Open Forum For Reader Questions!
February 21, 2011 
49 Comments
For those of you that have been on this journey with me for some time on this website, you know that I periodically have open forums where readers can ask questions for myself and other readers to answer. I will keep checking this post throughout the week, feel free to jump in and discuss or ask any topic you’d like. I’ll try my best to chime in but hope that YOU do too!
I’ll kick off the discussion with a simple question that is themed off last week’s post where I allowed people to promote their rehab and performance websites. As an ultra-savy reader here, what are your other top 3 rehab, sports medicine, performance, or fitness websites that you go to and read most often? Why?
If a bunch of people get going on this discussion, I’ll take the results and create a future poll so that we can vote on the top websites (other than mine of course…) that you guys go to as a resource for us professionally.
Anyway, enjoy the open forum…
My top 3 fitness/rehab sites besides your’s are:
- Mike Robertson’s Blog
- Eric Cressey’s Blog
- Alexander Lechner’s Blog on gymnastics(german): http://einfaches-training.blogspot.com/
Besides that I have one question:
How would you tackle somebody’s really tight hip flexors? Especially how often and long would you have him/her stretch the hip flexors.
Cheerio,
Ernie
Ernie – not an easy question to answer. Anterior cross syndrome is the human way right now! reversing this postural adaption is not going to be easy, but I have seen improvement in people with daily foam roll and stretching. But it could take months to see a huge an improvement. So, bottom line is it wont come overnight, work on it daily…
Thanks for your input!
That’ll keep me on it
Cheers!
Mike- Question about the ACLR-BPTBG gone wrong. WHat suggestions do you have for the PTG post-op ACL who just can’t seem to recover ext. mechnsm/quad fxn despite NMES and biofeedack during a variety of exercises and various SAFE OKC/CKC activities that will not compromise graft. Any other pearls? On similar note, what suggestions do you have for managing the PTG post-op ACL’s who do develop signficant pat. tendonitis/ant. knee pain that limits rehab?
In addition to this one:
Cressey
Robertson
Mile Scott
Eric Cressey, AsTony Kornheiser would say, that’s it! That’s the List!! There’s too big a gap between Eric’s and yours and the others.
Question from your shoulder DVD’s, even though dynamic stability is your main focus, how much weight in general do you allow your colege/Pro pitchers to use for sidelying ER and prone horizontal abduction?
Good question Nick, I dont limit it, honestly. Whatever challenges the person is OK with me. I dont buy into the fact that we have to limit the weight (that will be a future blog post). I have had people s/p cuff repair at 12 lbs for ER. As long as form is good and they are challenged, I am fine with it but would say that most people max between 7-9 lbs in my experience. But dont jump to this too fast, this takes weeks to months to get that high.
Hi Mike,
Thanks for a great reply about the weights with the two shoulder exercises. As a follow up question, do you also not limit pitchers with the forearm exercises? Curious if your college pitchers do the forearm exercises from the throwers ten program and just use a couple of sets with 5lbs like the old school books recommend. I’m guessing not.
Thanks again,
Nick
I follow your shoulder rehab protocol and throwers program. What adjustments or additions would you make for rehabilitation of a female fastpitch softball pitcher following SAD?
Hmmm, would wonder if SAD solved her problem. Obviously avoid any elevation > 90 deg abduction. Would still focus on dynamic stability more than anything else, that is probably the problem and impingement secondary.
I live in south Florida and work in a sports clinic that sees alot of high school and college athletes. With the capability of truly playing year round sports we get our fair share of softball players. In general I would say most of their problems stem from instability issues. Completely agree with the dynamic stab approach.
There are also a few interval softball programs out there as she returns to throwing. There are a couple people who presented at the ASMI conference this past Jan. in Tampa who are doing some good work with it at the University of Delaware. (Lynn Snyder-Mackler PT, ATC, Sc.D and Dr. Michael Axe). Softball pitching is grossly under-researched…..hence no real pitching guidelines established.
Besides this site and Eric Cressey’s, I spend a good bit of time perusing slaptear.com since shoulder injuries and rehab are what I’m most interested in.
Interesting to see the patients perspective on that site!
http://www.craigliebenson.com/
http://complementarytraining.blogspot.com/
and all the Q&A posts by Mark McLaughlin on the EliteFTS.com
1. My Physical Therapy Space (Evidence in Motion Blog)
Powerhouse of orthopaedic physical therapy researchers, educators, and clinicians. Also, information about legislative/payor issues as well as private practice business information. LOTS of information on residencies and fellowships in PT.
2. Body in Mind: Lorimer Moseley and his research group out of Australia
Present research and information related to pain science, neuroscience, and treatment of pain especially chronic pain
3. Physical Therapy (PT) Think Tank: Critical observations of physical therapy, health care, and science. In addition, innovative technology and how to leverage technology in clinical practice, education (patient and professional), staying current, and research.
**
**I am bias because I contribute to PT Think Tank
Craig Leibenson & Gray Cook
I work with several people who have had hip or knee replacements. Do you know of anyone who specializes in this kind of rehab? I’ve seen some patterns emerging that I’d like to discuss with someone who is quite knowledgeable in this arena. Any help would be appreciated!
Hi Dan I am a physical therapist with 23+ years experience in orthopedics and manual therapy. Currently working on my doctorate in manual therapy and have teaching experience in orthopedics at a couple universities. In my youth, I was a professional athlete in 2 sports (minor league only) a long time ago and have worked with athletes from all over the spectrum of abilities… that said, the last 5 years my practice has been all geriatrics and I see a good deal of hip and knee replacements on a regular basis. I would be happy sharing back and forth with you. Please feel free to email me at tf8560@comcast.net whenever you get a chance.
Thanks Tom, always an open invite for someone like yourself to submit a guest post here!
Your site is great. I also use Cressey’s site.
Any thoughts on HS activation s/p ACLR with HS graft? The protocols vary– I really like the tball HS curls but not sure how soon post-op a pt can safely generate that amount of force. Thanks for any feedback!
Hi Shannon. I am involved in research dealing with ACL injuries, but more about pre-operative rehab than post-op rehab. However, the protocol that we follow (linked at the bottom of the post) calls for no resisted hamstring activity until 12 weeks post-op for those with HS grafts. We use this as it allows plenty of time for the graft sites to scar down to the other hamstrings.
I will tell you that in patients who produce a forceful hamstring contraction before 12 weeks (how soon before, I am not sure), they often experience a “pop” and exquisite, transient pain in their hamstring, which causes them some unease as they fear that they have reinjured themselves. It is sometimes hard to explain to them that this is to be expected and is just scar tissue tearing.
http://www.udel.edu/PT/PT%20Clinical%20Services/RehabGuidelines/ACL.pdf
Agree, better safe than sorry. Like that t-ball exercise but best to let that scar up a bit first.
Another great exercise as you get to this stage is the single leg modified RDL. Basically Stand on affected leg, knee slightly bent, keep upright trunk posture and bend at the hips bringing your hands to the ground or you can do it holding a med ball and touch that to the ground…….make sure they maintain a neutral knee alignment but awesome exercise for glut activation, knee stability, and H/S, Quad strength.
Love the site and the content Mike! Personally I wish you wrote more!
Could you, or would you possibly write an article about the differences you have seen injury wise, and what you would do training wise for quarterbacks as compared to baseball pitchers??
Wish I wrote more too! Considering my 12-hour/day 7-day/week work schedule for most of the year I am kind of limited! Now you know what I do on all those flights!
FB is different as the angular velocity is slower, but the ball is heavier. The volume is also much lower in football. But I wouldnt train them differently.
Definitely yours, Mike, and Cressey’s youtube videos for certain exercises. I am wondering if anyone knows a good way to tape to unload peroneal muscles in a 20+year old female who is a supinator and has lateral leg/ankle/foot pain and is awaiting her orthotics…she wants to start running.
will defer to someone else on this tape? All those kinesio/spidertech/rock tape users, any thoughts?
Hi mike love the site, as I’m a silent reader and love picking up new techniques, what are your 2 fav rythmic stab exercises for the shoulder?
Thanks for commenting Paul! Hard to say, there are so many!!! The standard stabs with the patient supine and arm in elevation and/or ER is simple, easy, and efficient. Sometimes the best aren’t the most crazy! Maybe this will be a good video post one day…
Hey Mike!
If you are looking back at school… What courses best prepared you for your Physical Therapy courses. Which courses were recommended as being beneficial but didn’t help out?
What do you wish you focused on more? less?
Anatomy is the most obvious, physiology the second. After that, not much!!!! But seriously, having a good business sense is always helpful.
Thanks for the feedback everyone. SLS dead lifts are great, especially since they also pull in the core nicely. The med ball recommendation is a good one, haven’t done that before.
Mike, Ernie, I often use Thomas test position to stretch the patient, using my leg to bend their knee during the stretch also gives good Rectus stretch as well. I also have some patients (usually athletes) put 1 foot behind them on a rolling stool while they lunge/squat with the other leg. As they lunge, they roll the stool back and get a good quad workout on 1 leg and a pretty good hip flexor stretch on the other. Good form is key! At home, they can substitute the arm of a couch for the stool. Obviously not all patients are appropriate for this one! Eric Cressey also has a good hip flexor self stretch in 1/2 kneeling.
I went to a cont. ed course this past weekend and 1 technique that we learned was a trigger pt. release for the hip flexors. (First let me say I do not claim to be a heavy manual therapist, but I’m trying to incorporate more manual techniques) First take the hip through a scour test and assess for tightness/discomfort/pinch in the groin/hip flexor. Can add hip IR to intensify. Assess SLR strength bilaterally. The side with the TP tends to be weaker. Palpate ASIS and work inferiorly and medially until you find the TP. Be fairly aggressive and strum perpendicular to TP for 30-60 sec. (It will hurt, use common sense on how aggressive you can be) Reassess scour and SLR strength and both will often be improved. I was the example the instructor used and I was amazed at how much my strength improved immediately. I have tried it twice this week on 2 different patients (2 x 1 min) and both had immediate gains in pain free hip ROM and SLR strength. We will see how long it lasts or how often the treatment is needed…
Nice advice, thanks
hi, my favourite sites are
Anthony Carey – http://www.functionfirst.com
Eric Cressey
Nick Tumminello – also has some interesting exercises
Dr Warren Hammer – more technical stuff re rehab
Btw, a bit off-topic, what are your thoughts re how students are taught palpation skills. Traditionally, i believe it’s mostly wear shorts n t-shirt and practise with your lab partner to identify the major landmarks, muscles, etc. But now it seems some uni are using plastic models as the main way of teaching – “ok go and feel the structure on plastic model”. Anybody want to share their thoughts on this?
Thanks
That can’t be good, palpating a plastic model!
Hi Mike
Charlie Weingroff – always enforces me to thinking
Patrick Ward – massage and strenghtening
Yours and Eric Cressey – just love my shoulders too much:)
My question is similar to mentioned above about tight hip flexors or any other like positive lats test. I know there is a lot of discussion of stretching techniques especially static stretching with a lot of cons and pros of each but what it would be your choice of technique and devoted time especially in prescription for homework for the “tight” patients
Thanks,
Greets from Poland
Homework is tough as tightness often has several other factors, including inhibited areas. In general, for homework, I usually recommend some form of self-myofascial like foam roll, massage stick, trigger knobs, etc based on location. This is followed by static stretching and then dynamic stretching. But probably have some areas you want to activate too.
Mike,
Just wondering what journals you read on a regular basis. I know you’ve done/read JOSPT. I currently have been looking into the Journal of Neurologic Physical Therapy. Any other thoughts/comments?
I like AJSM, JOSPT, JAT, JSCR, Phys Ther in Sport, JSES, Journal of Bodyworks and movement therapies, and sports health. Those tend to be the ones I actually read each month.
@everyone: I am developing a basic, simple (to improve compliance) exercise program for a group of electrical utility line workers. The purpose is to help decrease the incidence of shoulder injury in this population. Any of you have any experience with preventative exercises for the overhead population or have any suggestions of what to teach? What I have come up with so far is a “wobble” exercise in which the arm is fully elevated and wobbles ant/post while holding a resistance band for x amount of time, a post capsule stretch, thoracic extension stretch, and basic RC strengthening.
Hamp – do they all have post capsule tightness? I wouldnt stretch anything that you didnt assess as being tight. Stick to the basics – ER and scap, especially lower trap.
Hey Mike!
I am finishing up my 2nd year of DPT school and getting ready for my 3rd year clinical rotation at a sports medicine facility. I am really excited about it, but I feel like my program did not provide me enough education on soft tissue massage (cross friction,TP, ART, Graston, etc). Do you have any recommendations for textbooks, DVDs or websites that provide solid information about them?
Thanks,
Francisco Maia
Search my site… you’ll find plenty…
Hope all is well with you all so far this “spring.” Has anyone read the article in the current Sports Health regarding GH ROM changes over a season in MLB pitchers? I was wondering what you thought.
To me, it showed the Orioles know how to stretch well. That’s about all I can take from this. However, it does bring up some very interesting questions. The authors make no mention of injuries in their subjects. It would be interesting to see if their shoulder injuries/days missed due to injury were inline with the rest of the league, or if they had less days lost to injury. The current accepted concept that a greater chance of injury occurs with loss of IR and total motion should lend us to believe that their pitchers faired well in this regard. I wish they had included this information in their data. My guess is that their pitchers did not experience less injuries than the rest of MLB. I’ll try and explain my thought process below and ask that you consider it and, everyone, feel free to rip it apart.
So, this brings us to the question of the correlation between IR deficit changes and total rotational ROM changes through a season, and injury. It makes sense that if…
GIRD and decreases in total rotational ROM = Increase in injury
then/therefore:
no GIRD/TRROM differences = less chance of injury.
I don’t believe it is that easy. I think we stretch our players and are right in doing so. It makes sense that ROM limitations contribute to aberrant mechanics and thus aberrant forces when throwing. However, I also believe that the loss of IR ROM in some(most?) throwers that is seen in association with injury may be more of a CLINICAL SIGN than a CAUSATIVE FACTOR. We have to at least consider this.
Here is my rationale. When we talk about loss of IR influencing the shoulder mechanics with throwing, we are actually implicating the posterior capsule. If the posterior capsule is “tight”, then the humerus will not be able to translate posteriorly during throwing while in the ER/abducted position which causes internal impingement. I get this. However, what if the IR deficits that are not caused by posterior capsule tightness? In my practice, I see more IR loss without capsular restriction which I assume is from adaptive shortening of the ER musculature. The studies correlating GIRD and injury do not define the cause of the GIRD. If the IR restriction is due to changes in ER muscle length, then the IR deficit should not have a direct relation to the position of the humeral head and the glenoid (or placing the supraspinatous more anteriorly causing a contact between the tendon and the posteriorosuperior glenoid) in the full cocked position. If IR is limited due to adaptive changes of the external rotators brought on by repetitive eccentric demands, then perhaps the correlation between IR deficits and injury can be looked at as a relationship not of causation, but prediction. If the shoulder is being overloaded to the point of causing muscle contracture, then maybe there is too much of a workload on the shoulder. I am suggesting that injuries associated with GIRD, but without posterior capsule contraction, may not be a result of GIRD, but of workload (resulting in adaptive shortening of the external rotators, subsequently causing GIRD).
These thoughts came to me while enjoying a microbrew from my beer of the month club, so I thought I’d share them with someone who may understand them. I appreciate you all considering my ramblings.
Pete
Mike, I am posting this here in the hopes that many Physical therapists will see it. first let me say, that as a stroke survivor, I think I received the best Physical therapy available anywhere, and my therapists were very encouraging that I would regain total function and I did. that was 3 years ago and I continue to improve. as one of 2000 members of an excellent stroke support group on facebook and as the creator of my own support group, I would like to remind therapists that what they say to patients about their prognosis and posibility of recovering function can dramatically affect that patients outcome. yesterday one member posted “My PT said my arm is the best its ever going to get so why bother with exercises” another today said “when I asked my PT how long he thought I’d be in a wheelchair. he said oh, you’ll never walk again. that man just walked a 2k walkathon, I have one memebr who is severely depresed because she sees no hope for her future because she was dicharged from PT because there was no use continuing because she wasn’t going to improve. all of this is hogwash and was discouraging to these patients.Stroke patients are getting younger and younger some of our members are in their 20s and they must have hope. We support our members by encouraging them to never lose hope,keep working, the brain can rewire itelf by neuroplasticity. we tell them never ever ever give up.and we have many miracles amoung our members.many have far exceeded PT predictions. One girl with double brain stem stroke and locked in. wastold she would be in nursing home. today she is a vibrant active young wife and mother. I am saying to therapists. Please if you can’t encourage patients, don’t say anything. If you would like to know more about our group visit us at https://www.facebook.com/pages/Strokes-Suck/218900689078 reapectfully, Alice Naquin RN, nurse practtioner, survivor
Hi Mike,
I’ve been a fan of your site for the last year plus. I’ve learned a lot from your postings and shoulder DVD. I also appreciate your Reading List. I’ve recently come across a book titled, “Clinical Examination of the Shoulder” by Todd Ellenbecker. Have you a chance to read this? Any thoughts? I’ve recently started reading the book and think it’s pretty good. Just thought you may be interested. Thanks for all you do.
Frank
Mike,
I have followed you and Eric Cressey for a while now. I must say you both do a lot to help our profession and our patients. I have a strong baseball background and spend much of my practice in the area of biomechanics, with throwers and even more in depth with LE biomechanics in runners and dancers.
I have a couple of questions for you today:
1 – I know pitch type has been downplayed a bit with regards to injuries in pitchers. However, what are you thoughts on the role of the seemingly more significant use of the circle change and splitfinger in medial elbow pain, especially in higher level pitchers. I feel these pitchers require more activity in the flexor mass, leaving them more susceptible to microtearing in this muscle group.
2 – There is much talk about limiting pitches/innings in our pitchers today. Obviously more pitches equals more wear and tear. Do you feel that this a direct relationship – that is more pitches wears down the structures, etc. Or, do you feel that more pitches = more fatigue = equals poor mechanics = more stress. (If that makes sense!!!). I guess my question is do u feel that if these young throwers were trained better in both mechanics and general strengthening/endurance we could avoid some of these problems. I guess you could use the analogy of driving a car 200k on the highway vs 200k in stop and go traffic. The car is obviously better equipped for the highway….
I am a PT and know how to rehab a pitcher’s shoulder, but does anyone have good advice on how to teach my 9 year old son how to pitch properly??
Hello,
I think I may be going crazy. I’m starting to find, perhaps non existent circular truth of all unified as the shape to the infinite. (basically, and im sure you’re already picturing this, but this is mainly context). The point of two cones (actually present in 3) >< since the space, while appearing to have depth, does not by the simple fact that the space is identical in theoretical value, but it actually the same as two circles on two separate pages of graph paper being held together. That the same value of X has X' in the false sense of a depth in Y, does not change the fact that they are 2 circles of the same 2d space.
So, where am I going with this… well. This idea is evident in everything and every quantifiable magnitude. I have been able to resolve a diminshed chord. I see the same things over and over again but different because they are their own occurance. I can not stand to speak to anyone because I finish the entire conversation before most of the verbal communication.
But the thing that makes me sick… is the truth of what it means to expand into the .14
I have noticed more and more in my thoughts, behavior, and ability, that the knowledge has made me all to aware of abstract in the definite. One will win, but can either alone exist without the other? So either the circles will be in complete…. or the space between the 2 papers closes until the space is truly a paradoxical occupation of being twice at the same time… and therefore collapses into perpetual meaningless that, we might consider as off the page of graphing paper entirely… Nothing and everything,… only possible by this thought of empty, limitless of void.
So I'm either insane, brilliant (really blurry line of delineation), or im just a kid on the computer with nothing better to do than ramble nonsensical strings of barely cohesive sentences of thought.
regardless: irrational men expect the world to adapt to them while the rational men adapt to the world as it currently is. Therefore, all progress, nay, all of anything that is or can ever be, was made my irrational men.. with the irrational thought that truth and deception, and all stems of the two… even existed at all.