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

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.

Running Injuries: Prevention From The Ground Up Part 2

By Kirsten Carmichael DPT, CSCS, SFG I, MFDc

Last blog post we talked about the foot and ankle in regards to sports and running injuries.  Today, moving up the kinetic chain we'll talk about the importance of a strong and stable hip and core and some of our favorite exercises.

The core and hip muscles play a very important role in controlling movement all the way down to your foot.  When these muscles are weak or not firing optimally we will often see the hip and knee "crash in" which can cause a lot of dysfunction and pain.  Think about the load through those structures with running which can be 5-12 times your body weight (depending on form and speed). If your mechanics are faulty that is a lot of load being distributed through the wrong places. Note that if you are limited in ankle mobility this can also cause similar movement dysfunction and see our last blog post for how to assess and work on this.  Shown below is an example of what happens when weakness/lack of motor control or an ankle mobility restriction is present.

And here is what it looks like when all of the stabilizer muscles fire together and the knee, hip, and ankle stay in good alignment.

That being said, here are some of our favorite exercises for engaging and strengthening those stabilizer muscles to promote a solid foundation for good movement (and help prevent future injury).

Clams: an excellent exercise for activating the deep hip muscles.  Shown here using a mini-band for some added resistance.  This exercise is great because it isolates each individual side.  Place the band above the knees, lie on your side, and with your knees bent bring them up to about a 60 degree angle at your hip.  Keeping your feet together, rotate your top knee up.  Make sure you don't "cheat" by rolling the top hip back and you should feel a good burn along the outside of your hip.  We usually start with 20 reps on each side.

Bridging: here is an exercise that works the bigger glute muscles.  We like to use the mini-band around the knees to get a little extra muscle activation.  With both knees bent and feet flat on the floor engage your abs by drawing in your belly button and squeeze your glutes as you lift your hips up from the floor.  You want to make sure you avoid arching in your low back.  Perform 20 repetitions.

Bird/Dog: This exercise has great "bang for your buck" for improving stabilization along many different areas (neck, shoulders, low back, hips) and is a great core control exercise.  Begin in a hands and knees position and keeping your abs tight reach "long" not "high" and extend your opposite arm and leg as pictured.  Make sure your low back stays neutral (we could balance a glass of water without spilling) and do not allow it to arch.  Perform 20 repetitions.

Mule Kicks and Hip Extension on Elbows: next on our list of favorites are some "glute burners" performed in a plank position on elbows.  By doing these exercises on your elbows instead of up on your hands you are able to better maintain your low back in a neutral position (avoiding arching).  Maintaining that neutral spine helps to also engage your core.  In the first picture you lift one leg with the knee bent squeezing your glute for a one second hold at the top.  In the second picture you lift with the leg straight (knee extended) and again squeeze those glute muscles for one second on the top.  Perform on both sides, 2 sets of 10 reps each.

Forearm Plank: This is an awesome core exercise that is easy to perform anywhere and doesn't stress out the low back like a lot of other popular core exercises.  Line yourself up with your elbows under your shoulders, eyes focused on your fists (to maintain a proper neck position), and a neutral spine (again avoiding an arch in the low back).  Keep your abdominals tight and squeeze your glutes.  The goal is to build up to 3 sets of 30 seconds and then you can begin to add movement to make the exercise more difficult from there.

Side Plank: Last but not least is the often forgotten side plank.  If you have a healthy shoulder this is an awesome exercise for working both core and glute muscles together (while also working those shoulder stabilizers).  If you are comfortable line your elbow up under your shoulder and push up from the elbow and the feet.  If this is too difficult you can modify by bending both knees and pushing through the knees instead.  Again the goal is to alternate sides holding for 3 sets of 30 seconds on each.

There you have it!  Since these are stability and activation exercises (and not heavily loaded strength training) they are great to perform before your work out or run to get everything firing and optimize your form.  Think of it as a quick stability and movement prep routine. Stay strong and injury free out there!

If you like our stuff and want more tips and tricks follow our blog, Facebook, and Instagram accounts @gonextlevelpt

Running Injuries: Prevention From The Ground Up Part 1

By Kirsten Carmichael DPT, CSCS, SFG I, MFDc

I frequently get to work with runners and one common complaint is with foot/ankle discomfort or pain.  I decided it would be great to provide some preventive tips and tricks starting at the feet and working my way from the ground up.  These are also great tips for other athletes who may be experiencing similar problems.  Give them a try! 

First, many problems up and down the leg can occur from a limitation in ankle mobility.  To test this you can stand with your toes about 5 inches away from the wall in a lunge position.  Keeping your heel on the ground, bend your knee and reach it as close to the wall as possible.  If your knee easily touches the wall your mobility is looking good.  If you can't reach the wall without your heel lifting or feel stiffness in your ankle then this is an area to work on.  In the same position as the test (see video below) you can perform some active glides.  We recommend performing 10 repetitions on each side. 

Next, there are some great tools to keep your soft tissue mobility looking good.  One awesome tool for plantar fascia health is rolling on a lacrosse ball.  Simply place your foot on top of the ball and roll along the ball of your foot, the inner arch, and along your heel.  If you feel any tight or "crunchy" areas then give these spots a little extra love.  

You also want to make sure the soft tissues in your calves stay loosened up.  Sometimes using a foam roller for this area can be a bit awkward so I prefer to use a stick.  If you get in a half kneeling position as shown you can also get a little extra stretch on the calf as you roll.  If you find any "bumps" in the road you can move the stick (as shown) side to side to create a cross sectional release.  I usually recommend 10 rolls up and down on each side again spending a little extra time on any trouble spots. 

Now that you've mobilized your ankle joint and soft tissues you want to stretch in that newly found range of motion.  A good gastroc stretch is first on the list as shown.  Make sure you keep that toe pointed straight ahead and your heel on the ground. 

Deep to that gastroc muscle is the often neglected soleus muscle.  As shown below move the back foot in just a bit and give the knee a bend to stretch this guy as well. 

Finally, after all of this mobilization and stretching it is great to reinforce those deep muscles that support your arches.  A great way to get this started is called "arch doming". In standing you will focus on grounding your big toe and making an arch along the inside of your foot (see video below).  I usually recommend 20 repetitions. 

Definitely give all of these a try pre-run or work out to make sure your mobility and stability are in check before you load the system.  Performing some of the soft tissue release and stretching after can also be beneficial if anything has tightened up along the way.  Over time you will develop a beautifully balanced foot and ankle and prevent any future issues! 

Hope you found these tips useful!  If you are still experiencing any pain or discomfort contact us!  We love nothing more than to help athletes perform pain-free and at their best! 

Follow our blog, Instagram, and Facebook (@gonextlevelpt) for upcoming posts with more tips and tricks and all things sports releated! 

Is there a higher risk of lower extremity injury after a concussion?

By Kirsten Carmichael DPT, CSCS, SFG I, MFDc

I always have my eye out for the latest research in the world of concussions and some very interesting studies have been emerging lately. The question being asked is do athletes have an increased risk of sustaining a lower extremity injury following a concussion?

One study by Lynall et al in 2015 retrospectively looked at injury data in Division I collegiate athletes.  They found these athletes were almost twice as likely to experience lower extremity musculoskeletal injury after concussion when compared with controls.

Another more recent study in May 2017 found similar findings with collegiate athletes.  Herman et al reported that the odds of sustaining a musculoskeletal injury were 3.39 times higher in the concussion athletes.

Yet another recent study by Lynall et all published in November 2017 looked at high school athletes. This study found that for every previous concussion, the odds of sustaining a subsequent time-loss lower extremity injury increased 34%.

So, what gives with all this increased injury risk?  It is suspected that lingering deficits in gait and dynamic balance may have something to do with it.  Lynall et al has proposed there may be reduced cortical excitability impairing the brain’s ability to effectively control and coordinate movement after concussion.  Further, this may have something to do with delayed reaction and movement time.  If we think about this in relation to the high physical and cognitive demands of athletics it is easy to see where the potential for injury may occur.

With this information how do we make a change to help lower the risk?  Currently many concussion protocols primarily utilize neurocognitive testing, static balance tests, and symptom reporting.  It is proposed that utilizing more functional balance assessments would be beneficial (especially using sport specific tasks such as cutting and jumping).  This sounds a lot like what I do at Next Level in my exertion assessments.  During an exertion evaluation the athlete completes multiple dynamic tasks testing the vestibular system at high levels and elevating the athlete’s heart rate.   We consider the specific nature of each sport and look to progress all aspects before return to play including cutting, changing direction, accelerating/decelerating, jumping, running, throwing, coordination, reaction time, and cognition.  The goal of future research will be to take a deeper look at functional movement after concussion and come up with a dynamic assessment that is easy to implement in our concussion protocols across all levels of athletics.

Exertion Physical Therapy-where we jump, cut, change direction, and get sport specific :)

My take home message from this research is that concussions are something that should be taken seriously for many reasons.  If you have a concussion it is important to get evaluated to make sure everything clears (including those dynamic balance and sport specific tasks) before returning to sport to avoid the risk of musculoskeletal injury.  Hopefully soon everyone in athletics will have more detailed assessment tools and we can see the incidence of these injuries go down.

References

Lynall RC, Mauntel TC, Padua DA, Mihalik JP. Acute lower extremity injury rates increase after concussion in college athletes. Med Sci Sports Exerc. 2015;47(12):2487-2492.

Herman DC, Jones D, Harrison A, et al. Concussion may increase the risk of subsequent lower extremity musculoskeletal injury in collegiate athletes. Sports Med. 2017;47(5):1003-1010.

Lynall RC, Mauntel TC, Pohlig RT, et al. Lower extremity musculoskeletal injury risk after concussion recovery in high school athletes. J Athl Train. 2017;52(11):1028-1034.

Post Concussion Physical Therapy

By Kirsten Carmichael DPT, CSCS, SFG I, MFDc

How does a Physical Therapist help someone post-concussion?

Most concussions (80-90%) will resolve within a 7-10 day time period.  For a small percentage of people symptoms last beyond 2-3 weeks and in these cases a Physical Therapist may be able to help.

The vestibular system located in the inner ear senses motion of the head and helps stabilize your eyes while you are in motion.  If the vestibular system is disrupted you may continue to experience dizziness, sensitivity to motion, difficulty balancing, etc. 

Testing eye movement during an evaluation

A Vestibular Physical Therapist can provide a detailed assessment to determine the nature of your symptoms and begin exercises to help the system adapt and heal. 

Training convergence with a Brock String

Balancing on an unstable surface and getting in some rotational work

A Physical Therapist can also address any underlying issues with the neck that may present with a concussion.  It is always important to assess if dizziness and headaches are actually coming from the cervical spine.  We also initiate cervical strengthening exercises as early as possible.  Strengthening the neck has been found to reduce the odds of concussion which is important when returning to sport.

Working the scapular muscles and strengthening the neck wearing a special cervical weight

 Research has also found that getting moving as soon as possible after a concussion is important.  With exertion therapy we monitor you through a progressive and sport specific return to play program. We work with your doctor to make sure you are ready to return to sport. Additionally, we make sure you have regained your strength, agility, plyometric, and reaction time to prevent any future musculoskeletal injury.

Heart rate monitor on and ready to get moving on the Airdyne bike

Working on some dynamic stability training

  Higher level training challenging the vestibular and cardiac systems in multiple                                    planes

If you are experiencing lingering concussion symptoms contact us and see what we can do to help you get back in the game!

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!