Articles & Resources

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

Click HERE to view video.

Commentary by Orlando Magic Strength Coach, Joe Rogowski.

Click HERE to download this article.

Interview by Art Horne

Stu, in both your books and dvd’s you emphasize this concept of “capacity” and it’s importance, yet when discussing with sports medicine and strength colleagues this concept is still either misunderstood or not truly appreciated.  Can you discuss this concept briefly and also touch upon how a collegiate basketball athlete can protect their “capacity” during the course of a day while attending classes, etc during a normal school day so that they are either able to be productive during a therapeutic exercise program later in the day or able to train at a high level without getting hurt?

Answer: Athletes have a capacity for work. On one hand it is important for most players to dedicate the majority of the training capacity for basketball. This is well understood. But consider the player who has an injury history, and the injury must be managed. Lets use the example of a flexion intolerant back. The BB player sits on the bench then, when standing up, takes a while to gain full extension of the spine and hips because of stiffness, discomfort, or even pain. Sitting (spine flexion) stole some capacity. Now consider off-court activities such as computer work (and more sitting) or driving to practice (more sitting with spine flexion). This used some of the spine capacity to train so that they will break into pain sooner during the BB training session. I would have to say that most flexion intolerant BB players I have consulted with did the damage in the weight room. They did not have the discipline of perfect form during squats and cleans, and ended up damaging the spine discs with flexion motion. The load associated with the squat and clean on long body levers really exacerbates this situation. So the original injury mechanism was repeated flexion bending of the spine under load. Subsequently, they are limited in the number of bending cycles their spine can undergo – this is their capacity. It is compromised. Now consider the player who brushes their teeth or ties their shoes with spine flexion. They just used up some of the tolerable bending cycles performing a non-BB activity. Discipline of movement form off court allows more of the capacity to be available for BB training. This is a concept that can be extremely important in getting nagging injuries better, and in enhancing on-court performance. Coaching this goes beyond BB specific training! 

I often find most freshmen college athletes are not able to disassociate their backs and hips when arriving on campus to start a training program.  Can you discuss the importance of the “Hip Hinge” in the basketball athlete and how you would teach it to an incoming athlete or someone rehabilitating from injury?

Answer: Athleticism comes from having great athletic hips – jumping, running acceleration, and cutting are all enhanced. However, for the hips to fully express their athleticism, the spine or core must be stiffened. Consider the vertical jump off a single leg takeoff. Here the power comes from explosive contraction of the hip extensor. But the core must be stiffened at this instant to prevent an “energy leak”, and a loss of power that should have been projected into the floor.  So, the ability of the athlete to train hip motion with a stiffened core is paramount for enhancing on-court performance. This is also essential for off-court strength and speed training, where emphasis on hip power generation with a stiffened core enables a higher training load with more safety. Thus, the fundamental movement pattern we call the “hip hinge” is needed.
Here we start standing, the palms are rested on the front of the thighs. Stiffening the core to prevent spine motion the athlete begins the squat motion with the hands sliding down the front of the thighs, and the hips travel back. As the hands reach the knees, carry the upper body weight down the arms resting on the knees. Now the knees should be over the mid foot. If they are not, pull them back by moving the hips back.
Now when standing up, simply slide the hands up the thighs and pull the hips forward. But ensure the  knees remain over the mid foot. This ensures a perfect hip hinge. It enhances performance and safety!

In your video, The Ultimate Back: Enhancing Performance you discuss the importance of an Anchor Point or in Latin a “punctum fixum” – can you discuss exercises in which basketball athletes must be clearly proficient in prior to engaging in rotational medicine ball exercises?

Answer: This also goes back to the previous question. Explosive hip motion requires the core to be stiffened or locked. Try a lateral stepping drill with a soft core and the hips are slow. But then stiffen the core and the hips are able to snap and explode. This is because the core is now the “fixed point” for the hip muscles to pull from.
For me the rotational med ball exercise is a slightly different issue. I have been brought in as a consultant to Pro teams after the players started with back pain. A previous consultant had them throwing med balls sideways explosively, into a wall. They damaged their discs with repeated twisting. They did not understand that the discs will damage doing this. The only way to protect against this is to rotate about the hips and not the spine. The core muscles are designed to stop motion, not create twisting motion. The hip joints and muscles are designed to be the power generators.  So here, a fixed core prevented injury and allowed a higher tolerable training capacity. But it also increases athleticism too.
 
In general, what logical progression that you would follow when dealing with a freshmen basketball athlete based on the above? (example: front bridge then front bridge with 4-point lifts, to prone touches, etc).

Answer: This really depends on the athlete and as you know I can only decide this after I have performed an assessment to determine the balance between their various fitness attributes. I need to see if any movement flaws exist which need correction. Then work on hip mobility and power generation and stability in the core. Then move on to endurance, strength and full power and speed production. This process is detailed in my “Ultimate back fitness and performance” book.

You mention the importance of the latissimus dorsi as a stabilizer throughout the video, yet many strength coaches and basketball athletes train them primarily as a pulling muscle through chin-ups and not as the massive lumbar stabilizer that you make them to be. Can you expand on their importance in preserving the spine during strength training?

Answer: This is an interesting question and one of culture. In Russia you would not be even asking this question because emphasis on the lats is ingrained in their training culture. For example, when performing a bench press, “bending the bar” through the sticking point with latissumus dorsi is common in Russia yet I have to coach this in North America. The same can be stated when squatting with a bar across the shoulders. At the bottom of the squat the athlete focuses on hip abduction together with lat contraction. This stiffens the spine, adds back extensor torque, and facilitates the hip extensors. It results in a higher lift with less risk of injury. Again, this is not well practiced in North American training but is a staple in Russia. This is just one technique where performance is enhanced together with a reduced injury risk – a real win-win.

Obviously with basketball athletes there is a concern with long levers and subsequently tall spines, what exercises should strength coaches either avoid or be very strict when prescribing and coaching?

Answer: Again, I have to state that I could only answer this after assessing the athlete. But as a general approach I would probably avoid deep squatting a 7 foot tall center and focus on creating hip power off one leg over the short range to mimic a foot plant with a single leg takeoff. Again – this is short range hip extensor explosion with a stiffened core. That’s how the great ones take off from the top of the key and dunk a BB!

Thanks for your questions Art – keep up your great work. Remember I learn from you with your “on the court experience” as much as you learn from me with our mechanistic investigations.

For more information, or to order McGill’s dvd’s and books, visit backfitpro.com.

By Art Horne 

It was first described to me during the summer of 2005 when I visited my good friend Mike Potenza, who was working at the time as the S&C coach at the University of Wisconsin for both the men's and women's ice hockey teams (by the way, both teams won national championships that year).  He introduced me to Steve Myrland, a former strength and conditioning coach at both the professional and collegiate level and a guy that I now describe to others as simply "the strength Zen master."  While having coffee one morning, Steve was describing to Mike and I the frustration he was having with a college strength coach who only "saw the world through the hole in a 45 pound plate," and the coach's inability to see and embrace the importance of movement, function and anatomy.  Now, all of us have taken a 45 pound plate from the rack, lifted it to squat bar height, peered through the tiny 2 inch hole and loaded it up onto the bar.  The view just prior to loading is exactly what Steve was talking to me about.  The world, (or weight room or even more simply your athlete's performance continuum) has a very limited offering if only viewed through this hole, compared to the massive area that the plate encompasses, which basically equates to the entire rest of his or her development.

Up until that point in my very young career, I considered myself a "strength" guy.  If it wasn't heavy, it wasn't training. If it didn't have chains hanging off of it, or if your training partner didn't have to pull the bar off your throat, then you simply weren't working hard enough.  About two minutes into our conversation I realized that I was one of the strength coaches that Steve was talking about.  I guess the hole in the plate which I was coaching through at the time never allowed me to see the epidural injections that some of our athletes were getting due to their back pain, or the multiple ACL injuries our female athletes were incurring on a yearly basis.  Steve challenged me to remove the dense piece of iron that obscured my vision and allowed me to evaluate and prescribe a training program that reflected the whole athlete (with respect to his/her sport, previous injury, movement impairments, volume at practice or games, current and future goals and yes, even strength development) and not just the athlete I once saw through the hole in the 45 pound plate.

Now, I'm still a strength guy, but my view on strength development (what really matters - a future blog) vs. numbers improvement (by any means necessary) has changed dramatically.  The next time you load the bar and you peer through that tiny hole, I simply challenge you to think about athletic development in its totality.  If all you have is a hammer then everything looks like a nail; if all you do is load plates, then the window in which you have viewed the world, and the development of your athletes have been limited.  Believe me, the world looks a hole lot different when you begin to look at it with a pair of fresh eyes; or at least a pair not obscured by only iron.