Articles & Resources

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by Brian McCormick

Over the last few weeks, a study from U.C. Davis on ACL injury prevention has made its way through the Internet with headlines like “Land on your toes, save your knees.”

However, the actual study’s conclusions differed from the headlines’ implications (“Alterations to movement mechanics can greatly reduce anterior cruciate ligament loading without reducing performance” by Casey A. Myers and David Hawkins in the Journal of Biomechanics). The reports circulating the Internet vary from incomplete to inaccurate, while the study suggests instructions that should be common teaching practice.

The study used 14 female college and high school girls basketball players with at least two years of basketball experience and no prior knee issues. Subjects were instructed to run at “game speed” and make a jump stop at a certain point.

The players executed multiple jump stops without any instructions. After a series of repetitions, the researchers instructed the players to use a specific technique to measure their intervention: “The intervention targeted: increasing the amplitude of the jump prior to landing, increasing the amount of knee flexion at landing, and striking the ground with the toes first, (Myers and Hawkins).”

The study found:
“Subjects increased their knee flexion angle an average of 5.3° and moved the center of pressure at contact an average of 6.6 cm closer to their toes. There was no change in shank angle relative to the vertical during landing...The subjects basically performed the intervention jump stops with greater bend at the knees and landed more on their toes” (Myers and Hawkins).

Here is the big issue with the headlines:
“Jump stops were performed with the toes striking the ground first during the intervention condition versus the majority of jump stops performed with the heels striking the ground first in the baseline condition” (Myers and Hawkins).

Based on my reading of the published study, I have one issue with the study and one issue with its reporting.

The study measured a controlled jump stop in a closed environment. Even if the players were instructed to go game speed, how many players go game speed in drills? Further, in similar drills where players run to a certain spot and jump stops, they slow down before executing the jump stop. Their stride length decreases and speed slows in order to make a more controlled jump stop.

Executing a jump stop in an open environment as a reaction to a stimulus (defender) is a more involved skill. An open-skill jump stop occurs at game speed and without anticipation or preparation. In some occasions, players prepare before executing the jump stop, thinking ahead about their move, but in most cases, the move is a reaction to a defender or situation.

Second, adding the ball and defenders change the skill execution. Executing the jump stop while catching a pass, dribbling or rebounding a ball differs from a planned jump stop.

Therefore, while the specific adaptations suggested by the study may reduce the sheer force on the knee, and may be valuable to incorporate, the findings provide only a starting point, as a coach or trainer would need to incorporate the same findings in open skills to enhance the efficacy of the instruction in a real world setting.

As for the reporting, the study does not advocate a “toe landing.” Instead, the study  found that landing with a deeper knee flexion and initiating the landing with the toes lead to reduced force at the knee.

“While toe strikes that were accompanied by an increase in knee flexion angle at contact produced the largest decreases in peak tibial shear force (PTSF), some subjects were able to reduce PTSF without increasing their knee angle, (Myers and Hawkins).

Therefore, some subjects were able to reduce the force without deepening their knee bend; however, these subjects may have had a deeper knee bend than others at the outset or they may have run at less than full speed.

As for initiating the landing with the toes, what coach teaches players to initiate a landing with their heels? How does a player develop throughout high school and college with a heel-strike landing from a vertical jump?

When teaching jumping mechanics, I have seen two methods:

1. Land like a Ninja: Land softly; initiate the landing on your toes and the balls of your feet and sit back to a flat foot as your knee-bend increases, and you sit down by dropping your hips. 
2. Dorsiflexion: Dorisflex your foot (toes up) and land on the balls of your feet. In this landing, there is less knee flexion. This landing takes advantage of the stretch-shortening cycle for repeat jumps. Even when landing with a dorsiflexed foot, the heel should not hit the ground and certainly should not initiate the contact.

In the article, a reporter interviewed U.C. Davis Women’s Basketball Coach Sandy Simpson:

“It almost always happens coming down from a rebound, catching a pass or on a jump-stop lay-up,” Simpson said. “It doesn’t have to be a big jump.”
His comment suggests one misunderstanding of the mechanics of the injury and points out the flaw with the study that I mentioned above: the ball makes the game jump stop different from the jump stops in the study.

As for the misconception, many coaches who have eliminated the jump stop for fear of ACL injuries have encouraged stops with a smaller vertical component. However, the study’s intervention encouraged the players to jump higher. As Simpson says, and the study suggests, the vertical component does not necessarily influence the incidence rate of injuries, and, in fact, a greater amplitude may decrease injuries (possibly by creating a more straight-down landing, which may help to control the sheer force on the ACL caused by controlling the anterior movement of the tibia).

I have never witnessed an ACL tear on a jump stop. Instead, I have seen injuries on cuts and stops when moving forward. I know two players who tore their ACLs when landing from a rebound, but there was some contact in each case.

It is not the same sport, but I saw some pictures recently of a Division I outside hitter; we assume that OHs land on two feet at the same time, but that never happened. Further, the player did not land with a balanced body, as with a basic, closed-skill jump stop. If we watched slow-motion footage of players landing from rebounds, I imagine that we would find that oftentimes players land one foot at a time and in off-balanced positions. Therefore, to reduce ACL injuries in these instances, we need to practice these landings starting in closed environments and moving to open skill executions.

“Hawkins recommends warm-ups that exercise the knee and focusing on landing on the toes and balls of the feet. The study does not definitively prove that these techniques will reduce ACL injuries, Hawkins said: that would require a full clinical trial and follow-up. But the anecdotal evidence suggests that high tibial shear forces are associated with blown knees,” (from the article, not the actual study).

These exercises should be part of a dynamic warm-up. Jumping, skipping, and running with proper technique should be taught early in the season and emphasized at the beginning of practice to prepare the players for the open skills during practice sessions and games.

“Simpson said that the team had tried implementing some changes during last year's preseason, but had found it difficult to continue the focus once the full regular season began.”

This is the attitude that I do not understand. Coaches have time to run 20 out-of-bounds plays and practice every possible scenario, but not to ensure the safety of their players? I have heard this excuse for years. However, what helps your team more, an extra OB play or having your entire team healthy for a full season?

I have watched college practices; there is plenty of wasted time to incorporate exercises to reduce the potential of injuries. This is like when I worked the Cal Women’s Basketball Camp and sat with the athletic trainer as she pointed to girl after girl who was at-risk for ACL tears; I asked why she did not do a session to teach the girls or at least make them aware. She said that the coaches said that there was not time. We had this conversation while watching the girls play “Land-Sea-Air,” the ultimate camp time-waster.

Even better, the study found that when using the intervention technique, subjects jumped higher after the jump stop than they did with their old technique. Not only would teaching the improved technique potentially lead to fewer injuries, but it could also improve performance! It is a win-win situation, yet one ignored by many coaches and trainers. This is not a matter of adding resistance training sessions or incorporating plyometrics. The intervention effectively suggested that teaching a more effective jump stop - a fundamental basketball skill - would lead to decreased risk of an ACL tear. It isn’t a matter of adding anything, but improving the typical instruction to create a more effective jump stop.

From a skill development perspective, coaches can start with the closed skill used in the drill. Emphasize the higher amplitude on the jump, the toe-to-heel landing and the deeper knee flexion. Next, move to more involved skills. Execute the jump stop with a ball in one’s hands. Then, jump stop while dribbling; then jump stop on the catch; then, land with the ball from a rebound. Finally, move toward the open-skill application by having players jump stop as a reaction to a verbal or visual stimulus (for youth players, Red Light-Green Light works well).

Eliminating ACL injuries is likely impossible. However, incorporating better technique instruction into normal footwork and jump stop drills as well as incorporating proper landing technique into dynamic warm-up drills may reduce injuries and improve performance, which ultimately leads to a better team performance and more wins.

by Art Horne

A review of:
Jenkin M Sitler MR, Kelly JD. Clinical Usefulness of the Ottawa Ankle Rules for Detecting Fractures of the Ankle and Midfoot. J Ath Train. 2010;45(5):480-482.

Basketball season is back and with it comes a new season of early morning conditioning runs, late night pick-up games, and of course, a few ankle sprains along the way.  Like clockwork, gasps by teammates and spectators can be heard followed by the uncertain question after such injury, “is it broken?” 

First introduced in 1992 by Stiell et al, the Ottawa Ankle Rules were a guideline for caregivers after ankle trauma to determine whether or not an ankle/foot x-ray was warranted in the evaluation and care of the athlete.  Having been designed to have a high sensitivity for detecting significant fractures, its other goals include decreasing unwarranted radiation and avoiding long waits in the emergency rooms for x-ray evaluation.

Based on the Ottawa Ankle Rules, Stiell et al recommended x-ray evaluation after an ankle sprain for the following:

1. Patients 55 years and older (not the typical NCAA college basketball athlete)
2. Those that were unable to bear weight for 4 steps both at the time of injury and during evaluation.
3. bone tenderness at the inferior tip or posterior edge of the lateral malleolus or
4. bone tenderness at the inferior tip or posterior edge of the medial malleolus.

For those athletes with a suspected mid-foot fracture, x-ray evaluation were recommended for those that:

1. had pain at the base of the 5th metatarsal, cuboid or navicular.

Exclusion criteria include:

1. injury past 10 days
2. pregnancy
3. patients under the age of 18
4. presence of isolated injuries to the skin.

What does this all mean?

If a college athlete sustains an ankle sprain and is able to walk off the court and does not have bony pain either the medial or lateral malleolus and is void of bony pain at the base of the 5th (or other midfoot bone) then it is highly likely that he/she does not have a fracture.  Conversely, if an athlete sprains their ankle and is unable to bear weight at both the time of injury and at the time of evaluation (once the emotional piece has settled), an x-ray evaluation is warranted due to the very high likelihood of a fracture.

The Ottawa Ankle Rules Modified – Buffalo Rule

“The Buffalo Rule was derived to increase the diagnostic accuracy of the Ottawa Ankle Rules, with the point tenderness criterion directed to the crest or midportion of the malleoli (distal 6 cm of the fibula and tibia), reducing the likelihood of palpating over injured ligament structures.”

Big Cost Savings

“The Ottawa Ankle Rules are reported to result in a 19% to 38 % reduction in radiography costs associated with excluding ankle fractures after sprain injury.”

“The Buffalo Rule is reported to result in a 54% reduction in radiography costs."

“National cost savings estimates with implementation of the Ottawa Ankle Rules range from $18 to $90 million annually (depending on the payor mix involved).”

Conclusion

“Based on the current research, it is recommended that the Ottawa Ankle Rules and, by extension, the Buffalo Rule be included in both athletic training clinical practice and educational programs.  In the present era of cost containment, increased awareness of unnecessary tests and procedures will only become meaningful.  Accordingly, clinicians will need to use the information presented in the systematic review, combined with their own practical experience and the patient’s values, to determine how best to apply the data in an evidence-based manner.”

References

Jenkin M Sitler MR, Kelly JD. Clinical Usefulness of the Ottawa Ankle Rules for Detecting Fractures of the Ankle and Midfoot. J Ath Train. 2010;45(5):480-482.

Leddy JJ, Smolinksi RJ, Lawrence J, Snyder JL, Priore RL. Prospective evaluation of the Ottawa Ankle Rules in a university sports medicine center: with a modification to increase specificity for identifying malleolar fractures. Am J Sports Med. 1998;26(2):158-165.

Leddy JJ, Kesari A, Smolinski RJ. Implementation of the Ottawa Ankle Rules in a university sports medicine center. Med Sci Sports Exerc. 2002;34(1):57-62.

Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992;21(4):384-390.

by Devan McConnell

Recovery and regeneration are hot topics in the field of Sports Performance. In my experience, much of the information about regeneration is anecdotal, and that which is not is often highly debated. At Stanford, I try to implement a multitude of different recovery strategies. Some may work better than others, and I am always learning and honing my protocols, however in my mind it’s better to be doing something directed at recovery and regeneration than doing nothing at all. Here are a few of the tools and protocols I will use with my athletes throughout the year.

1. Hydrotherapy- This can take several different forms, and as I said before, much of the research and recommendations on hydrotherapy is conflicting, but what seems to be constant is that some sort of hydrotherapy is beneficial, and the faster you get your athletes in the water, the greater the benefit. We will implement cold tub baths, hot tubs, contrast baths, contrast showers, and hydro-massage, where we can use pressurized water within a tub to apply direct massage. From time to time we will also perform pool workouts. It is important to note if the athlete is finished training or competing for the day, as this will influence which protocol we will use, and whether we finish hot or cold.

2. Stretching- Maybe one of the simplest and most often used protocol is just good old-fashioned post practice/workout static stretching. Not only  can we restore some length to overworked tissues, but we can also trigger the parasympathetic nervous system to begin bringing down heightened physiological markers and start relaxation. We will also employ other stretching techniques, such as Active Isolated Stretching, Partner Stretches, Fascial Meridian Stretches, etc.

3. Self Myofascial Release- This would consist of the use of foam rollers, massage sticks, various balls of different size and density, as well as other soft tissue tools. The purpose post exercise is to decrease the tone of soft tissue, release trigger points, activate the parasympathetic nervous system, and begin the process of returning the body back to baseline.

4. Lower Body Elevation and Breath Work- These are two very simple ways to begin the recovery process, which we will usually pair together. We simply have the athletes lay out on the turf along with their feet elevated up against a wall. At the same time, they are instructed to put one hand on their stomach, and the other on their chest. For about 5 minutes we will just focus on deep belly breathing, attempting not to let the chest rise and fall with each breath. This diaphragmatic breathing pattern facilitates relaxation, quickly brings heart rates down, and helps with venous return.

5. Cobblestone Mat Walks- We set up several cobblestone mats and the players walk back and forth barefoot for a few minutes. Eastern Medicine has long preached about the benefits of cobblestone walking, as the bottom of the feet are said to have a sort of “road map” to the rest of the body, where specific acupressure points can influence heart rate, blood pressure, relaxation, etc. Even if you do not believe this, after a tough training session, practice or game, it just feels good on the feet. Happy feet make a happy player!

6. Post Workout Nutrition- Nothing fancy here, just a carb/protein drink immediately post exercise to facilitate recovery via muscle protein synthesis, glycogen repletion, and hydration.

7. Yoga- We have a yoga instructor on staff that we can set up sessions with. From time to time we will utilize yoga for its relaxation and regenerative properties.

8. Flush Rides- Flush rides on the bikes post game can help bring down heart rates and work out some of the “tightness” the players often report feeling. 10-15 minutes of low level riding also allows players to “debrief” and relax with each other.

9. Mobility/Dynamic Cooldown- Mobility of the ankle, hip, and thoracic spine is always important, and by having a brief mobility circuit set up where the players perform one or two drills for each area serves the double purpose of adding in mobility work and slowly bringing athletes back down from a heightened sensory level after a strenuous session or game. Similar to the secondary effect of flush rides, the psychological benefit of “debriefing” together post game is an added bonus.

All in all, we have many tools available to help aid in recovery and regeneration of our student athletes. Some are well documented, while others are a bit outside the box. I believe what is most important when it comes to recovery practices are to make sure you are always doing something. Consistency in my mind is perhaps the biggest factor of whether or not a benefit will be seen in performance from utilizing recovery methods. Another important factor is to not get stuck using just 1 or 2 modalities. Like the exercises we prescribe, the body will adapt to recovery methods used over and over, eventually decreasing the effectiveness. Therefore, it is important to use a multitude of different tools in order to continue to see a positive response.

Recovery and Regeneration are a hot topic in Sports Performance these days for a reason. With so much on our athletes plate every day, and the level of competition so close, the ability to recover faster than your opponent could be the difference between winning and losing. If you aren’t spending a few minutes addressing this crucial part of the training and adaptation process, you might not be getting all you could be from your athletes.

by Art Horne

This past week I blogged about Rhabdo in an effort to raise an awareness between collegiate Sports Medicine and Strength Staffs as we begin to enter basketball pre-season across the country; this after 19 high school Oregon football players were treated for what appears to be Exertional Rhabdomyolysis.

Below is a summary of three articles outlining the cause, treatment (refer) along with some prevention points that should be reviewed by both the basketball athletic trainer and strength coach prior to beginning your fall training programs.

Key Points / Cliff Notes Version (modified from Clarkson)

1. “Exertional Rhabdomyolysis is the degeneration of skeletal muscle caused by excessive, unaccustomed exercise.  Symptoms of rhabdomyolysis include muscle pain, weakness and swelling; myoglobinuira (presence of myoglobin in the urine); and increased levels of muscle enzymes and other muscle constituents in the blood.”

2. Myoglobin in the urine causes your urine to become dark in color similar to cola.  “In rare cases, myoglobin can precipitate in the kidneys and cause renal failure” and ultimately death.

3. Severe episodes tend to occur at the beginning of a training program (think freshmen joining your otherwise veteran team), when exercise is extreme or excessive (boot camp style or circuits with repeated bouts to failure), and when accompanied by heat stress (summer or fall workouts) and dehydration (I would be willing to bet that the majority of our basketball athletes are more often than not, not properly hydrated).  “Insufficient acclimatization, inadequate diet and lack of specific physical conditioning may also contribute to this condition.”

4. “Certain individuals may be predisposed to rhabdomyolysis, possibly due to a latent metabolic disorder.”

What is it?

Rahabdomyolysis is defined as “a degeneration of muscle cells and is charactierized by a group of conditions including muscle pain, tenderness, weakness, and swelling; myoglobinuria (presence of myoglobin in the urine); and increased levels of sarcoplasmic (muscle) proteins and other muscle constituents in the blood.” (Clarkson)

“One of the proteins released from damaged muscle cells is myoglobin.  High levels of myoglobin in the blood (myoglobinemia) result in a “spill over” of myoglobin into the urine (myoglobinuria).  In certain situations, myoglobin can precipitate in the kidneys and cause renal failure.” (Clarkson)

“Equally dangerous can be the leakage of potassium into the bloodstream, which under certain circumstances can interfere with propagation of the heartbeat.  Another danger is posed by the possible leakage of excessive calcium into the cell, creating a state of hypocalcemia in the bloodstream, which can lead to irregular heartbeat, muscle spasms, and other symptoms.” (Claps)

Signs and Symptoms

• Symptoms of Rhabdo include: persistent muscle pain and weakness, swelling and dark urine (tea or cola colored).  
• These symptoms at first may present similarly as a case of delayed-onset muscle soreness (DOMS), however,  change in urine color and severe muscle pain often set this condition apart and should be taken very seriously.

Prevention

• During the first few days of training camp or return to school (either summer training or fall classes) never begin your program with repetitive, excessive exercise.  Strenuous activities, circuits or “mental toughness” training should only be conducted with well-conditioned athletes.
• If ambient temperature is hot, be sure to have your athletes drink plenty of water or provide additional water breaks during the training. 
• Athletes should never try to manipulate their diet suddenly heading into camp or pre-season training in an effort to lose weight or reach a goal weight set by coaches.  Any manipulation in diet should be monitored with lower intensity exercise first to make sure the athlete responds well before exposing them to strenuous exercise.
• If your athlete reports dark urine a day or two after an exercise session report them to your team physician or sports medicine staff immediately.
• If your athlete reports feeling dizzy during an exercise session, especially those in warmer weather, have them stop and rest immediately. 
• Know your athletes. Get complete medical histories of each basketball athlete you work with and discuss with your athletic trainer/strength coach who may be at risk after evaluating their baseline assessment/testing prior to beginning strenuous exercises.
• Progress training slowly.  Back off training if DOMS seems severe – don’t automatically assume your athlete  didn’t train during the summer, or are wimps.

Take Home Message

Specificity of training is important.  Just because your athlete has been playing pick-up ball all summer doesn’t mean that they are ready to endure a circuit of max dips followed by max  push-ups finishing with max tricep extensions.  Summer pick-up does not provide “protection” against this type of exercising.  Ease into max effort drills slowly. 

Ego Trip. In a world where toughness matters and quitting an exercise before your team finishes simply is not an option, some individuals will go well beyond a tolerable level of muscle injury in an effort to impress their coaches and teammates.  Start freshmen or lower trained athletes with lower weights than their older counterparts when doing circuits until a reasonable amount of adaptation and fitness has occurred.

An Ounce of Prevention.  Most reported military cases of “heat stress, rhabdomyolysis and acute renal failure have occurred during the first few days of training during which excessive repetitive exercises (e.g., push-ups, squat jumps) have been used.   In the college setting, repetitive, strenuous exercises should be limited or avoided until a base level of fitness can be established.

“Most cases of rhabdomyolysis do not require hospitalization, and individuals recover within one week.  However, in certain individuals, rhabdomyolysis can be severe.  The combination of heat stress (hyperthermia) and rhabdomyolysis can produce acute renal failure, which in rare instances can result in death.” (Clarkson)

References

Brudvig, T. and P. Fitzgerald, 2007. Identification of Signs and Symptoms of Acute Exertional Rhabdomyolysis in Athletes: A Guide for the Practitioner. Strength and Conditioning Journal. Vol 29, 10-14.
Clarkson. P. 1993. Exertional Rhabdomyolysis and Acute Renal Failure.  Physiology. Vol 15, Number 3, 1993.
Clap, F. 2005. Exertional Rhabdomyolysis. Strength and Conditioning Journal. Vol 27, Number 3, 73-74.

A review by Art Horne

Some kids just always seem to get hurt, year after year they show up in your athletic training room like clockwork, even for injuries sustained outside of their sport.  How many times can the same athlete get hit by a car while riding their bike on campus? Or what about the other athlete that just seems to always be in for a new injury evaluation every Monday whether they had a game on the weekend or not.  But is it just bad luck, or does their psychological profile lend them to behaviors that clearly puts them in harm’s way at a much greater rate than their teammates?

The following serves as a brief review from Urban Johnson’s article, Sport Injury, Psychology and Intervention: An overview of empirical findings, from the Centre for Research in Sport and Health, Halmstad University.

From this article, Johnson reviews psychosocial antecedents to sport injury, “the most influential stress-injury model aimed at predicting the occurrence of sport injury was developed by Andersen and Williams, 1988, and modified by Williams and Andersen, 1998.  It posits that individuals with personality characteristics that tend to exacerbate the stress response, with a history of many stressors, and with few coping resources will be more likely, when placed in a stressful situation, to appraise the situation as stressful and thus exhibit greater physiological activation and attentional disruption.  The muscle tension, distractibility, and perceptual narrowing that occur during the stress response appear to be the mechanisms behind increased injury risk (Andersen & Williams, 1999)”

Risk Factors

Personality: “relationships are often found between injury outcome and risk factors such as internal or external locus of control, competitive trait anxiety, low self-esteem and low mood state early in the season.”

History of Stressors: “the vast majority of these studies have found a positive relationship between injury and high life stress, daily hassles, and life changes.  These findings suggest that preoccupation with life change may affect concentration on training and competition and increase the likelihood of injury.”

Coping Resources:  Several studies, “report a relationship between athletes low in coping resources and prediction of injury. Hanson et al (1992) found the coping resources were the best discriminator of both severity and number of injuries.”   Some other studies, “have shown a direct effect, with athletes low in social support exhibiting more injuries”, while other studies, “have found a relationship between negative life events and injury outcome only for athletes low in both social support and coping skills.”

Intervention Studies

Although there is some research to suggest that relaxation techniques, counseling, imagery, and team building are affecting in limiting the number of reported injuries “the implementation and assessment of controlled intervention that might lessen the stress response and reduce injury vulnerability is sparsely documented.”

Where do we go from here? Implications for practice

1. Major Life Stressors: “major life event stress and daily hassles seem to have a direct or indirect effect on injury resiliency and vulnerability.” So where do we go from here? In a recent article I posted the “Mood Questionnaire” that we use prior to training and/or practice.  This gives me at least some talking points if an athlete scores low under, “Joy of Competition & Training”, “Focus” or “Sharpness” and allows me to pull that athlete aside and have an additional conversation and follow up as needed.  “Because of their close relationships with athletes, coaches and therapists are in a unique position to recognize athletes at-risk and help them. They are in a position to teach athletes how to expand their range of coping skills and thus to meet troublesome life events and daily hassles.”

1. Recognize Effect of Personality Variables on Injury Outcome:  “People with high competitive trait anxiety, an external locus of control, pessimistic lifestyles, chronically low moods, and aggressive behavior seem to be at greatest risk of injury.”   With this said, Johnson suggests and we have simply added a “psychosocial risk assessment” as part of our general screening examination at the beginning of the season.  This can be as simple as:

ANXIETY SCORE:  Please rate yourself.

Prior to competition, how would you rate your anxiety level?  10 being the highest, and 0 being the lowest. ­­­____

1. Prevention Techniques and Skills: “Relaxation techniques, including somatic relaxation techniques focusing on breathing and/or progressive muscle relaxation show promise. So does the practice of having athletes keep daily or weekly notes during the season.” Again, by tracking athletes at least once a week with a simple mood score/questionnaire, you are able to see trends develop with noticeable spikes in mood or fatigue becoming talking points for all of those involved including the sports medicine and strength & conditioning.  “Coaches and sport psychologists should consider implementing intervention programmes for athletes with a high injury-risk profile.”

by Art Horne

Bill, can you describe some common themes that you’ve observed when it comes to evaluating and treating the basketball athlete?

Absolutely.  Most of our basketball players initially present with very poor lumbopelvic stabilization.  Because of the this you’re going to see compensations associated with an anterior shift of their center of gravity associated with an anterior pelvic tilt.  Think of the classical Janda lower crossed syndrome.  The portion of the oblique that controls the pelvis will tend to be lengthened and weak, the glutes will be rendered ineffective because of the pelvic tilt, hamstrings may test stiff or short, and ankle mobility into dorsiflexion is reduced.

Shifting the center of gravity forward puts these athletes in a constant state of active plantar flexion which will result in relative weakening of the toe extensors and dorsiflexors.  Every squat, cut, or jump becomes knee dominant.  What you end up with is a quadriceps dominant athlete with potential for multiple injuries from lower back/sacroiliac problems, to patellar tendinopathy, to Achilles tendinopathy, or even plantar foot pain diagnoses.

Depending on severity of the pelvic tilt, you’ll see a proportionate loss of hip extension, hip rotation, especially internal rotation, and adduction.  Not only does this affect performance in general, but the resulting deficits can cause premature wear’n’tear on the hip joints themselves as a bony block can be created by the altered acetabular angle associated with the pelvic tilt.  This doesn’t even consider the soft-tissue adaptations that will occur.

Hip external rotators will lengthen and weaken, adductors will become stiff or short, quads will stiffen increasing loads on the SI joint, hip joint, and the knee. 

When it comes to training college teams, I’m always looking for the most bang for your buck.  What “global” or “general” corrective exercises can strength coaches, athletic trainers and physical therapists employ to help alleviate these dysfunctions?

It basically comes down to emphasizing  opposing muscle groups to that get overemphasized during practice and play.  For instance, agility, shooting, and jumping all place huge demands on the quads and knees.  Your corrective elements should try to shift emphasis away from the knee and toward the hips.

First this may be a little more specific but use your warm-up time for corrective purposes.  Active forms of hip extension like glute bridging progressions, active hip internal rotation, and active adduction, which often gets ignored, will go a long way to improving and maintaining hip mobility. Without this mobility, your chances of even accessing the necessary hip musculature is much less.  Make sure to reinforce a stabile spine throughout.

Prioritize restoring and maintaining lumbopelvic stability.  If you don’t, the adaptations up and down the kinetic chain will persist no matter what exercises you throw at them.  Many times we’ll have to start simply with floor exercises in supine, quadruped, and sidelying to teach our athletes how to recruit the core musculature, especially the external oblique, and hold pelvic position/neutral lumbar spine.  Most athletes tend to be rectus abdominis dominant.  You’ll see this in a typical plank exercise with rectus dominant athletes showing a large thoracic kyphosis.  This often gets ignored and the faulty pattern gets reinforced.

Emphasize posterior chain.  Box squats with the athlete pushing the hips back throws the emphasis on the hips versus the knee, so we can still get our athletes strong and emphasize weak points without the concern of adding overload to the knee.   Romanian deadlifts, low cable pullthroughs, and even back extensions can have corrective properties if proper movement patterns such as hip extension are reinforced.

Split stance exercises like split squats, Bulgarian split squats, and reverse lunges allow the athletes to work on hip mobility in hip flexion and extension as well as improving stability.  Again, a vertical tibia is essential to prevent adding to knee stress.  Make sure you’re getting good hip extension of the trailing leg.  Asymmetrical loading is a great way to enhance trunk stiffness/pelvic stability that you’ll need to gain hip extension mobility.

I’d also include a little bit single leg stance activity.  It’s not about getting incredibly strong on a single leg but more about enhancing stability.  I don’t buy the play on a single leg, train on a single leg mantra.  Overemphasize single leg work and you’ll end up with athletes that can’t handle the high force conditions associated with basketball.  Your primary exercises should be double leg.  Single leg work is merely a supplement.

What is the one thing most people miss when dealing with knee pain in the basketball athlete?

The knee pain is a symptom of the problem, not the problem.  Focusing on the knee and not the influences on the knee will only result in ongoing knee pain.  We know that a lack of lumbopelvic stability, hip rotation, hip abduction strength, and hip external rotation strength will all contribute to overload on the knee.

Prospective studies on anterior knee pain show these deficits develop in athletes with anterior knee pain.

During your presentation at the 2010 Basketball Symposium hosted by BSMPG you touched upon the importance of breathing and beside the obvious need for breathing, can you elaborate on the relation to performance?

We’re really emphasizing developing better breathing technique for a couple of reasons.  Our primary concern initially was to restore effective breathing to strengthen the diaphragm and improve lumbopelvic stability.  Because of the arrangement of our internal anatomy with the liver on the right and the heart on the left, the left side of the diagphragm tends to be flatter or less like a canopy than on the right.  Mechanically this reduces effective stabilization on the left compared to right.  The left side of the pelvis will tilt anteriorly with a relative right side posterior pelvic rotation.  This in turn will affect hip mobility or trickle upward affecting shoulder girdle and spine function.  Performing the breathing exercises has allowed a lot of our corrective programming to “stick” a little more effectively

What we didn’t expect was a secondary effect which was an increase in cardiac output which we identified by our athletes experiencing a reduction in resting heart rate by as much as 4-5 beats per minute.  After talking with Larry Cahalin and then reading the resisted breathing study that you guys did with the hockey team at Northeastern University, we’ve concluded that our breathing work is improving cardiac output via an increase in venous return.  Typically we will have our athletes perform cardiac output development work for longer durations up to 60 minutes in a heart rate zone of 120-150 bpm.  By adding in the breathing exercises and resisted breathing protocols from the study I mentioned, we’ve been able to cut way back on the long slow duration work which the athletes really appreciate.

I know you have an extensive library – what 5 books would you recommend for those working with basketball athletes primarily in a rehab setting should read?

Keep in mind that I don’t think there is a singular resource that has all the questions answered, but here’s  my short list and in the interest of overdelivering throw in a couple extra:

Ultimate Back Fitness and Performance by McGill
Clinical Application of Neuromuscular Techniques, Volume 1: The Upper Body by Chaitow
Clinical Applications of Neuromuscular Techniques: The Lower Body, Volume 2 by Chaitow
Assessment and Treatment of Muscle Imbalance:The Janda Approach by Page, Frank, and Lardner
Diagnosis and Treatment of Movement Impairment Syndromes by Sahrmann
The Malalignment Syndrome: Implications for Medicine and Sports by Schamberger
I’d also recommend the courses from the Postural Restoration Institute

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Commentary by Orlando Magic Strength Coach, Joe Rogowski.