Injury Prevention and Care

I Have Knee Pain And I don’t Know What It Could Be…An Introduction to Synovial Plica and Plica Syndrome

  |   Injury Prevention and Care   |   No comment

When attempting to understand synovial plica in relation to plica syndrome, we must first understand the anatomical structures affected. Let’s start with learning about plicae.

 

 

Anatomy of Plica

 

Plica is a term used to describe a fold in the lining of the knee joint. Imagine the inner lining of the knee joint as nothing more than a sleeve of tissue. This sleeve of tissue is made up of synovial tissue, which is a thin, slippery material that lines all of the joints. This synovial tissue is important because it allows for movement of knee joint without restriction. 

 

 

 

 

Screen Shot 2015-11-10 at 8.27.59 AM

 

 

 

 

Four plica synovial folds are found in the knee, but only one seems to cause trouble. This structure is called the medial plica. The medial plica of the knee is a thin, well-vascularized intraarticular fold of the joint lining, or synovial tissue, over the medial aspect of the knee (Griffith & LaPrade, 2008). It is present in everyone, but can be more prominent in some people. Proximally, it is attached to the genu articularis muscle, while distally it courses over the far medial aspect of the medial femoral condyle to attach to the distomedial aspect of the intraarticular synovial lining of the knee. At this location, it basically blends into the medial patellotibial ligament on the medial aspect of the retropatellar fat pad (Griffith & LaPrade, 2008). The medial plica is composed of relatively elastic tissues which asymptomatically conform to the changes in shape and lengths of the plica folds as the knee flexes and extends. 

 

 

Causes of Plica Syndrome

 

A plica causes problems when it is irritated. This can occur over a long period of time, such as when the plica is irritated by certain exercises, repetitive motions, or kneeling. Activities that repeatedly bend and straighten the knee, such as running, biking, or use of a stair-climbing machine, can also irritate the medial plica and cause plica syndrome.

 

Injury to the plica can also happen suddenly, such as when the knee is struck in the area around the medial plica. This can occur from a fall or even from hitting the knee. This injury to the knee can cause the plica, and the synovial tissue around the plica, to swell and become painful. The initial injury may lead to scarring and thickening of the plica tissue later. The thickened, scarred plica fold may be more likely to cause problems later.

 

In some patients, particularly those who may have had injuries or multiple surgeries over the medial aspect of the knee, the medial synovial plica may become very thick and fibrotic and may catch over the medial aspect of the medial femoral condyle (Griffith & LaPrade, 2008).

 

In all patients, the medial synovial plica will glide over the anteromedial aspect of the medial femoral condyle with flexion and extension of the knee. In most patients, this gliding motion of the plica will occur without any symptoms, because of the high viscosity of the native synovial fluid of the knee. However, in patients with effusions, which decreases the viscosity of their synovial fluid, patients may either have crepitation or a catching of their medial synovial plica with flexion and extension of the knee (Griffith & LaPrade, 2008). This crepitation or catching can occur with patients while going up or down stairs, squatting and bending, and other types of activities. Since the medial synovial plica does have an attachment to the genu articularis muscle, and also an indirect attachment to the quadriceps musculature due to its attachment to the joint lining, it is dynamically controlled by the quadriceps muscles. Thus, medial plica irritation is more common in patients who have poor quadriceps tone or other problems with joint muscle balance around the knee (Griffith & LaPrade, 2008).

 

 

Symptoms of Plica Syndrome

 

The primary symptom caused by plica syndrome is pain. There may also be a snapping sensation along the inside of the knee as the knee is bent. This is due to the rubbing of the thickened plica over the medial aspect of the femoral condyle where it enters the joint. This usually causes the plica to be tender to the touch. In thin people, the tissue that forms the plica may be actually be felt as a tender band underneath the skin. In rare cases where the plica has become severely irritated, the knee may become swollen.

 

 

Diagnosis of Medial Plica Pathology

 

One of the most important points in diagnosing medial synovial plica pathology is obtaining an appropriate history from the patient. Patients usually describe pain which is dull, achy, and increases with activity. When asked to point to the area of their pain, they will commonly point to the proximomedial aspect of the knee, proximal to the medial joint line (Griffith & LaPrade, 2008). Most patients will complain of an achy type pain over the medial aspect of their knee, which is aggravated by activity and can be particularly bothersome at night. Their complaints of night pain over this area of the knee are due to the effects of inflammation, which can be particularly bothersome with activities. Patients most commonly complain of pain with activities which stress their patellofemoral joints, such as ascending and descending stairs, squatting and bending, and arising from a chair after sitting for an extended period of time. In addition, they may note difficulty with sitting still for long periods of time without having to move and stretch their knees. They also may complain of a catch over the anteromedial aspect of their knee upon arising from a chair following prolonged periods of sitting. In some patients, plica catching may present as a pseudo-locking event to their knee when they have been sitting down for an extended period of time and they first arise. Some patients may describe these pseudolocking events as instability or catching of their patella (Griffith & LaPrade, 2008). Clicking, giving way, and pseudo-locking have been reported in approximately 50% of all patients who present with medial plica irritation. Patients who might have problems with activity-related effusions may also complain of pain over the anterior aspect of their knee. While these activity-related effusions may not be directly caused by medial plica pathology, and are more commonly due to underlying quadriceps mechanism weakness, meniscal tears, and/or osteoarthritis, but they can cause secondary medial plica irritation. In addition, patients who have had postoperative or post-injury weakness of their affected extremity may develop pain over the anteromedial aspect of their knee in the region of the medial synovial plica. A definitive diagnosis of medial plica irritation is usually obtained by physical exam. A normal examination of the patellofemoral joint should always include an examination of the patient’s medial synovial plica fold to determine if they have any irritation of this structure (Griffith & LaPrade, 2008).

 

 

 

Screen Shot 2015-11-10 at 9.15.32 AM

 

 

Treatment of Plica Syndrome

 

The main treatment regimen for medial plica irritation is non-operative. For patients who have medial plica irritation as their main diagnosis without any underlying knee pathology contributing to their plica irritation, there is a very good chance that their symptoms will improve with a guided rehabilitation program (Griffith & LaPrade, 2008). The most successful rehabilitation programs focus on strengthening the quadriceps muscles, which are directly attached to the medial plica, and avoiding activities which cause medial plica irritation. These exercises can include quadriceps sets, straight leg raises, squat variations, and mini-squats, as well as, a walking program, the use of a recumbent or stationary bicycle, a swimming program, or possibly an elliptical machine (Griffith & LaPrade, 2008). Patients should work on gradually increasing strength over time to overcome any strength deficit in their quadriceps mechanism. Concurrent with this, patients should also work on a frequent hamstring stretching program throughout the day. As mentioned previously, tight hamstrings can increase the force needed to extend the knee, which can be an important source of medial plica irritation. Thus, it is important to make sure that the hamstrings are stretched frequently to diminish this extra stress on the anterior part of the knee (Griffith & LaPrade, 2008).

 

 

 

 

 

References

Griffith, C. J., & LaPrade, R. F. (2008). Medial plica irritation: diagnosis and treatment. Current reviews in musculoskeletal medicine, 1(1), 53-60.

Read More

An Introduction to Cuboid Syndrome

  |   Injury Prevention and Care   |   No comment

Cuboid syndrome is a common source of lateral foot pain in many athletes. It is believed to arise from a subtle disruption of the arthrokinematics or structural congruity of the calcaneocuboid joint (Durall, 2011). This presumed alteration in arthrokinematics and/or congruence of the calcaneocuboid joint can either develop chronically, or after a traumatic event such as an ankle sprain. In order to fully understand what cuboid syndrome is, let’s define a couple of terms:

 

 

Arthrokinematics = Arthrokinematics refers to the specific movement of joint surfaces. The specific movements of joint surfaces can include things such as rolls, spins, and glides. So in other words, it describes whether bones roll on each other, glide on each other, or spin on each other. This is an important biomechanical concept because it explains how to mobilize synovial joints in the human body, as well as why that synovial joint moves the way it does.

 

 

Now that we’ve covered what arthrokinematics are, let’s begin to understand the anatomy and mechanics of cuboid syndrome.

 

 

Anatomy and Biomechanics of the Cuboid Bone

 

The cuboid is located in the lateral midfoot, surrounded by the calcaneus posteriorly, the fourth and fifth metatarsals anteriorly, and the navicular and lateral cuneiform medially (Durall, 2011). The calcaneocuboid joint function is dependent on midtarsal joint mechanics, since the navicular and cuboid bones move essentially in tandem during gait. The mechanics of the calcaneocuboid joint are highly variable, but the principal movement at this joint is medial/lateral rotation about an anterior/posterior axis with the calcaneal process acting as a pivot (Durall, 2011). The cuboid is unique for the simple fact that it is the only bone in the foot that articulates with both the tarsometatarsal joint and the midtarsal joint (Patterson, 2006). It is also the only bone linking the lateral column to the transverse plantar arch. Consequently, the cuboid acts as a keystone of the rigid and static lateral column giving inherent stability to the foot (Patterson, 2006).

 

 

Screen Shot 2015-11-02 at 8.57.05 AM

Right foot plantar view

 

 

The calcaneocuboid joint is intrinsically stable due to the congruence of its articular surfaces and reinforcement from ligaments and tendon attachments (Durall, 2011). These reinforcing ligaments include the dorsal and plantar calcaneocuboid, dorsal and plantar cuboideonavicular, dorsal and plantar cuboideometatarsal, and the long plantar ligament (Patterson, 2006).

 

Screen Shot 2015-11-02 at 9.05.41 AM

Ligaments of the lateral foot

 

 

Ligaments don’t get all the fun in providing stability for the calcaneocuboid joint. The peroneus longus tendon, which forms a sling around the lateral and plantar aspects of the cuboid before inserting on the plantar aspect of the lateral first metatarsal base and medial cuneiform, also assists with calcaneocuboid joint stabilization (Durall, 2011). The peroneus longus muscle originates on the upper one-third of the fibula, then travels distally down the shaft of the fibula and posteriorly around the lateral malleolus (Patterson, 2006). From here it continues to travel in a plantar lateral direction until the tendon reaches the cuboid. Here the path of the tendon then changes directions and travels anteromedially through the cuboid’s peroneal groove and inserts on the lateral base of first metatarsal and first cuneiform (Patterson, 2006). The cuboid is a pulley for the peroneus longus tendon; muscle contraction from midstance through the late propulsive phase exerts an eversion torque on the cuboid. Eversion of the cuboid via the peroneus longus tendon is thought to facilitate load transfer across the forefoot from lateral to medial as stance progresses (Durall, 2011).

Screen Shot 2015-11-02 at 9.16.41 AM

Peroneus longus tendon

 

Although the normal mechanics of the midtarsal joints are not fully understood, the talonavicular and calcaneocuboid joints are thought to play a vital role in the transition of the foot from a mobile adapter during weight acceptance, to a rigid lever during push-off and in rearfoot-to-forefoot load transfer during propulsion (Durall, 2011). During early stance when the calcaneus is everted, the forefoot tends to flex and extend more; during push-off, the calcaneus is inverted, and the forefoot is more rigid. This phenomenon is attributed to the orientation of the talonavicular and calcaneocuboid joint axes, which become parallel during calcaneal eversion, increasing motion in these joints and in the forefoot in general. Conversely, calcaneal inversion during push-off causes the midtarsal joint axes to diverge, which reduces mobility in the midtarsal joint and the forefoot (Durall, 2011).

Some of these theories about the biomechanics of the midtarsal joints can be applied an ultra-marathoner  we are working with who started experiencing lateral foot pain a couple of weeks ago. After a proper differential diagnosis, it became apparent that she was experiencing cuboid syndrome. But the head-scratching question she had was how she got it. Due to what we saw during the diagnosis and throughout her time here at Accelerate, we’ve noticed that she runs with a relaxed arch, even though we are supposed to have a rigid foot during the push-off phase of the gait pattern. Debbie’s tight extensors are causing her dorsal aspect of her foot to be rigid during her early stance, which is what we want. However, they are still taking over during her push-off phase as well. This becomes a problem due to reciprocal inhibition. Reciprocal inhibition describes the process of muscles on one side of a joint relaxing to accommodate contraction on the other side of that joint. Due to this common biomechanical law of the body, her tight and contracted extensors during both the early stance and push-off phases of her gait are causing her flexors to be in a relaxed state at the plantar aspect of her foot, thus not creating a rigid forefoot during push off. That said, running 60-100 miles at time does have influence on the durability of proper mid foot mechanics during running gate and thereafter.

Etiology of Cuboid Syndrome

 

Although the etiology and pathomechanic mechanism of cuboid syndrome is still unclear, there have been several proposed theories including excessive pronation, overuse, and inversion ankle sprains (Durall, 2011). It is also thought that cuboid syndrome arises from forceful eversion of the cuboid while the calcaneus is inverted, with resultant disruption of calcaneocuboid joint congruity. Loss of congruency between the calcaneus and cuboid may be the source of lateral foot pain. The peroneus longus may also play a role in the development of cuboid syndrome, since this muscle imparts an eversion moment on the cuboid. Impaired peroneus longus function may also affect calcaneocuboid joint stability (Durall, 2011).

 

 

Several other factors may increase the likelihood of cuboid syndrome, including midtarsal instability, excessive body weight, ill-fitting or poorly constructed orthoses or shoes, exercise (ie, intensity, duration, frequency), inadequate exercise recovery, training on uneven surfaces, and sprain of the foot or ankle (Durall, 2011). Cuboid syndrome may be more prevalent in individuals with pronated feet due to the increased moment arm of the peroneus longus. In one study, 80% of the patients with cuboid syndrome presented with pronated feet, but it can also occur with supinated feet (Durall, 2011).

 

 

Signs and Symptoms of Cuboid Syndrome

 

The symptoms of cuboid syndrome resemble those of a ligament sprain. Pain is often diffused along the lateral foot between the calcaneocuboid joint and the fourth and/or fifth cuboid metatarsal joints and may radiate throughout the foot (Durall, 2011). Tenderness may also be present along the peroneus longus tendon, the cuboid groove, the dorsolateral and/or plantar cuboid, or the origin of the extensor digitorum brevis muscle. Poor gait is also common with cuboid syndrome, with pain and/or weakness most pronounced during push-off or with side-to-side movements (Durall, 2011).

 

 

Diagnosis of Cuboid Syndrome

 

Although there are no definitive validated diagnostic tests for cuboid syndrome, two clinical maneuvers have been described; the midtarsal adduction test and the midtarsal supination test (Durall, 2011). During the adduction test, the midtarsal joint is manipulated passively in the transverse plane while the calcaneus is stabilized. This maneuver compresses the medial aspect of the CC joint and distracts the lateral side. The supination test is similar by adding inversion and plantar flexion (Durall, 2011).

 

 

Treatment of Cuboid Syndrome

 

1. Manual Therapy Techniques

 

– There are several manual therapy techniques that can be used to treat cuboid syndrome. One technique that is widely used is called the Cuboid Whip. During this manipulation technique, the clinician cups the dorsum of the patient’s forefoot, placing thumbs on the plantomedial aspect of the cuboid. The patient’s knee is flexed 70° to 90° while the ankle is placed in 0° dorsiflexion. With the patient’s leg relaxed, the clinician abruptly “whips” the foot into inversion and plantarflexion while delivering a low amplitude, high velocity thrust to the cuboid (Durall, 2011). Another manipulation technique that can be used is called the Cuboid Squeeze. During the cuboid squeeze, the clinician slowly stretches the ankle into maximal plantarflexion and the foot and toes into maximal flexion. When the clinician feels the dorsal soft tissues relax, the cuboid is “squeezed” with the thumbs (Durall, 2011).

 

 

2. Exercise Prescription

 

– There are several exercises that can be prescribed to alleviate the symptoms of cuboid syndrome and correct for it. Such exercises are:

 

 

 

Any many other variations of exercises like towel grabs inversion, towel grabs eversion, and single leg strengthening and balancing exercises. The goal of all of these exercises are to strengthen the muscles surrounding the arch of the foot as well as the flexors of the foot, such as the peroneals, flexors, and extensors. Stretching the gastrocnemius, soleus, hamstring, and/or peroneus longus and strengthening the intrinsic and extrinsic foot muscles may also help prevent recurrence of cuboid syndrome (Durall, 2011).

 

 

3. Kinesio Taping

 

– Kinesio taping can also be used as a technique to prevent the symptoms of cuboid syndrome from occurring again, following successful manipulation techniques and exercise prescription.  Kinesio tape is different from ordinary tape in that it is able to lift the upper layers of the skin, which creates more space in between the dermis and the muscle. This created space relieves pressure on the lymph channels in the area between the muscle and the dermis, thus allowing for better lymph flow and drainage through an affected area. Not only does does kinesio taping help the lymphatic system, it also helps the neuromuscular system as well. The created space from kinesio tape houses various nerve receptors that send specific information to the brain. When the space between the epidermis and the muscle is compressed during an injury like cuboid syndrome, these nerve receptors are compressed. Kinesio tape allows for created space that relieves pressure from these nerves in order to send proper messages and information to the brain. This increased space also allows for muscles to have greater contractility, which in turn pushes more fluid through the muscle, resulting in better muscular performance. Various kinesio taping techniques have been suggested, with a common goal of supporting the medial longitudinal arch (Durall, 2011).

 

 

Conclusion

 

So, what have we learned? We’ve studied the anatomy and biomechanics of cuboid syndrome, underlining the major theories that contribute to the occurrence of the signs and symptoms. We’ve learned that we need to have flexed and extended forefoot during early stance, and a more rigid forefoot during push-off. In our client case, we’ve learned that we need to work on strengthening intrinsic, extrinsic, foot flexors in order to alleviate her symptoms, but most importantly the proper firing biomechanics of the lower limb. Strengthening these structures will make her arch stronger, and reciprocal inhibition will allow her extensors to relax during the push-off phase so she could instead become more rigid during push off. The A March shown above in the exercise prescription section would be a good exercise to practice due to her having to focus on her rigidity during the push off phase. We’ve gone over the diagnosis and treatment of cuboid syndrome, which include manipulation techniques, exercise prescription, and kinesio taping. Understanding how the structures around the foot allow for proper gait, as well as being able to understand the anatomy and biomechanics of your clients will allow the clinician to become successful in properly diagnosing someone with cuboid syndrome, and any other ailments in the future.

 

 

 

 

 

References

Durall, C. J. (2011). Examination and Treatment of Cuboid Syndrome A Literature Review. Sports Health: A Multidisciplinary Approach, 3(6), 514-519.

Patterson, S. M. (2006). Cuboid syndrome: a review of the literature. Journal of sports science & medicine, 5(4), 597.

Read More

Are You Walking Around Hyperinflated?

  |   Injury Prevention and Care, Performance Training   |   No comment

What if you could fix your back pain, knee irritation, neck spasms, to name a few…and increase your athletic outputs by taking a couple proper breathes and locking in that pattern?

 

What is Breathing?

 

 

Breathing is the most underappreciated of all human movements. Since breathing is a human movement pattern, it can be mechanically altered by a combination of factors. Breathing plays an important role in its influence on movement quality, stability, and posture. If breathing is “normal” or “functional”, posture and stabilization will be maintained in a healthy manner. Conversely, if breathing is “abnormal” or “dysfunctional”, it not only affects posture and stabilization, but can also create countless other health issues. On average, we breath 20,000-24,000 times a day. Any problems we have in breathing are therefore multiplied 20,000-24,000 times a day.

 

Breathing affects every system of our bodies to include, but not limited to, our cardiovascular, respiratory and musculoskeletal systems. Many individuals have misconceptions about breathing and consider it solely as an action of inhalation and exhalation. What is less understood is breathing’s role in posture and movement. The exchange of respiratory gases into and out of the lungs has many implications. The human body has three cavities that are designed to aid in the movement of air and support the upright posture of our human structure based on the pressure differences between them. These cavities include the cranium, thorax, and lumbo-pelvic femoral complex. This dynamic displacement of air defines the active movement that occurs during breathing and muscular activity.

 

Breathing is the origin of all movement patterns. Because it is one of our most frequent behaviors, any disturbances that create and/or inhibit these pressure gradients to occur between the head, thorax, and/or pelvic complex will lessen its efficiency and places a strain on the body’s ability to adapt. The manner in which individuals breathe affects their appearance and function of these cavities, and predicts the level of discomfort an individual may experience throughout their lifetime from both a physical and psychological standpoint.

 

 

Optimal Breathing

 

Optimal breathing includes moving air in and out of the thorax in a way that maintains optimal diaphragm position and optimal rib cage position for controlled tri-planar movement. The biggest challenges in positioning the diaphragm and the rib cage are:

 

  1. To get the diaphragm into a properly domed position
  2. To get the rib cage on both sides into full internal rotation

 

Both of these challenges are overcome if the person can get into a full state of exhalation when they breathe out.

 

Maximizing the removal of previously un-exhaled air allows the anterior rib cage to come all the way down, all the way in, and translate back so the diaphragm can take on a fully domed shape and the rib cage can get into full internal rotation. This is called maximizing Zone of Apposition

 

Screen Shot 2015-11-17 at 3.57.38 PM

 

Using this corrected diaphragm and rib cage posture for proper diaphragmatic breathing involves maintaining the newly attained Zone of Apposition as they transition from exhalation to inhalation.

 

zoa

 

A proper Zone of Apposition includes fully translating the diaphragm muscle back (posteriorly) so it lines up properly with a neutral lumbar spine and the pelvic outlet. This retro diaphragm position must be maintained so the diaphragm and the rib cage do not come forward when air starts to come into the chest wall. Support from the hamstrings and the internal abdominal obliques helps to maintain this posteriorly positioned diaphragm and rib cage position so synchronized abdominal and chest wall expansion can occur during inhalation.

 

Screen Shot 2015-11-17 at 4.00.12 PM

 

If this pattern of inhalation maintains enough posterior diaphragm translation (via hamstrings and internal abdominal obliques) to support lumbar spine and pelvic outlet posture, then it could be referred to as properly coordinated diaphragmatic breathing.

 

 

Hyperinflation

 

The most common form of breathing disorder is hyperventilation. Hyperventilation results from increased respiratory demands due to mechanical or emotional stress, or merely habit, and leads to respiratory alkalosis and an increase in the body’s PH. This, in turn, results in a host of physiological changes, including:

  1. Loss of dissociation of oxygen from hemoglobin in the blood, known as the Bohr affect. This is a paradox: the more we breathe, the less oxygen is available to our tissues
  2. Depletion of adrenal steroids, testosterone, estrogen, and progesterone
  3. Changes in brain wave patterns
  4. Increases in neural excitability, increased sympathetic drive, leading to:
    • Reduced cerebral blood flow
    • Altered intracellular pH and metabolism
    • Vasoconstriction and bronchoconstriction
    • Increased capillary pressure reduces blood supply to local tissues
    • Local tissue in hypoxia, which triggers release of neuropeptides and pro-inflammatory substances from nociceptive terminals
    • Activation of beta-adrenergic receptors at the motor endplate/sarcolemma via release of norepinephrine and leading to release of acetylcholine and on-going depolarization
    • Less oxygen available to move calcium through the gradient to unlock actin-myosin cross-bridges, leading to muscle stiffness
    • A switch in energy production from aerobic/oxidative phosphorylation to anaerobic/glycolysis, which is less efficient and destabilizing to homeostasis.
    • Fatigue
    • Headache
    • Digestive disorders

 

Breathing acts as an extrinsic influence on all other oscillating physiological systems, improving their efficiency and preventing energy waste on non-productive functions

 

When breathing synchronizes its oscillating cycles with that of other physiological systems, it allows for the rest and recovery of these systems

 

 

 

References

Blandin, J & Anderson, J. (2015). PRI integration for fitness and movement. Restoring and altering reciprocal activity. Principles. Breathing (33-37). Lincoln, NE.

Read More

Autografts vs. Allografts: Which choice is the better choice?

  |   Injury Prevention and Care, Performance Training   |   No comment

It has been debated for many years in the sports medicine field whether autograph or allografts are the better choice for an anterior cruciate ligament (ACL) tear. It has been fluctuating back and forth between the years, teetering between an autograft patellar tendon, an allograft hamstring tendon or patellar tendon, or an autograft hamstring tendon. There never seems to be any consistent or consensual basis on the topic. A study done on non-contact ACL injuries states that “An estimated 80,000 anterior cruciate ligament (ACL) tears occur annually in the United States” (Griffin et. al, 2000).

 

Screen Shot 2015-10-27 at 11.58.51 AM

 

As the rise of ACL injuries continues to increase with each passing year, this question seems all the more relevant to many current and future athletes. Before we continue to delve into this question, let’s first define autografts and allografts.

 

An autograft is a graft transferred from one part of a patient’s body to another, such as one’s own patellar or hamstring tendon to replace their torn ACL (Taber’s Medical Dictionary).

 

 

Screen Shot 2015-10-27 at 12.03.23 PM

 

 

Screen Shot 2015-10-27 at 12.04.42 PM

 

 

An allograft is an organ or tissue transplanted from one member of a species to another genetically dissimilar member of the same species, such as a cadaver’s hamstring or patellar tendon to replace the athlete’s torn ACL (Taber’s Medical Dictionary).

 

 

Screen Shot 2015-10-27 at 12.08.26 PM

 

One would assume that receiving a tissue from a cadaver would put them in a vulnerable position for tissue rejection. However, recipients of allografts take immunosuppressive drugs to prevent tissue rejection from occurring. The reconstruction of an ACL is crucial to the longevity of any given athlete due to it’s importance in maintaining the stability of the knee, particularly in activities involving cutting, pivoting or kicking. People with ruptured ACL’s have unstable knees that generally become more damaged over time. Therefore, surgical reconstruction is vital for the athlete in order to get back to regular sport activity. Now that we are familiar with the terminology, let’s see what the current research has to say about which is the better choice.

 

 

 

 

Autograft Research:

 

A study done on the rehabilitation after ACL reconstruction followed up with 68 patients two years after surgery to determine which method was the best. Thirty-four patients chose the patellar tendon graft, and 34 patients chose the hamstring tendon graft (Heijne & Werner, 2010). The patients were evaluated preoperatively for 3, 5, 7, and 9 months, and then 1 and 2 years after ACL reconstruction. The results from this study showed that the outcome regarding graft choice anterior knee laxity was in favor of the patellar tendon graft, and that the hamstring tendon graft led to larger laxity compared with the patellar graft. There was also a significant difference in rotational knee stability in favour of the patellar tendon graft. The patellar tendon graft resulted in higher activity level than hamstring graft. Another finding was that 2 years after ACL reconstruction, patients who chose the hamstring graft showed both significantly lower quadriceps and hamstrings strength ratio in comparison with patients operated on with patellar tendon graft as well as when compared with their own preoperative values (Heijne & Werner, 2010). The conclusion of this study shows that the patellar tendon graft leads to more stable knees with less anterior laxity and less pivot shift. Patients with hamstring ACL reconstruction need more hamstring strengthening exercises. Some of the study’s data indicated that patients operated on with hamstring grafts might need slower rehabilitation protocols, focusing more on hamstring strength than those with patellar tendon graft. Athletic patients with the patellar tendon ACL reconstruction returned to sports earlier and at a higher level than those operated on with hamstring tendon grafts (Heijne & Werner, 2010).

 

 

A second study on the patellar tendon versus the hamstring autograft for ACL ruptures in adults gathered 1597 young to middle-aged adults for this study. The results demonstrated that all of the movement tests they performed on the patients (instrumental, Lachman, pivot shift) for static stability consistently showed that patellar tendon reconstruction resulted in a more statically stable knee compared with hamstring tendon reconstruction (Dooley, Chan, Dainty, Mohtadi, and Whelan, 2006). Conversely, patients experienced more anterior knee problems, especially with kneeling, after patellar tendon reconstruction. Patellar tendon reconstructions resulted in a statistically significant loss of extension range of motion and a trend towards loss of knee extension strength. Hamstring tendon reconstructions demonstrated a trend towards loss of flexion range of motion and a statistically significant loss of knee flexion strength (Dooley, Chan, Dainty, Mohtadi, and Whelan, 2006). The conclusion of this study explains that while patellar tendon reconstructions are more likely to result in statically stable knees, they are also associated with more anterior knee problems (Dooley, Chan, Dainty, Mohtadi, and Whelan, 2006).

 

 

The third and final study did a meta-analysis comparing patellar tendon and hamstring tendon autografts. The researchers of this study gathered 1348 patients in the patellar tendon group, and 628 patients in the hamstring tendon group (Freedman, D’Amato, Nedeff, Kaz, and Bach, 2003). The results of this study showed that the rate of graft failure in the patellar tendon group was significantly lower, and a significantly higher proportion of patients in the patellar tendon group had a side-to-side difference of less than 3 mm on KT-1000 arthrometer testing than in the hamstring tendon group (Freedman, D’Amato, Nedeff, Kaz, and Bach, 2003).  The KT-1000 knee arthrometer is an objective instrument to measure anterior tibial motion relative to the femur for anterior cruciate ligament reconstruction (Arneja & Leith, 2009). There was a higher rate of manipulation under anesthesia or lysis of adhesions and of anterior knee pain in the patellar tendon group. Patellar tendon autografts had a significantly lower rate of graft failure and resulted in better static knee stability and increased patient satisfaction compared with hamstring tendon autografts. However, patellar tendon autograft reconstructions resulted in an increased rate of anterior knee pain (Freedman, D’Amato, Nedeff, Kaz, and Bach, 2003).

 

 

 

 

Allograft Research:

 

The first study in this section talked about the comparison of auto and allograft hamstring tendon constructs for ACL reconstruction. The study gathered 84 patients total, with 37 choosing autografts and 47 choosing allografts (Edgar, Zimmer, Kakar, Jones, and Schepsis, 2008). The results of this study showed that at short to intermediate term follow-up, an allograft hamstring construct performs just as well as an autograft hamstring construct in all clinically monitored parameters (Edgar, Zimmer, Kakar, Jones, and Schepsis, 2008). Given some of the potential advantages of allograft constructs (no donor-site morbidity, shorter operative time, a potential graft tissue source for backup when harvested tissue is inadequate, and the ability to preoperatively select the appropriate length and diameter graft, thus adjusting to the size and weight of the patient), allograft constructs are becoming more widely used. The performance of the allograft counterpart of the typical autograft hamstring construct performs as well by all criteria at short to intermediate term followup (Edgar, Zimmer, Kakar, Jones, and Schepsis, 2008).

 

 

The second study looked at allografts versus autograft ACL reconstruction to see which method led to the least amount of complications. Their results showed that patient age and ACL graft type were significant predictors of graft failure for all study surgeons (Kaeding et.al, 2011). Patients in the age group of 10 to 19 years had the highest percentage of graft failures. The odds of graft rupture with an allograft reconstruction are 4 times higher than those of autograft reconstructions. For each 10 year decrease in age, the odds of graft rupture increase 2.3 times (Kaeding et.al, 2011). The conclusion formed from their data revealed that there is an increased risk of ACL graft rupture in patients who have undergone allograft reconstruction. Younger patients also have an increased risk of ACL graft failure (Kaeding et.al, 2011).

 

 

The final study in this section tested allograft ACL reconstruction in the young, active patient. Their results showed that high activity allograft patients had a 2.6 to 4.2 fold increase in the probability of graft failure compared with low activity bone-patellar tendon-bone allograft patients and low and high activity bone-patellar tendon-bone autograft patients (Barrett, Luber, Replogle, and Manley, 2010). Patients undergoing bone-patellar tendon-bone autograft reconstruction reported significantly fewer problems on a visual analog scale and scored significantly higher on the postoperative Tegner activity scale than patients undergoing allograft reconstruction (Barrett, Luber, Replogle, and Manley, 2010). The active allograft group is 2.6 to 4.2 times more likely to fail compared with low-activity allografts and low and high activity autografts. We conclude that fresh-frozen bone-patellar tendon-bone allografts should not be used in young patients who have a high Tegner activity score because of their higher risk of failure (Barrett, Luber, Replogle, and Manley, 2010).

 

 

 

Conclusion

 

Based on the three studies demonstrated above about allografts, the athlete should stay away from allografts due to the increased risk of ACL graft rupture and higher risk of failure. So this leaves the option of autografts. But which one? Well, based on the studies above, research shows that a patellar tendon autograft is the best way to go for the serious athlete. This is due to the patellar tendon autografts having a significantly lower rate of graft failure and resulting in better static knee stability and increased patient satisfaction compared with hamstring tendon autografts. All of the studies shown in the autograft section demonstrate that patellar tendon graft lead to more stable knees with less anterior laxity and less pivot shift. Patients that choose to go with the hamstring tendon autograft need more hamstring strengthening exercises, and slower rehabilitation protocols that needs to focus on hamstring strength than those that choose the patellar tendon autograft.

 

Furthermore, these studies show that athletic patients with patellar tendon autografts returned to their sport earlier and at a higher level than those operated on with hamstring tendon grafts. However there is a word of caution for the patellar tendon autograft, that all three studies agreed upon; and that is that the patellar tendon autograft reconstructions resulted in an increased rate of anterior knee pain, especially in a kneeling position. Besides the anterior knee problems, the patellar tendon reconstructions resulted in a statistically significant loss of extension range of motion and a trend towards loss of knee extension strength. Those that went with the hamstring tendon reconstructions demonstrated a trend towards loss of flexion range of motion and a statistically significant loss of knee flexion strength.

 

 

The big take home message here is that there will obviously be a handful of pros and cons between the choice of hamstring or patellar tendon autografts. Perhaps the biggest determiner in answering this question is what your sport is, what you really cannot afford to lose in terms of knee flexion/extension and knee pain, and weight out whether the pros and cons work for you on your field or court.

 

 

 

 

References:

“A.” Taber’s Cyclopedic Medical Dictionary. Philadelphia: F.A. Davis, 2013. 123-24. Print.

 

Arneja, S., & Leith, J. (2009). Review article: Validity of the KT-1000 knee ligament arthrometer. Journal of Orthopaedic Surgery, 17(1).

 

Barrett, G. R., Luber, K., Replogle, W. H., & Manley, J. L. (2010). Allograft anterior cruciate ligament reconstruction in the young, active patient: Tegner activity level and failure rate. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 26(12), 1593-1601.

 

Dooley, P. J., Chan, D. S., Dainty, K. N., Mohtadi, N. G., & Whelan, D. B. (2006). Patellar tendon versus hamstring autograft for anterior cruciate ligament rupture in adults. The Cochrane Library.

 

Edgar, C. M., Zimmer, S., Kakar, S., Jones, H., & Schepsis, A. A. (2008). Prospective comparison of auto and allograft hamstring tendon constructs for ACL reconstruction. Clinical orthopaedics and related research, 466(9), 2238-2246.

 

Freedman, K. B., D’Amato, M. J., Nedeff, D. D., Kaz, A., & Bach, B. R. (2003). Arthroscopic Anterior Cruciate Ligament Reconstruction A Metaanalysis Comparing Patellar Tendon and Hamstring Tendon Autografts. The American journal of sports medicine, 31(1), 2-11.

 

Griffin, L. Y., Agel, J., Albohm, M. J., Arendt, E. A., Dick, R. W., Garrett, W. E., … & Wojtys, E. M. (2000). Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. Journal of the American Academy of Orthopaedic Surgeons, 8(3), 141-150.

 

Heijne, A., & Werner, S. (2010). A 2-year follow-up of rehabilitation after ACL reconstruction using patellar tendon or hamstring tendon grafts: a prospective randomised outcome study. Knee Surgery, Sports Traumatology, Arthroscopy,18(6), 805-813.

 

Kaeding, C. C., Aros, B., Pedroza, A., Pifel, E., Amendola, A., Andrish, J. T., … & Spindler, K. P. (2011). Allograft versus autograft anterior cruciate ligament reconstruction predictors of failure from a MOON prospective longitudinal cohort. Sports Health: A Multidisciplinary Approach, 3(1), 73-81.

Read More

Increased Strength and Power vs. Improved Aesthetics: Who Wins?

  |   Injury Prevention and Care, Performance Training   |   No comment

When preparing for an assessment of any kind, one has to take into consideration the goals, abilities, and functional needs that the an athlete may have. When Walter came in to Accelerate Sports Performance, he was looking to rehabilitate a bulging lumbar disc, rebuild a slowly atrophying body due to his movement limitations, and reach levels of elite performance. We knew that meant having to increase his strength and endurance in order to relieve the compressive forces on his spine. Walter is an intelligent athlete, and he knew that gaining size was not the answer to getting stronger. This is not to say that gaining size means that one cannot get stronger, rather much could be done with his current physical stature via mitochondrial plasticity.

 

 

An article on heavy resistance training explains that “Heavy resistance training is associated with increased body weight, lean body mass, and muscle cross-sectional area. The increased muscle cross-sectional area is mainly brought about by hypertrophy of individual muscle fibers” (Tesch, 1988). However, one does not need to only look for size in order to gain strength.

 

 

Here at Accelerate, we know that packing in strength, increasing mitochondrial density, and enhancing neuromuscular adaptations  is the real key to making an athlete stronger without necessarily having to increasing mass dramatically. Our goal was to achieve these goals without adding further unnecessary compressive forces to his spine via body wieght.

 

 

Another article describing the plasticity of mitochondria explains that “Mitochondria in skeletal muscle tissue can undergo rapid and characteristic changes as a consequence of manipulations of muscle use and environmental conditions (Hoppeler & Fluck, 2002). They also explain that “Strength training has a major impact on muscle myofibrillar volume” (Hoppeler & Fluck, 2002).

 

 

Walter’s first assessment here at ASP was on 7-7-14, and his re-assessment was on 10-8-15.  Due to Walter’s lumbar impingement, we did not prescribe a strength assessment. Therefore, in order to create the strength assessment data needed for comparison to his re-assessment, we gathered Walter’s prescribed programs created by our strength and conditioning staff and estimated his 1 rep max based on his 3 rep recorded numbers. This was quite essential in Walter’s case. It would have been a contraindication to max load him or prescribe common baseline testing exercises for that matter. Below are some examples of compressive forces and the direction of forces on the lumbar spine:

Screen Shot 2015-10-26 at 8.34.17 AM

(Normal discographs under increasing pressure)

Screen Shot 2015-10-26 at 8.34.31 AM

However, we did need to increase his core strength, stability, and create a good zone of apposition (and related imbalances) in order to release those compressive forces from his lumbar spine. When Walter came in for his first assessment, he could not stand in work functions for long periods of time, as he would experience lumbar pain and radicular down his legs. Now, he has the core strength, stability, and diaphragmatic adaptations to stand in work functions for long periods of time. Even more impressive, his new overall strength has released those compressive forces from his lumbar spine and he no longer experiences the previous symptoms he experienced during his first assessment. The question becomes: Could Walter have had those strength gains, without actually increasing his mass and size? We decided to answer this question by gathering the data from Walter’s first assessment and his re-assessment, and translating them into readable graphs below.

 

 

 

 

Raw Data:

 

Re-Assessment Comparision Chart

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Here we have Walter’s raw data gathered from his first assessment at ASP, his previous programs, and his re-assessment. Due to a possible bulging disc in his lumbar spine, strength testing was terminated during his first assessment. Instead, we focused on his lower body elasticity and cardiac output. The numbers we have gathered for his strength were based off of previous programs that were prescribed to Walter during his time here at ASP. Included in this raw data, we also have the percentage increase from his first assessment to his second assessment, and the integer increases within the various tests

Lower Body Elasticity:

 

Vertical Jump (Inches) Graph

 

 

 

 

 

 

 

 

 
Here we have Walter’s vertical jump, measured in inches on our vertical jump mat. The X-axis represents the time frame of each assessment, and the Y-axis represents inches measured. This graph allows us to see the linear progression Walter has achieved from his first assessment to his second assessment here at ASP. Located at the bottom of the graph are the dates from his first assessment and his second assessment, demonstrating the timeline between prescribed strength training.

 

 

Screen Shot 2015-10-21 at 4.12.05 PM

 

 

 

 

 

 

 

 

 

 

 

 

Here we also have Walter’s vertical jump, measured in inches on our vertical jump mat. However, it is demonstrated as a column of percentage increase to better visualize Walter’s achievements during his training here at ASP. The X-axis represents the time frame of each assessment, and the Y-axis represents the percentage increase. This graph allows us to see the tremendous improvement in his vertical jump from his first assessment to his second assessment. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

 

Broad Jump (Inches) Graph

 

 

 

 

 

 

 

 

 

 

 

 

Here we have Walter’s broad jump, measured in inches using a measuring tape. The X-axis represents the time frame of each assessment, and the Y-axis represents inches measured. This graph allows us to see the linear progression Walter has achieved from his first assessment to his second assessment here at ASP. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

 

Screen Shot 2015-10-21 at 4.15.01 PM

 

 

 

 

 

 

 

 

 

 

 


Here we also have Walter’s broad jump, measured in inches using a measuring tape. However, it is demonstrated as a column of percentage increase to better visualize Walter’s achievements during his training here at ASP. The X-axis represents the time frame of each assessment, and the Y-axis represents the percentage increase. This graph allows us to see the tremendous improvement in his broad jump from his first assessment to his second assessment. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

 

Left Leg Lateral Bound (Inches) Graph

 

 

 

 

 

 

 

 

 

 

 

 

Here we have Walter’s left leg lateral bound, measured in inches using a measuring tape. The X-axis represents the time frame of each assessment, and the Y-axis represents inches measured. This graph allows us to see the linear progression Walter has achieved from his first assessment to his second assessment here at ASP. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

 

Screen Shot 2015-10-21 at 4.17.49 PM

 

 

 

 

 

 

 

 

 

 

 

 

Here we also have Walter’s left leg lateral bound, measured in inches using a measuring tape. However, it is demonstrated as a column of percentage increase to better visualize Walter’s achievements during his training here at ASP. The X-axis represents the time frame of each assessment, and the Y-axis represents the percentage increase. This graph allows us to see the tremendous improvement in his left leg lateral bound from his first assessment to his second assessment. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

 

Right Leg Lateral Bound (Inches) Graph

 

 

 

 

 

 

 

 

 

 

 

 

Here we have Walter’s right leg lateral bound, measured in inches using a measuring tape. The X-axis represents the time frame of each assessment, and the Y-axis represents inches measured. This graph allows us to see the linear progression Walter has achieved from his first assessment to his second assessment here at ASP. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

Screen Shot 2015-10-21 at 4.23.39 PM

 

 

 

 

 

 

 

 

 

 

 

 

Here we also have Walter’s right leg lateral bound, measured in inches using a measuring tape. However, it is demonstrated as a column of percentage increase to better visualize Walter’s achievements during his training here at ASP. The X-axis represents the time frame of each assessment, and the Y-axis represents the percentage increase. This graph allows us to see the tremendous improvement in his right leg lateral bound from his first assessment to his second assessment. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

 

Strength:

 

Hex Bar Deadlift (lbs) Graph

 

 

 

 

 

 

 

 

 

 

 

 

Here we have Walter’s hex bar deadlift, measured in pounds. The X-axis represents the time frame of each assessment, and the Y-axis represents pounds measured. This graph allows us to see the linear progression Walter has achieved from his first assessment to his second assessment here at ASP. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

 

Screen Shot 2015-10-21 at 4.26.55 PM

 

 

 

 

 

 

 

 

 

 

 

 

Here we also have Walter’s hex bar deadlift measured in pounds. However, it is demonstrated as a column of percentage increase to better visualize Walter’s achievements during his training here at ASP. The X-axis represents the time frame of each assessment, and the Y-axis represents the percentage increase. This graph allows us to see the tremendous improvement in his hex bar deadlift from his first assessment to his second assessment. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

 

Neutral Grip Bench Press (lbs) Graph

 

 

 

 

 

 

 

 

 

 

 

 

Here we have Walter’s neutral grip bench press, measured in pounds. The X-axis represents the time frame of each assessment, and the Y-axis represents pounds measured. This graph allows us to see the linear progression Walter has achieved from his first assessment to his second assessment here at ASP. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

Screen Shot 2015-10-21 at 4.29.09 PM

 

 

 

 

 

 

 

 

 

 

 

 

Here we also have Walter’s neutral grip bench press measured in pounds. However, it is demonstrated as a column of percentage increase to better visualize Walter’s achievements during his training here at ASP. The X-axis represents the time frame of each assessment, and the Y-axis represents the percentage increase. This graph allows us to see the tremendous improvement in his neutral grip bench press from his first assessment to his second assessment. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

 

Safety Bar Squat (lbs) Graph

 

 

 

 

 

 

 

 

 

 

 

 

Here we have Walter’s safety bar squat, measured in pounds. The X-axis represents the time frame of each assessment, and the Y-axis represents pounds measured. This graph allows us to see the linear progression Walter has achieved from his first assessment to his second assessment here at ASP. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

 

Screen Shot 2015-10-21 at 4.32.08 PM

 

 

 

 

 

 

 

 

 

 

 

 

Here we also have Walter’s safety bar squat measured in pounds. However, it is demonstrated as a column of percentage increase to better visualize Walter’s achievements during his training here at ASP. The X-axis represents the time frame of each assessment, and the Y-axis represents the percentage increase. This graph allows us to see the tremendous improvement in his safety bar squat from his first assessment to his second assessment. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

 

Pull-Up (lbs) Graph

 

 

 

 

 

 

 

 

 

 

 

 

Here we have Walter’s pull-up, measured in pounds. The X-axis represents the time frame of each assessment, and the Y-axis represents pounds measured. This graph allows us to see the linear progression Walter has achieved from his first assessment to his second assessment here at ASP. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

 

Screen Shot 2015-10-21 at 4.33.47 PM

 

 

 

 

 

 

 

 

 

 

 

 

Here we also have Walter’s pull-up measured in pounds. However, it is demonstrated as a column of percentage increase to better visualize Walter’s achievements during his training here at ASP. The X-axis represents the time frame of each assessment, and the Y-axis represents the percentage increase. This graph allows us to see the tremendous improvement in his pull-up from his first assessment to his second assessment. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

 

Conventional Deadlift (lbs) Graph

 

 

 

 

 

 

 

 

 

 

 

 

Here we have Walter’s conventional deadlift, measured in pounds. The X-axis represents the time frame of each assessment, and the Y-axis represents pounds measured. This graph allows us to see the linear progression Walter has achieved from his first assessment to his second assessment here at ASP. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

 

Screen Shot 2015-10-21 at 4.35.33 PM

 

 

 

 

 

 

 

 

 

 

 

 

Here we also have Walter’s conventional deadlift measured in pounds. However, it is demonstrated as a column of percentage increase to better visualize Walter’s achievements during his training here at ASP. The X-axis represents the time frame of each assessment, and the Y-axis represents the percentage increase. This graph allows us to see the tremendous improvement in his conventional deadlift from his first assessment to his second assessment. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

 

Woodway:

 

Woodway (Speed Protocol) - Speed Per Round Graph

 

 

 

 

 

 

 

 

 

 

 

 

Here we have Walter’s Woodway speed protocol, measured in miles per hour. The X-axis represents each round Walter successfully completed, and the Y-axis represents the miles per hour measured. This graph allows us to see the linear progression Walter has achieved from his first assessment to his second assessment here at ASP. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

 

Woodway (Speed Protocol) - Average Speed Graph

 

 

 

 

 

 

 

 

 

 

 

 

Here we have Walter’s Woodway speed protocol, measured in miles per hour. The X-axis represents the time frame of each assessment, and the Y-axis represents the miles per hour measured. This graph allows us to see the linear progression Walter has achieved from his first assessment to his second assessment here at ASP. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

 

 Screen Shot 2015-10-21 at 4.39.04 PM

 

 

 

 

 

 

 

 

 

 

 

Here we have Walter’s Woodway speed protocol, measured in miles per hour. However, it is demonstrated as a column of percentage increase to better visualize Walter’s achievements during his training here at ASP. The X-axis represents the time frame of each assessment, and the Y-axis represents the percentage increase. This graph allows us to see the tremendous improvement in his Woodway speed protocol from his first assessment to his second assessment. Located at the bottom of the graph are the dates from his first assessment to his second assessment, demonstrating the timeline between prescribed strength training.

 

 

Screen Shot 2015-10-21 at 4.40.03 PM

 

 

 

 

 

 

 

 

 

 

 

 

Here we have Walter’s Woodway speed protocol during his first assessment, measured in minutes. The X-axis represents the time frame of each assessment, and the Y-axis represents the minutes measured. This graphs allows us to see how long Walter performed total work, and how long he performed total work with the added rest periods at the end of each round, which can be translated to cardiac output. Located at the bottom of the graph is the date from his first assessment here at ASP.

 

 

Screen Shot 2015-10-21 at 4.41.00 PM

 

 

 

 

 

 

 

 

 

 

 

 

Here we have Walter’s Woodway speed protocol during his re-assessment,  The X-axis represents the time frame of each assessment, and the Y-axis represents the minutes measured. This graphs allows us to see how long Walter performed total work, and how long he performed total work with the added rest periods at the end of each round. When comparing this to the graph above, we can see that Walter performed total work for a longer duration, which correlates to having a greater cardiac output. Located at the bottom of the graph is the date from his second assessment here at ASP.

 

 

Woodway (Speed Protocol) - Total Work vs. Rest Ratio Graph

 

 

 

 

 

 

 

 

 

 

 

 

Here we have Walter’s Woodway speed protocol during his first assessment, graphed as a pie chart. This pie chart demonstrates Walter’s work to rest ratio during his first assessment here at ASP. The blue pie represents the total amount of work completed in minutes, and the red pie represents the total amount of rest accumulated at the end of each round in minutes. Located at the bottom of the graph is the date from his first assessment here at ASP.

 

 

Woodway (Speed Protocol) - Total Work vs. Rest Ratio #2 Graph

 

 

 

 

 

 

 

 

 

 

 

 

Here we have Walter’s Woodway speed protocol during his re-assessment, graphed as a pie chart. This pie chart demonstrates Walter’s work to rest ratio during his first assessment here at ASP. The blue pie represents the total amount of work completed in minutes, and the red pie represents the total amount of rest accumulated at the end of each round in minutes. Located at the bottom of the graph is the date from his second assessment here at ASP.

 

 

 

 

Conclusion:

 

When Walter first came into Accelerate Sports Performance, he came in looking to relieve a serious ailment. He could not stand for long periods of time during work-related functions, nor could he put any load through his spine. Fortunate for our unimpeded implementation, Walter was an intelligent athlete that understood that increasing body mass and size was not going to align with our goals, as this would only exacerbate the already serious problem. Now over one year later, Walter is exceeding his performance goals at a functional size. He no longer experiences pain-like symptoms from his bulging lumbar disc, nor does it hold him back during any lifestyle activities. His success was largely due to focused work on centralizing his L4-L5 disk by prescribing core strengthening, stability, postural, and respiratory exercises and integrating strength him proximally to distally.

 

 

So the question remains: can one demonstrate increases in power and strength, but not see it physically? Based on the evidence gathered from Walter’s re-assessment here at ASP, we can confidently answer “yes” to that question. The graphs and data shown above demonstrates the answer to that question in tremendous form; that just because one may not see massive gains in size during strength training, doesn’t mean that they are not increasing their strength and power during the process.

 

 

 

 

References:

 

Hoppeler, H., & Fluck, M. A. R. T. I. N. (2003). Plasticity of skeletal muscle mitochondria: structure and function. Medicine and science in sports and exercise, 35(1), 95-104.

 

Roaf, R. (1960). A study of the mechanics of spinal injuries. Journal of Bone & Joint Surgery, British Volume, 42(4), 810-823.

 

Tesch, P. (1988). Skeletal muscle adaptations consequent to long-term heavy resistance exercise. Medicine and Science in Sports and Exercise, 20(5 Suppl), S132.

Read More

Shoulder Health in the Plane of the Scapula

  |   Injury Prevention and Care, Performance Training, Video   |   No comment

What is the plane of the scapula?

 

The plane of the scapula can be defined as the normal resting position of the scapula as it lies on the posterior rib cage at an angle of 30-45˚ (Johnson 2005). It can also be defined as the angle assumed by the face of the glenoid fossa (Starkey & Ryan, 2010). In simple terms, this arm position is the angle in which the scapula is laterally facing outwards from an individual’s upper back. The picture below gives an illustration of where exactly the plane of the scapula lies:

 
Screen Shot 2015-05-18 at 9.25.35 AM

Why move within the plane of the scapula?

 

There are several reasons that explain why it is beneficial to move within this plane. The first, and probably the most important reason, has to do with simple physics. When one is in the plane of the scapula, the mechanical axis of the humerus approximates with the mechanical axis of the scapula (Johnson, 2005). This optimally aligns the deltoid muscles and the supraspinatus muscle for elevation of the arm, thereby avoiding subacromial impingement during shoulder abduction (Paine & Voight, 2013).

Screen Shot 2015-05-18 at 9.25.25 AM

 

Another reason for moving within the scapular plane is that it puts less stress on the shoulder capsule. When the arm is raised overhead in the sagittal or frontal plane, the shoulder capsule is stressed from obligatory humeral rotation. For example in the frontal plane, the anterior capsule structures are tensioned, which may complicate soft tissue healing in patients who have glenohumeral injuries/instability. Whereas within the scapular plane, the inferior part of the capsule is relaxed, since no humeral rotation is required (Paine & Voight, 2013).

 

A final reason for moving within the plane of the scapula can be explained by the rule of the length-tension relationship. Since the rotator cuff muscles originate from the scapula, the position of the humerus in the scapular plane increases the length-tension relationship of the deltoid and rotator cuff muscles, therefore helping to facilitate optimal muscle force (Paine & Voight, 2013).

 

Overall, research has suggested that exercises completed in this specific plane can provide great benefits for improving shoulder function. Improvements in function and shoulder biomechanics include relief of the anterior capsular structures of the shoulder, decreased chance of rotator cuff compression, and an overall improvement of the shoulder complex neuromuscular performance. As well as improving the overall function of the shoulder, the improvements also reduce the chance of pain and injury for the shoulder complex, particularly in overhead throwing sports/ movements. (Paine & Voight, 2013)

 

Pressing exercises in the plane of the scapula vs the frontal plane

 

An example of a strength exercise being performed in the scapular plane is the 2DB bench press. A study done on the avoidance of shoulder injuries during resistance training showed that performing this exercise, or any overhead press within the scapular plane will help minimize anterior capsular distension (Davies, Durall, & Manske 2001).

 

Several studies have shown the importance of exercising in the scapular plane versus exercising in the sagittal or frontal planes. For example, a study conducted on the assessment of internal and external rotation in the frontal plane versus the plane of the scapula found that isokinetic strength testing of the shoulder’s internal and external rotators within the scapular plane had several advantages to testing in the frontal plane. Abducting the arm within the frontal plane tends to place the glenohumeral joint into more of a closed packed position. This position may place undesirable stress on the soft tissues of an injured joint, and may even be uncomfortable for healthy subjects (Hellwig & Perrin, 1991). Movement within the scapular plane minimizes tension/rotation of the inferior portion of the capsule and enhances stability of the glenohumeral joint by allowing a maximal amount of congruity between the head of the humerus and the glenoid fossa (Hellwig & Perrin, 1991). Because greater stability and increased comfort are important factors to consider when strength-testing or rehabilitating the shoulder, the scapular plane should be the preferred position.

 

 

External rotation in the plane of the scapula

 
Studies have also shown that external rotation within the plane of the scapula is more beneficial in terms of the amount of torque produced during concentric and eccentric contractions. The study done by Hellwig and Perrin demonstrated that assessing isokinetic strength of the shoulder internal and external rotators in the scapular plane changes the peak torque to body weight ratios for concentric external rotation. They found external rotation peak torque to body weight ratio values to be significantly higher in the plane of the scapula than in the frontal plane (Hellwig & Perrin, 1991). This correlates with the previous finding of increasing the length-tension relationship when one is within the scapular plane, thus increasing the amount of torque and muscle force produced. The table below illustrates the degree of muscle activation during external rotation in several different positions:

 

Screen Shot 2015-05-18 at 9.25.02 AM

The table above demonstrates 3 of the 4 rotator cuff muscles and deltoid muscles that are activated during external rotation and abduction. Here we can see that performing external rotation while standing and in the scapular plane at 45˚ abduction shows the infraspinatus and teres minor being the most active, when compared to the supraspinatus, middle deltoid, and posterior deltoid (Andrews, Escamilla, & Yamashiro, 2009).

 

This is due to the role that the infraspinatus performs during glenohumeral abduction. At about 70˚, the humeral head becomes depressed by the infraspinatus, teres minor, and subscapularis to allow the humeral head to clear the acromion process. At 115˚, the humeral head is externally rotated by the infraspinatus and teres minor in order to clear the greater tuberosity of the humerus under the acromial arch.

 

Rhythmic stabilization in the plane of the scapula vs outside of the plane of the scapula: Is it still beneficial?

 

Rhythmic stabilization movements are short, rapid movements in an acute area performed for a short period of time, i.e., 10 seconds. These movements can be used to enhance shoulder function, as they improve neuromuscular control, proprioception, and dynamic stabilization. Physiologically speaking, these exercise drills facilitate agonist/antagonist muscle co-contractions, which allows for efficient coactivation to occur. This restores the balance in the force couples of the shoulder joint, and thus enhancing joint congruency and joint compression (Townsend et al, 1991). Research has shown that rhythmic stabilization movements performed in the plane of the scapula, and at the end-range external rotation positions can greatly benefit the shoulder complex, especially for the overhead throwing athlete who is either recovering from injury, or who is preventing injury in the first place. In saying this, rhythmic stabilization exercises performed in different planes can be beneficial for the injury prevention of any athlete, as different angles though the various possible ranges of motion can be targeted and improved on (Wilk et al, 2002).

 

 

References
 
Durall, Chris J., Robert C. Manske, and George J. Davies. “Avoiding Shoulder Injury From
Resistance Training.” Strength & Conditioning Journal 23.5 (2001): 10.
 
Escamilla, R. F., Yamashiro, K., Paulos, L., & Andrews, J. R. (2009). Shoulder muscle activity
and function in common shoulder rehabilitation exercises. Sports medicine, 39(8), 663-685.
 
Hellwig, E.V. & Perrin, D.H. (1991). A comparison of two positions for assessing shoulder
rotator peak torque: the traditional frontal plane versus the plane of the scapula. Isokinetics and Exercise Science, 1, 1-5.
 
Johnston, T. B. (1937). The movements of the shoulder joint: A plea for the use of the plane
of the scapula as the plane of reference for movements occurring at the
humero‐scapular joint. British Journal of Surgery, 25(98), 252-260.
 
Paine, R., & Voight, M. L. (2013). THE ROLE OF THE SCAPULA. International Journal of
Sports Physical Therapy, 8(5), 617–629.
 
Starkey, Chad, Sara D. Brown, Jeffrey L. Ryan, and Chad Starkey.Examination of Orthopedic
and Athletic Injuries. Philadelphia: F.A. Davis, 2010. Print.
 
Wilk, K. E., Meister, K., & Andrews, J. R. (2002). Current concepts in the rehabilitation of the
overhead throwing athlete. The American Journal of Sports Medicine, 30(1), 136-151.

Read More

Success on the Court!

  |   Injury Prevention and Care, Performance Training, Photos, Video   |   No comment

Congrats, boys, on a tremendous win! Physically and mentally you outperformed an elite opponent.

 

Paris led all scorers with 21 points and a major spark in the second half while Ivan hit the game winner with 0.8 to play. See article below and gain some insight into the leading scorers training ingredients.

 

 

#repostmonday @chefboyparis #athlete #basketball #oakland #soldiers #dreamvision #ASPEED #ASPnation

A video posted by AccelerateSP (@acceleratesp) on

 

In this resistance based power protocol we take between 40% and 60% of Paris’s max resisted sprint capability and apply for short/moderate bouts for long durations. The key is that the athlete can maintain that pace throughout the entire session with the HR in the appropriate ranges during the work/rest portions of the session. In this case Paris was running with 25lbs of resistance at a speed of 9+mph for bouts of 10 seconds with 50 seconds of rest. His hard work and perseverance has served him well!

Read More

Shear Knee Forces in Weightlifting Exercises

  |   Injury Prevention and Care, Performance Training, Video   |   No comment

Introduction

 

All athletes are subject to various amounts of momentum, force, and overall impact on the knee. It is paramount that athletes build stable, synergistic, and efficient levers up and down the kinematic chain when engaging in their preferred sport.   Throughout the course of this article we will look at five different exercises; the dynamic squat, the barbell squat, the power squat, the front squat, and the lunge. With each exercise, we will discover the differences in shear and compressive forces on the tibiofemoral joint and the patellofemoral joint, as well as take a look at knee kinetics that occur during the different phases of each exercise. From the studies presented below, we can present and rank the following exercises in order from most stressful knee forces to least stressful knee forces:

 

1. Lunge

2. Front squat

3. Power squat

4. Barbell squat (unrestricted)

5. Barbell squat (restricted)

6. Dynamic squat

 

The Dynamic Squat

 

There are several studies that look at diverse exercise movements that involve flexion and extension of the knee joint. One such study involves examining knee biomechanics during a dynamic squat exercise, as illustrated in the picture below:

convexMoment Arm

 

In this study, the researchers examined tibiofemoral shear and compressiveforces, patellofemoral compressive forces, knee muscle activity, and knee stability relative to athletic performance, injury potential, and rehabilitation (Escamilla, 2001). Their results showed several things; first, that there were low to moderate posterior shear forces restrained primarily by the posterior cruciate ligament (PCL), that were generated throughout the squat for all knee flexion angles. Second, there were low anterior shear forces restrained primarily by the anterior cruciate ligament (ACL), that were generated between 0 and 60° of knee flexion. And third, patellofemoral compressive forces and tibiofemoral compressive and shear forces progressively increased as the knees flexed and decreased as the knees extended, reaching peak values near maximum knee flexion (Escamilla, 2001). Hence, training the squat in the functional range between 0 and 50° knee flexion may be appropriate for many knee rehabilitation patients, because knee forces were minimum in the functional range. The Barbell Squat (Back)   As mentioned above, the previous study only looked at the knee biomechanics during a bodyweight dynamic squat. However, even with just a normal bodyweight squat we can see that there are still compressive and shear forces acting on the knee joint. Here we will take a look at another research study that observed the effect of knee position on hip and knee torques during a barbell squat. ABTo be more specific, this study examined joint kinetics that occurs when forward displacement of the knees are restricted, versus when such movement is not restricted. The methods included seven weight-trained men who averaged about 27.9 years, being videotaped while performing two variations of parallel barbell squats (Fry, Schilling & Smith, 2003). The first variation performed was permitting the knees to move anteriorly past the toes (unrestricted), and the second variation performed was providing a wooden barrier to prevent the knees from moving anteriorly past the toes (restricted), as shown in the picture below: The results of the unrestricted squat showed that knee torque for all participants averaged about 150.1 N·m with a mean standard deviation of 50.8 N·m. Hip torque for the unrestricted squat was 28.2 N·m with a mean standard deviation of 65.0 N·m. The results of the restricted squat showed that knee torque was 117.3 N·m with a mean standard deviation of 34.2 N·m. Hip torque for restricted squat was 302.7 N·m with a mean standard deviation of 71.2 N·m. The restricted squats also produced more anterior lean of the trunk and shank and a greater internal angle at the knee and ankles. The illustration below provides a more detailed description of the torque produced at the knee and hip during both variations of barbell squats:   This study’s experimental studies demonstrate that although restricting forward movement of the knees may minimize stress on the knees, it is likely that forces are inappropriately transferred to the hips and low-back region. Thus, appropriate joint loading during this barbell exercise may require the knees to move slightly past the toes while the center of gravity remain directly above the midfoot.UnvsRES

 

The Power Squat, Front Squat, and Lunge

 

A final study done on knee forces looked to analyze intersegmental forces at the tibiofemoral joint and muscle activity during the power squat, the front squat, and the lunge, as illustrated in the picture below. The results for this study showed that maximal posterior shear of 495 N (±72) occurred with the lunge at 103° of knee flexion. During the power squat and the front squat, the posterior shear forces were the same, with a maximum of 295N (±32) at 93° and 295N (±33) at 97° of knee flexion (Growney, Lutz, Meglan & Stewart, 1996). Joint compression forces of 500-600 N remained relatively constant throughout the descent and ascent phases of the power squat and the front squat. The lunge produced the highest joint compression, reaching a maximum of 716 N (±70) at 76° (±25°) of knee flexion. A rapid increase in joint compression during the lunge occurred with the foot strike when stepping forward with the right leg, but the force remained relatively constant during the descent and ascent phases of the exercise (Growney, Lutz, Meglan & Stewart, 1996). The means of maximal extension moments were similar for all exercises, measuring 113 N-m (±23) for the lunge, 89 N-m (±12) for the front squat, and 86 N-m(±13)for the power squat at terminal flexion. Significant differences between the exercises were most notable when the knee flexion angle approached its peak.

 

In particular, the lunge exercise was found to have significantly higher posterior shear forces (tibia force on femur) than both the power squat and front squat at several exercise events (Growney, Lutz, Meglan & Stewart, 1996). These differences appeared when the knee was flexed at 60° in the descent phase, 90° in both the ascent and descent phases, and in the maximal magnitude of the shear force. Similarly, higher maximal net extension moments about the knee were observed in the lunge than in either the power squat or front squat. Significantly higher net extension moments in the lunge compared with the other two exercises were observed when the knee was flexed at 90° while in the descent phase (Growney, Lutz, Meglan & Stewart, 1996). The lunge net extension moments were significantly higher than the front squat moments at 60° of knee flexion during descent.   To summarize, the mean tibiofemoral shear force was posterior throughout the cycle of all three exercises. The magnitude of the posterior shear forces increased with knee flexion during the descent phase of each exercise. Joint compression forces remained constant throughout the descent and ascent phases of the power squat and the front squat. A posterior tibiofemoral shear force throughout the entire cycle of all three exercises in these subjects with anterior cruciate ligament-intact knees indicates that the potential loading on the injured or reconstructed anterior cruciate ligament is not significant. The magnitude of the posterior tibiofemoral shear force is not likely to be detrimental to the injured or reconstructed posterior cruciate ligament. These conclusions assume that the resultant anteroposterior shear force corresponds to the anterior and posterior cruciate ligament forces.  

 

Conclusion  

 

Throughout the course of this paper we have looked at five different exercises; the dynamic squat, the barbell squat, the power squat, the front squat, and the lunge. With each exercise, we have discovered the differences in shear and compressive forces on the tibiofemoral joint and the patellofemoral joint, as well as taken a look at knee kinetics that occur during the different phases of each exercise. From the studies presented above, we can present and rank the above exercises in order from most stressful knee forces to least stressful knee forces:

 

1. The lunge

2. The front squat

3. The power squat

4. The (unrestricted) barbell squat

5. The (restricted) barbell squat

6. The dynamic squat

 

It is important to take into account the stresses you are loading the knee with and incorporating exercises that may be more conducive to athletes’ longevity and injury prevention in regards to tibiofemoral or patellofemoral dysfuntion or related symptoms. That said be creative, empirically driven, and subjective in your approach to practicing or prescribing core and lower body strength exercises:

 

 

 

References

 

An, K.N., Growney, E.S., Lutz, G.E., Meglan, D.A. & Stuart, M.J. (1996). Comparison of intersegmental tibiofemoral joint forces and muscle activity during various closed kinetic chain exercises. The American Journal of Sports Medicine. 24, (6). 792-799.

 

Escamilla, R.F. (2001). Knee biomechanics of the dynamic squat exercise. Med. Sci. Sports Exerc., 33, (1). 127–141. Fry, A.C., Smith, J.C. & Schilling, B.K. (2003).

 

Effect of knee position on hip and knee torques during the barbell squat. J. Strength Cond. Res. 17, (4). 629–633.

Read More

Low Back Pain Introduction (Part 1 of 3)

  |   Injury Prevention and Care, Photos   |   No comment

At ASP we have clients who take part or compete in the super-G, extreme skiing, surfing, gymnastics, rugby and football among others.  What all of these sports have in common are highly compressive forces via impact or ground reaction, associated with forward flexion, rotation, and/or extension.

 

Sources of Injury

 

In the USA, low back pain is the 2nd most frequent reason for physician visits, the 5th ranking cause of hospital admissions, and 3rd most common cause of surgical procedures (Bakhtiary, 2005).  The majority of low back injuries are not caused by a single event, but rather a culminating injury event resulting from a history of excessive spinal loading (Liebenson, 2007).  Therefore, to understand the source of injury it is important to consider athletic activities as well as activities of daily life that repeatedly apply excessive stress to the spine.

 

Colored in blue are the intervertebral disks which act as shock absorbers between vertebra and colored in pink are ligamentous structures that help provide stability to the spinal column.

 

Regarding injury to the lumbar spine, there are three common mechanisms to consider:

-Compression or axial loading to the spine

-Shear resulting from torque or rotation in a horizontal plane

-Tensile stress produced from excessive motion on the spine

 

Structures & Symptoms

The first picture above displays a top view of a healthy intervertebral disk.  The annulus fibrosus is the sturdier outer portion of the disc, which houses the central aspect called the nucleus pulposus, a gelatinous mass in the center of the disc. Repeated flexion of the lumbar spine creates compression in the anterior region of the disk, as well as stretching or tension posteriorly.  With aging, the disks lose water content and become less flexible and also thinner.  The posterior aspect of the annulus fibrosus is the thinnest portion and if there has been any degeneration of that structure the nucleus pulposus may herniate and compress the spinal cord or the nerve roots (Moore and Dalley, 2005).  This is depicted in the second image with the nucleus pulposus migrating posteriorly through a weakened section in the annulus fibrosus and impinging on the spinal nerve.

 

Depending on the level of nerve-root irritation, symptoms such as pain, numbness, or weakness can radiate down into the posterior thigh, calf, heel, and foot (Kolar, 2005). L5-S1 and L4-L5 are the levels most commonly involved in disk herniation due to the fact that 75% of flexion occurs at L5-S1 and 15-70% at L4-L5 (Prentice, 2004).  Disk herniation at these levels can affect various lumbosacral nerves: superior and inferior gluteal (buttocks), sciatic (thigh), common fibular (foot), tibial nerve (foot) (Kolar, 2005).  In addition, a degenerative disk can cause surrounding musculature to tighten in order to support the low back.  These shortened muscles can also cause nerve compression of the lumbosacral plexus. For example, the piriformis muscle helps to stabilize the hip and when overly tight can compress on the sciatic nerve stemming from L4-S3.

 

A deep understanding of the associated anatomy is very important for proper preventative exercise prescription as well as diagnosis and rehabilitation.  Next week, we will discuss a few things we do at ASP to avoid or rehab the associated structures.

Read More