Giving the gift of HOPE

Personally, I spend an abundance of times trying to learn how to be the best therapist I can be. I read articles. I watch webinars. I follow a lot of extremely smart people on social media (sup Twitter). I think there are a lot of therapists out there that go out of their way to continue growing as clinicians. To be honest, the field of physical therapy attracts the types of people who want to help their patients at all costs, so the fact that most PTs do this is not a surprise.

The other day, I was thinking about something one of my patients said to me last week and it’s really resonated with me. She was discussing how did after her first post-evaluation follow up visit, saying her hip felt much better. She spoke about how she doesn’t feel like her hip is “catching” as often and that she feels like she’s getting stronger.

This was all fantastic to hear, but she finished her subjective with the statement that has resonated with me:

“You’ve given me hope”.

Think about that statement for a second. It caught me off guard at the time, because I typically expect the specifics when speaking to my patients about how their treatment is coming along. About how they have less (hopefully) pain, feel stronger, have better mobility, etc. But that powerful word she used has stuck with me: Hope.

So when I saw her again, after a period of reflection, I asked her what it was about our time together that gave her hope. I wanted to learn. I wanted to know what it was about our interaction that gave her this powerful feeling. She responded pretty simply (I’m paraphrasing): You sat and listened to me, let me tell you my story, my fears, what I want out of this process. And after you listened, you explained things in a way that made sense and made me feel like “I’m going to through this”.

Lost in all the time I’ve spent learning new manual interventions or coming up with different exercises to implement with my patients were the development of my “soft skills” (admittedly, I hate this term, but here we are).

I really subscribe to the notion that patients respond best to PTs who they truly like, PTs who they feel genuinely care about their well being. It really is that simple. Now, there are times where I’ll have patients tell me that they appreciate how much attention I pay to them and how specific I am with interventions, but at the end of the day, if they thought I was a dick or felt like I didn’t listen to them, I don’t think I’d get nearly the type of buy in that I do.

But these “soft skills” are fluid, ever changing skills. It’s not as simple as either you got or you don’t. We must hone these skills. We must never stop learning new approaches to patient interaction. And most importantly, we must put these skills into practice every single day. Because your knowledge base and clinical expertise, in my opinion, will only get you so far. If the most important person in the patient-clinician relationship (hint, it’s the patient) doesn’t buy into YOU, then your “expertise” doesn’t mean a thing.

3 Ways to Avoid Injury Busts During Your Fantasy Football Draft

Every year, just a week or two before the NFL season begins, millions of people sit in front of computers or meet up with their buddies in order to do something that will dictate the next four months of their lives: Draft their fantasy football team. There are tons of different strategies, whether it’s the new Zero RB approach, no QBs until round 8, or the tried and true best player available strategy. But oftentimes, your approach really doesn’t mean anything if your fantasy team comes down with the sickness of all sicknesses: the Injury Bug.

Many people may read an article or two about big players coming back from injury or sleepers who could take advantage of an injury-prone player ahead of them on the depth chart. But one injury-related strategy gets overlooked all the time and it could make or break your season. What strategy is that?

Injury Pattern Recognition

As a physical therapist (PT), I spend my days helping clients recover from injuries/surgeries, manage pain, optimize movement, and, ultimately, return to doing the things they love. However, one major part of a PT’s job that often gets forgotten is injury prevention. We spend years honing our skills in order to identify risk factors and impairments that could predispose people to injury.

One way of doing so is by recognizing patterns. This pattern recognition is crucial to effectively and efficiently correct these risk factors before they lead to injury. And I believe this skill can translate into finding value in your drafts while also avoiding taking risks that just aren’t worth the ROI.

So, without further adieu, here are the top 3 things skilled drafters should do in order to help prevent coming down with the injury bug.

#1 : Target players two seasons removed from surgery

This one comes with a bit of a caveat, as not all surgeries are created equal. Injuries like patellar and achilles tendon tears fall into a category of their own due to their history of severely limiting football players even after their first incident. However, with many other surgeries, a player’s fantasy stats tend to decline slightly the year after surgery, only to spike again to more “normal for that player” levels in the seasons that follow.  I bring this up because we have guys such as Jordy Nelson and Le’Veon Bell who are returning from serious knee injuries that required surgical reconstruction, both of whom are going the first two rounds of most drafts.

Now, by no means am I saying you should completely avoid taking these guys. Guys like Adrian Peterson have shown us that anything is possible with these remarkable athletes. However, I do think we have to temper expectations a bit, especially early in the season, as it takes time for guys to get comfortable with their movement patterns and build confidence in their legs. Remember, these players are spending month after month re-learning how to walk and run and regaining strength and motion they had in abundance just last year. This takes time and we’d be kidding ourselves if we didn’t take that into consideration.

One other consideration with players coming back from ACL surgery is how far removed they are post surgery. A lot of research has come out that has shown that waiting at least 9 months post ACL reconstruction can significantly reduce the risk of re-injury. So a guy like Nelson, who tore his ACL almost 11 months ago will, statistically, have a lower likelihood of re-tearing his ACL vs some one who suffered their injury during Week 5 of the season like Jamaal CharlesJust another thing to keep in mind.

So, who are some guys that fall into this category that we should keep an eye on heading into draft season?

  • Dez Bryant: Obviously, he’s not a sleeper, but since he played last season following injury, I’m counting this as season two post injury. He’s poised for a huge bounce back year.
  • LeSean McCoy: I know, he’s been an injury risk in the past. However, he suffered a hamstring strain before last season even started, tried to play through it, and was never the same as the injury lingered all season. He’s reportedly healthy heading into this season and should be good to go in an improving Buffalo offense.
  • Dennis PittaThis is a deep reach, but he did miss all of last season following two hip dislocations and appears to be showing glimpses of the potential he had prior to injury. He’s currently not even being chosen in most drafts, so this wreaks of a super low risk, high reward pick
  • Michael FloydHe suffered three dislocated fingers that needed surgical repair prior to last season. He didn’t seem to hit his stride until much later in the season, but consistency was a bit of an issue. However, in this potent Cardinals offense with plenty of passes to go around and an ADP making him the 26th WR off the board (according to Fantasy Pros), there could be some value to be had.

#2: Avoid Overpaying for the Dreaded Re-Injury

We’ve seen guys suffer the same type of injury over and over again, year after year. Sam Bradford and his oh-so-fragile knees. Jordan Cameron and his concussions. Arian Foster and his…..everything. We know better, but keep getting burned by convincing ourselves that this year will be different.

What’s worse is when we reach for guys who are not only prone to injury, but who are coming back from the SAME INJURY that they dealt with in the past. Re-injury rates will increase more often than not in two very clear cut scenarios: Coming back from injury too soon AND recurrence of pathology to the same structures. There’s just no way around this. How else do you explain Tony Romo injuring the same clavicle (collar bone) on three separate occasions? Or Jamaal Charles tearing his ACL in both his right and left knees in a 5 year span? Are they just the unluckiest guys in the world?

The involved structure (regardless of tissue type) weakens with injury. On some occasions, if the injury is minor in nature and enough time is allowed for proper healing, nothing lingers and that player never thinks about it again. However, with the pressure to return to sport on these million dollar athletes, proper healing time is not always achieved, leaving the player susceptible for re-injury or compensation (more to come on this).

This comes down to a risk/reward analysis. Would I take Charles in the mid to late 1st round with his injury history, being 30 years old, and two capable backs (Charcandrick West and Spencer Ware) behind him? Not a chance. But if he slips to the late 2nd round because everyone is spooked off? I just may take that chance because the value provided in a best case scenario is off the charts.

Take your time and keep this in mind when considering drafting guys in the first couple rounds. It’s just not worth it to take unnecessary risks early in the draft when there are guys with very similar value and no significant injury risks to worry about available. Also, don’t forget about the value that can be had by drafting the backups of these injury prone players later in drafts, as this could be a sneaky way to take advantage of a star with injury issues.

#3: Watch for Compensatory Injuries Following Surgery

Many people were burned last year thinking that Victor Cruz wouldn’t skip a beat upon his return from a patellar tendon repair. However, during camp, he began to have issues with a calf strain that lingered for weeks. Although all the focus was on how his knee was healing post surgery and whether he’d be ready from a timeline standpoint, the calf strain was not talked about enough. Why did the strain develop? How serious was the strain?

These are the questions you should be asking yourself when you consider drafting someone coming off major surgery. It’s very common for players to compensate as they go through their rehabilitation, which makes the presence of a skilled physical therapist during the process that much more important. Being that PTs are the “movement experts”, our job is to make sure that a player restores their optimal movement patterns and these inefficiencies are identified and corrected early on during their rehab.

In Cruz’s case, players coming back from patellar tendon repairs already have a tough time without the presence of a compensation, so developing this calf strain on top of it was the nail in the coffin for his 2015 season as it required surgical intervention. This is obviously a worst case scenario, but you see how the initial surgery wasn’t even the primary issue anymore, showing how important avoiding compensatory injuries can be.

As you head into your drafts as week 1 nears, do a google search about each player coming off some type of major injury and see if there are any mentions of missing time due to “soreness”, “tightness”, or “discomfort” in a region of the body other than what was originally injured (Obviously, if they mention any of those terms about the original injury, take caution). This will give you insight into how the player has been recovering and will allow you to make a much more informed decision about that player’s prospects for the upcoming season.

If you can follow this advice and avoid making a critical mistake in your drafts, you’ll give yourself a leg up on all of the other teams in your league because I can assure you 99% of your league isn’t taking these things into consideration. So do yourself a favor and be the 1%. You’ll thank me later.

 

Find all of Dr. Ziad Dahdul’s work at fflockerroom.com where he serves as Injury Analyst

Find Dr. Dahdul on Twitter at z_dahdul, where he provides injury analysis in real time and will answer all of your fantasy injury questions!

What Does Evidence Based Practice Really Mean?

Social media is essentially the library of the 21st century, allowing us to accumulate knowledge and better ourselves as clinicians at the touch of a button. But, at the same time, it is a very deep rabbit hole that is extremely hard to navigate. We live in a time where you can find blog posts, watch Instagram or Snapchat videos, and find links on Twitter 24/7, 365. And for the most part, this is a great thing.

However, it appears that with more and more platforms available for people to express their ideas, it becomes harder to wade through the muck because it can be overwhelming at times. I know I’ve seen a ton of exercises and interventions via social media that I now utilize on a daily basis. Are these exercises based on evidence? Not really. Is the self-mob following the convex-concave rule for the targeted joint? Probably, but I’d follow up with my own question, Does it matter?

Nevertheless, we use what gets us results, and I’ve found some amazing interventions on social media and I plan on using them irregardless of whether there’s research to back it up or not.

Point is, if we only utilize interventions and exercises that are validated with randomized controlled trials or meta analyses, we’re limiting ourselves tremendously and, to be quite honest, probably all delivering the same level of service on a daily basis. Evidence is important to use as a guiding principle when educating the population on incidence of pathology, providing causation/correlation for risk factors to a specific disease/condition, and so on. But what we forget to lean on too often is the fact that there are clinicians out there with years of experience treating tens of thousands of patients and have seen first hand, in the trenches, what’s effective and what’s not. And if we ignore the knowledge that’s being shared with us just because there isn’t evidence behind it, we’re really doing our patients a disservice. Also, evidence tends to be significantly behind current practice and really just needs time to catch up.

I’m not here to prove that evidence doesn’t matter and that the literature is pointless. Far from it. I have changed as a clinician every year since I began practicing 6 years ago. I don’t do half of the things I learned in school for a variety of reasons, but one main reason is that I’ve learned and seen interventions that just work better for ME. And if I can provide effective care in a more efficient manner, I have to do it. There are so many innovative clinicians out there and I wouldn’t be challenging myself to be a better PT if I sat and waited for the evidence to catch up.

So my advice: if you see a blog post or video of an intervention or exercise that you can implement into practice and immediately (and safely) help your clients with, do it. Use the evidence accordingly and always make sure your treatment “principles” are guided by the wealth of resources available to us across all platforms.

ACL Prevention Screen Recap

Last weekend, I and three of my PT colleagues went to Biola University to perform a movement screen on their women’s soccer team. This was actually a follow up from the initial screen we performed in October, so it gave us a good idea of how the girls did over the course of the season and whether any of their measures changed over time.

In October, we gave the girls strength, mobility, and proprioceptive exercises to perform throughout the course of the season as an adjunct to their strength program and practice schedule.

This time around, we had 4 stations that stayed consistent:

  1. Double Leg SquatIMG_0647
  2. Single Leg Step Down IMG_0656
  3. Eccentric Weight Acceptance (from jump) IMG_0645
  4. MMTs: Quads, Hamstrings, Hip abductors, Hip Extensors IMG_0661

However, we took out our acceleration drill from the previous session and added the L cutting test, consisting of a 10 yard sprint, followed by a plant-and-cut to the right, then left. (Shout out to Trent Nessler for the inspiration on this one).  IMG_0648

I’m in the process of reviewing the data and comparing the pre and the post results, which I’ll update on this blog at a later time.

Some common movement faults and impairments that we found across the board that were interesting:

  • With the cutting motion, the most consistent fault was a wide plant foot relative to the knee, essentially creating a larger valgus moment at the knee right at the onset of the cut
  • There was a pretty even split between either a proximal contralateral hip drop and knee valgus during the single leg step down, sometimes both at the same time. However, both occurring together didn’t seem as prevalent
  • The girls showed good improvements in weight acceptance during the plyo drill, with the greatest carryover being eccentric knee flexion instead of stiff knees upon landing. We emphasized this at the previous screen and they seemed to take it to heart
  • MMTs of the hips continued to be weak, but at first glance, not quite as weak as it had been. Hopefully the increased emphasis on this will continue to improve as we progress their home program
  • One main impairment during the double leg squat was lacking at least 90 degrees knee flexion at max depth, with common compensations being excessive trunk flexion and some heels off the ground (link to ankle dorsiflexion)
  • Proximal stability seemed to be a common theme across the board. There was a high prevalence of trendelenburg hip drop during their sprints, ipsilateral trunk side bend/contralateral hip drop during SL movements, and excessive trunk flexion (lack of hip mobility) during DL squats at end range.

The head coach of the team, Erin Brunelle, was amazing in her follow through in regards to incorporating the Santa Monica PEP program 3 times per week into their practice schedule. She reported that they were very consistent with this and will continue to do so during their summer training.

For our follow up this time around, I’ll be sending the girls video links to determine if electronic instruction is more effective than paper (they were handed HEPs last time around). This will allow them to have some instruction via video so that they can hopefully better perform the corrective exercises to help with their impairments.

One of the biggest takeaways was how receptive the girls were to our instruction and cuing. They seemed to really understand the importance of awareness and taking action to do everything in their power to minimize the risk of injury. I got a sense that they really took ownership of their learning experience and can see how helpful this information can be in regards to their health and their performance. It was definitely a great learning experience all the way around.

IMG_0665

ACL Injury Prevention: Why Expectation is the Key

Last year, I decided to put together a screen of sorts that can be used on different populations to help identify certain risk factors that could predispose folks to ACL tears. Scouring the literature was a chore, but the biggest take away from my lit review was the fact that there really isn’t a ton of conclusive evidence or consensus on what constitutes a risk factor.

There’s a big distinction that needs to be made between correlation and cause, which I think has taken on the same meaning for many people. I try to stress that there is no predicting when these types of injuries are going to happen, the evidence just doesn’t seem to back it up (feel free to correct me if you have research that proves otherwise). I’ve seen too many clinicians out there stating that they can “PREVENT ACL INJURIES” if you are screened for this, that, or the other. This is purposely deceptive, in my opinion, and tells the general public something that just isn’t true.

My way of explaining a screen when I perform one: ” We’re doing this screen to pick out limitations or weaknesses. Once we identify these issues, we’ll give you a set of mobility and strength interventions/exercises that you can perform to address these limitations. This will hopefully give you the strength, mobility, and stability you need while playing insert sport that will optimize your movement patterns and performance.”

Obviously, if this is an athlete who I work with one-on-one, the terminology changes and I’d be able to do more hands on cuing and guiding, but the point is that I don’t mislead them into thinking that I’m going to miraculously prevent an ACL tear from happening. All I can do is give them the tools and the guidance to be as prepared for their sport as possible.

I truly believe that patient expectation is critical to any intervention we perform or exercise we prescribe. Over-promising and under-performing is just about the worst way to go about forging clinical relationships. Being honest about what the athlete/client can expect and working your ass off with to make it happen is all we can do. And hopefully, with a lot of sweat, hard work, and skill, we get the outcomes that we’re looking for

Will Steph Curry ever come back?

Answer: YES. (sorry for scaring you with that title)

Game 4 of the Warriors/Blazers series is tonight and the title of this column is probably something every Warriors fan is pondering right now as they try to win back to back championships: when is Steph Curry coming back? Curry has been out for the last 2+ weeks after suffering a grade 1 MCL sprain of his right knee. This followed a mild right ankle sprain he suffered just a couple games before that.

Curry heads into tonight’s game officially listed as questionable, but all signs indicate that he likely won’t play tonight and still does not have a timeline to return to action. Curry was originally expected to only miss 2 weeks with today being 15 days since the injury, so he will still be within the originally set time frame if he comes back tonight.

So why is this injury so limiting for a basketball player? Understanding the function of MCL will definitely help us better understand this. It’s primary function is to prevent the knee from a valgus force (which you can see on picture A in the image) and provides knee stability during cutting movements and any changes of direction. So any time you plant your foot, stop on a dime, and change directions, the MCL on your plant leg is loaded and providing stability to allow you to move dynamically and explosively.

valgus

So take a second and picture Curry as he’s out there on the court. Can you see him? How many times a game is he changing directions, cutting on a dime, coming off screens, sliding to stay in front of the opposing guard…? The list goes on and on, so it stands to reason that he’ll not have all of his explosiveness if he tries to come back too early. And to top that off, consider that he sprained his ankle just a couple games before that and has an extensive history of ankle instability over the years. When you think of it from that standpoint, it makes a ton of sense why they’re taking their time and allowing him to heal fully before coming back.

Grade 1 ligament sprains typically require anywhere from 3-21 days to go through the inflammatory and repair phases of tissue healing, followed by a remodeling phase that can take much longer. Again, grade 1 sprains are usually considered mild and he’s probably safe at this point from a healing point of view, but for someone that relies on his quickness and elusiveness as much as Curry does, it’s smart for the Warriors to take their time and not rush the MVP back into the line up.

If Curry doesn’t play tonight, expect him to be back within the next 1-2 games. I mean, it’s not like they need him to beat the Blazers anyways, right?

Rant Time

Just a few thoughts about today’s AFC Championship game, which if you know me at all, did not go the way I had expected and hoped:

  • That Denver defense was dominant. They kept the Patriots offense on its toes all day and really never allowed the passing game to find any rhythm with the quick passes and screens. It remains to be seen how the Broncos model will work against the Panthers, who have a plus tight end in Greg Olsen, but don’t have any elite receivers that need to be cued in on. Their pass rush and corners are their strength, which doesn’t necessarily match up well with the Panthers’ strengths
  • Tom Brady never got comfortable today. I’ve been watching the Brady-led Pats for 15 years and have never seen him look that out of whack while going through his progressions. Not even the 2007 Super Bowl loss to the Giants (vomit) was as bad as today was. Have to tip your cap to the Broncos’ defensive game plan.
  • The Patriots first priority this off-season has to be the offensive line. It required mixing and matching all season and it proved to be their undoing this year. Besides keeping their running backs healthy, this is priority number 1.

So it looks like the Carolina Panthers open a 3.5 point favorite going into Super Bowl 50. Despite what the Broncos just showed against the Patriots, I don’t see how the Broncos offense is going to score enough to keep up with the Panthers high powered offense. This has always felt like the year of Cam Newton and I don’t see it stopping here.

Prediction: Carolina Panthers 35, Denver Broncos 20

Go Panthers!