Boston Sports Medicine and Performance Group, LLC Blog

This is part 1 of the weekly “Friday Five” series where I ask 5 tough questions to world class elite coaches.

Irving "Boo" Schexnayder is regarded internationally as one of the leading authorities in training design, especially in the Jump events.  He coached triple jumper Walter Davis, long jumper John Moffitt, and 19 NCAA Champions.

Boo will be speaking at the Boston Sports Medicine and Performance Group (BSMPG) on May 19-20, 2012.

You can also see his complete jumps DVD package for the Long, Triple and High Jump (plus a weight training bonus).

Q1 – SpeedEndurance.com:  A lot of confusion and mystery lies with the true volumes of jump training that is sufficient for stimulating neuromuscular adaptions and teaching. While small doses are often looked at as the goal, teaching takes repetition. Could you expand on how important the sequence of the training year and the quality of foot strike?  Can you explain why it seems that some programs thrive off of higher volumes while some just lead to injury?

BOO:  As far as foot strike, the ability to properly dissipate impact forces through full-footed landings is obviously a huge help to staying injury free while jump training. I think there are two other, more subtle keys to successful progression and remaining injury free in jump training. The first lies in variety, specifically advancing training cycles in a timely fashion. The other is taking a purposeful approach to the process.

Just as athletes do, we as coaches tend to settle into comfort zones. You get your athletes doing particular forms of jump training. Then, as mastery is approached, it’s time to move on to something else, but our natural tendency is to breathe easy and admire our work for a while. Periodic shifts in exercise choice, volume and intensity are critical, even though they might make life for the coach tougher. Successful higher volume programs do this and show a bit of a pioneer spirit.

Also, everything done must have a very specific purpose. That purpose might be establishing initial volumes, technical development, high end or low end elastic strength development, or whatever. It’s easy to fall into a “this is my fallback workout” philosophy if you are not targeting something specific. This is the primary rationale behind the small volume programs, and I think this is the key with high training age athletes who have already accumulated injuries and other physical issues over the course of a career.

In either case, whether it is failure to progress or mindless repetition, at this point jump training quits being a stimulus and becomes simply another piece of baggage that must be carried around that increases injury risk.

Q2 – SpeedEndurance.com: You mention that Olympic lifts are great harmonizing agents to a program. With your experience could you address what mechanisms and systems such as posture and coordination enable the lifts to transfer to sprinting and jumping?

BOO:  The results I see in my program are the main reason I feel strongly about using Olympic lifts. I don’t want to give anyone the impression that I researched them first and then started to use them. My personal journey was more of a matter of seeing huge gains and then figuring out why.

I think the orders of joint firing and the mixing of absolute strength, power, and eccentric activity show huge transfer into sport specific skills. Also, the need to stabilize the core while performing something functional like an Olympic lift does more for the body’s core than all the crunches in the world. In short, they are highly functional.

I am a fan of functional training. But I have never gone completely that way, always keeping a base in more old school approaches. Maybe it’s because I started my career in football, but it’s also because I have watched too many great athletes train that way to scrap it.

I think a key variable in strength training is the amount of muscle tissue activated in the course of a repetition. That variable, more than any other, affects blood chemistry and endocrine responses. Many exercises are functional but don’t elicit enough muscle fiber activation to accomplish this. Olympics are where gross movements meet functional training and old school meets new school.

Continue reading on speedendurance.com   

See Coach Schexnayder at the 2012 BSMPG Summer Seminar as he talks, "Mulitjump Exercises: Applications for Teaching, Training, and Rehab"

Coach Schexnayder joins Chris Powers, Craig Liebenson, Bill Knowles, and Alan Grodin as Keynotes speaers.  See these world class speakers along with the best Sports Medicine, Hockey and Basketball therapists and performance coaches throughout the weekend - May 19-20.

Register today before seats fill up!

By Art Horne

With recent season ending ACL injuries to New York Knicks Iman Shumpert, and Chicago Bull’s point guard Derrick Rose coming on the same day, (not to mention Eric Maynor from the Thunder and Spanish Star Ricky Rubio earlier this season) discussion has arisen as to how these terrible injuries could have been avoided.  Although the possible contributing factors are endless, ranging from previous injury to simply fatigue, one area worth shedding more light on, especially in the case of young Rose, is the implication of the kinetic chain as a whole.

Let’s start at the ground and work our way up.

I think we’d all agree that the big toe is a big deal.   But how closely are we looking at this “pivotal” body-ground juncture?

In a study by Munuera et al, researchers found that “Hallux interphalangeal joint dorsiflexion was greater in feet with hallux limitus than in normal feet.  There was a strong inverse correlation between first metatarsophalangeal joint dorsiflexion and hallux interphalangeal joint dorsiflexion.” (Munuera et al, 2012). 

TRANSLATION: People with abnormally stiff or limited motion at the great toe had excessive motion at the joint just distal.

If you don’t have mobility where you need it, you’ll surely get it somewhere else.

Let’s move up the chain shall we?

In a study by Van Gheluwe and his group,  researchers looked at how a stiff or limited great toe joint changes the way we walk.  In their study, “two populations of 19 subjects each, one with hallux limitus and the other free of functional abnormalities, were asked to walk at their preferred speed while plantar foot pressures were recorded along with three-dimensional foot kinematics.  The presence of hallux limitus, structural or functional, caused peak plantar pressure under the hallux to build up significantly more and at a faster rate than under the first metatarsal head.  Additional discriminators for hallux limitus were peak dorsiflexion of the first metatarsophalangeal joint, time to this peak value, peak pressure ratios of the first metatarsal head and the more lateral metatarsal heads, and time to maximal pressure under the fourth and fifth metatarsal heads.  Finally, in approximately 20% of the subjects, with and without hallux limitus, midtarsal pronation occurred after heel lift, validating the claim that retrograde midtarsal pronation does occur.”

TRANSLATION: if you have a limited motion in your great toe, pressure changes will occur – increase pressure changes will cause pain over time (think blister on your foot).

And pain changes the way we move – period.

Let’s take a look at the ankle.

In an article  by Denegar et al, the authors outline the importance of regaining normal talocrural joint arthrokinematics following an ankle injury.   The authors note,

 “All of the athletes we studied had completed a rehabilitation program as directed by their physician under the supervision of a certified athletic trainer, and had returned to sports participation.  Furthermore, all had performed some form of heel-cord stretching. None, however, had received joint mobilization of the talocrural complex.  Despite the return to sports and evidence of restoration in dorsiflexion range of motion, there was restriction of posterior talar mobility in most of the injured ankles.  Posterior talar mobilization shortens the time required to restore dorsiflexion range and a normal gait.  Without proper talar mobilization, dorsiflexion range of motion may be restored through excessive stretching of the plantar flexors, excessive motion at surrounding joints, or forced to occur through an abnormal axis of rotation at the talocrural joint.” (pg. 172)

TRANSLATION: I repeat, Without proper talar mobilization, dorsiflexion range of motion may be restored through excessive stretching of the plantar flexors, excessive motion at surrounding joints, or forced to occur through an abnormal axis of rotation at the talocrural joint.” (pg. 172)

If you don’t have normal ankle motion, and specifically at the talus, your ankle motion (although appearing normal) is probably coming from other joints and/or in a combination with foot pronation.

Foot Pronation = Tibial Internal Rotation

Tibial Internal Rotation = Femoral Internal Rotation

Tibia and Femur Internal Rotation  =  Knee Valgus (or knee collapse)

Knee Valgus = BAD

But just because you have some extra motion doesn’t mean you’re doomed right?

No.

But, excessive motion without the ability to control that motion certainly does.  So where does knee control come from? The Hip!

But hip strength, control, and neuromuscular timing is seldom appreciated, and in the case of the basketball athlete it is certainly poorly measured, especially after ankle injury.

In a study by Bullock-Saxton, researchers investigated muscle activation during hip extension after ankle sprain and showed a changes in timing of muscle activation in the ankle sprain grouped compared to the non-injured group.

 “the results highlight the importance of the clinician’s paying attention to function of muscles around the joints separated from the site of injury.  Significant delay of entry of the gluteus maximus muscle into the hip extension pattern is of special concern, as it has been proposed by Janda that the early activation of this muscle provides appropriate stability to the pelvis in such functional activities as gait.” (pg. 333)

In another study examining ipsilateral hip strength/weakness after the classic ankle sprain, researchers demonstrated that subjects with unilateral chronic ankle sprains had weaker hip abduction strength and less plantar flexion range of motion on the involved sides (Friel et al., 2006)

“Our findings of weaker hip abductors in the involved limb of people with chronic ankle sprains supports this view of a potential chronic loss of stability throughout the kinetic chain or compensations by the involved limb, thus contributing to repeat injury at the ankle.” (pg. 76)

“If the firing, recruitment, and strength of the hip abductor muscles in people with ankle sprains have been altered because of the distal injury, the frontal-plane stability normally supplied by this muscle is lacking, and the risk for repeat injury increases.  Weak hip abductors are unable to counteract the lateral sway, and an injury to the ankle may ensue.”

TRANSLATION: Ankle sprains cause neuromuscular changes up the chain and specifically in the hip.  If this weakness is not addressed after an ankle injury,” frontal-plane stability normally supplied by this muscle is lacking.” 

Lack of frontal-plane stability + Knee Valgus = Injury

Of course suggesting that the above points are exactly the reason for which Rose suffered his injury is certainly a stretch and not the intention of this post, nor is it to question the treatment that he or any other NBA player received prior to their devastating injury (for the record, the Chicago Bulls Sports Medicine and Strength Staff are regarded as one of the very best in the league).  What I am suggesting however is that examining athletes and patients with the use of advanced technology to determine a state of readiness to participate, and/or examine more closely changes in gait and neuromuscular firing is certainly worth pursuing, especially in light of the ever-rising salaries within professional sports.  A quick look is certainly worth the small investment.

One thing is for sure, ACL injury is not limited to teenage females or only seen on the soccer pitch.

Previous Posts:

The NBA Should Have Learned From The NFL - Injuries On The Rise

Did The NBA Lock-out Ultimately End Chauncey Billups' Career?

See lectures directly related to gait, injury prevention, and performance at the 2012 BSMPG Summer Seminar:

1. Dr. Bruce Williams: Hit the ground running: Appreciating the importance of foot strike in NBA injuries

2. Dr. Bruce Williams: Breakout Session: Restoring Gait with evidence based medicine

3. Art Horne and Dr. Pete Viteritti: Improving Health & Performance - Restoring ankle dorsiflexion utilizing a manual therapy approach

4. Dr. Tim Morgan: Biomechanics and Theories of Human Gait: Therpeutic and Training Considerations

5. Jose Fernandez: Advanced Player Monitoring for Injury Reduction

See the most advanced player monitoring equipment currently available at the 2012 BSMPG Summer Seminar:

References:

Munuera PV, Trujillo P, Guiza L, Guiza I. Hallux Interphalangeal Joint Range of Motion in Feet with and Without Limited First Metatarsophalangeal Joint Dorsiflexion. J Am Podiatr Med Assoc. 102(1): 47-53, 2012.

Denegar, C., Hertel, J., Fonesca, J.  The Effect of Lateral Ankle Sprain on Dorsiflexion Range of Motion, Posterior Talar Glide, and Joint Laxity.  J Orthop Sports Phys Ther. 2002; 32(4):166-173.

Van Gheluwe B, Dananberg HJ, Hagman F, Vanstaen K. Effects of Hallux Limitus on Plantar Foot Pressure and Foot Kinematics During Walking. J Am Podiatr Med Assoc. 96(5): 428-436, 2006.

Bullock-Saxton, J. E., Janda, V., & Bullock, M. I. (1994) The Influence of Ankle Sprain Injury on Muscle
Activation during Hip Extension. Int. J. Sports Med. Vol. 15 No. 6, 330-334.

Friel, K., McLean, N., Myers, C., & Caceres, M. (2006). Ipsilateral Hip Abductor Weakness After Inversion
Ankle Sprain. Journal of Athletic Training. Vol. 41 No.1, 74-78

Smith RW, Reischl SF. Treatment of ankle sprains in young athletes. Am J Sports Med. 1986;14:465-471.

If you haven't been living under a rock you know that the annual Boston Marathon took place this past Monday, April 16th.  With it came over 25 000 registered runners and thousands more non-registered runners tackling heartbreak hill and the 26.2 mile Boston course.  Although many of the leaders looked strong heading into the final mile, thousands more never experienced the thrill of victory but instead suffered the agony that so many runners face on a daily basis - a running injury that either limits or completely stops their running.

So what caused this running injury?  The answer might surprise you - it's the way you hit the ground!

Learn more about why you continue to ice your knees and shins and how you may be able to avoid these pains in the future with only a simple change in your stride.

Below is a summary of Professor Davis' article:

Do Impacts Cause Running Injuries? A Prospective Investigation

By Irene Davis, Bradley Bowser and David Mullineaux

“Up to 79% of runners sustain an injury in a given year. Approximately 80% of shod runners are rearfoot strikers. It is plausible that rearfoot strikers with increased impact loads, may be at greater risk for the development of an injury that those with lower loads. In summary, previous studies have documented higher impact loading in runner with a history of injury. However, these studies were retrospective in nature and cannot establish causative relationships. Therefore, the purpose of this prospective study was to compare the impact loads of rearfoot strike runners who go on to develop a running injury to those who have never been injured. It was hypothesized that runner who went on to develop a running- related injury would have higher vertical impact peaks, vertical average loadrates, vertical instantaneous loadrates and peak tibial shock.”

Davis and her group went on to recruit 240 female rearfoot strike runners aged 18-40 who ran a minimum of 20 miles per week.  Data was collected including ground reaction forces, vertical average loadrate, peak vertical force, etc.  Running mileage and injuries were reported monthly for 2 years.

“Our injury findings were consistent with previous literature. It has been reported that between 20-80% of runners get injured in a given year, and 57% of our runners sustained a prospective injury. In terms of injury distribution, iliotibial band syndrome, anterior knee pain, tibial stress syndrome, and plantar fasciitis were also among the top five injuries in much larger study of 2002 runners.

As hypothesized, all impact loading was greater in the injured runners compared with the never- injured group. All impact variables were significantly higher, except for VILR. Interestingly, FZ, the peak value of the vertical force, was identical between groups. This further underscores the importance of impact loads in the development of these injuries."

Sudden impacts are BAD! Notice the sudden spike with the RFS?

(RFS=Rearfoot Strike, FFS = Forefoot Strike, MFS = Midfoot Strike)

"The fact that all running injuries were included increases the significance of these results. While it is recognized that the etiology of running injuries is multi-factorial, this suggests that impact loading may be global indicator for the development of an injury. Based upon the odds ratio for VALR, reducing impacts is likely to result in an overall reduction of injury risk. Based on previous sports, adopting a midfoot or forefoot strike pattern will reduce these impacts. However future studies of injury patterns in midfoot and forefoot strike runners are needed.”

Want to avoid these sudden impacts associated with injury? Better think about adopting not only a different gait, but also a different pair of shoes.  Many modern running shoes have heels that are simply so thick that they prevent you from making contact with the ground in any other way than with the heel - and thus the dreaded impact forces!

Learn more about transitioning back to mother earth by reading BAREFOOT IN BOSTON: A Practical Guide to Achieving Injury Resolution and Enhancing Performance

BSMPG wishes the over 30,000 runners in the 2012 Boston Marathon the best of luck!

Run Strong!

Boston Marathon meet Barefoot in Boston

The Barefoot Running Symposium is presented by the New England Barefoot Runners. This symposium is available to the general public at no charge on a first come, first serve basis.

This FREE event occurs during (and is part of) the 1st Annual Boston Barefoot Running Festival. This event showcases well known international speakers who have been studying running biomechanics for years. It includes pioneers of the barefoot running movement who have written books, who have previously shared their experiences through speaking engagements and barefoot running workshops.

Additional speakers are well established barefoot runners with stories of how this change in running has taken them to higher levels.

Boston Public Library
Rabb Lecture Hall
700 Boylston Street
Boston, MA 02216

Saturday, April 14, 2012
1PM – 4PM

Click HERE to read more about this exciting event and the speakers that will be there including the leader in Barefoot research - Irene Davis!

Watch Irene Davis lecture in the video below as she describes the challenges with the traditional heel strike during running and how going with less on your feet might just be the answer to your injury woes.

Not sure if baring your sole is a good idea?  Read BAREFOOT IN BOSTON, and learn how the shoes on your feet are doing more harm than good.

Postural Function of the Diaphragm in Persons With and Without Chronic Low Back Pain

by Pavel Kolar et al.

Excerpt taken from JOSPT, April 2012, Vol 42, Number 4 p. 352.

Despite the high prevalence of low back pain in the population, options regarding effective treatment strategies are still limited, possibly due to the lack of knowledge of the underlying mechanisms.9 Trunk stabilization and postural trunk control may play an important role in the etiology of low back pain.9 In turn, the function of the diaphragm may affect how the trunk is stabilized, especially during postural activity.11,15,22 Various studies have shown that the pelvic girdle and lumbar spine are reflexively stabilized and braced prior to the initiation of extremity movements.3,13,17,22 The central nervous system must be able to anticipate movement and stabilize the entire core musculature automatically to provide a stable base from which the muscles performing the movement can pull.

Trunk bracing maintains all spinal segments in a biomechanically neutral position during the course of any movement. Segmental movement (eg, hip joint movement) is therefore related to the synergistic activity of the spinal extensors and all the muscles modulating intra-abdominal pressure (ie, abdominal muscles, the diaphragm, and the pelvic floor). The diaphragm is the muscle that contributes the intra-abdominal pressure modulation and plays an important role in spinal stability.7,16,18,27,31

Insufficient function and poor coordination of postural, or stabilizing, muscles are considered to be important etiological factors in spinal disorders associated with low back pain, such as deformational spondyloarthrosis (with or without spinal disc herniation), spinal disc protrusion, and/or spondylolisthesis.5,12,21,25

Continue to read the remainder of this article by clicking HERE.

CONCLUSION

We found reduced diaphragm movement when isometric flexion against resistance of the upper or lower extremities was applied.  The combined, more cranial position in the anterior and middle portions of the diaphragm and, particularly, the steeper slope between the middle and crural portions of the diaphragm in patients with chronic low back pain may contribute to low back pain symptoms. However, given that the results are based on crosssectional analysis, we cannot exclude the possibility of reverse causation. Still, the results support the theory that patients with low back pain complaints present with compromised diaphragm function,
which may play an important role in postural stability.

KEY POINTS

FINDINGS: We found reduced diaphragm movement in patients with chronic low back pain compared to healthy controls when isometric flexion against resistance of the upper or lower extremity was applied, mainly in the anterior and middle portions. This pattern of diaphragmatic recruitment resulted in a steeper angle in the middle-posterior part of the diaphragm and likely a greater strain during activity on the ventral region of the spinal column.

by Jeff Cubos

It’s been over a year since I first began the Dynamic Neuromuscular Stabilization program. Since that initial “A” course, my clinical thought process has expanded exponentially through following up with the “B” and “C” courses, my privileged opportunity to visit Motol in Prague, and the day to day reflections of my current practice.

Well recently, I had the privilege of taking part in another DNS A course that was put forth by Michael Maxwell of Somatic Senses and taught by Alena Kobesova and Brett Winchester. This particular experience was quite special for me because not only was it local (hence no flight costs), but it provided me with the opportunity to share my experiences to date with many of my friends and colleagues who attended the course…including my wife.

I would say however, that the most beneficial aspect of being present was that it afforded me the opportunity to “fill in the gaps”.

Continue to read this article by Jeff Cubos by clicking HERE

Meet Jeff Cubos and other top therapists and strength coaches as attendees at the 2012 BSMPG Summer Seminar.

Register today before seats are filled!!

BSMPG has begun plans to host DNS Course "B" in Boston in the spring of 2013.  Due to the overwhelming response of our Course "A" offering, we have begun plans to host course "B" next spring.

Stay tuned to bsmpg.com for complete details.

Click video below to watch interview with Boston Course "A" instructor, Clare Frank who would also be teaching Course "B" upcoming.

Click below to watch an interview with Craig Liebenson as he talks about the DNS approach.

See Craig Liebenson at the 2012 BSMPG Summer Seminar - May 19th and 20th in Boston MA.

Hurry - this program has a limited number of seats!

Recommended readings from this past week in Sports Medicine and Performance.

Enjoy! Remember to register for the 2012 BSMPG Summer Seminar, May 19-20 in Boston MA.  Seats are limited.

The Brain: How The Brain Rewires Itself 

Vitamin D and Athletic Performance  

Variability in Leg Muscle Power and Hop Performance After Anterior Cruciate Ligament Reconstruction    

I recently took part in a workshop where both manual and instrument assisted soft tissue therapy were heavily promoted as the gold standard in plantar sided foot pain presentations. While certainly such therapeutic interventions as Active Release Techniques and Graston Technique may act as positive adjuncts in the management of such cases, I often find myself using exercise interventions with relatively more rapid results. As always, patient management should always be context dependent but this is what I’m finding.

Interestingly, when therapists do consider exercise interventions, heel raises/lowers off stairs seem to be the “exercise of choice”. Often such presentations are acute or “hot” and based on Craig Purdam’s work on tendinopathies, such exercises may be too advanced for significant progress to be made.

Now before I introduce some alternative exercises, I’d like to address the “One Toe Syndrome”. Patients with plantar sided foot pain, especially women for some reason, often present with this “syndrome”. They may indeed have five toes, as most of us do, but if you look closely the toes actually function as one unit rather than five individual units.

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The "One Toe" Syndrome

Continue to read this article by Jeff Cubos by clicking HERE.

Remember to Save the Date for the BSMPG 2012 Summer Seminar - May 19-20th in Boston MA.