Persistent Football Injuries - first found on Specialist Pain Physio

Persisting football injuries are the scourge of the dressing room. Whilst everyone accepts that injury is ‘part of the game’ and part of sport, this does not necessarily make it any easier for the player, whatever the level, or the treating clinicians. A range of pressures and expectations exist, which impact upon the experience and the outcome. Managing these in the best way is one of the key components of a successful approach. Kieron Dyer, in his new book, describes the suffering he endured as a result of his recurring injuries and pain, which certainly had an impact upon the longevity of his career.

“Even though I knew I was injured, there was a lot going through my mind when I was celebrating with the fans…..I couldn’t cope with a career that had become a continuous cycle of hope and despair. If there were an end in sight to it, it would be different, but no one could seem to cure the problem” ~ Kieron Dyer

Addressing an acute injury is a well known and understood process: diagnose the problem, administer the right messages and treatment, start rehabilitation as soon as possible, build fitness and sport specific training with a gradual return to play. So why is it that some plays become besieged by persistent and recurring injuries and pain?

The broad brush answer is the same for any person experiencing chronic pain and injury. There are a number of vulnerabilities and contextual factors at play, meaning that protective measures rightly kick in, but do not necessarily ‘reset’ to an appropriate level of vigilance. As a consequence, this loss of differentiation means that more and more moments are perceived as potentially threatening. It only needs to be a possible threat for a protect state to be initiated, with the perception of pain being part of this state.

The first step of understanding, especially for the player, is that pain and injury are neither the same, nor well related. We have known this for many years:

“The period after injury is divided into the immediate, acute and chronic stages. In each stage it is shown that pain has only a weak connection to injury but a strong connection to the body state.”

  ~ Wall (1979) Co-founder of Textbook of Pain

To fully describe the complexities of an emergent chronic problem is beyond the scope of this blog — we cover many of the important dimensions in the Pain Coach Workshops. Chronic pain and injury is a specialist field requiring a broad knowledge of a number of areas together with experience of working with suffering individuals. These include science pertaining to pain and survival, philosophy, cognitive science, psychology, sociology, anatomy and physiology to name but a few. This knowledge then has to be applied phenomenologically with meaning and effect. We need a means to deliver treatment and provide practical tools that allow the person to pursue a purpose and achieve results. The means that I propose and offer is that of coaching, pain coaching, which is all about getting the best of an individual.

A brief insight into the vulnerabilities for developing chronic pain is useful. We are essentially on a timeline, which means that every episode in our lives is logged as an experience with a learning effect. Significant events in particular will shape us as we journey through the ups and downs. We know that early life stressors have a particular effect as the biology that protects us is evoked at a young age, at a time when the person is maturing and reliant upon others for safety and security. When this secure base is compromised, there is a vulnerability to suffering a range of complete person problems from depression to irritable bowel syndrome to chronic pain states. The sensitivity manifests in different ways in different people of course. In recent times we have heard about terrible situations, which will impact upon brain, body and behaviour ~ the 3 come as a unified package of course, the person. Dyer has bravely described his early experiences, which will have been a huge factor in how he subsequently sensed himself and the world.

In terms of pain, as a perception in the face of a perceived threat, the responses and actions become increasingly prevalent as the range of threats increases. For the player, these threats come in the form of their own thoughts (inner dialogue) like any other person, but also from the pressures of performing, from the club, from the fans, from not understanding their pain and why it persists, as well as other day to day influences. Peak performance emerges from a focused approach, from having energy, from being in flow and from minimising distractions. It is the inner dialogue that forms the greatest distraction.

Players must understand pain as the first step. It is their pain, and they can be given knowledge and tools to manage and overcome the problem. They understand that the experience is also affected by distractions that come in the form of old beliefs about pain and injury together with the aforementioned pressures. As Dyer realised, “So I hadn’t been pulling my hamstring at all. It just felt like it. Fans and others see an injury prone player but do not know the reality of pain”.

“So I hadn’t been pulling my hamstring at all. It just felt like it. Fans and others see an injury prone player but do not know the reality of pain” ~ Kieron Dyer

For anyone to manage and overcome a pain problem, an encouraging environment must be created in which the knowledge and skills are put into practice. This would include alleviating the pressures in the best way so that the focus can be on recovery within a realistic time frame. This time frame may not suit everyone, but the risks of ignoring this for the sake of a hasty return are high. A player clearly has the strengths of focus and perseverance to enable him or her to reach the professional level. They will also have overcome a number of challenges and set backs along the way. Drawing out examples of these helps the player establish the characteristics they hold, which they can use to address the current challenge of pain and injury. Maintaining a focus upon the right steps and managing the consequences of drifting off course is the route to success, encouraged and enabled by skilful clinicians who share the picture of the desired outcome. This is no different to clarifying where you are sailing your boat, setting sail in that direction and using skills and strengths to maintain course, manage the boat in tricky waters and get back on course as quickly as possible.

A programme to address persistent pain and injury (the two are different as you will know) must be complete. The clinician establishes the full story, the back story, the context and the circumstances before confirming with the player where he or she is going. This is why knowing your players is vital, and being able to have open conversations that are more likely when we practice deep listening and create an encouraging, compassionate environment. The biopsychosocial model is one that offers a framework to consider all of the factors, but of course it is how they all come together as the experience of the person that is important. It is the person who feels pain, not the body part, and hence ‘how the person is’ becomes highly relevant together with their approach to life and challenges. This style of doing life, possibility or problem, opportunity or obstacle, will often play out when it comes to pain. And this is where we deliver new choices that are the basis for moving onwards.

There are many challenges to managing and treating a complex, chronic and persistent pain and injury problem in football, especially in the professional game. Dyer describes the experience from the player perspective, delivering a stark insight. Players at the top level may receive vast rewards for their abilities, yet they are under a range of pressures that have a huge impact on pain and injury that need to be understood and addressed skilfully, to maximise the potential for recovery and return to play. This is always the goal.

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Richmond delivers The Pain Coach Workshop for Football ~ a 1 day workshop for medical teams who want to build on their skills to be able to effectively manage the range of factors that need addressing in persistent and chronic cases of pain and injury. The Pain Coach Workshop for Sport is a more general experience for problem pain in sports. Call us now to book your workshop t. 07518 445493

Keeping it Eclectic...

This dynamic warm-up is meant to be performed before each training session and game. It should be introduced in the pre-season period and maintained throughout the season. All sections of the warm-up should be completed in order with the exception of the strengthening component, which should not be performed prior to games.

Setup:
Two lines of cones should be lined up 5 yards away from each other, with 5 yards separating each cone. Players should queue in two lines, one behind each set of cones. Players should stay even with the player in the line across from them throughout the warm-up. On the way down the line of cones, players should stay to the inside, and as they make their return, should stay on the outside of the cones.

4 Great Dynamic Warm Up Drills

Part 1: Dynamic Movement

The first player in each line will begin by jogging down along the inside of the cones. The next player in line should begin when the player in front of them reaches the next cone. When players get to the end of the cones, they will back pedal back to the starting position. They will then jog down again, but at the halfway point they will transition into a back pedal. When they reach the end, they will begin by back pedaling and at the halfway point they will turn and jog forward the rest of the way back. The next movement is a side shuffle with a change of direction every 2-3 steps, which will be performed both down to the end of the cones, and back to the starting cone. These previous three exercises will help players prepare for transitory movements that they will frequently need to perform during their sport. Players will begin the next movement by facing their partner across from them and performing a carioca with a knee drive down to the end and back again, facing the same direction. Finally, players will perform a low skip down to the end, and a high skip aiming for power on the way back. Descriptions of the different movements are below.

1. Jog
2. Back Pedal
3. Jog to Back Pedal - At the halfway point, players should perform a 180 degree turn from a forward jog into a back pedal. They should continue to travel in as straight a path as possible without deviating too far in either direction. It takes a fair amount of neuromuscular control and proprioceptive awareness to be able to perform this efficiently, so younger players may have a difficult time at first.
4. Back Pedal to Jog - On the return to the starting cone, players will begin by back pedaling and, at the halfway point, will transition into a forward jog. This one is challenging to players because it forces them to turn into an area in which they have no visual reference.
5. Side Shuffle with Turns - Throughout this movement, players should keep their knees bent, toes pointed in the same direction the player is facing (not the direction in which they are moving), and maintain a slight forward trunk lean. They should not click their heels together or cross their feet over each other.
6. Carioca with Knee Drive - This is similar to the basic carioca that most players and coaches are familiar with, but it adds more of a power producing component and is a precursor to fast pace change of direction training. As the athlete brings their back leg forward across the front leg, they should drive the knee up and across their bodies. This is meant to train a quick hip drive to change direction and accelerate.
7. Low Skip - In this movement, athletes are performing an abbreviated version of a skip. They are still bringing their knees high, but they are taking smaller steps and their bodies are staying low to the ground. There should not be much vertical excursion as they perform this movement.
8. High Skip - In this variation of the skip, players are exploding off of one leg while driving the opposite knee into the air to get as much vertical excursion as possible. A common movement pattern seen in youth athletes is that they will drive up the arm on the same side as the knee that is driving up. For the purposes of optimizing performance through efficient movement strategies, cue athletes to drive the opposite arm and leg up at the same time. Doing so mimics walking and running patterns. One reasonable exception to this would be when training basketball players who need to be able to produce power while driving up the arm and leg on the same side of the body as they go up for a layup.

Part 2: Dynamic Stretches

In this component of the dynamic warm-up, players begin at the first cone, perform the stretches down to the last cone, and then jog back to the beginning. Holding long, static stretches can potentially hinder performance, so players should only hold these stretches for 3-5 seconds before moving on to the other side. The stretches described below target some of the main muscle groups that are used in soccer including the quads, hamstrings, calves, hip muscles, and groin. Make sure athletes are feeling the stretch where they are meant to be feeling it. Below are some modifications players can make if they are not feeling the stretch properly.

1. Walking Quad Stretch - Players should grab their ankle, pull it straight back behind them with a bent knee. If they do not feel a stretch in the front of the thigh, then have them squeeze their glute muscles for more of a stretch. Cue athletes to keep the knee of the leg they are stretching pointed toward the ground
2. Figure 4 Stretch - Players will cross one ankle over the opposite knee, and then sit their hips down and back as though they are going to sit in a chair. They should feel a stretch in the back of their hip. If they do not feel a stretch, have them either sit down lower into the stretch, or they can grab hold of the leg they are stretching from the shin, and pull the leg up towards their chest, keeping their shin parallel to the ground.
3. Airplane Stretch - This movement not only provides a stretch to the calf and hamstring, but also helps practice single leg balance. Players will begin by standing on one leg and bringing the other leg straight back behind them as they hinge forward from the hips. Both hip bones should remain facing the ground and players should not rotate at the hips or trunk. The players’ elevated leg should be in as straight a line as possible with their back as they slowly lower down, and arms out to the side to form an airplane shape.
4. Triple Threat Lunge - This is also commonly referred to as “World’s Greatest Stretch”, and for good reason. It helps to stretch the hamstrings, hip flexors, and calves, all of which are common areas of sensations of stiffness or tightness in soccer players. The players begin by taking a large step forward with the left leg, going down into a low lunge position with the left elbow inside the left knee and the right leg as straight as possible. Keeping the back knee straight will provide a good hip flexor stretch. The player will then rotate to the left, reaching the left arm up towards the sky, and then rotate back to neutral and place the left hand along the outside of the left foot. The final step is to shift the hips backwards and straighten the front knee while attempting to keep the hands on the floor. Once the knee is straight, pull the toes up off the floor for more of a calf stretch. Repeat on the other side.
5. Inch Worms - To begin inch worms, players will reach down to the floor and place both hands on the ground (it is ok if they have to bend their knees). From there, they will walk their hands forward until they are in a plank position. Next, they are to take small steps forward towards their hands, driving the heels down toward the ground each step of the way. They can also try to angle their feet in slightly as they walk their feet towards their hands.
6. Lateral Lunges - In this dynamic stretch, players will face sideways, take a step out with their lead foot, bend that knee, and shift their body weight towards that side in order to feel a stretch in the opposite groin area. After holding for 3-5 seconds, they will stand back upright and perform a small hop off the front leg to pivot and turn to face the opposite direction and perform on the other leg.

Part 3: Plyometric Training

In this portion of the dynamic warm-up, players will begin by bounding from the start cone to the end, jogging back to start, performing broad jumps down to the end cone, jogging back to start, and then performing single leg hop and hold halfway down on one leg, and the rest of the way with the other leg. Once they have reached the end cone after their last single leg hop, the first player in each line will jog back to the starting cone, and the players behind her will line up along the cones facing the other line of players. From there, players will perform the single leg lateral hops, square rotational hops, and split stance hops. For all of these exercises, athletes should be trying to keep their knees over their ankles and not extending beyond their toes,  get >30 degrees of knee flexion upon landing, and sitting their hips down and back with a slight forward trunk lean. It is helpful to tell players that they should not hear themselves or their teammates landing in order to improve their ability to absorb load and force.

1. Bounding - Begin by standing on the left foot, hopping forward and diagonally to the right, and landing on the right foot. Hold the landing for 3 seconds and then hop from the right foot, forward and diagonally to the left, and land on the left foot. Continue this process down to the end of the cones. When performing this exercise, players should make initial contact of the ground with the ball of the foot, then immediately drop the heel down, bend the knee, and sit the hips back with a slight forward trunk lean.
2. Broad Jumps - Players begin with feet about hip width apart, sit back into a squat, and then jump forward to land on both feet and sink down into a squat again. Players should try to land with both feet about hip width apart and facing forward, initial contact is made with the balls of the feet first and then immediately drop the heels down and sit back into a squat.
3. Single Leg Hop and Hold - Here, athletes will hop forward on one leg, hold the landing for 3 seconds, and then hop forward again on the same foot. At the halfway point down the line of cones, athletes will switch to the other leg. If an athlete is having difficulty performing this movement, tell them to take smaller jumps and focus on the quality of their landing as opposed to the distance they jump. If they need to regress the single leg aspect, they can begin by jumping off one leg and landing on both, then jumping off both legs and landing on one, and then they can go back to single leg hops.
4. Single Leg Lateral Hops - At this point, players should be lined up facing the line across from them. They will stand on one leg, hop to the side, hold the landing, then hop back to the starting position and landing on the same leg. They should repeat this 5 times on each leg. If this is too difficult, players can perform skater hops instead in which they will begin on the left leg, hop to their right and land on the right leg, hold the landing for a second, and then hop from the right leg to the left and land on the left leg.
5. Square Rotational Hops - Similar to the Broad Jumps, players will begin with both feet on the ground about hip width apart. They will then sit down into a squat, jump straight up into the air, turn 90 degrees to the right, and land facing what was previously their right side. This will be repeated 3 more times until the player is facing the way they started. They will then repeat this process going to the left.
6. Split Stance Hops - Players will begin in a split stance position (step one foot forward in front of the other), and sink down into a split squat. From there, the athlete will drive up into the air, bringing the back leg to the front and the front leg to the back, and then sinking back down into that split squat position. The opposite arm should drive up with the knee as it comes forward to mimic running. Players should be able to stay in one spot as they perform these jumps. Perform 5 repetitions on each side (10 total jumps).

Part 4: Strength Training

The strengthening component of the dynamic warm-up should be performed prior to training sessions, but not games. This is to prevent muscle fatigue prior to a game. As players demonstrate mastery of each exercise at the prescribed repetitions, increase the amount that they are performing. For example, if they are able to perform 10 squat to heel raises without their mechanics breaking down (often a sign of fatigue) for two training sessions in a row, then increase to 12 repetitions the following session. For this part of the dynamic warm-up, players should still be positioned in the same place they were for the end of the plyometric training portion.

1. Squat to Heel Raise - Players will begin with feet about hip width apart, facing the line of players across from them. They will sit down into a squat, stand back up, and then go up onto their toes to perform a heel raise. Begin with 8-10 repetitions and work up to 15-20 repetitions as the season goes on and the players’ mastery of the movement improves.
2. Split Squat Isometric Holds - Set up is the same as it was for the Split Stance Hops in the Plyometrics portion. One foot will step slightly ahead of the other and sink down into a split squat. The back knee should be hovering just above the ground. Players should hold this position for 20 seconds to begin with and progress up to 60 second holds on each side.
3. Bridges (Progression  to Single Leg Bridges) - Players will now lay on their back with their knees bent and feet flat on the ground. They will squeeze their glute muscles and lift their hips off the ground, keeping their backs and the backs of their thighs in as straight a line as possible. They will hold for a second at the top, then slowly lower back down. Their hips should remain level throughout the movement. Once they are able to perform 20 repetitions, they can be progressed to Single Leg Bridges. Make sure they are not swinging the other leg and utilizing momentum to lift their hips off the ground. The leg that is not working should be straight up in the air, with the soles of the feet pointing towards the sky.
4. Hamstring Walkouts - Players start in a bridge position and then take little steps out until the legs are completely straight, and then bring the legs right back up to the starting position. Players should perform 6 total walkouts, and work their way up to 12.
5. Plank with Hip Extension - From a forearm plank position with the back of the body in as straight a line as possible, and without over extending or arching at the low back, players will kick one leg straight up off the floor a few inches, and then return it to the floor and repeat on the other side. Their hip bones should stay facing the floor throughout the exercise. Have them perform 5 on each side to begin with and work their way up to 10 on each side.
6. Plank with Rotating Hip Drops - From a forearm plank position, players will rotate at the trunk to bring their right hip to touch the ground, go back to the middle position and pause, and then rotate to touch the left hip to the ground. Players should always pause for a second in the middle before rotating to the other side. Movements should be slow and controlled. Begin by performing 5 on each side and gradually work up to 10 on each side.
7. Plank with Hip Abduction - From that same forearm plank position, players will bring one leg out to the side, return it to the middle, and then repeat on the other side. The leg that is moving should remain about an inch or two off the ground and the trunk should not rotate.
8. Side Plank Thrusters - From a forearm side plank position, drop the hips to the floor, and then push them into the air as high as possible. Perform 5 times on one side, then switch to the other side. Eventually work up to performing 10 repetitions on each side. The body should be in a relatively straight line from the shoulder to the hip to the ankle.
9. Side Plank with Hip Abduction - From a forearm side plank position, slowly lift the top leg off the bottom leg and then lower it back down again. Begin with 5 repetitions on each side and then work your way up to 10 on each side. The toes of the working leg should face straight ahead and not rotate up to the sky.

Thanks again to Dr. Nicole Surdyka PT, DPT, CSCS 

@dr.nicolept on instagram

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...

Pain and Injury at Wimbledon

This post was first found on Specialist Pain Physio

Seven retirements and a very painful injury on-court recently at Wimbledon have given the tournament a different feel. Pain and injury are part of sport, but many people have been surprised by the turn of events. Federer has called for a review of the system and several players have complained about the state of the courts. All are factors of course. The game is simply made up of the synergy of players, court and tournament. When all are ticking, we see great tennis.

The very painful moment

Bethanie Mattek-Sands was screaming out in pain this week after her knee appeared to give way. One report suggested that she could have sustained a knee cap dislocation. This can be extremely painful until relocated. Seeing the dislocation can add to the trauma. When our body does not appear as we expect, the sight can trigger feelings of aversion.

Why so much pain?

Pain is a part of the way we protect ourselves. There are many other things going on when we are in state of protect: change in movement, change in sense, altered thinking and emotion, change in perception. In other words, the world looks different and feels different as we take action in the name of survival. This is a normal shift of state in the face of a perceived threat. Pain is a lived experience when there is a perceived threat. Pain is not well related to injury. This is the common misunderstanding. Just because it hurts a lot, it does not mean that the injury is more severe. We have known this for a long time ~ see here: pain in sport, 3 key points.

When thinking about the reasons for the pain response, the context is key. In other words the situation plays a significant part in the pain experience. As well as potential tissue injury, where that possible injury occurs and what is happening is highly relevant — it always has to happen somewhere! The full picture perceived creates a learning opportunity. If this is possibly dangerous, I need to remember what happened and where so that next time I can react differently.

All of this information is processed together with sensory information from the body, based upon what is already known about injury and the situation. In essence we make a best guess about the possible causes of the sensory information on a background of our previous experiences. In effect, we weigh up the evidence: new information vs what we know, which then suggests a scenario. If this is a potentially dangerous situation, pain can then form part of the experience. The more danger perceived, the more intense the pain.

How much danger did Bethanie perceive when her knee gave way at the biggest tennis championship in the world, in front of a big crowd, when each game is career shaping?

Whatever the outcome for Bethanie, I wish her well.

Messi’s knee

In 2012 Lionel Messi was running into the box when he brushed the keeper as he came out to meet him at speed. Messi managed to get a shot away (he missed) before he hit the ground clutching his knee. He was quoted as saying that he thought his career was over because of the pain.

How dangerous was the situation to Messi? Consider: the perceived injury (he did not know about the extent of the damage at that point), the game, the crowd silent, the body part involved, how knee injuries are thought of in the culture of football, the immediate thoughts about injury and what it means and much more.

Messi was taken off the field on a cart and whisked to hospital where he was scanned. What was the injury? A bruise.

Pain and injury are not the same. The terms are often used synonymously, but this is not correct usage. A further example is phantom limb pain. The person suffers pain in a limb that no longer exists.

Why have there been so many injuries?

We have seen multiple retirements during games at Wimbledon this year. Whilst some people have been frustrated, we must also consider that these players have to make choices. These are based on the culture of the sport, the system, their career, their income and their understanding of pain.

There will be a weighing up of the pros and cons, and each individual will consider different factors before deciding. We do not know what those factors are in each case, so we cannot make any specific assumptions or criticise. In life, how many assumptions are made when someone is being critical of another without knowing the full picture?

“aches and pains are part of sport

In sport, the day to day aches and pains are a well known part of the deal. Simple measures are taken to address theses responses so that the athlete can continue to perform: e.g./ physiotherapy treatment, massage, ice baths, stretching, periodisation. However, despite the level of fitness, each body needs to adapt to the demands of the training and play. Without this time, there can be a tipping of the ‘build-breakdown’ balance towards the breakdown (inflammation). A state of chronic inflammation is likely to explain a range of common problems that can become significant.

When an acute injury occurs in sport, there is pressure to resume play as soon as possible. Do players return too soon? Are they fully ready? Being ready means that the body tissue are robust to withstand the stresses and strains, movement patterns are normalised (and not guarded), body sense is acute and thought patterns focus on the game and not on the body.

“the clues are in the story

We do not know all the factors involved with each player at Wimbledon who had to retire, but the points described above are relevant and need consideration. When clinicians are assessing an injury, this is especially so. Each injury or pain moment (the two are different) occurs in a context as we have established. Nothing happens in isolation, we are on a timeline, and hence we must consider how the person may be primed by prior learning. What are the influences upon this current moment? Some will be obvious and some more hidden. This is why allowing the person to tell their story is vital. The clues lie within their narrative, so we must listen actively and be open.

This is a brief look at some of the key issues. Pain and injury are always going to feature in sport. We need to draw upon the pinnacle of our knowledge of pain and bring this into the athletic world. In other words, we need a shift in the thinking away from the biomedical model, instead looking at the wider picture: a true biopsychosocial, or sociopsychobio model. Here is a reminder of the key points:

The key points:

• pain and injury are poorly related
• pain is suffered by the (whole) person not a body part (e.g. tendon pain ~ the primary focus remains on the tendon rather than the person)
• pain does change when it is understood by the person and they actively create new patterns

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• For more information on overcoming pain and resuming sport and play: Pain Coach Programme
• Clinician Pain Coach Mentoring
• For lectures and workshops: Understand Pain, Pain Coach, Pain in Sport, please contact us painphysiolondon@gmail.com

via Richmond Stace - Specialist Pain Physio

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...

In this case study you’ll see how I blend take The Eclectic Approachand throw in a little yoga as to treat a youth athlete. 

History: Pt is a high-level gymnast with a h/o acute hamstring injury 8 months ago. She was treated in a traditional outpatient PT setting and is now pain free with ADLs. She still has pain during running, tumbling, and vaulting preventing her from competing at her highest level. Alleviating factors include rest, activity avoidance, over the counter pain medication.  

Objective:

• R SLR PROM lacking 20 degrees from opposite side 
• FADDIR decrease and painful pinch with overpressure
• Unable to maintain transverse abdominis (TA) contraction and breathing with hook lying knee lifts, significantly more ASIS movement on R
• Bridge with increased activation of hip flexors on R
• Palpable soreness of proximal R HS near ischial tuberosity 
• Test/retest of gymnastics skills complicated by concurrent UE injury (different mechanism of injury but could be another case study on its own) that limited UE weight bearing during the first 1-4 visits. 

1st Visit:

• Corkscrew hamstring/sciatica tensioner (see Dr. E's post here) 
• Hip inferior glide grade III
• Home program: self standing hamstring/sciatic nerve tensions (see Dr. E's post here)
• By end of treatment seeing 5-10 degree improvement in R SLR PROM

2nd Visit:

• SFMA Rolling - patient had the most difficulty going supine-prone
• IASTM proximal hamstring 
• Posterior chain activation exercise including single leg bridge, double leg bridge with single leg lift
• Yoga poses: Warrior I, II, III series for challenging hamstring response to stress and concentric/eccentric loads
• By the end of treatment session pt lacking only 5 degree PROM test by SLR compared to unaffected side. Also able to perform splits and cartwheel pain free. 

3rd and 4th visit: 

• Completing practice pain free (with the exception of vaulting - separate wrist issue) 
• Strength deficit on R - unable to perform single leg squat to the floor 
• Worked on retraining of landing mechanics with 2 footed and single leg jumping to improve force distribution during gymnastics. 
• Continuing posterior chain activation exercises from above with additional of single leg squat.
• Yoga poses to focus on pelvic control and neutral spine in quadruped with extension of arms and legs. Progressing difficulty of core rotational stability. 
• Added chair pose with emphasis on seating femoral head in acetabulum through tactile cueing of hip ERs prior to starting pose. Pt seeing immediate improvement in squat by being able to lower down farther and with decreased pain. 
• Instructed on how to use yoga strap to perform a self-inferior glide/hip corkscrew for R hip (will post a video of this soon!) 
• By 4th visit had equal HS PROM for the first time in 8 months. 

Final Thoughts:

• Sciatic neurodynamics was very important for regaining full hamstring motion needed for gymnastics 
• Activation of posterior chain and hip external rotators crucial to retraining squatting 
• This may be obvious…but your rehab needs to be SPORT specific. Too many times I see gymnasts who are “discharged” from PT, however still have deficits that either severely limit their gymnastics or put them at high risk for re-injury. 

Christine Walker owns her own PT practice inside in Charlotte, NC where she helps active adults and athletes get back to the activities and sports they love without painkillers, injections, or multiple trips to the doctor's office. To learn more visit her website or connect with her on Twitter.

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...

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What can happen when a patient returns to sport too early after an injury? Re-injury perhaps? Listen in to find out more about a patient who re-injures his knee by returning to soccer too early.

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Untold Physio Stories is sponsored by the EDGE Mobility System, featuring the EDGE Mobility Tool for IASTM, EDGE Mobility Bands, webinars, ebooks, Pain Science Education products and more! Check it out at edgemobilitysystem.com .  Be sure to also connect with Dr. Erson Religioso at Modern Manual Therapy and Jason Shane at Shane Physiotherapy.

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...

 

 

Today's Q&A Time is from a regular blog reader who works with a high level figure skater. She asked a question about breathing that was so specific I reached out to Charlie Weingroff and Julie Wiebe, two of my colleagues who I thought could give a better answer than I could.