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 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

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

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!