A Day in the Life of Post ACL Sports Physical Therapy

By Kirsten Carmichael PT, DPT, CSCS, SFGI

Post ACL reconstruction surgery is one of the most common things I see as a sports Physical Therapist.  Here at Next Level you will see many patients working through different phases of return to sport rehabilitation. Here's a glimpse of some of our different phases of progress.  It is important to respect the healing of your graft and to have a PT who understands how much loading is appropriate (and when) so that you can continually build strength and keep moving towards your sport specific goals.

In early therapy if your quad is have trouble firing we use NMES (neurmuscular electrical stimulation) to help the muscles contract.  Due to all of the swelling these muscles become inhibited after surgery.  It is a big goal to get them firing again.

Also in early therapy our goals are of course to get you walking normally again. As quickly as possible we begin training more functional patterns, challenging your core strength, strengthening your hips, and retraining balance.

Regaining single leg strength is another big goal.  Therapy often involves many different exercises utilizing only one leg at a time so no compensation is allowed.    

As you continue to get stronger another goal is to keep your mobility looking good.  We work hard to restore full range of motion of the knee but also to maintain mobility particularly of the quad (we don't want it getting too tight) and the other tissues surrounding the knee.  Myofascial decompression (cupping), instrument assisted soft tissue mobilization, rolling, and mobility bands all help to accomplish this. 

And then we continue to work hard on strength, stability, and endurance...sweat is normal here.

Your Physcial Therapist will progressively load you and watch your movement patterns so that you continue to get stronger. 

Once you meet specific strength, mobility, pain-free criteria you will move into more dynamic and sport specific training.  Here is where things get fun!

 A sports specific physical therapist will have the tools to cater this towards your individual sport's demands and be able to ramp you back into these activities in a controlled environment.

As you can see most of the rehab process looks like a strength and conditioning program but tapered down initially to respect the healing process and integrity of the graft.

 If you are looking for a therapist specialized in returning athletes to sport give us a call or send us a message! 

From Physical Therapy to Training Here's 5 Reasons Why I love Those Kettlebells

 By Kirsten Carmichael PT, DPT, SFG I, CSCS

I commonly get asked what’s the deal with the kettlebells.  My answer is they are an amazing all in one tool. You can rehab injuries, build strength, endurance, and power all at once.  Kettlebells have in fact been around for ages but their popularity seems to come and go in phases like so many things in the fitness world.  There is always something new and flashy but the kettlebell will forever be a staple you can use anytime, anywhere for a full body workout. Here are some cool benefits of training with kettlebells (and why I use them as both a physical therapist and strength coach).

11)    They are fantastic for your shoulders.  As a physical therapist improving the strength and dynamic stability (ability of the deep shoulder muscles to really lock the ball in the socket) are key.  Since my patients can’t take me home with them for manual exercises, I use kettlebells and their unique weight distribution to train this.  Kettlebell arm bars, get ups, bottoms up work, windmills...they all improve stability and mobility of the shoulder girdle. Also, when pressing the kettlebell allows the shoulder to move in more planes of motion than a conventional barbell.  The ability to rotate is huge for your cuff muscles as well as preventing injury (because you don’t jam your tendons).

22)    Kettlebells build incredible grip strength.  This is so important for everything from sports to performing daily activities.

33.)    You can train power, strength, and endurance all at one time.  Again, your more dynamic movements like swings, cleans, and snatches with the kettlebell train power while also sparing wrists/arms that receive a great deal more stress with the barbell versions. 

44.)    You can train stability and mobility at the same time.  Just take a look at the get up…that requires all kinds of shoulder and hip mobility but trains strength and stability at the same.  And it doesn’t get any more functional than getting up from the floor and back down again.

55.)    You can train literally anywhere.  You don’t need to spend a lot of money, and you don’t need a ton of equipment or space. 

Interested in our approach to injury rehabilitation or looking to improve your fitness?  Contact us today to learn more about our Physical Therapy and Strength and Conditioning services and community!

Arm Care Part 2-Dynamic Stabilization

In the last blog we talked about some of the most important arm care exercises for strength.  This time we will add on and go over some nice options for building dynamic stability.

The shoulder is the most mobile joint in the body.  Often times when we see shoulder trouble it is not an issue of mobility but rather a lack of stability. If we think about the function of the "core" muscles of the shoulder (the rotator cuff) they are not designed to be prime movers of the shoulder but rather help hold (stabilize) the ball in the socket. In baseball during pitching these muscles help control the deceleration phase.  If stability is lacking it often leads to shoulder pain and can trickle down the chain where the forces impact the elbow and cause problems there.

In Physical Therapy we utilize a lot of manually resisted exercises to help improve dynamic shoulder stability where the therapist applies forces with their hands in different directions in certain positions or exercises.  However, there are some great exercises that can get those dynamic stabilizers firing and can be done at home or the gym.  Here are a few examples to get started with! (Shout out to my model Craig Valentine, owner of my home Loomis Kettlebell Gym and Del Oro baseball alum).

Kettlebell Arm Bar: This is a great exercise for getting the stabilizers going in the shoulder.  The offset weight of the bell cues those muscles to fire to keep the arm from moving.  The goal here is to really engage the lat muscles and "pack your shoulder" holding the arm strong.  Start light with this exercise as these muscles aren't the big movers.

Sidelying External Rotation Catches:  We talked in the last blog about sidelying external rotation with the weight being one of the very best exercises for strengthening the cuff.  Here we put a little spin on the same exercise making it more dynamic by doing a drop/catch with a small medicine ball (two pound weighted ball shown here).  You can start slow as you learn to control the movement and then increase your tempo from there.

90/90 Wall Dribbles: With overhead athletes we want to make sure we train these muscles in the functional positions of your sport.  So getting the arm up into an overhead range is important.  These are surprisingly fatiguing but train great stability!

 Wall Clock Dribbles: Again this is another exercise that allows you to move and work the stabilizers through a greater range of motion also making sure we engage those muscles overhead.

Prone Ball Drops: Here we get some more scapular stabilizers involved and change up the position by lying prone over a ball.  These are also very fatiguing so start with short bouts and work your way up from there.

Now we have both strength and stability arm care covered!  Hope everyone's spring seasons are getting off to a pain-free start.  And as always keep those arms strong and healthy!!! Follow us for more tips on Instagram and Facebook @gonextlevelpt

Arm Care Part I- Strengthening

  As mentioned in my last post with the rapid approach of baseball and softball season I wanted to share some arm care tips.  Baseball arm care gets a lot of attention due to the nature of pitching and the common injuries that occur.  That isn't to say that other overhead athletes (like myself who plays volleyball and softball) couldn't absolutely benefit from these exercises too.  The shoulder is a ball and socket joint with a ton of mobility that allows us to perform motions like throwing.  The trade off for all the mobility is often a lack of stability.  This means it is critical to keep your shoulder strong especially as an overhead athlete.

Thanks to the work of many researchers out there who have shared their awesome findings (Mike Reinold, Kevin Wilk to name a few) we have EMG studies telling us the exercises that get the most activation for each muscle.  Mike Reinold discussed at the last SF Giants Sports Medicine Conference the importance of continuing to perform the exercises that we know work even if they aren't the flashy ones we're seeing on Instagram. That being said what should we include as part of our strengthening program for the rotator cuff and scapular muscles?  Here are a few of the basics that are key for a healthy arm.

Sidelying external rotation gets the most bang for your buck when strengthening the rotator cuff.  Use a towel roll under your arm for 20% more muscle activation. 

This is a definite "oldie but goodie" as external rotation can also be strengthened with a band.  Bands give a different kind of resistance compared to weights and it is important to slowly return to your starting position so you can reap the eccentric benefits. Keep the towel roll in the mix for this one too for extra muscle activation.

Prone Y's are great for strengthening scapular muscles particularly lower trapezius.  If you don't have a table a ball or a bench in the gym also works.  Make sure you start with a light weight, often the upper trap is tempted to compensate with this one.

Another great exercise for lower trapezius activation is the banded W.  This can be done sitting or standing.  I really like sitting on the ball because it helps to cue some extra postural engagement.

Finally a great exercise for serratus anterior is banded wall slides.  With this exercise pay careful attention that you keep your mid back slightly rounded (so that it is not flat).  This helps with upward rotation of the scapula and is a critical muscle for overhead athletes.

These are a few great basics to add to your arm care routine.  Aside from strength we also train overhead athletes to build dynamic stability.  Often that involves manually resisted exercises but next time I will go over some good options you can do on your own.  Keep those arms healthy everyone! 

And if you are having pain come see me!  Sports like baseball require full body movement assessment from the ground up.  Make sure you are moving well and pain-free so you can stay in the game and perform at 110%!

San Francisco Giants 4th Annual Sports Medicine Conference

Last weekend was spent learning the latest in baseball rehabilitation at the SF Giants Sports Medicine Conference.  It was a wonderful opportunity to reconnect with former colleagues from the Bay Area and the Giants sports medicine team!

Not a bad view at the conference

A wide variety of information was presented on some of the latest surgical and non-surgical treatment options and rehabilitation for the shoulder, elbow, hand, and knee.  We also had an update on the latest in concussion management from a baseball perspective.  As well some great discussions on injury prevention.  There was a common trend among multiple presenters emphasizing the need to address the entire kinetic chain in baseball pitchers and work from the ground up. The body is not designed to throw hard for the number of repetitions that pitchers undergo.  During the presentation by Stan Conte it was reiterated that if you don't use your legs and core (or you are lacking mobility down the chain) you end up throwing with your arm and that is where trouble often presents. A sound strength and conditioning and arm care program are key in staying healthy and throwing hard. 

Hearing perspectives on dealing with injuries and working with the medical team from Dusty Baker and Duane Kuiper

We learned some great techniques for restoring mobility after throwing as well as updates on dynamic stabilization training and best exercise practices. It was further discussed by Mike Reinold during his presentations that research continues to show that the best exercises are ones that have been our staples and are not necessarily the flashy ones you may see on Instagram.  Sticking to these basics as a part of your arm care program and (ideally) having a professional who helps you restore mobility and provides manual resistance training are how the pros are taken care of.

Mike Reinold demonstrating some dynamic stabilization training progressions

We also had a great opportunity to hear a players perspective of coming back from injury.  Joe Panik discussed how the medical team coordinated to get him back to play after his thumb injury. 

Player guest speaker Joe Panik

It is always an inspiring experience to hear research, clinical pearls, and current practices from the professional level.  From the medical doctors, to the athletic trainers and physical therapists, and strength coaches everyone shared some excellent information that can be directly relayed into practice.  Spring is rapidly approaching and if you are looking for a Physical Therapist to take care of any pain that may present or to maintain mobility and arm care programming check us out!

More posts to come on some more detailed baseball tips as we head for spring training and into season!  Follow us on Facebook and Instagram @gonextlevelpt

Aerobic Exercise Speeds Concussion Recovery

The recommendations for activity following concussion have been changing with the current guidelines being a shorter period (24-48 hours) of rest following injury.  We are now finding that this shorter period of rest and early subthreshold aerobic activity are beneficial in speeding recovery after concussion.

A recent study by Leddy et al looked at adolescent males who came to a concussion clinic less than 10 days from injury.  They were grouped into an exercise and rest group.  The exercise group completed the Buffalo Concussion Treadmill Test (used to determine an appropriate submaximal heart rate) and performed 20 minutes of exercise daily on the bike or treadmill.  This was compared to the group that was advised to completely rest from physical activity.  The exercise group recovered in mean of 8.29 days from initial visit and 13.04 days from day of injury.  The rest group recovered in 23.93 days from initial visit and 28.43 days from day of injury.  These findings indicate recovery time from initial visit was significantly faster for the exercise group.  Also, none of the exercise group participants had delayed recovery (>30 days of symptoms) while four participants in the rest group had delayed recovery. From day 4 forward the exercise group had a significantly lower total symptom score compared with the rest group. 

This study is an excellent start in support of early subthreshold aerobic exercise following concussion injury.  The study also had some interesting discussion about the benefits of aerobic exercise including:

·         Enhances neuroplasticity acutely to promote neuron growth and repair

·         Reduces heart rate at rest and reduces submaximal exercise heart rate by reducing sympathetic activity

·        By improving Autonomic Nervous System balance aerobic exercise may also improve sleep (a big deal in many patients after a concussion injury)

The recommendations continue to move towards a more active approach to concussion management.  A Physical Therapist can assess you and help determine the appropriate prescription for aerobic exercise since too much can exacerbate symptoms and delay recovery. We say this for so many other types of injuries in Physical Therapy and now we can also apply it to concussions…Exercise is Medicine!!!

Leddy JJ, Haider MN, Hinds AL, Darling S, Willer BS. A Preliminary study of the effect of early aerobic exercise treatment for sport-related concussion in males. Clin J Spsort Med. 2018;1-8.

Return to Sport Following Concussion-New Research on Exertion Testing

If you have gone through concussion therapy at Next Level you are probably familiar with strapping on the heart rate monitor and getting your sweat on with exertion testing and training.  Now the research is starting to take a closer look at intensive and dynamic exertion testing and its importance in the return to play process.

A recent study published in October 2018 looked at using a new concussion exertion protocol called the Gapski-Goodman Test (GGT) developed by the Chicago Blackhawks medical staff.  This test was designed to help with clearing athletes as one piece of the return to play process following a concussion.

Currently the most researched physical exertion test has been the Buffalo Concussion Treadmill Test (BCTT).  This test (as described in the name) is performed on the treadmill with increasing difficulty through a progressive increase in incline.  The BCTT tests aerobic capacity in a single linear direction only which may not be provocative enough to reproduce symptoms in high level athletes. As stated in this current study, “The BCTT, therefore, may not provide an adequate challenge to all physiologic, vestibular, and oculomotor systems necessary for athletes returning to anaerobic and dynamic, multiplanar, high-risk contact sports"¹ The GGT in comparison has been created to provide “alternating aerobic and anaerobic states in addition to sport-based vestibular and vision challenges designed to mimic a dynamic sporting environment.”¹

The study found that while 100% of the athletes successfully passed the BCTT, 14.6% had an exacerbation of symptoms with the GGT (or modified GGT). The study discusses how the GGT with its more intensive and dynamic exercise selection potentially tests the vestibular and oculomotor and anaerobic systems more thoroughly than the BCTT.  This is important because these systems must be functioning properly for safe return to the unique challenges of sports.

New research is taking a closer look at testing similar to what we have been doing here at Next Level: dynamic, intensive, and sport specific exertion testing and training

It is exciting to see this dynamic form of exertion testing emerging in the research.  It is possible for patients to feel symptom free before they are fully physiologically healed after a concussion. Exertion testing therefore can play an important role in making sure we stress these systems to mimic the demands of sport to ensure symptom free and safe return to play.  

Here at Next Level we use a combination of testing depending on the severity of your symptoms.  We may perform the BCTT which can be extremely helpful in establishing a target heart rate for beginning aerobic training.  As vestibular therapy progresses, we monitor for when it is appropriate to begin dynamically challenging the systems with more intensive exertion testing and training.  We have utilized very similar testing to the GGT and incorporate coordination and reactive drills that are sport specific as needed. 

When working with your doctor to obtain clearance for full return to play exertion testing and training are one useful part of the evaluation and treatment process.  We will be keeping an eye on the future for further research supporting exertion training!  And in the meantime we will keep the heart rates up and the sweat going as we help athletes recover and return to sport. 

11.)    Marshall CM, Chan N, Tran N, DeMatteo C. The use of an intensive physical exertion test as a final return to play measure in concussed athletes: A prospective cohort. Phys Sportsmed.2018;1-9.