How Rehab Differs Between Traumatic and Atraumatic Shoulder Instability

The latest Inner Circle webinar recording on How Rehab Differs Between Traumatic and Atraumatic Shoulder Instability is now available.

 

How Rehab Differs Between Traumatic and Atraumatic Shoulder Instability

How Rehab Differs Between Traumatic and Atraumatic Shoulder InstabilityThis month’s Inner Circle webinar is on How Rehab Differs Between Traumatic and Atraumatic Shoulder Instability.  In this presentation, I highlight the major differences in the evaluation and treatment process.

This webinar will cover:

  • The difference between traumatic and atraumatic shoulder instability
  • The import factors to consider that will change your rehab progression
  • Should you immobilize or not?
  • The primary focus for rehab for each type of instability

To access this webinar:

 

4 Myths of IASTM

Instrument assisted soft tissue mobilization (IASTM) is really a great manual therapy skill to have in your tool box.  However, there are many myths and misconceptions regarding IASTM that I really believe are holding people back from getting started and seeing the benefits of IASTM in their practice.

In this video, Erson Religioso and I discuss some of the myths of IASTM that led us to develop our online educational program at IASTMtechnique.com to teach people how and why we use IASTM:

4 Myths of IASTM

 

To summarize some of the myths of IASTM discussed in the video:

  • IASTM MythsIASTM does not have to be expensive to learn or perform.  You do not need to spend tons of money on certification courses and crazy expensive tools.  Erson and I have a quick and easy online educational program at IASTMtechnique.com that will get you started right away.  We even talk about how you can get useable tools for as little as $5!
  • IASTM does not have to be complicated to learn.  If you are already performing manual therapy or massage, you know everything you need to know to start using IASTM.
  • IASTM should not make everyone black and blue!  Let me actually rephrase that for emphasis, IASTM is not about being so aggressive that you leave large purple marks and essentially produce superficial capillary hemorrhage.  Some redness and petechia is OK, but the over aggressive black and blue is not ideal.
  • IASTM tools do not provide as much feedback as my hands.  IASTM is a way to compliment your hands, it is not a replacement!  In fact, it gives you a different feel that really helps your palpation skills.

 

 

Learn How to Start Performing IASTM Today!

Erson Religioso and I’s online educational program will teach you everything you need to know to start using IASTM today!  IASTM does not have to be complicated to learn or expensive to start using.  Learn everything about IASTM including the history, efficacy, tool options, different stroke patterns, basic techniques, advanced techniques, and how to integrate IASTM into your current manual therapy skills and treatment programs!

IASTM Technique 2.0 has now be released with updated research, new content, and now includes how to perform cupping and use mobility bands!  Get started today!

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How and Why You Need to Learn IASTM

Learn IASTMErson Religioso and I have a nice video for you discussing why and how we both started using instrument assisted soft tissue mobilization (IASTM).  Like many people, I held out initially as I wanted to hear and see more.  However, the more I learned the more interested I became.

IASTM has now become a game changer for me and something I deeply integrate into my manual therapy techniques, and think you should too.  It doesn’t have to be complicated, expensive, or time consuming to start using IASTM.

In this video, Erson and I describe how and why they both started using IASTM, how we integrate IASTM with other manual techniques and exercise, the major benefits of IASTM, and then some brief technique demonstrations.

 

How and Why You Need to Learn IASTM

 

Learn How to Start Performing IASTM Today!

Erson Religioso and I’s online educational program will teach you everything you need to know to start using IASTM today!  IASTM does not have to be complicated to learn or expensive to start using.  Learn everything about IASTM including the history, efficacy, tool options, different stroke patterns, basic techniques, advanced techniques, and how to integrate IASTM into your current manual therapy skills and treatment programs!

IASTM Technique 2.0 has now be released with updated research, new content, and now includes how to perform cupping and use mobility bands!  Get started today!

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A Simple Approach to Running Analysis for Clinicians

This week’s post is an amazing article by my friend Chris Johnson on what he looks for during a running analysis.  Chris is my go-to resource for running related injuries and rehabilitation.  He’s also recently developed an app on the iTunes app store to help runners, which I have reviewed and found to be really impressive.  Check it out at the end of this article!

 

A Simple Approach to Running Analysis For Clinicians

a simple approach to running analysis for cliniciansThe ultimate special test for runners is RUNNING.

For some odd reason, when runners seek medical consultation, clinicians routinely neglect watching them run during the rehab process. While it may not always be appropriate to take an injured runner through a formal running analysis at the time of presentation, at some point it’s imperative to take the time to watch them run. Only then will you gain a more complete understanding of perhaps what landed them in your hands in the first place.

A great deal of research has emerged over the past several years specifically looking at various characteristics of the running gait and their associated implications. A few prime examples include but are not limited to the following:

  •      Footstrike
  •      Step rate
  •      Hip adduction
  •      Loading rates
  •      Speed

By taking the time to understand the running gait along with ways to shift loads in the lower extremity, clinicians will ultimately be in a better position to help runners return to consistent training in a timely manner through manipulating physical loads on the ecosystem.

While this may seem daunting to those new at running analysis, it can actually be quite simple.  The purpose of this post is to provide clinicians with a simple framework to approach conducting a running analysis using what I call “The Four S’s of Running Analysis.”  These are:

  •      Sound
  •      Strike
  •      Step rate
  •      Speed

While it’s important to appreciate that overground and treadmill running are different animals, approaching every running assessment in a systematic manner is important. Clinicians are encouraged to use the resources at their disposal while understanding their relevance and limitations. By developing proficiency in performing a running gait analysis, clinicians will ultimately refine their clinical decision making and improve their outcomes in terms of restoring one’s float phase.

 

Sound

Before you even watch someone run, close your eyes and listen to the sound of their running gait. As clinicians, there is a great deal of information that can be ascertained by simply listening to one run.

  •      Does the runner land quiet, or is does it sound like they are going to put a hole through the ground or treadmill belt?
  •      Do their feet sound similar or is there a strike asymmetry?
  •      Does the sound of their footstrike change as a function of being shod versus unshod?
  •      Does the sound change as a function of different shoe types?

One of the simplest cues to consider in the event that someone is “overstriking” is to simply instruct the runner to “quiet your feet down.” This may be particularly relevant if the goal is to reduce the vertical ground reaction force (vGRF).

It’s important to appreciate that when one does go to quiet down their feet, that they tend to increase the ankle and knee joint excursions. On the other hand, if landing sound increases, so does the vGRF secondary to decreasing ankle joint excursion while increasing the hip joint excursion (Wernli et al. 2016).

It has been the author’s experience that under a shod condition that a rearfoot strike lends itself to reducing the sound of impact whereas when a runner is barefoot that a forefoot strike serves to quiet down the sound of impact through using the triceps surae to dampen the vertical rate of loading (VRL).

 

Strike

Let’s not complicate things! Does the runner land with a noticeable heel strike or forefoot strike, or do they exhibit a midfoot, or “flat-footed” contact? Is their strike symmetrical?

Also, the point in the race or training session we are discussing matters because one’s strike pattern tends to change over the course of the run, especially during competition (Larson et al 2011).

Over the past several years, there was a considerable buzz around forefoot striking as a means to address common running related injuries. This was due in large part to the book “Born to Run,” in conjunction with Daniel Lieberman’s classic manuscript that appeared in Nature (Lieberman et al 2010) coupled with a craze by the mass media.  It should be mentioned that coaches have long used barefoot training as means to incorporate variability into a runner’s program.

Training runners to incorporate a forefoot strike into their training may prove effective some, such as those with tibial stress syndromes, anterior compartment syndrome, and anterior knee pain.  Caution should be exercised in the context of a past medical history remarkable for injuries involving the calf muscle complex, plantar tissues of the foot, and/or metatarsals as it will bias the load to these regions.

On the other hand, if a runner is dealing with an Achilles tendinopathy or recovering from a calf muscle strain, a heel or rearfoot striking strategy would perhaps be indicated as research has shown that such a strategy reduces Achilles tendon force, strain, and strain rate relative to a FFS pattern (Lyght et al. 2016).

In my opinion, one strike pattern is not necessarily superior to others, but rather, that every strike pattern has unique characteristics and implications (Almeida et al 2015) and serves a purpose pending the context and intent.

By taking the time to understand the implications of each strike pattern, clinicians will be better able to understand the potential changes to consider making as a means to shift load to different regions of the lower extremity. As with any change, however, clinicians must be mindful that it should take place in a slow and gradual manner.

Finally, never take a runner’s word if they tell you that they utilize a certain strike pattern as research has shown that a runner’s subjective report of their strike is not necessarily accurate (Bade et al. 2016).

 

Step Rate

Running is largely about rhythm and timing.

It’s therefore no surprise that over the past several years, a considerable amount of research has focused on step rate or what’s more commonly known as cadence as a simple and practical means to address common running injuries.

The idea is that by increasing the number of steps while keeping running velocity constant, a runner can effectively reduce the magnitude of each individual loading cycle despite increasing the total number of loading cycles for a given training session. This ultimately occurs through a reduction in one’s stride length as when step rate and stride length are manipulated independently, the benefits only occur with a reduction in stride length.

runcadence appBecause I think this is so important, I actually developed a cadence app, RunCadence, which is specifically designed to help runners and clinicians apply cadence to rehab and training for runners through the use of accelerometry coupled with a metronome.

Research has shown that increasing one’s step rate by as a little as five percent above preferred while keeping velocity constant can reduce shock absorption at the level of the knee by upwards of 20 percent. Additionally, increasing step rate by 10 percent above preferred significantly reduces peak hip adduction angle as well as peak hip adduction and internal rotation moments (Heiderscheit et al. 2011).

More recently, a study showed that irrespective of whether one utilizes a rearfoot or forefoot strike pattern that increasing one’s cadence by five percent results in lower peak Achilles stress and strain.

Decreasing one’s stride length through step rate manipulation has also been shown to lead to a wider step width with an accompanying decrease in contralateral pelvic drop (CPD), peak hip adduction, peak ankle eversion, as well as peak ITB strain and strain rate (Boyer & Derrick 2015).

Lastly, clinicians should also bear in mind that increasing one’s step rate greater than 10% above preferred while keeping running velocity constant tends to occur at a greater metabolic cost so as they say, “the juice ain’t worth the squeeze.” So at day’s end, remember that the sweet spot is between 5-10% when it comes to increasing cadence based on the current body of literature.

 

Speed

Anytime one discusses running, it’s important that we account for the amount of ground covered in a given time. This is referred to as running velocity, which is the quotient of distance and time.

The typical units that we go by in the United States are min/mile or miles/hour (mph), though most of the world relies on the metric system (m/s or km/hr). So make sure you have a converter bookmarked on your web browser.

Running is typically classified into one of five categories based on speed (Novachek 1998):

  1. Jogging = 2m/s or 4.5mph
  2. Slow running = 3.5m/s or 7.8mph
  3. Medium running = 5m/s or 11mph
  4. Fast running = 7m/s or 15mph
  5. Sprinting = 8m/s or 17.9mph

Additionally, to run faster, a runner must push on the ground more forcefully, more frequently, or a combination thereof (Schache et al 2014).

At speeds < 7m/s the ankle plantarflexors reign supreme as they contribute most significantly to vertical support surfaces and increases in stride length (Dorn et al 2012). At faster speeds, however, the energy sources tend to shift proximal as a means to increase stride frequency in order to increase speed.

The reality is that most runners seeking our services will fall under the category of joggers and slow runners unless one works with speed based running athletes and short course racers.

Once a runner has reached a point in their rehab where they are a candidate to undergo a running analysis, the question naturally becomes, “what speed should we select?” This question is best answered by primarily considering the runner’s pre-injury status along with the severity, region, type of injury, and agreed upon goals.

It’s also essential to clearly identify the runner’s typical training and race intensities to better understand the entry point to having them run as well as the various speeds worth taking them through as part of the analysis.

It should also be mentioned that a thorough running analysis may require a couple sessions to work them up to faster velocities to ensure tolerance to progressive loading. Unfortunately, a common pitfall in the clinic is reluctance, or failure to have runners work up to faster speeds. This invariably leads to a myopic view of one’s running while engendering the potential for hasty clinical reasoning as we transition runners back to training.

In retrospect, running is an activity that has relatively predictable performance demands. By taking the time to develop proficiency in conducting a simple running analysis while applying the research as it relates to shifting loads in the lower extremity, clinicians will be better positioned to help runners return to consistent and healthy training and beyond.

 

Download the RunCadence App

running_cadence_appRunCadence was developed by two physical therapists to help the running community apply step rate to running via real time step rate notification and metronome.
Start using RunCadence to get more in tune with your running. While no shortcuts or “hacks” to running exist, gait retraining using cadence is the next best thing.  Click below to download:

 

 

About the Author
chris_johnson_headshot

Chris Johnson, PT, is the owner of Zeren PT and Performance in Seattle, WA.  In addition to being a highly skilled physical therapist and performance enhancement specialist for runners, Chris is also certified triathlon coach (ITCA), three-time All-American triathlete, two-time Kona Qualifier, and is currently ranked 16th (AG) in the country for long course racing.

How to Stabilize the Scapula During Shoulder Elevation

One of the most common compensations we see with people with limited overhead shoulder elevation is lateral winging of the scapula.  Anytime you have limited glenohumeral joint mobility, your scapulothoracic joint is going to try to pick up the slack to raise your arm overhead.

This is common in postoperative patients, but also anyone with limited shoulder elevation.

Stabilizing the scapula during range of motion is often recommended to focus your mobility more on the shoulder than the scapula.  As with everything else, as simple as this seems, there is right way, a wrong way, and a better way to stabilize the scapula during shoulder elevation.

In this video, I demonstrate the correct way to stabilize the scapula, and show some common errors that I often see.

 

How to Stabilize the Scapula During Shoulder Elevation

 

Learn Exactly How I Evaluate and Treat the Shoulder

Interested in learning more?  Join my acclaimed online program teaching you exactly how I evaluate and treat the shoulder.  It’s a comprehensive 8-week online line program that covers everything you need to know about clinical examination, dynamic stability drills, manual therapy techniques, rotator cuff injuries, labral tears, stiff shoulders, and more.
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Layering The Basics For Optimal Movement

This week’s post comes from my friend and colleague at Champion, Dave Tilley.  Dave is no doubt one of the most impressive up-and-coming PTs out there right now and we are thrilled to have him part of our team at Champion.  In this day and age, I’m seeing more and more students and young professionals skip the basics.  In this post, Dave talks about how he focuses on some of the basics to achieve optimal performance.

 

Layering The Basics For Optimal Movement

Within my first few weeks of working at Champion, I remember one day Mike Reinold said, “Over the years I think people have overcomplicated things a lot. I’m actually trying to get back to the basics, and just do them really well.”

This stuck with me as I reflected back on my first few years coming out of PT school.  After graduating, I dove into a lot of continuing education trying to catch up with all the new information available. I found myself swimming in a ton of really complicated material related to evaluation, treatment, and research concepts.

I think I let myself get into the complex material a little too much, and I found myself missing a lot of basics when working with clients. The more I learn and gain experience, I am finally able to find the balance. Overall, I have drifted back into making sure the basics are done really well before utilizing more complex approaches.

Coming from my gymnastics background, it’s a sport that is built around mastering the basics and revisiting them constantly. The gymnasts I coach do 45 minutes of basics daily in their workout.

The highest-level elite athletes I have worked with do the basics better than anyone else, and this it what makes the sport so hard.

These same high-level athletes tend to be the best compensators on the planet, having nervous systems that “get the job done” even if it means sacrificing tissue health.

When treating them, it often comes down to revisiting basics first. These “basics” include soft tissue or joint mobility, baseline strength, fundamental dynamic control, and more. It’s only once these factors have been addressed that we can start tweaking the complicated variables of program designed, complex movement patterns and high-level performance.

Here are a few “layers” of categories I consider for the maximizing movement, performance, and rehabilitation.

Layering The Basics For Optimal Movement

Performance / Competition Level Basics

  • Does the person have a well-structured program design, which utilizes appropriate work to rest ratios and a periodized model that fits their goals?
  • Does the person understand the basics of nutrition, hydration, sleep, and recovery methods to maximize the training effect from the point above?
  • Is there some form of athlete monitoring (ideally subjective and objective) for understanding what is happening physiologically and psychologically during the training?
  • Does the athlete have tools or strategies for competition planning, stress management, and mental preparedness?

Sport / Skill Level Basics

  • Has the athlete grown up in a sporting environment that allowed a large range of sensory, motor, and movement based fundamentals to develop. With growing rates of early specialization and year-round training, this tends to become and issue in older athletes?
  • Does the athlete understand a large range of fundamental movements  (squat, hinge, run, push, pull, jump, etc) and are they equally represented in the program. As skill specific training increases this may drop off but it should never be completely lost?
  • Do they understand and show the basics of sport specific movements being trained. Examples include fundamental shaping for gymnastics skills, basic mechanics for pitching, or mastery of barbell only clean/snatch movements in Olympic Lifting?

Movement Level Basics

  • Within the skill specific patterns, does the athlete possess the basic movement components required to complete them. Examples for this may include having adequate overhead mobility or squat depth to hit the Olympic lifting positions, having basic lumbopelvic strength during the gymnastics drills, or adequate single leg stability to transfer dynamic force during a baseball pitch?

Joint Level Basics

  • If the basic movement patterns are not demonstrated, we have to work backwards even further to check the joint level basics within each movement pattern.
  • Within the overhead mobility example, does the person show adequate thoracic spine mobility, glenohumeral capsular and soft tissue mobility, underlying scapular or rotator cuff strength, and basic dynamic stability? For the stride mechanics, is there adequate hip, ankle, and great toe mobility present, along with glute strength and internal hip co-contraction to tolerate the high forces being generated?

 

Where to start for checking off the basics depends on the client. It depends on if they are rehabilitation or performance based, their history, and their evaluation.

It’s important to remember these categories are not mutually exclusive. They are very much interactive. If someone is week 1 postoperative from an ACL surgery, I’m not really worried about his or her power clean mechanics just yet. But, I still may be considering sleep, nutrition, hydration, maintaining metabolic capacity, and training the uninvolved areas of the body to optimize their rehabilitation.

A gymnast or athlete who is not injured but comes to me for performance goals, we may spend more time on the skill specific movements and overall training concepts. However, if they are missing some fundamental strength and joint mobility we may consider that within the treatment sessions.

With this said, I do think that reading and trying to understand complicated concepts is important. After all the human body is pretty complex. To make progress in the fields of human movement, I think we need to break down these larger usually more theoretically constructs.

With that said, we have to always remember that basics and foundational concepts will always need to be in place. As people say, a house built on sand is doomed from the beginning. When troubleshooting a client’s lack of progress in training, rather than spending 30 minutes trying to correct their 3 degree tibial internal rotation asymmetry maybe we should consider the fact they averaged 5 hours of sleep and worked 10 hour days last week.

It’s good to take a step back and make sure we have addressed the low hanging fruit before we scale the entire tree. Only once the basics are covered can we start tackling more complex concepts to help optimize their movement or performance. Just a few thoughts from my point of view, but I hope people found this helpful to think about.

 

About the Author

Tilley-Headshot-400-widthDave Tilley, DPT, is a physical therapist at Champion PT and Performance. Dave comes from an extensive gymnastics background, being a former competitive athlete for 18 years and having 12 years of coaching experience. His unique background as a former athlete and current optional level coach gives him a one of a kind approach to the performance and rehabilitation of gymnasts.  Along with his clinical work, Dave is has a website, http://shiftmovementscience.com, that helps teach coaches, athletes, and healthcare providers about optimal performance and injury reduction concepts.

Integrating Performance Based Physical Therapy

The latest Inner Circle webinar recording on Integrating Performance Based Physical Therapy is now available.

 

Integrating Performance Based Physical Therapy

Integrating Performance Based Physical TherapyThis month’s Inner Circle webinar is on Integrating Performance Based Physical Therapy.  This presentation is actually my talk from the recent Champion Bridging the Gap From Rehab to Performance Seminar that we conducted in Boston last month.  

I wanted to share this with Inner Circle members as I feel the topic is important as performance based therapy is definitely the future of our professions.  Performance therapy is something that is performed to help people optimize themselves and improve performance, no matter what performance means to you.  You don’t need to be injured to benefit from performance therapy.  This is a lot of what we do at Champion and something that I really wanted to share.

We are actually going to be releasing an online version of the Champion Bridging the Gap From Rehab to Performance Seminar, which will include this presentation, plus others from Lenny Macrina, Dave Tilley, Rob Sutton, and Kiefer Lammi.  

Inner Circle members can access my talk now, and get early access to purchase the seminar.  Everyone else will have to wait until the official launch next week!  Plus, if you’d like to purchase the seminar, I also have a $10 off coupon just for Inner Circle members.  All the links will be in the Inner Circle Dashboard.

This webinar will cover:

  • What is “performance therapy”
  • The need for a paradigm shift in what we do
  • What I look for in my movement assessments
  • The components of manual therapy I perform
  • How to integrate and maximize your outcomes with corrective exercises

 

To access this webinar:

 

An Easy Drill to Enhance Thoracic Extension

Thoracic mobility drills are commonly given to people to enhance mobility.  I have shown some common thoracic mobility drills in the past, and recently showed a newer muscle energy technique I have been using.  If you haven’t seen these yet, you should check them out:

 

One of my big principles of rehabilitation and corrective exercises is that you follow up mobility drills with some sort of activation or strengthening drill.  You want to use the body in this newly gained mobility.

For some reason, I feel like this is often ignored with thoracic mobility.

I would actually argue that a very common reason for having limited thoracic mobility is poor endurance into thoracic extension.  The muscles can’t maintain an extended posture and resort to the path of least resistance, a slouched posture.

If you are going to spend time working on thoracic extension mobility, you should follow that up by working on thoracic extension endurance.

In the video below I show an extremely easy way to start working on thoracic extension endurance.  Certainly not groundbreaking, but an important drill that is often overlooked.

 

An Easy Drill to Enhance Thoracic Extension

 

Learn How I Enhance Thoracic Mobility

If you want to learn more about how I enhance thoracic mobility, I have a presentation on Enhancing Thoracic Mobility.  I review some of the self mobility and manual therapy techniques I use to enhance thoracic mobility. This webinar will cover:

  • The importance of thoracic mobility
  • Manual therapy techniques to improve thoracic mobility
  • My favorite self mobility drills to improve thoracic mobility on your own
  • Correct exercises to enhance movement after gaining thoracic mobility
  • How to put it all together to maximize outcomes

To access this presentation:

 

 

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