Archive for February, 2011

Are Our Youth Athletes Soft

Posted in Guest posts, Z.S. Basketball Training, Z.S. Tennis with tags , , , , , , , on February 23, 2011 by zenithstrength

Here’s a guest post from Dr. Craig Liebenson one of the premier Sport Chiros and injury experts in the world.

His article talks about playing in pain and the consequences of playing a sport year round and the evidence showing that playing year round is not in the best interests of an athlete who wants to reduce the likelihood of injuries. He also discusses certain risk factors that can predispose an athlete to overuse injuries and what to look for during the initial assessment.

Enjoy.

Many a High School coach expects youth athletes to play through pain. Is this survival of the fittest? Or a recipe for disaster? Could Stephen Strassberg’s arm injury have been prevented? Let’s take a look at some facts. A successful athlete will learn how to tell the difference between hurt & sore. If they don’t they won’t make it. Today we are seeing an epidemic in overuse injuries in the youth. Girls with non-contact ACL injuries in basketball, soccer, etc. Boys having Tommy John surgery for elbow problems. Growth plate injuries or stress fractures from running, basketball, tennis & baseball.

Are year round programs, early specialization, and single sport athletes desirable? 3 reasons not to play a sport year round. Certain sports such as gymnastics & figure skating have always been early specialization sports. While most good football, baseball or basketball players traditionally played 2 or 3 sports – until now! Coaches pressure kids into choosing. Is this working?

The American Sports Medical Institute USA Baseball Medical & Safety Advisory Committee Guidelines state,  ”Baseball pitchers should compete in baseball no more than nine months in any given year, as periodization is needed to give the pitcher’s body time to rest and recover.  For at least three months a year, a baseball pitcher should not play any baseball, participate in throwing drills, or participate in other stressful overhead activities (javelin throwing, football quarterback, softball, competitive swimming, etc.).”

In high school 9th graders are lifting weights with 12th graders. This even though many 9th graders may not even biologically have achieved development commensurate with their chronological age! So in fact, the 4 year chronological gap may be even greater in biological age.

Lets look at the knee as an example of the problem of overuse injuries. Patello-femoral pain syndrome (PFPS), also know as runner’s knee, is the most common type of knee pain. Pain is felt around and under the knee cap. Almost anyone can get it, but if mostly affects the highly active person due to overuse or the sedentary person due to underuse. It is very common in teens. A few of the most common clinical presentations seen in practice include patello-femoral tracking disorders, iliotibial band syndrome (ITBS), post-operative functional limitations after anterior cruciate ligament rupture, partially torn medial meniscus, knee osteoarthritis, and post-operative functional limitations after knee arthroplasty.

While knee pain is common, it’s tricky to find good information about it. An excellent source is Mike Reinold, ATC, PT’s website. He is the Head Athletic Trainer and Assistant Director of Medical Services of the Boston Red Sox Baseball Club The Problem Getting good care for knee pain is a challenge. The conventional wisdom about PFPS is often based on outdated thinking. As an example when the revolutionary text Myofascial Pain and Dysfunction: The Trigger Point Manual was reviewed in the New England Journal of Medicine the reviewer stated, “while pain is the most common reason people seek health care modern medical education for pain is sorely lacking.” The book’s lead author, Janet Travell, M.D. was White House Physician for John F Kennedy.

Chronic musculoskeletal problems and overuse syndromes are particularly baffling to modern medical management. In the esteemed Journal of Bone and Joint Surgery in 2002 Freedman et al wrote that “It is … reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.” And, in  2005 Matzkin et al wrote that “training in musculoskeletal medicine is inadequate in both medical school and non-orthopaedic residency training programs.”

Where are we at?

A consensus is beginning to emerge from cutting edge think-tanks. Ronald Bahr MD, PhD from the Oslo Sports Trauma Research Center said, “Overuse injuries may represent as much of a problem as acute injuries in many sports.”

A new Norwegian study (Soligard T, et al) (Warm-Up article)  published in the prestigious British Medical Journal (2008) shows that a 20 minutes warm-up program developed by the Oslo Sports Trauma Research Center in collaboration with FIFA significantly reduces injury risk in female youth football players. John Brooks, a sports injury expert put the study’s results in perspective:  “The wider sporting population at all levels should adopt this warm-up programme to reduce injury in all sports”.

For all overuse syndromes a sports medicine-orthopedic specialist should be seen who will perform an orthopedic and functional examination to rule out serious conditions, discover “weak links”, and help you identify specific goals of treatment. Once your pain is under control, and your health care provider has ruled out serious conditions, you can begin your rehabilitation process. If your pain persists or worsens be sure to consult with your doctor.

Assessment

There are two distinct aspects to assessment. Orthopedic & functional. Orthopedic assessment is focused on the mechanism of injury (more important for acute problems) and the diagnosis of the pain generator (i.e. sprained ligament, fracture, tendinitis, etc.). The orthopedic assessment includes orthopedic tests and often imaging. While the functional assessment is more geared to identify the source of biomechanical overload in the kinetic chain. The source(s) of overload are the predisposing and precipitating factors which lead to activation of a pain generator. The functional-biomechanical assessment is more appropriate for chronic or recurrent problems. A common finding in the functional assessment is a breakdown in the kinetic chain arising from dysfunction in the subtalar region such as hyperpronation. Poor ankle mobility at the tib-fib joint or limited ankle dorsiflexion mobility can also lead to compensatory sub-talar hyperpronation and subsequent problems up the chain. Other foot/ankle issues to assess include inhibition of the fore foot muscles of the transverse arch (toe flexors) or poor balance.

When evaluating hip-pelvis dysfunction gluteus medius insufficiency is one of the first dysfunctions to assess. Poor hip abduction strength/coordination is another consideration. Mobility of hip extension (psoas),  abduction (adductor muscles), internal/external rotation should all be screened.

Checking for quad dominance and determining if the posterior chain (glute-ham) complex is controlling sagittal plane motion during squats/lunges is critical.

Another factor in any knee complaint is overall posture and abdominal-core function. Without appropriate core control such as during a stability ball walk out,  ham curl with the ball, or Russian ham curls the knee could become the symptomatic link in the kinetic chain.

Treatment Approaches

Modern care for knee pain consists of 4 components. First-Aid, Sparing , stabilizing, and  functional integrated training (FIT).

1. First-Aid If your pain is flaring up or acute, ice or anti-inflammatory medication may help. Use the R.I.C.E. formula:

  • Rest: Avoid putting weight on the painful knee.
  • Ice: Apply cold packs for 10-20 minutes, several times a day.
  • Compression: Use an elastic bandage such as a simple knee sleeve that fits snugly without causing pain.
  • Elevation: Keep the knee raised up higher than your heart.

2. Sparing strategies

It has been said the knee has “no place to hide”. Functionally it’s fate is often sealed by the foot or hip to which it is linked in the kinetic chain (see figure ) (Griffin 2000). There are various sources of biomechanical overload for the knee. One of the most common is inward collapse of the knee secondary to either foot hyperpronation or weakness of the outside of the hip. A key factor in the lower quarter kinetic chain dysfunction is gluteus medius weakness. It is essential to make a patient aware of the dangers of valgus overload of the knee. Basic flexiblility (i.e. psoas/piriformis/adductors) exercises should be taught.

Video of Inner Knee Collapse During Landing a Jump

Dynamic Warm-Up – The 11+ from FIFA

Dynamic Warm-Up from JBMT

3. Stabilizing strategies

Terminal knee extension exercises (heel raise, pillow push) have been recommended to train the vastus medialis oblique. Heel slides have been recommended to train hamstring/quadriceps co-activation . Gluteus medius training (the clam shell),  glut max exercise (bridge, hip thrust, etc), and hamstring training are essential from an isolated stability perspective.

4. Functional Integrated Training (FIT)

Neuromuscular functional training has been shown to improve both performance and lower-extremity biomechanics The four main components of this training are plyometric and movement, core strengthening and balance, resistance training, and speed training.  The lateral band walk and the supported functional reach are 2 excellent examples.

Dead lifts, split squats, reverse lunges, and box squats are all excellent examples of  functional exercises which can be utilized to train mobility and stability. These are performance enhancement challenges which nearly all patients with knee problems should be progressed to.

Selected Bibliography:

Bobbert MF, van Zandwijk JP 1999. Dynamics of force and muscle stimulation in human vertical jumping. Med Sci Sports Exerc 31:303:310.

Ganley KJ, Powers CM 2005. Gait kinematics and kinetics of 7-year-old children: a comparison to adults using age-specific anthropometric data. Gait Posture. 21(2):141-5.

Hewett TE, Paterno MV, Myer GD 2002. Strategies for enhancing proprioception and neuromuscular control of the knee. Clin Orthop Relat Res 402:76-94.

Hewett TE, Myer GD, Ford KR, Heidt RS Jr, Colosimo AJ, McLean SG, van den Bogert AJ, Paterno MV, Succop P 2005. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 33(4):492-501.

Hewett TE, Myer GD, Ford KR 2005a. Reducing knee and anterior cruciate ligament injuries among female athletes: a systematic review of neuromuscular training interventions. J Knee Surg 18(1):82-8.

Liebenson CS 2006. Functional problems associated with the knee-Part one: Sources of biomechanical overload..  Journal of Bodywork and Movement Therapies, 10;306-311.

Liebenson CS 2007. Functional problems associated with the knee-Part two: Rehabilitation fundamentals for common knee conditionsJournal of Bodywork and Movement Therapies, 11;54-60.

Liebenson CS 2002a. Advice for the clinician and patient: Functional training part one: new advances.  Journal of Bodywork and Movement Therapies, 6;4:248-253.

Liebenson CS 2003. Advice for the clinician and patient: Functional training part two: integrating functional training into clinical practice.  Journal of Bodywork and Movement Therapies, 7;1:20-24.

Liebenson CS 2003a. Advice for the clinician and patient: Functional training part three: transverse plane facilitation.  Journal of Bodywork and Movement Therapies, 7;2:97-103.

Liebenson Functional training for performance enhancement. Journal of Bodywork and Movement Therapies,

Mascal CL, Landel R, Powers C 2003. Management of patellofemoral pain targeting hip, pelvis, and trunk muscle function: 2 case reports. J Ortho Sp Phys Ther  33:647-660.

Myer GD, Ford KR, Palumbo JP, Hewett TE 2005. Neuromuscular training improves performance and lower-extremity biomechanics in female athletes. J Strength Cond Res 19(1):51-60.

Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Ortho Sp Phys Thera 2010;40:42-51.

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Speed Training for Young Athletes

Posted in Guest posts, Z.S. Tennis, Z.S. Training with tags , , , , , , on February 8, 2011 by zenithstrength

Sometimes as coaches we forget to adapt our coaching styles based on the age and development of the our clients.

Here’s a guest post video from Dave Gleason regarding training youth athletes in the 6-10 year old range and developing key skills such as coordination, agility, mobility and stabilization while keeping the session fun. It definitely gets you thinking about changing some things around training younger clients.

Check out the video:

For more info on youth training check out the IYCA.