With so many questions requested after the first three posts, including research and validity of different measurements techniques, I wanted to go over some of the research studies and show why many teams struggle to implement technology and evidence based medicine into sport. Going to google scholar and looking up the different methodologies isn’t hard, implementing it is another story.The primary reason teams fail to get data or even objectively measure the athlete is time and the annoying and boring factor. No matter what works, if the athlete is not engaged or feels like the technology isn’t helping, they are gone. An athlete will jump into an MRI and wait patiently if they feel they injured something, they will not spend every day getting full body Tensiomyography testing or do HRV on their own unless the process is clearly showing benefit. Also no matter how great the data sets, it’s only an extension of the therapist and the program. Getting Thermograms of athletes after practice and scraping them up with different civil war tools is likely not going to help when even PRP injections show limitations.
In my experience, many therapists are on two sides of evidence based medicine (EBM). One side, are those that say the want EBM and read research but don’t practice it. The other side are those that want it and request internal or external audits as they want to improve their craft. It’s extremely difficult to be organized enough to implement objective technologies, and many times doing so scares the people involved. What if management sees we are not doing anything? What if the measurement doesn’t show the good job we are doing? With the world watching tweets and ESPN updates on injuries, more and more coaches and therapists are on the hot seat for good reason. If they are the best in the world at what they do, why isn’t it showing all the time?
Case Study- Hamstring Therapy
Hamstring injuries are often tricky and how things heal are not going to be easy to evaluate in a collaborative way. When doing therapy, it’s hard to say one is 85% or ready to go, and TMG can objectively measure Neuromuscular Contractle Pattern of the injured muscle. While fascia is important, without muscle diagnostics we can’t tell if someone is ready to go or not. When I work with post college athletes, it is likely that they have come in with a few injuries that were not fully rehabilitated and due to the age of the athlete, compensations may be very ingrained.
Hamstring tears are difficult to heal because most don’t have world class hands manipulating tone and dealing with myofibril damage over time. With such a scarcity, most athletes never heal properly and pull up again in a frustrating cycle of events. When the hamstring is not repaired properly, I have seen back issues start and the old game of chicken and egg discussion comes up with people assuming that the original problem was neural to begin with. While I am not arguing that back issues can cause hamstring pulls, often I see bad rehab on hamstrings change lumbar mechanics because of shortening and compensation with the QL. One of the most emotionally frustrating feelings for an athlete is to have a conflict in diagnosis and cause of the injury, so as coaches we need to be careful on the communication with collaborative approaches. Imagine being on the table and two therapists say two different things? I hate it. The best therapists talk generally in order to be considerate about other opinions, the therapist I trust most with hamstring pulls doesn’t care and just speaks his mind. Yes he is that good, and now with TMG and Thermography he can back it up.
One question people ask is how much therapy or deep tissue can one take? I have sent a lot of athletes down to a therapist for the three day resurrection and often 95% of the completion is done. Three day of 2-4 hours seems like a lot, but the entire body should be treated plus the injury site. Often collateral damage is there to protect and compensate, and past general issues to the body need to be cleared up. If one has the skill to slowly get deeper and the athlete is fit, the therapy can be done. If an athlete is not fit, soreness and inflammation will be higher. I have seen an olympic hurdler soak up hours and hours of therapy in midseason form, while an injured athlete who was chronically out struggled because he wan’t use to massage and was out of shape.
Cyriax work is hard on the hands and takes skill. Some think they can do it because they say they can do it and feel it but my palpation skills are good enough to feel what is good and what is amateur. Experts can feel it and overlay software combined with MRI and MSK US is the name of the game, especially now with cameras and thermography. Test the therapist, are they finding it on their own or making things up?
TMG is useful for monitoring the changing of tone, even if symmetry is compromised temporarily. Depending on the timing and season, therapy must be done carefully or one can fry the injury site and weakening the area. Nutrition and solid blood work can ensure that one is regenerating properly, as HRV doesn’t always pick up on local and chemical changes. I have had athletes make dramatic changes in those areas and HRV failed to see the difference because local issues may not be summarized by HRV. It’s not that HRV doesn’t work, it’s just limited to some areas. Too many people tweet about changing it because Heart Rate monitoring is convenient to test.
One question many have is why did the hamstring tear in the first place. A combination of biomechanics and fatigue management (global and local) is the culprit. Sometimes emotional as athletes have been injured because they were not ready, and this is why half the game is between the ears. Weak glutes, poor orthotics, disc issue, too much hamstring curls? Who knows, but the reality is we need to do a better job of measuring this stuff and doing more research with real teams as well as college subjects.
I remember attending a gait seminar and the slow motion video was being reviewed and several comments were made by experts. One therapist asked where was the video of the fix, meaning it’s great to point out problems but someone has got to fix it. Time after time we see people talking about the FMS and that is fine, but why is 21 scores so rare? With people saying that 14 is ok, why is 21 not the standard if it’s a better rating? I know the question is beating a dead horse, but zombie zebras are still running around.
I swear by eccentric work combined with deep tissue massage early and often in the rehabilitation phase of hamstring repair. One can measure fascial length changes and some great research on this was given to me by Cameron Hill a few years ago. I find that RDLs and deep squats help in later phases, but creative single leg exercises and not GHR work. I know some believe that the GHR is the greatest thing since sliced bread, but I have seen elastography show that some athletes don’t respond well. I do think one can do the exercises and never want to blame weight training for injuries, but one must be careful about doing anything, even if it’s strength training a local muscle group. If one is going to do GHR exercises make sure the athlete is exceptionally strong and is doing them in the offseason. I am not suggesting the exercise but have seen the medical imaging to see that they are very intense to soft tissues behind the knee. Massage is to help with tone and malleability of the the tissues and to prevent guarding, but sometimes it helps with site specific work and inducing the repair process a little. I know people think graston is the poor man’s PRP, but without training and and good nutrition, you can find yourself with ruined injury sites.
One question I hear is how important is flexibility and is 90 degrees enough. I think more range of motion coupled with very strong glutes and hamstrings is a better combination. With a solid program and consistent therapy, 120 degrees and racehorse hamstrings will be strong enough to help with forces during top end speed. The tight = speed crowd is not my cup of tea, not because I think flexility is magic, but facial length and eccentric strength is a set of indices for health. I have yet to see someone test facia strength, so I will keep doing weights and sprints and take it from there. I think more range of motion one has, to keep joints stable strength must rise. Muscle testing to me is too conflicting, but a well rounded program with weights has a looks right flies right result with structure. TMG ratios between muscle groups and drift testing with optojump is an important functional result.
In summary, measuring and documenting therapy is a way to see what factors caused the injury and what is working or not working. In the next post I will talk about thermography and pressure mapping for coaches, and show how return to play may change because of those technologies.