotation as well. To pass this test you must be able to reach your fingers to your contralateral scapula. Where at on the scapula? The midpoint of the spine of your scapula is our targeted destination. However, you need to look for symmetry of movement from side to side, check out how much effort is required, and if there is any deviation of posture to achieve this position. Additionally, a person is not allowed to "crawl" their hands up or down their back for either test. It has to be done with one smooth motion and without "warming" up.

This is not the same as Upper Extremity Pattern #2 but it IS the same. Get it?

If you want a quick and easy way of doing this if you are unsure of your anatomical landmarks just grab yourself a tape measure and assess the distance from your longest finger tip to the first wrist "crease" or wrinkle of your wrist just below your palm. Got that measurement? Okay well you want your hands to be within 1.5 times that measurement to be considered acceptable and don't forget to switch arms and check both ways.

So what do you do if fail these tests? That is a debate for another day but you honestly need more information. However, if you want to use a trial-and-error method then all you need to do is try something out like flopping on a foam roller, lacrosse ball, or getting a massage and seeing if there is  a difference afterwards. How will you know if there is a difference? Retest! Mobility may work may not fix this so don't assume that is what it is! It could just as easily be a motor control or stability issue. Here is a sample of what breaking down one of these tests looks like.

While these tests are far from all-inclusive or the be-all-end-all they are a great starting place to screen or assess for potential risk of injury. If you can do this it doesn't mean you won't injury your shoulder or that you are 100% good to go but if you can't I do know that you deviate from normal into abnormal. Abnormal or dysfunction in my book is the same as pathological and may lead to future injury down the road. Get to work on bullet-proofing your shoulders before it is too late and you are under the scalpel.

!!Update!!

 Some people asked for a video to help clarify a few questions that they had regarding this post and I have finally gotten the time to deliver. Here it is...

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Low Back Pain in a Collegiate Basketball Player

Howdy Readers! Today I wanted to take some time to report on a case that I was presented with during this previous basketball season. Then I will discuss how I addressed the case and what I wish that I could have changed about the case. I will also be using my findings from the patient's Selective Functional Movement Assessment (SFMA), and so here is the SFMA acronym legend:

FN: Functional & Non-painful
FP: Functional & Painful
DN: Dysfunctional & Non-painful
DP: Dysfunctional & Painful

Background:

A 21 year old NCAA division III basketball player was competing in a JV basketball game when he suffered a direct blow to the low back by an opposing player's elbow. The supervising athletic trainer (I was busy prepping the varsity team to play) determined there were no gross deformities, ruled out neurological involvement (dermatomes & myotomes WNL), and ruled out any potential fractures. Nevertheless, the player was unable to return to play and finish the game due to pain.

This player had a previous history of catastrophic injury as a high school basketball player when he was undercut by an opponent. He fell on his upper back and hit his head suffering a fractured scapula and traumatic brain injury that lead to him being placed into a medically-induced coma. Additionally, he had a history of low-back pain during high school. The year previous to the current incident this athlete suffered a season-ending concussion as well.

After the game was over this athlete returned to his hometown with his parents. The parents and the athlete planned to see a family friend that is an orthopaedic surgeon in the following days. Upon consulting with the doctor it was revealed to the athlete that he had degenerative joint disease (DJD) in his lumbar spine and he was sent back to me for rehabilitation at my discretion.

Upon hearing this I definitely began to dismiss the DJD because I knew that suffering an elbow to the low back in one game of basketball didn't give this player DJD. I began to talk with the patient about pain science, how it didn't matter if he had DJD because he had it before when he was pain-free, and how we weren't going to attempt to change it. I did discuss how we would perform an SFMA and evaluate in which patterns he was moving dysfunctionally & why they were dysfunctional.

Assessment:

SFMA Top Tier Results & Breakout Findings--
Cervical Flexion = DN: Tissue Extensibility Dysfunction
Cervical Extension = FN
Cervical Rotation = Left - FN / Right - DN: (Tissue Extensibility Dysfunction)
Upper Extremity Pattern 1 = DN (Bilaterally, Left worse than Right): (Functional Shoulder Pattern Stability/Motor Control Dysfunction)
Upper Extremity Pattern 2 = FN (Bilaterally)
Multi-Segmental Flexion = DP (Posterior Chain Tissue Extensibility Dysfunction)
Multi-Segmental Extension = DN: (Thorax Extension Stability/Motor Control Dysfunction, Hip Extension Tissue Extensibility Dysfunction)
Multi-Segmental Rotation = DN (Fundamental Rotational Pattern Stability/Motor Control Dysfunction, Hip ER Tissue Extensibility Dysfunction)
Single Leg Stance = DN (Lower Posterior Chain Tissue Extensibility Dysfunction)
Overhead Deep Squat = DN (Hip and Lower Leg Posterior Chain Tissue Extensibility Dysfunction)

Plan:

Based upon my SFMA findings I decided to attack the greatest areas of dysfunction first. I determined that the hip flexion/posterior chain TED (~40 degrees passive SLR), and cervical flexion & rotation were the patient's greatest limitations. This is what I formulated my initial treatment plan around as well. I began with an easy 5 minute warm-up on a stationary bike followed by some instrument assisted soft tissue mobilization (IASTM) to the posterior neck, proximal hamstrings attachment near the ischial tuberosity and distal attachment of the biceps femoris to prepare for some Muscle Energy Technique (MET).

Day 1: Pain (7/10)

Upper Trap MET

I performed MET techniques (redundancy?) for the upper trap, scalenes, and posterior neck extensors. I performed 3 sets of autogenic isometric inhibition on the right side and an extra set on the left side. This brought cervical flexion and rotation to FN immediately following application of the MET treatment.

I then instructed the patient to perform a couple sets of supine kettlebell carries. Each set lasted until the patient neared fatigue and was unable to retract and "pack" the shoulder/scapula. This was performed bilaterally. Reassessing the upper extremity pattern 1 revealed decreased winging compared with baseline.

MET for the Scalenes

Before Treatment

Next, I performed MET for the posterior hamstrings. Specifically, I also instructed the patient on performing an autogenic isometric inhibitory technique. I performed this bilaterally and found that the patient's passive SLR increased ~20 degrees immediately by the end of treatment.

After Treatment

The patient was unable to attempt rolling exercises due to passive back pain so instead of attempting to restore rolling I had the patient perform some light stretching hip external rotation and calf stretching after having their glutes and gastroc/soleous worked out using a rolling stick by my student.

Easy Hip ER Stretch

Straight Leg Gastrocnemius Stretch - Towel prevents pronation

Bent Knee Soleus Stretch - Towel prevents pronation again

Day 2: Pain (4/10)

The patient returned the second day with increased cervical flexion and rotation patterns but they were no longer functional. I repeated the previous days IASTM and MET techniques and once again these patterns were FN after application. In attempt to prolong these gains, I applied some Rock Tape to the upper traps and scalenes. Once again I had the patient do some kettlebell carries while in a supine position. 

The passive SLR was still increased from the previous day but was still about 15 degrees short of normal. The patient was able to foam roll without increased pain and so I had him foam roll the entire posterior leg chain before IASTM to the aforementioned patterns. Again, we used the previous day's MET application to the hamstrings and this increased the passive SLR to normal.

Due to the patient's ability to have such drastic increases in mobility in such a small amount of time I suspected crucial core stability issues. In attempt to progress this patient quickly I wanted to restore rolling ASAP for the supine to prone upper extremity rolling pattern. I spent about 15 minutes working on rolling with him before calling it a day. Rolling was definitely not perfect but was much better than when we began.

Day 3: No Pain?

On the third day of treatment the athlete returned with FN cervical flexion, and rotation patterns and now Multi-Segmental Flexion was a DN. The athlete reported being sore in the shoulders and hips but no longer was experiencing any pain. We were now about 7 days out from initial injury. I continued to work on rolling patterns and was able to progress to some quadruped and tall-kneeling exercises before the day's end. I could tell that the athlete was very excited to return to basketball so I began his RTP progress with some easy free-throw shooting.

Return to Play and Further Treatment:

Unfortunately, the next day the athlete returned home for spring break and was no longer under my supervision. Despite my best efforts to provide a substantial home-exercise program for this athlete he was so enthused by his progress that he did not stick to his HEP and instead played basketball and rested his entire break.

Upon returning to school the athlete was no longer compliant with his rehab despite the presence his many dysfunctional movement patterns (MSF, MSE, UE #1, MSR, SLS, ODS) and would no longer come for rehab. Reluctantly, I continued to let him participate in practice and JV games. It wasn't because I didn't care about making him better but more because of it being an issue of me being stretched too thin between other athletes that had issues and wanted my help and patients like him that needed my help but wanted none of it because they no longer suffered. It is not an ideal situation but it is the way the world works sometimes. Ideally for me I wish I had been in a position where there was somebody(like a strength coach) that was familiar with the FMS and corrective exercises to help these athletes overcome their dysfunction.

Points of Distinction & Conclusion:

What I thought was interesting regarding this case was the patient's history of traumatic injury to the left scapula and the presence of ipsilateral hypertonic neck muscular and poor scapular stability when compared bilaterally. I do not know if this was present since his previous injury but its hard for me to ignore such a glaring "coincidence" when I see it. When I initially worked with this athlete I had a little contempt for the incomplete rehabilitation that he must have been put through following his previous injuries. 

However, I soon began to feel and conclude that much of this could have been the athlete's own doing and not that of previous clinicians. I even tried the route of touting injury prevention, performance enhancement and how he may be a ticking-time bomb for re-injury and recurrence of back pain. Some people, patients, and athletes just do not seem to want help unless they are physically writhing in pain and unable to walk. I am not sure if this is pride or pure laziness! 

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It moves, it breaths...it LIVES!

I wonder if any of my blog readers are still "sticking" around?

Howdy Readers (if I have any left)!

I just wanted to take a quick moment to let you all know that I am still alive. I have so many post ideas, videos, and things that I want to share with you all. However, I am ashamed that I have let my dedication to posting slack so much!

I thought that this short post could be used to sum up some of the changes that are about to occur in my life and to state what I have been up to. First of all, I have now successfully defended my thesis and only have a few tiny edits and format changes to make before finally submitting it. Secondly, this means that I am only a couple of weeks from completing my Master's degree at Illinois State University. I had a lot of great classmates, and instructors with a variety of backgrounds and personalities that have helped me diversify how I think about, look at and treat my patients. I owe a huge thank you to all of them.

This also means that soon I will be finishing my tenure at Illinois Wesleyan University as a graduate assistant athletic trainer.  This is a bitter sweet feeling for me. I have made a lot of good memories, learned a lot, and met some great people over the last two years. I will miss working with the Men's Basketball team at Illinois Wesleyan. I had a great time working with them and it was a blast when they went to the NCAA Div. III Sweet Sixteen last year and the Final Four this year. They were the first team that I was solely responsible for after becoming certified as an athletic trainer. My interactions with the players, the injuries, coaches, fans and parents have been integral in influencing my clinical practice. Over the past few weeks I have received a lot of praise from them, their parents, and the coaches but the truth is I owe them just as much thanks.

What makes this even more bittersweet is the fact that they will be the first and last team that I solely work with for quite a while. This is because I have decided to accept a doctoral student position at the University of Miami (Florida) to get my PhD in exercise physiology. There, I will work as a research assistant instead of being a clinician like I did with my master's.

This is going to be a huge change of pace, culture, and life for me. I have lived in the midwest all my life, loved cold weather, and never attended a private college before. I am definitely in for some culture and climate shock when I get there. However, I do look forward to trying my hand at continuing my clinical skills in a non-traditional fashion for an athletic trainer. I don't have anything set in stone and who knows how busy I will be but I may attempt to do some small-scale concierge or private 1on1 work clients that will focus on injury prevention and performance enhancement. Coincidentally, there was a very fitting article related to this type of service over at The Manual Therapist today.

I am getting to the point of this post where I need to wrap it up, say good bye and get back to work. There is much to be done with moving, preparing my thesis for publication, scholarships, and getting back in shape myself. It is a very exciting time for me and I hope that from this point on I will be able to contribute to my blog more frequently than I ever have before since it's inception. In fact, this blog is now over a year old! I know this because I just received a domain renewal notice ;) I have received about 100,000 page views in the past year. I hope that I can increase that exponentially over the next 365 days! I wish you all the best.

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Help Me, Help You: I'm on Google Help Outs!

Hey everybody! It's an exciting yet very interesting time for me right now. I am half way done with data collection for my master's thesis, and if I finish it on time then I'll be graduating in the beginning of May.

On top of that and the focus of this post is that I am trying a new hat on for size with an endeavor into the world of Google Helpouts.  Google Helpouts is a relatively new service where Google tries to pair up everyday people needing specific help with experts in the respective fields of need. For instance, if I needed help with my car Google would set me up with a car mechanic to see if they could assist me via video chat.

So here is the part where I come in... I want to use Helpouts to assist people with moving better, feeling better, and performing better. I believe with my movement based system of assessment (FMS & SFMA) I will be able to help others achieve these goals. I am going to approach this initially with an injury prevention, movement analysis, performance enhancement and nutrition focus.

I look forward to broadening my pool of people to work with and if that person is you I can't wait to get started in assisting you to achieve your goals. Google has generously offered me a code allow you to have your first Helpout session with me for free (ADAM99V). Each session will last a minimum of 45 minutes if needed at a rate of $25. Check out my profile and schedule a Helpout with me ASAP! Can't wait to see what this brings! 

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Where Have I Been?

Howdy Folks! I am sorry that I haven't been blogging even a quarter as much as I would like to be lately. However, in all fairness I have been pretty busy. What have I been busy with you might ask? Well...on top of being an athletic trainer for a collegiate basketball team (that is ranked #4 in its division for the entire country and likely to win their second conference championship in a row), I have been busy working on and trying to complete the research project for my master's thesis.

Dr. Erson Religioso over at The Manual Therapist has been interested in my research project and asked me to write a guest blog for him where I would discuss what I was doing with and looking at for my research. I was honored but it also gave him some time off from blogging to spend with his new-born baby girl! Congrats to him for sure! Anyways, here is a link to my guest blog where I talk about my research! I need to get back on the blogging train and finish my self-SFMA series as well! Sorry for the delay, everyone.

I've got some cool cases related to my patients, SFMA, PRI, and Rock Tape to blog about once I get some more free time! Can't wait to share them all!

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A Year in Review: 13 Lessons of 2013

Happy New Year and welcome to 2014! This is my first post of the year and my 75th post overall.  This is going to be a reflection on some of the things that I learned in the previous 365 days. I was inspired to write this post after reading many of Mike Reinold's similar posts over the last few years. I guess I learned a lot this year because this turned into an epically long post. Sorry.

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Top 5 Posts of 2013!

Happy Holidays and a Happy New Year to all of my readers! I'm not sure if I actually have any dedicated readers yet but happy holidays to any happenstance readers as well! This post is a highlight of my top 5 viewed posts of 2013. I know it isn't technically 2014 yet so maybe I will be proved wrong. However, if you are new to my blog or haven't read all of my posts then maybe this recap will enlighten you to a popular post that you missed.

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My SFMA: A Case Study - Cervical Breakouts

Time to make an assessment of myself

Today's post is second part of my self-SFMA(Selective Functional Movement Assessment) case study series.  Specifically, We will look at the dysfunctional cervical spine movement patterns from my SFMA Top Tier Post.  In the first post/video, I was dysfunctional/non-painful (DN) for the Cervical Flexion Pattern, and the Cervical Rotation Pattern to both the Right & Left.  However, I was functional/non-painful (FN) for Cervical Extension. In case you missed it, here is the 7 top tier tests again.

The SFMA works by assessing 7 general top tier movement tests. From there you perform a "breakout" of each dysfunctional pattern to determine the cause of dysfunction. Dysfunction movement patterns are broken down using an algorithm that funnels and filters the problem into either a mobility dysfunction or a stability &/or motor control dysfunction (SMCD).

Assessment:
This video will look at the dysfunctional cervical spine patterns. Specifically, cervical flexion and cervical rotation to the left and right. I was functional for the cervical extension pattern so that pattern does not require a breakout assessment. Here is the breakout video:

Results:
Cervical Flexion Top Tier = DN (Unable to bring chin to sternum. Why? We don't know yet.)

Active Supine Cervical Flexion Test = DN (Still Unable to bring chin to sternum. Why? We don't know yet.)
If I was now FN we would know that there is a postural and motor control dysfunction or stability/motor control dysfunction...or both, affecting cervical flexion. This includes the c-spine, T-spine, and shoulder girdle postural dysfunction. Laying supine removed the postural and stability requirements of the gravity dependent/loaded standing position from the top-tier tests

Passive Supine Cervical Flexion Test = FN (Chin is now to sternum)
We can now assume the cause of the dysfunction was due to an active cervical spine flexion stability dysfunction or motor control dysfunction...or both. We know it is not a mobility issue because I had full motion when all stability and motor control requirements were removed and the movement was performed passively. If it was due to mobility reasons then my GF would not have been able to passively bring my chin to my chest. Mobility problems always present with consistent findings!

Cervical Rotation Top Tier = DN to the Left & Right (Can not rotate chin to mid-clavicle or at least 80 degrees, Why? We don't know yet)
This test no longer requires this degree of rotation and the ability to bring the chin to the clavicle, at least this is how I was instructed in October of 2013.

Active Supine Cervical Rotation Test = FN (At least 80 degrees of rotation bilaterally without a significant asymmetry)
We now know that the dysfunction was related to a postural and motor control dysfunction or a stability and motor control dysfunction...or both. This is why my top tier cervical spine rotation test was dysfunctional, not because of my perceived tissue "tightness."


Treatment:
It is said that there are many ways to skin a cat...that being said the SFMA is a tool or a system of assessment. It is not a specific approach to treatment. However, there are general guidelines based off of the findings and it also lays a road map of treatment for you(eg. mobility before stability, working your way down the top tier tests). Specifically, in my case I do not have any mobility dysfunctions within the cervical spine but if I follow the philosophy of the SFMA then I need to address the SMCD of the cervical flexion pattern before attempting to correct SMCD dysfunction of the cervical rotation.

There are many avenues for treating this dysfunction from dry needling to IASTM to MDT principles to using the 4x4 Matrix or etc. I can't advocate that one approach will be better for addressing my dysfunction than another...but I do have a system of assessment to judge the efficacy of each potential intervention. Perhaps IASTM and MDT combined will work great for 90% of my patients but I don't know that...all I need to know is how to assess-intervene-reassess. Oh and I should probably stay within my practice act, so use what tools you have and those that you are comfortable with.

Thoughts? Do you think my breakouts and assessment have been accurate so far? What would you do with me? I know what I would do....finish the SFMA breakouts, first. Come back as I continue to break out my many dysfunctional movement patterns.

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1 Month of The SFMA: My Reflections

It has now been exactly a month since I took the Selective Functional Movement Assessment certification course in St. Louis, MO. You can read my initial course review here. I have been trying to incorporate the SFMA into my clinical practice as much and as often as possible since then. I wanted to take the time to highlight some thoughts and self-reflections from this process so far.

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The SFMA Course Review, 9/5/13-9/6/13

This past weekend I had the pleasure of attending the Selective Functional Movement Assessment(SFMA) certification course in St. Louis, Missouri. More specifically, the course was hosted on the beautiful campus of Logan Chiropractic College/University.  Logan did a great job of hosting this seminar and they were very accommodating and even had snacks/refreshments/coffee available. The only thing I could think to gripe about was my poor cellphone service in the basement classroom that we used. ;)

I was first introduced to the SFMA by a mentor of mine during my senior year of my undergraduate when he attended an SFMA course himself. He gave me some background about what it was and what they were trying to teach and ever since then I had wanted to learn it myself. Reading the book Movement by Gray Cook and becoming FMS certified didn't help my anxiousness either.

For those of you that don't know what the SFMA is..."The Selective Functional Movement Assessment (SFMA) is a series of 7 full-body movement tests designed to assess fundamental patterns of movement such as bending and squatting in those with known musculoskeletal pain. When the clinical assessment is initiated from the perspective of the movement pattern, the clinician has the opportunity to identify meaningful impairments that may be seemingly unrelated to the main musculoskeletal complaint, but contribute to the associated disability. This concept, known as Regional Interdependence, is the hallmark of the SFMA.

The assessment guides the clinician to the most dysfunctional non-painful movement pattern, which is then assessed in detail. This approach is designed to complement the existing exam and serve as a model to efficiently integrate the concepts of posture, muscle balance and the fundamental patterns of movement into musculoskeletal practice. By addressing the most dysfunctional non-painful pattern, the application of targeted interventions (manual therapy and therapeutic exercise) is not adversely affected by pain." -SFMA.com

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Guest Lecture on Dry Needling (Videos Included!)

I am finishing up my last year of graduate school and for one of my courses we have guest speakers from other health professions come and present to our entire athletic training graduate program. This week we had a pleasure of a having a local Physical Therapist(PT) come and present to us on Dry Needling.

Dry Needling is a practice that is growing in popularity in the United States and more and more clinicians are getting trained in it. Athletic Trainers, at least in my state, do not have it in their practice acts to perform dry needling so we must refer out to others that are able to do so. I have referred a patient to this particular PT for dry needling in the past and they had great results from the treatment.

This PT presented on the background of Dry Needling and discussed how it differed from traditional acupuncture (local twitch response on trigger points vs. meridian therapy), and we learned how he incorporated this "modality" into his clinical practice. We also discussed related research to dry needling and it was a pretty informative lecture. Ultimately, he presented the case of undergraduate athletic training student (that is doing a clinical rotation at his clinic)and their chronic injury that coincidentally mirrored that of the patient's that I referred to him. He then went on to utilize dry needling on this student in front of us as part of his lecture, I whipped out my camera to get some video footage of it for all of you!

Before I show you all the footage I will present you with his case:

History:
A 23 y.o. college student has been experiencing R side LBP that began insidiously and has been progressively worsening over the past 2 years. He also reports occasional radicular symptoms to his R posterior thigh area. He rates the intensity of his symptoms between 3/10 - 8/10 that worsen with prolonged sitting in class and while driving. He also notes that he avoids heavy lifting activities at the fitness center including dead lifts and squats. His symptoms are generally decreased with ambulation.

Imaging(who cares, right?):
x-rays were unremarkable, L-Spine MRI revealed moderate disc bulge at L4-L5 level

Self-Report Measures:
Modified Oswestry Disability Questionairre: 14/50 = 28%
Fear Avoidance Belief Questionairre - Work Subscale: = 13

Significant Past Medical History: R ACL reconstructive surgery ('11)

Objective Findings:
ROM:  
repeated trunk flexion = no change in sx, repeated extension = pain that increased with repetition, repeated R side gliding = no change in symptoms, repeated L side gliding = no change in symptoms
Sensation: 
B LE = intact to light touch and pin prick throughout
MSR:
B patella and B Achilles = 2+
Strength:
R knee ext = 5/5, R knee flex = 5/5, R hip abd = 4-/5, L knee ext = 5/5, L knee flex = 5/5, L hip abd = 4+/5
Mobility: 
moderate thoracic spine hypomobility; moderate lumbar spine hypermobility w/ pain provocation
Palpation:
severe R glut max, glut medius, and piriformis hypertonicity w/ pain provocation; elicitation of local twitch response w/ palpation
Assessment: Myofascial Pain Syndrome related to poor strength and stability of lateral hip musculature and core stabilization and hypomobility of the thoracic spine.

Treatment: Dry Needling of the "trigger points" found in the gluteus maximus and gluteus medius. Followed with IASTM of the surrounding musculature and appropriate rehabilitative exercises for strength and stability. There wasn't a true home exercise program recommended to this patient but I would expect that he usually gives them one. I am curious how patients would respond to light IASTM prior to the dry needling instead of doing the opposite.

Here are the two videos! Enjoy! Anyone else have experience with dry needling via patients or personally? I haven't felt it but I am curious to how it feels! I have witnessed it to be an effective treatment but I am still apprehensive about "trigger points" as a topic or entity or our ability to detect them reliably.

Gluteus Maximus Dry Needling

Gluteus Medius Dry Needling (Really Long Needle!) Shorter Video

This weekend I am off to St. Louis to officially get trained in the Selective Functional Movement Assessment (SFMA) and I am very excited! I was introduced to this by my mentor during my senior internship as an undergraduate and have wanted to take this course since then. If you have read Gray Cook's movement you are probably familiar with the system but if you aren't then the simplest way of describing it is to call it a movement based evaluation system. System and movement are the keywords in that sentence. It is the medical professional evaluative half of the Functional Movement System (brother to the Functional Movement Screen). I will write a course review next week and post it here!

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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!

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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.

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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.

History:

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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The Edge Mobility Band Review

(Disclosure: This was not a free item given to me for review. I paid for this on my own but I have learned a lot from the creator of this product and that information has helped me and my patients a ton so maybe that makes me biased. If that is a bias I hope I continue this bias for a long time.)

Today I will be reviewing the Edge Mobility Band which is part of the Edge Mobility System by Dr. Erson Religioso, DPT of The Manual Therapist. I have been following his blog for quite awhile now and from the start I was very intrigued by the magical blue bands that he kept using on his patients and in his videos.

I would watch his videos and read his blog posts about the increased function, mobility and decreased pain associated with using these bands as part of his treatment protocol. At the time I was unaware of the Voodoo floss bands so this was my first exposure to compression wrapping for anything other than edema prevention/reduction. I even tweeted at him back in April of this year to inquire whether a poor graduate student like myself could substitute a resistance band for his bands and get the same effect. He answered my tweet with complete honesty and told me that there was nothing magical about the Edge Mobility Bands. He stated that a simple resistance band should suffice.

While there may be nothing magical about these bands there is definitely something special about their construction and design considering that I wasted many hours trying to experiment with resistance bands instead of coughing up $24 bucks for two Edge Mobility Bands of my own. Most of those experiments led to cutting off the circulation of extremities, excessive body hair pulling, and the constant rolling and tearing of many thera-bands. It simply wasn't a feasible substitute for me but maybe it works or would work for somebody that is more coordinated, stubborn or cheap than me.

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Ten Handy Apps for In The Clinic and On The Field.

I recently got a new phone and I have been in the process of downloading new apps for it. This is my first Android phone so I am getting used to it but it has made me think about how much I use different apps on a daily basis in the clinic, on the field or in the classroom.

This also gave me the idea of telling you all about ten different apps that I find myself using quite frequently. I am always looking for more apps that will help keep me organized and productive so if you have any suggestions please feel free to comment below.

I have both an iPad and a Samsung Galaxy S4 so this list will include both android and Apple apps but many are available to users of many different devices. Now onto the list and in no particular order...

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Can Edge Mobility Bands Really Improve Mobility? Let Us Investigate.

Sorry for the delay in posts everybody! I have been busy with a combination of work, working on my thesis, and pre-season football practices. Enough complaining...lets get to the post!

I recently got myself a few new toys to use in the clinic when I bought myself a pair of Edge Mobility Bands from The Edge Mobility System. I am in the process of experimenting more with these bands so I can write an extensive and fair review of them to publish here. Nevertheless, I have already started to find them handy and beneficial when treating my athletes.

  

I have been using them with great success to increase mobility and decrease pain of a few football players that have been complaining of persistent and chronic knee pain. In particular, I have been using them to increase hip internal rotation mobility and I made a video to showcase this technique with the help of some of the athletic training students that are assigned to me. The student I use in this video also used to be a football player (kicker) in college and is normally restricted with Right (kicking leg) Hip IR especially compared to his Left leg.

I learned this technique from a video made by the owner of the Edge Mobility System products and the author of TheManualTherapist.com, Dr. Erson Religioso, DPT. You can find his original video and post of this mobilization here. 

...Enough jabbering on my part, here is the video. I hope you enjoy it and I can't wait to show you all more!

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My First Guest Blog at ATCHacks!

For my second and final year of graduate school I will be featured as a semi-regular guest blogger at ATC Hacks. The series will be called "Grad Life" and as you might guess it will be about my time as a graduate student and graduate assistant athletic trainer.

I will be discussing things like advice for prospective graduate students, reflections on my own experiences, and anecdotes related to my own trials and tribulations. Here is a link to my first post! It isn't very long or informative, it is just more of an introductory post! This is the same website that featured me on their "In The ATR" series and you can find that post here if you haven't checked it out yet.

My next post will be my 50th blog post which I am considering a mini milestone, so I hope that I can make it something interesting for you all! To also go along with that piece of news is the fact that you can now type in EatRunRehab.com and it will redirect you to my site. No more worries about the long URL or spelling rehabilitate correctly! ;)

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I Am Suffering From Clinical Summer Doldrums

I am not sure if the title of this post makes any sense but what I am trying to say is that I am itching to get back into the clinic. All of my athletes(patients) are on summer break and I won't be dealing with any athletes for another two weeks or so. I love being an athletic trainer and I have been reading/watching/learning a lot this summer that I want to use to advance my skills as a clinician.

With no athletes to fix I have resorted to offering a helping hand to others outside of my athletic training world. I work as a barista for a part-time summer job to help foot some of my bills and fortunately for me over the past week this job has been a source for me to help some people with musculoskeletal issues.

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Strengthen and Mobilize Your Feet!

I have put together a video compilation of some of my favorite mobility and strengthening exercises for the foot. The target of most of these will be for the intrinsic soft tissues of the feet but you can't fully target just one area or muscle of the body with an exercise. I didn't think of all of these ideas and I tried to give credit to those that I learned them from where I could!

These would be good for anyone with a history of ankle, lower leg or foot injuries. It doesn't matter if you wear Hoka One Ones or nothing on your feet because all of us should have strong and mobile feet. Your feet do a ton of work for you and are your main contact point with the ground. Take care of them!

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