Boston Sports Medicine and Performance Group, LLC Blog

by Art Horne

I remember being taught in school that people have low back pain because their hamstrings are tight.  Therego, stretch the hamstrings and resolve the low back pain.  It was a simple solution to a very complex and often misunderstood problem and yet as a student it was a clean and direct resolution to an often nagging dilemma.

Further testing and evaluation always “proved” the hamstrings as the culprit since so many of the low back pain patients were never able to touch their toes, and of course toe touching was a direct result of hamstring length.  Again, this bore out to make sense since after spending an exhausting amount of time stretching these patient’s hamstrings, and then retesting, some measurable change were noted (sometimes) with the patient inching closer to their toes.  The only problem in this clean and concise “hamstring-LBP” relationship was that these patients, no matter how long I stretched them or which stretching technique I employed ALWAYS ended up coming back the very next day for the same stretching routine and the same unresolved back pain.

Insanity: Doing the same thing over and over again and expecting different results.

Of course, many of these patients really never had “tight” hamstrings after all, but instead had hamstrings that were preventing them from a place they no had no business being in the first place. 

What do I mean?

Well, many of these patients, or at least the majority of them,  were flexion intolerant which means both flexing their spine and/or moving into flexion caused a reflexive “tightening” of the hamstrings to essentially keep them from FLEXING FORWARD and moving into a region which would exacerbate their current condition, or “a place they have no business being.”  In addition, many of these “tight hamstring” patients were never ever feeling a hamstring stretch, but instead were experiencing a neural stretch, which unfortunately after stretching only continued their “tight-stretch-pain-tight” cycle. 

Soo… Should I Stretch or Not?

1. First distinguish between hamstring tightness and neural tension.  Neural tension is always described differently than muscular tightness – that is if you’re listening.  I had a professor who told me that your patient will always tell exactly what is wrong with them if you listen long enough.  And if you listen just a little bit longer, they’ll also tell you exactly how to make them better.  This case is no different – of course, if you’re too busy catering water you’ll never have enough time to listen long enough.

2. Neural tension is often described as “pinching” or with other words that clearly denote nerve origin such as “zapping” or “burning.”  Muscle tension doesn’t zap or burn.

3. Confirm neural involvement with a slump test – then STOP stretching and begin a nerve flossing regiment if indicated.

4. Does the patient need more mobility (hamstring stretching) or do they simply lack the appropriate stability (or neuromuscular control) which ultimately is limiting them from moving into a place where they simply didn’t have the requisite control? I’m willing to bet that more often than not that stability/neuromuscular control is the limiting factor and not hamstring length – especially in low back pain patients.

So what does this have to do with integrated care?

1. On evaluation during pre-participation screenings a simply toe touch as a gross indicator of both ability and willingness to forward flex will “catch” those athletes who either have had previous back pain, current back pain or a complete lack of understanding relating to lumbar spine/pelvis position and an ability to disassociate them during normal daily living.

2. Those with pain or previous pain should be referred to sports medicine for further evaluation – yes, even those that don’t currently have pain.

3. Those that have trouble separating hip and lumbar motion should be placed into a “teaching” group while in the weight room until they can successfully “stiffen” their spine while gaining mobility and motion throughout the hips; both which are essential if any type of squat or deadlift pattern are prescribed in their program.  But really more importantly, these two patterns occur each and every day of their lives and must be grooved before major lumbar spine pathology presents itself.

Click HERE for a quick note on establishing a hip hinge.

Next week: A quick in-service to get both Sports Medicine and Strength Training hinging at the hips and teaching all athletes a great squat pattern. 

Click HERE to listen to this interview.

In this interview, Art discusses his new book, "Barefoot in Boston: A Practical Guide to Achieving Injury Resolution and Enhancing Performance", as well as discussing some research on barefoot walking and training versus wearing shoes, what to look for in minimalist shoes, how he has incorporated barefoot training with his basketball team, and much more..(including how to take a hack saw to a basketball shoe!)

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.

You know those fancy, air-filled, arch-cushioned, expensive-as-hell sneakers that you buy to enhance your performance? Well, what if we told you they were most likely not only decreasing your performance, but increasing your likelihood of injury? You would probably call us crazy, but people thought Galileo was crazy once too.  Are we comparing ourselves to Galileo? No, great guy though.  What we are saying is that we are proponents of an idea which is growing in popularity and for some very good reasons.  Barefoot training has recently become popularized as a potential benefit in injury rehabilitation programs. It is also purported to serve as an additional means of injury prevention and to enhance athletic performance.  However, limited clinical research is currently available to justify this practice and even less information is available describing how one may go about safely implementing a barefoot training program.  This book explores the scientific and theoretical benefits concerning the merits of barefoot training and offers real life solutions and alternatives to all the things separating you and your feet from mother earth, including examples of specific programs and training progressions.  By the time you are through with this book, you will be part of the movement and your feet will be on their way to a happier, healthier version of their formerly miserable selves.

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.

Question: A strength coach, an athletic trainer and a physician are in a car driving through the Arizona desert.  They get a flat tire.  Whose fault is it?

Answer: It doesn’t matter. They are all going nowhere together.
You can argue that the flat tire can be blamed on the strength coach for not ensuring the tires were made to withstand the rigors of the desert, or the athletic trainer for not checking the air pressure prior to the trip, or even the physician for giving the nod to drive over the speed limit even though the engine was never tested to perform at that speed.  The fact remains that each professional is stuck together going nowhere.  

Sound familiar?

When we work with our athletes who are unable to play for whatever reason we often end up blaming the flat tire on someone else when in fact we are all now stuck in the same car going nowhere. Prior to your next road trip, let’s make sure we all meet in the garage together and develop a plan for our athletes before taking “the car” out for a zip around town.

Remember, if you’re looking to go nowhere, any road will take you there.

Art Horne the Coordinator of Care and Strength & Conditioning Coach for the Men’s Basketball Team at Northeastern University, Boston MA.  He can be reached at a.horne@neu.edu.

Regardless of which side of the “barefoot” fence you sit, recent scientific developments by Harvard professor and barefoot enthusiast, Dr. Daniel Lieberman is sure to have you thinking about whether you should be reaching for your high top sneakers prior to your next stroll around the neighborhood or forgoing them all together in place of nature’s offering.  For those that continue to debate that running barefoot is just not feasible and perhaps dangerous, I’d have to offer a rebuttal…. I mean, barefoot running and training doesn’t mean going on an eight hour run looking for your next meal.  Unfortunately, the term “barefoot training” has been hijacked and equated with burning your shoes followed by a life of hugging trees and growing your hair out.  I mean, we’ve all tried to increase our bench press max right? But we didn’t start day one with 350 lbs on the bar.  Like everything else, the decision of how to and when to go barefoot is dependent on a number of factors, but is certainly governed by the law of progressive overload and common sense.  Several practical suggestions on how to implement some barefoot work into your team’s training can be found in the March issue of Training and Conditioning.  I’m not advocating you send your starting basketball center who’s been wearing Nike shocks their whole life for a run and plyo workout, but I’m pretty sure they have had shoes off recently, (maybe as recent as this morning when they woke up and walked to the bathroom) and their foot didn’t break right? So why don’t we take advantage of Mr. Wolff’s law and challenge your foot, ankle, and lower extremity just a little bit.  
Barefoot training won’t cure cancer but it just might put a smile on your feet again.

For a cliff note version of Dr. Lieberman’s Harvard work click here.

Art Horne Is the Coordinator of Care and Strength & Conditioning Coach for the Men’s Basketball Team at Northeastern University, Boston MA.  He can be reached at a.horne@neu.edu.

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