Boston Sports Medicine and Performance Group, LLC Blog

by Art Horne

At the college level many times both assessment and intervention decisions are made based on time availability and simple manpower, and not on what the student-athlete requires for optimal health and performance.  Juggling study hall, practice, classes along with rehabilitation and performance training leaves little time for “additional” work for either the student-athlete or the staff professional in charge to provide additional auxiliary services in the form of corrective work, soft tissue manipulation or additional strength training.  With that said, this extra “work” is often neglected or pushed aside until either the student-athlete is no longer able to participate in practices or games due to an injury or becomes crippled due to some form of debilitating pain.  In either case, unfortunately the student-athlete has now become a student-athlete-patient within your facility and the little time you had to address her problem prior (which of course is why it wasn’t taken care of in the first place, or even looked at – ignorance is bliss after all) has now become a major investment and drain on your time and services. 

In order to avoid the initial trap that so many sports medicine and performance departments fall into each fall it is paramount that both departments (Sports Medicine and Strength Training) first reach an agreement to implement a comprehensive screening program TOGETHER to tease out dysfunction, evaluate for painful movement patterns and address these minor “tweaks” before they become major pains.

Where to start:

It’s hard to rank which movement pattern is more important over another as each of the “Big Three” (squat, lunge and step) are all integrated and hold value within the context of all sporting events and training.  However, the only pattern among the three that is universally tested among college athletes and Strength Coaches is the squat, and thus, at least with regards to an integrated approach takes precedent over the others if having to choose only one.  Administering the test takes under a minute and produces so much more than just a number via the traditional FMS scoring system.

1. There’s something powerful about having members of both your sports medicine and strength staffs stand beside each other while evaluating a student-athletes overhead squat pattern during a fall pre-participation examination.  Because the strength coaches typically tests each athlete’s squat either later the same day or the next, this “pre-screening” allows strength coaches to see the movement pattern in an authentic form, not to mention in a rare one-on-one format which is never the case in a collegiate weight room due to traditional low coach to student ratios. 

2. When an athlete scores a “1” which means they cannot achieve a proper squat, it’s always nice to see the strength coach cross the name off the list of kids to max test later that day.  If you cannot squat to at least a “2” in the FMS overhead squat test then you simply haven’t qualified to load the pattern and go balls to the wall during testing – PERIOD.  This will sometimes be an issue among sports medicine professionals and strength coaches if the athletic trainer simply tells the strength coach that the athlete shouldn’t squat; but this is never a problem when the strength coach sees for themselves the awful pattern that the student-athlete exhibits.  The strength staff must be involved in your yearly pre-participation screenings to ensure buy in from all those involved in the care and performance of the student-athletes.  Remember: squatting is not a weight room exercise, it’s an expression of health, and allowing a student-athlete to max test a pattern that they cannot perform with their own body weight is simply irresponsible – PERIOD.

3. So, with that said, what do you do with the kid that scores a “1” on the FMS overhead squat test? As we discussed prior, time is of the essence and thus the underlying deficiency needs to be “teased out” and an appropriate intervention applied.  Both the FMS and The Selective Functional Movement Screen (SFMA) allows the clinician and/or strength coach an easy algorithm to follow with suggestions for corrective  work once the underlying deficiency is discovered.  Often times it’s the usual mobility suspects – t-spine, hips and ankle but just as often, these mobility issues requires a skilled clinician’s assessment and intervention.  On the flip side, in the case of a neuromuscular-stability issue a Goblet squat progression can be implemented by a strength coach during a training time in place of the squat, to begin coaching them back towards their end goal of a “3” or at least a “2” prior to max testing. (more on Goblet squat progression in a future post)

4. For all those athletes that score a “0” during the test – which means they experience pain, a comprehensive follow up evaluation is scheduled either later that day or within the week by a skilled clinician, (most likely a member of your Sports Medicine Staff) to determine the pain generator along with a rehabilitation plan to properly address.  So many times athletes will state that they have no pain on intake but then suddenly realize that during a simple movement that pain is actually present.  I’ve never had an athlete experience pain during a simple movement test (“It’s not a big deal, I just put ice on it after I train”) not miss time during preseason due to this pain or another greater underlying problem.

Now, some would say that when evaluating the overhead squat pattern utilizing the FMS scoring criteria that we basically all fall in as a “2” and that only a very few athletes score a “1” or a “3” and therefore  the test may be a waste of time.  Although it is true that the majority of athletes that I’ve evaluated using this methodology score a “2”, the means certainly justify the end, especially when you’ve i. discovered pain in this simple pattern and were able to treat it immediately and ii. Discovered a poor movement pattern and provided corrections which over time allowed the athlete to squat normally (which always makes the strength guys happy) but most importantly allows the athlete to achieve success in their individual sport – the reason they showed up in August for pre-season in the first place.  In the end, the OH squat test really only takes a minute but the effects of this evaluation and correction last throughout their college career.

Next week we will talk about evaluating the Multi-segmental Extension Pattern and what to do when you find a problem.

by Art Horne

Over the past several years I have made the integration of Sports Medicine care and Strength Training a core principle within our department.  This is relatively a new concept as strength coaches and sports medicine professionals have often been pitted against each other by sport coaches, athletes and often themselves.  Although this new path to better health and performance is clearly thwart with challenges, there are some simple steps that both departments can make that immediately impacts BOTH the health and performance of the student-athlete and leaves both professionals looking better in the eyes of all those around them.  Below is a question from a colleague that I wanted to share publicly.  In order to answer his question, as well as many others, it is my intention over the next few months to describe and share with you the many small steps that any college or university can implement in order to provide an improved care and performance model.

Question:

I would like to start out by saying that I really enjoy watching the videos and articles that you have released in reference to the approach you use at Northeastern University to bridge the gap between strength and conditioning and sports medicine. I am a strength and conditioning coach for a small Div. I college and also have a background in athletic training. I wanted to see if you could provide more insight as to how you take the results from the screening and testing that you do and then implement them into your programming. We screen our athletes, which consist of the FMS and a couple more orthopedic screens that we feel are applicable to the particular sport (Modified Thomas Test, Bridge w/ Leg Extension, Reach/Roll/Lift, etc….). How would you then use the results in the development of your program? Do you give each athlete individual work or do you use a systematic team approach addressing common faults or dysfunctions? I am torn as to what to do because as I am sure you are familiar with, time I have to spend with athletes is limited and getting them to comply with performing certain exercises on their own time can be very difficult at times. Any advice or examples that you could provide would be very beneficial. Thanks in advance for your time.

The Language Barrier:

The first step in any “relationship” is being able to understand what the other person is saying, and there is no greater communication gap in existence than the one that currently exists between Sport Medicine and Strength Training professionals.  In order to discuss dysfunctional movement patterns, corrective exercises, rehabilitation goals or substitutions/alternatives for strength exercises both parties must share a common language and then demand continuity with these terms.

I remember many years ago speaking to one of our staff members about a particular athlete and suggesting that she speak to the strength staff about an alternative exercise for an athlete who was suffering from some low back pain.  When asked what I recommended I immediately suggested a more spine sparing approach to her current “core strengthening” exercises and that we recommend McGill’s “Birddog” exercise which has been proven to be safer on the spine than the flexion based crunches the athlete was accustomed to in the weight room.  Not knowing what a “Birddog” exercise was, I quickly demonstrated the exercise to my co-worker at which time she smiled and said that she was familiar with the exercise but learned it as a kneeling opposite arm-leg reach.   Confused, (since McGill made the exercise famous as part of his “Big Three”) I asked another staff member what the exercise was that I was performing to which he replied, “a quadruped contralateral reach.”  Now slightly irritated (but happy that the name at least described the movement), I bolted over to the strength room to inquire about their knowledge of Stuart McGill, his research and what they called this particular exercise.  To my surprise McGill’s work had never been heard of and that this particular exercise was programmed as a “Flying Superman” within the student-athletes performance training.  It became painfully clear that the first order of business was getting both staffs to speak the same language, both within each department and across them. 

Because most of the members on your staff (both Sports Medicine and Strength) have come from a variety of educational backgrounds, continuing education courses and levels of expertise, it is important to begin formulating a shared exercise and assessment language in order for civil conversations to first take place.  By investing only a small amount of time and addressing this often overlooked, yet integral first step your staff will begin to enjoy the following benefits:

1. Provide improved services to your student-athletes.  Imagine the previous example taking place and a student-athlete approaching you for help with their kneeling opposite arm-leg reaches.  Now, the name basically tells you exactly what is needed, but imagine you knowing the exercise as a different name and perhaps emphasizing a different teaching point altogether.  Would you teach the athlete how to do the exercise “your” way? Find the athletic trainer who wrote the rehabilitation program to help them out? Or tell them that you’re sorry but you don’t know what they should be doing?  In any case precious time is wasted and as a fellow athletic trainer, this is something none of us has enough of.  In addition, you can imagine the frustration of the student-athlete witnessing your staff stumble through the most basic exercise descriptions!

2. A shared language allows staff members to be interchangeable because now each staff member is calling the same exercise the same name and teaching it while emphasising the same teaching points.  This allows athletic trainers to jump in and help with all rehabilitation programs, and not just “their own teams” as well as provide continued care during an athletic trainer’s absence (sick day, vacation or travel with another team).

3. Continued care and coaching along the performance continuum.   Here’s where the magic happens: whether the athlete your provide care for is one week into their ACL rehabilitation or the starting point guard for the basketball team pushing 300 pounds in the squat rack, the exercises if named the same, taught the same and progressed the same all fall along the same care-performance continuum.    Let’s examine the above example to really understand the power of the shared language.  Imagine on the far left hand side the student-athlete one week post-op ACL reconstruction and on the far right side the starting point guard pushing serious weight and performing at the highest level.  Moving along the continuum from left to right the athlete will experience and undergo exercises such as: Quad Sets, Straight leg Raises, Clams, Glute-Bridges, Mini-Band walks, Wall Squats, Body weight squats, Lunges, Box Jumps, and the list goes on.  At some time this athlete will be in the weight room and not be able to perform the Olympic lift for example programmed for the team that day but can certainly do pull-ups, side bridges and a number of other exercises that the strength coach has put in place during any particular phase or block of training.  If a shared language exists, the athletic trainer and the strength coach can have a civil and meaningful conversation about where the athlete is and discuss and implement substitutions for exercises that are not appropriate for them all while progressing the athlete safely along this care-performance line.  Not to mention, many of the rehabilitation exercises can be implemented safely within strength training program as substitutions for advanced exercises thus minimizing the athlete’s daily rehabilitation time and allowing the athletic trainer who is providing care for this athlete more time to focus on other athletes or say for example address soft tissue restrictions with the same athlete during “rehab” time which often requires a one-on-one time period, thus making their strength training time much more effective.

Now, some people may say that a couple of exercise names or switching names from time to time is really not a big deal.  Perhaps not.  If you only care for one team, perform all the rehabilitation by yourself and no other staff member helps you, then you can certainly come up with your own language.  But imagine for a moment a car factory where all the parts are all called different names, put on in different orders and actually assembled with various degrees of precision.  Would you ever buy a car from a factory like this?  The answer is a resounding no - so how can we expect our student-athletes to buy in to what we are saying if each staff member is saying something different?  By having an Exercise Pool to draw consistent language from, the number of benefits far outweigh any possible downside while also reducing the amount of confusion among your own staff and encouraging an atmosphere of shared help and patient responsibility. 

Next week: How a shared language during initial assessment can limit overall injury rate and increase performance immediately.

As your student-athletes return this fall I think it’s worth considering a concept that was introduced to me by my mother when I was a young boy.

When caring for plants or vegetables in your garden there is inherently an ongoing process from the time you plant the seed until the time of harvest.

Many outside people will only ever see the final fruits of your labor and not the countless man hours put forth prior to that final stage.  With any successful harvest, much effort has to be placed on the frontend including watering and fertilizing the plants, providing the plant with proper sunlight, protecting it from that first frost and other harsh weather and maybe most important - picking the weeds from around its base and providing it the opportunity to grow and develop.

In a similar scenario, in order to achieve elite athletic success, countless man hours must be put forth prior to actual competition to ensure that your athletes are able to grow and express their athletic ability when the lights come on. 

This of course means weeding the garden on a daily basis.

Many professionals who provide sports medicine care and strength training to collegiate athletes understand that water and fertilizer are of course necessary, but tending to the weeds is so often neglected, at least until it’s too late. 

When your athletes arrive this fall will you look at how they move – squat, toe touch, backwards bend – or will you wait until they have pain or injury to address their ankle dorsi-flexion, lumbar stability and psoas length and quality?

The challenge then is to find the time to take a look at your garden on a daily basis and provide the care and services that it so very much deserves.  In this case, and in the case of your garden at home, it is clear that you will only reap what you sew - and take care of.

Art Horne is the Director of Sports Performance at Northeastern University, Boston MA.  He can be reached at a.horne@neu.edu.

While taking a walk on vacation last summer with my fiancée, we stopped outside of a boutique when a dress caught her attention.  In town for a wedding the very next day along with a brisk change in weather, she decided that the dress in the window would work perfectly for the occasion.

Upon entering the store at 10:50 am we were quickly met by a sales person who promptly told us that they didn’t open until 11:00 am and that we’d have to wait outside until that time.

“But I’m going to buy that dress in the window – I just love it.  Can I just look?” She said.

“Sorry, You will have to wait outside - Store policy.”

And with those words the store door closed behind us while the three customer services reps inside read the paper, drank their espressos and chatted.  With the bitter taste of the rep’s reception fresh in my mouth we walked next door and dropped $200 on a similar dress.

What store policy doesn’t allow a customer to look at a product that they are obviously willing to purchase?

Would that policy have existed if the store owner was standing nearby?

It’s not that this store had a “policy” that didn’t allow customers inside until they were open that caused my blood pressure to rise, it was the fact that the customer service representative didn’t represent me, the customer.

So maybe you can’t open the cash register until 11, and maybe you really can’t allow anyone inside – but if you’re looking to make me a customer in the long run, you better at least sell me on the short term.

The challenge for many health care providers is that we too have policies that must be followed.  And maybe you aren’t able to care for the kid that walks in for treatment 10 minutes before you close, but knowing that there is a huge difference between telling them “sorry come back tomorrow” and “let me schedule you a time tomorrow where I can dedicate the time you deserve,” means the difference between that customer returning a day later and that same customer seeking services elsewhere.

Do your actions steps match your goals?

Lots of people talk the talk, but few walk the walk.

If you want to achieve your goals you’re going to have to understand that there is no escalator or elevator taking you to where you want to go.

Goals require walking the walk, plenty of hard work, and sweat.

Now get out there and take that first step.

Art Horne is the Director of Sports Performance at Northeastern University, Boston MA.  He can be reached at a.horne@neu.edu.

I was recently working with a patient who had injured her hamstring previously and was preparing for her upcoming sport season but just couldn’t seem to get over the hump in terms of running without pain.  I asked to see her squat, (which raised her eyebrows – because what does squatting have to do with running right?) but she appeased my wishes anyways only to fall backwards on her initial try, and then grab a table on her second attempt in order to gain some stability.

“How do you go to the bathroom?” I asked her jokingly to ease her embarrassment.

“I just kinda fall back on to it like everyone else does.”

Needless to say our evaluation really started then (as did a long conversation about sitting, squatting and getting her butt in gear).

As health care professionals we have to stop thinking about squatting as a strength coach’s responsibility, a weight room exercise, or something that causes tall guys knee pain and therefore shouldn’t be done.

Squatting is a movement that we all need for everyday activity and one of the purist expressions of health.  If your patients can’t squat or can’t squat without pain then this MUST be addressed, and addressed just as closely as the primary reason they first presented to you.  To no one’s surprise this particular athlete had difficulty recruiting her glutes and therefore was utilizing her poor hamstrings as the primary mover instead – a recipe for hamstring strains and continued pain.

A closer look into how your patients move might just reveal that their troubling squat pattern is the underlying cause to the problem that brought them in to see you in the first place. 

Art Horne is the Director of Sports Performance at Northeastern University, Boston MA.  He can be reached at a.horne@neu.edu.

So often individuals with knee pain miss out on the opportunity to resolve their troublesome and agonizing cases because the answer comes dressed in overalls, a hard hat and carries a lunch box.  Addressing knee pain means so much more than sitting back and relaxing in your local physical therapy or athletic training center with an ice bag and electrical stimulation on your knee.  Addressing knee pain takes hard work and requires that patients become an active participant in their care plan.

In a recent article published in Sports Health, Lake and Wofford reviewed current literature examining therapeutic modalities and their effectiveness for the treatment of patellofemoral pain syndrome (PFPS) or good old fashion knee pain.  Their findings come as no surprise to those that understand that knee pain is a real pain in the butt – meaning, quite literally it's cause is coming from your butt (or a lack thereof).  Conclusions drawn from their examination was that, “none of the therapeutic modalities reviewed has sound scientific justification for the treatment of PFPS when used alone.”

So what’s the answer?

Let’s not throw the baby out with the bath water quite yet.  A comprehensive treatment approach offering therapeutic modalities as needed with a focus on eccentric strength training along with an overall strengthening program for the hips and gluteus musculature in addition to providing mobility above and below the knee (hips and ankle) continues to be the best approach to getting athletes back to competition faster and putting smiles on knee pain sufferers  time and time again.

See additional knee pain articles below: 

Treating Anterior Knee Pain - Part I and Part II

Lake D., and Wofford N. Effect of Therapeutic Modalities on Patients With Patellofemoral Pain Syndrome: A Systematic Review. 2011. Sports Health, Vol. 3(2)p.182-189.

We fight an endless battle with gravity, the comforts of modern living and the pollutants in the air.

We are always in need of corrective exercise and performance training simply to maintain the delicate balance between suffering and just getting by for another day. 

A friend asked me why so much “Corrective” work in my programming.

“If you are always doing corrective work, then how come it never gets corrected?” He asked.  “And what’s the opposite of corrective work anyways,…. Destructive work?”

Good question.

You must admit that there are forces that you will never ever win against. You may delay them, but you will never win. Like death and taxes, aging and gravity always win.  Other “destructive” forces include poor posture, sitting and typing at the comfort of our computer terminal, poor exercise choices and poor exercise technique just to name a few.

These are all destructive in nature and if left unmanaged or not corrected, cause havic on our system.

Now, I am of the opinion that a great strength program in and of itself can be constructive and corrective  without specific “corrective exercises” but a great strength program may not always be able to address the regular “trauma” incurred while playing division one athletics or the previous wear and tear accumulated prior to beginning said strength program.  Sometimes, the cumulative destructive insult from all causative factors is even too much for a well planned strength program, and a comprehensive “performance plan” is at times necessary, which includes a corrective or rehabilitative flavor to address some of these cob webs.

Regardless of professional affiliation – PT, ATC or Strength coach, at least part of our job is to provide our patients and athletes with services that prepare them for this battle against nature.  And although you’ll never ever win this particular fight, it’s one that is surely worth fighting.

Growing old is tough. No sissies allowed.

Which of the four are getting the way?

You don't know what to do

You don't know how to do it

You don't have the authority or the resources to do it

You're afraid

Once you figure out what's getting in the way, it's far easier to find the answer (or decide to work on a different problem).

Stuck is a state of mind, and it's curable.

We asked what the Giants in Sports Medicine & Rehabilitation, Basketball and Hockey performance training have read or are currently reading and we brought their list to you.  

Click HERE to view our recommended library with an ongoing list from these speakers who presented at the BSMPG "Standing On The Shoulders Of Giants" 2011 summer seminar.

Click HERE to view George Mumford's most updated presentation from this year's seminar.

Click HERE to view George Mumford's reference list from the above presentation.

2011 BSMPG speakers, Ray Eady and George Mumford