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! 

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

Lessons Learned in the Land of Kettlebells

By Kirsten Carmichael DPT, CSCS, SFG I, MFDc

I distinctly remember having a conversation about kettlebell training with a patient a year and a half ago.  He asked if I had considered going for the Strong First certification and my initial reply was I just didn’t know if my shoulder was up for that.  I have been dealing with a labral tear from my years of volleyball and completing the snatch test (100 snatches with a 16 kg/35 pound bell in under 5 minutes) and overhead pressing with the same weight seemed like a daunting task.  However, the leaders in my Physical Therapy and Strength and Conditioning world (Cook, McGill, Liebenson, and of course Brett Jones, etc) reference kettlebell training and the work of Pavel frequently.  Naturally the next step in furthering my education was to sign up, buckle down, and see how things went.

                I have been using kettlebells for years with my patients as they are one of the most versatile tools for training functional movements.  I have never trained with the level of intent and focus as when I first met with my kettlebell coach (Craig Valentine, Loomis Kettlebell).  Fast forward through months of training (and special love to my shoulder with lots of arm bars, carries, and heavy get ups) and I passed my certification last weekend in Denver, Co.  There were a few shoulder hiccups along the way, but my awesome Strong First leaders helped me manage through all the high-volume work.  I wanted to share a few of the things I learned through this experience. It was one of the best and most rewarding events I have ever been through.

Sweaty and starving after completing the SFG certification

1.)    Kettlebell training has made me stronger than ever before.  The focus on stabilizing and strengthening my shoulder lead to some heavy get ups that I would never have thought possible.  I also can press a 44 pound kettlebell overhead without any shoulder pain. My training program was not fancy but man has it been effective in making me strong.  

2.)    You don’t need fancy equipment for an awesome work out.  Kettlebells are a simple piece of equipment that allows you to work your entire body.  Build strength, build endurance, train your stability…you can do it all.  Plus, they are portable.  Mine came on the road with me many times.

Tucker and my traveling bells 

Camping kettlebell

3.)    Kettlebell training reinforces seeing the big picture and looking at movement as a whole.  This has reinforced all that I have learned in the land of FMS (Functional Movement Screen).  As I was assessing a team member's dead lift at the course my instructor advised me to literally take a big step back and look at her, and the problem area jumped right out at me.

4.)    Kettlebell training transferred power to other areas.  I watched my vertical jump improve.  When I was home for Thanksgiving I decided to do some interval hill runs and felt like I was flying.  Even though I hadn’t been specifically training these things my kettlebell training improved them.

5.)    There is nothing more functional than kettlebell training and it is a tool that can be utilized by everyone.  The movements can always be progressed or regressed.  There is truly nothing more functional than getting up from the floor, squatting, picking something up from the floor, and carrying heavy things.  

Overall, I had a wonderful experience and am so excited to start incorporating all of the new things I learned into my physical therapy and coaching (as well as my own training).  Good thing there is no shortage of kettlebells over here!