I thought swimming was a "safe" activity? Part 1: Common Shoulder Injuries in Freestyle

Well, if you swim like your grandparent, then maybe.

When people think of swimming, thoughts of vacation and leisure tend to come to mind.  Such a gentle sport, or so you thought!
For the competitive or novice swimmer, the prevailing region of the body we treat is the shoulder.  In this blog, we'll be discussing the causes and solutions to help your shoulder pain while you swim.

What are the causes of shoulder injuries in swimmers?  As noted in the picture above, one of the most common stroke flaws resulting in shoulder pain occurs when the freestyler's hand crosses the midline of the body as the hand enters the water (should be in line with shoulder, not directly above the head or over).  This flaw is usually caused by an overrotation of the body and over time, can result in impingment of the shoulder, which is pain near the front or side of the shoulder when raising the arm to the front or side of the shoulder.  In addition, if the swimmer's core is not engaged particularly during breathing, that same overrotation of the body can result in the bottom hand drifting pass midline, causing more stress on the shoulder when the catch phase of the stroke is initiated.  Biceps tendonitis and rotator cuff tendonitis can also result from this type of hand entry into the water.  Another cause of shoulder pain occurs when a swimmer uses a straight arm pull instead of one with a bent arm, again causing a great deal of strain over time in the shoulder. 

Easy solutions-
-point it out to the swimmer!
-swim drills with hands at the 1 o'clock and 11 o'clock positions, aka, "superman" glide (should be able to see your hands in the periphery of your sight)
-work on hand entry, vertical forearm, and bent arm pull drills
-core drills in the water to keep your body in balance

Why DPTs Should Embrace and "Practice" Fitness

As you all know, Maven has always been about bridging the fitness and rehabilitation gap.  Although a steady number of rehab professionals are becoming like-minded, the vast majority of doctors of physical therapy continue to focus on addressing physical impairments or functional limitations through very rudimentary exercises and not the kind of functional strengthening that we, as the musculoskeletal experts, should really be incorporating into our plan of care. We seem to be stuck on exercises like biceps curls, mini squats, and straight leg raises; don't get me wrong, these exercises certainly have their place in the early stages of recovery, but need to be progressed before discharging a patient.

Simply put, patients separate rehab exercise from fitness or "gym" exercise as they are often not challenged enough by their rehab exercises and are looking to their personal trainers for a real workout, when in fact, fitness or strength goals and activities could easily have been weaved into their rehab visits with a physical therapist.

Why aren't more DPTs using the TRX suspension system or kettlebells instead of cable machines?  I thought that our profession has always been about restoring functional movement and strength?  Why isn't the Concept 2 rower a normal mainstay in all rehab facilities?  Are we still relying on passive care such as, ultrasound, joint mobilization, a quick rubdown, and e-stim?

If we, as DPTs, are truly concerned about wellness and prevention, which we tout in our profession, then why aren't we educating ourselves and our patients by discussing weight management, nutrition, and fitness?   Is it because we don't prioritize the after-care of our patients or are fixated on manual therapy?  The overall goal is to restore pain-free functional movement and prevent injury, as I wrote earlier.  If that's the case, then we should be offering sound advice and direction on how to achieve fitness goals in the safest, most efficient, and most effective manner.  Doesn't nutrition and food intake have a direct effect on healing, reducing joint stress, and pain reduction?  Doesn't creating a fitness plan transition towards discharge help our patients prevent injury and help reduce the burden on the failing healthcare system?

Physical therapists are one of the best positioned medical professionals to address movement impairments and provide safe and effective recommendations on exercise and weight management.  It's about time our profession steps up to the plate and fully embrace fitness as part of the rehab continuum...or else other professionals will continue to take it on and leave us in the dust with our ultrasound, e-stim, and passive manual techniques.

Why burpees are an essential clinical tool....

Yes, we love/hate them, and we know that you do, too.  Burpees.  Whether they're done with a chest-to-floor push-up at the bottom or a clap in the sky at the top (or both!), burpees are an envogue fitness activity for conditioning purposes, and they just never seem to get that much easier....no matter how fit you are...

Clinically, burpees(aka squat-thrusts, aka "M"urpees) can give us some valuable information about how our patients are faring during the plan of care. Would we use them on every patient we treat? Probably not, but for those patients who live an active lifestyle and want to return to their favorite activities post-rehab, they will find themselves doing burpees at some point during their stay at Maven. As one of Maven's key clinical movement assessment (and treatment) tools, burpees can be used qualitatively and/or quantitatively to:

1. assess a patient's healing progress after they've passed the subacute stage of an injury
2. provide clinicians with a general "clearing test" prior to discharging a patient
3. determine if a patient is ready to be progressed to more dynamic activities or return-to-sport
4. assess gross and regional dynamic joint and segmental stabilization in a closed-chain position (the most functional position for most everyday activities)
5. assess the general status of a patient's or athlete's muscular endurance and conditioning
6. reveal other areas of the body that may need to be screened and evaluated for injury prevention.

Key areas of closed-chain, dynamic stabilization and/or mobility are assessed at the:

• cervical spine
• scapula
• thoraco lumbar region
• lumbo-pelvic region
• hip
• ankle
• wrist
• knee 

The video below shows Dr. Lee explaining how to perform a standard burpee (sans claps or push-ups in this video). Hopefully, you can appreciate how much mobility the wrists, shoulders, hips, knees, ankles must have in order to execute the exercise correctly. Also, notice how the scapulae and trunk("core") muscles have to stabilize the body in motion during the burpee as well.

If a patient comes to us with a wrist injury, for example, and needs to return to competitive gymnastics, multiple repetitions of burpees should be able to be performed with ease before any kind of floor or beam routine can be resumed.  If a patient has pain during a burpee in the lumbar region, most likely, lumbopelvic stabilization is not adequate to keep the spine from overextending, so we need to work on this more to clear the spine.  If a patient bends more at the back and less at the hip when they squat down for the burpees, we know to look more closely at the hip and pelvis as a potential movement limiting factor that needs to be addressed.

These are just a few examples of how burpees can assist rehab professionals during their physical assessment of the active patient and progress them to a successful return to their fitness goals! 

Stay tuned for videos on our Youtube channel providing more insight into our clinical movement assessment tools!

What's triggerpoint dry needling?

Trigger point dry needling is an effectively used modality to treat musculoskeletal pain. Licensed healthcare professionals including doctors of physical therapy have been using dry needling all over the world including the United States.

Maven Sports Medicine has been at the forefront of pushing for rules and regulations in New Jersey to permit the use of this treatment modality, which finally received NJ State Board approval in 2011. Yes, as you all know, we like to move and shake. Obviously, there is contention with the NJ acupuncture state board, who claims that it is indeed "acupuncture" what we are doing, however, allow me to explain some significant differences (btw, I still refer patients out for acupuncture, if that clarifies the picture):

Acupuncture 
Acupuncture requires state licensure, 4 years of education and/or a masters degree.  Training includes extensive knowledge and application of eastern medicine, anatomy, which includes the meridian system, and herbal medicine.  The pulse (there are three in eastern medicine) along with the history and other clinical and subjective measures are used to determine where systematic, energetic dysfunction may lie, and intervention via acupuncture needles, herbal medicine, or acupressure is employed.  For example, back pain may be a result of stagnation or surplus of energy, "chi" in a particular meridian, and needles may be placed in a region away from where the pain appears to be located. 

Dry needling 
 A systematic method of addressing localized trigger point muscle pain using dry needles (that is, needles that do not have medication, developed by Travell and Simons, MD in the mid to late 1900s. Trigger points in muscles result from overuse, disuse/weakness, or (traumatic) injury to muscles.  Posture-related injuries also can lead to trigger points.  Palpation of the muscles or regions involved is performed with the goal of eliciting a patient's symptoms (whether localized or away from the region palpated), a "twitch" response, or "taut/ropy" bands of the muscle. 

Dry needling can also be used to treat long-standing tendinitis or old muscle tears/strains by bringing about a relatively "controlled" inflammation response to initiate the cascade of physiological responses necessary for tissue healing, as an adjunct to other physical therapy modalities.  Applying dry needling or "TDN" requires extensive knowledge of surface/musculoskeletal anatomy, of which DPTs are experts.  Keen palpation and joint assessment (as well as other components of our comprehensive evaluation) are also necessary skill sets, which we practice and use daily to determine where musculoskeletal injuries may be emanating from.

Dry needling, therefore, is absolutely within our physical therapy scope of practice, and I would never call it acupuncture- this would be an insult to the acupuncture profession and all the training that a licensed acupuncturist must go through.

What to expect
Patients often describe transient discomfort, particularly when a twitch response has been elicited.  Following a dry needling "session", we often have patients perform a few gentle active range of motion exercises to further the effects of the needle, ultrasound to relieve dry needling symptoms, and electrical stimulation with ice as well.  Discomfort or pain resulting from dry needling lasts for about 1-2 days on average and icing or over-the-counter NSAIDs can be used. After a few days, many people (especially if we target the right spot) report moderate to significant relief of their pain.  It's pretty amazing, actually.  We've used it on our everyday computer user to our elite athletes and have had good results, thus far.  Obviously, dry needling is not a panacea, or I'd be living in Fiji with my fam right now, but it does offer another way to help you get back to your activities.

Diagnoses
We have treated diagnoses including (cervicogenic) headaches, IT band syndrome, tennis/golfer's elbow, rotator cuff strains, Achilles tendonitis, neck and low back pain, hamstring and quad strains to name a few ailments. 

For more information on how dry needling may help you, contact us via email at mavenoffice@gmail.com or jerrymaven@gmail.com

Feed Your Injury

Having been in the field nearly 12 years, patients are often wondering what exercises or activities they should be doing at home or avoiding to help accelerate their recovery, but no one really asks,

"Is there anything I can eat or take (that is legal, of course) to help this injury get better?"

There is SO much one can do. 

Setting up the substrate-
our bodies exist in a relatively alkaline state (higher pH or more on the basic side of the acid-base scale).  Musculoskeletal injury causes localized inflammation in a particular region.  Inflammation is GOOD and NECESSARY for healing.  We just want to CONTROL the inflammation so that scar tissue is laid down in the injured area in a more organized fashion instead of one that is haphazard.  We also want to get better quicker, don't we??

So, in order to improve healing, do all that you can to minimize foods that might tip the scale towards inflammation. 

What does this mean?  Are you saying that foods can cause or increase inflammation?
Yes, of course, and you probably already know the macronutrient types that do. Read on-

Foods to eliminate or drastically reduce from your daily consumption (at least while you're healing from an injury or post-op surgery:
-Refined carbohydrates (breads, pastas, white rice, refined sugars) 
-Processed foods
-legumes (yes, a gray area that needs more evidence)
-For many reasons, cutting out these poor sources of carbohydrates will not only benefit your recovery, your waistline and body composition will improve. 
-Dairy (cheese and milk. Eggs are ok).
-Red meat (this is kind of a gray area as there are clear benefits to eating grass-fed red meat including creatine, BCAAs, etc).

Foods to add in or dramatically increase in your daily consumption (at least while you're healing from an injury or post-op surgery (this is by no means a comprehensive list, but will start you off in the right direction):
-Water, water, water- muscle is ~75-80% water.  Does drinking enough water/fluids make sense? During an injury, consider drinking alkaline water with a pH that is 8.0 (Eternal and Iceland spring are brands that I've consumed). 
-whey protein isolate (somewhat controversial since it's processed, but it's known for rapid and nearly complete absorption into muscle tissue.  For vegans, pea/brown rice protein are good alternatives)
-Omega 3 sources:
nuts (unsalted)- particularly almonds, walnuts
chia seed
salmon
avocados
veggies: purple, red, yellow, green
-substitute quinoa for grains (quinoa is a seed).

Obviously, your body has mechanisms in place to keep itself in homeostasis, but we can take an active role in helping our bodies minimize the energy needed to maintain this, ESPECIALLY when an injury is present.

Another temptation active folks face when side-lined during an injury is to reduce caloric intake.  My question back to you- If your body needs X number of calories to function at a certain level per day, do you think that reducing your caloric intake will assist or lengthen your injury progression?  I think the answer is obvious.  Remember, in the grand scheme of things, stabilizing your food intake won't put massive pounds on you (unless you eat poorly to begin with). It can only help, especially if you're feeding your injury the right things as we mentioned above.

Having said that, if you have any questions or concerns (there are almost always exceptions to every rule), send us an email!

The Maven approach to a successful multisport season- Part 1

What's our training philosophy here at Maven?

You all know from Mavenaction (mavenaction.com) that we believe health has to come first.

So, what is health?

Well, generally, we believe that there are 4 major components- physical, mental, emotional, and spiritual. Any strain or pull in one of these areas diminishes the effectiveness and overall state in the other areas.

For this blog's purpose, we'll be emphaszing the physical-

Fitness is, first and foremost, a major constituent to the foundation of general physical health and wellness, which allows one to take on any sport or athletic activity to a maximized level of performance. When we talk about fitness, we must also understand that "clean" nutrition gives fitness the necessary fuel to attain that level of performance. Sleep, rest, and recovery are also well infused components of being more healthy.

Put it this way, how can you even think of having your best race in your respective competitive sport (not exclusive to multisport) when you haven't sufficiently trained ALL of your body's energy systems, incorporated functional strength training as well as flexibility acquisition/maintenance and balance work (let alone managed a solid nutrition plan, recovery, and rest training) ?

Are you fit just because you can do an Ironman? Many people think so, but this is definitely not the case. You've seen them before- the skinny fat athletes, the overweight athletes who are very good at enduring, but have high, double-digit bodyfat.

From my own experiences competing in multisport endurance activities for the past 13 years, I can say for sure that aerobic conditioning (cardio) are merely one facet of fitness, but by no means do they complete the palette. I am faster (and fitter) at 37 than I was at 27. I have been PR'ing every race I've done this season since I really began to take fitness more seriously as part of my tri-training with Mavenaction and crossfit endurance, while my triathlon training volume has decreased....and continues to decrease. I have to admit, while the science supports this way of training, mentally/emotionally, it hasn't been easy...and, to be honest, tri-training is usually more fun than cross-training (don't we all tend to gravitate towards what we love to do?? I am not immune!). While I've been in the fitness industry for over 15 years, the last two years have been the most eye-opening even for me as far as my personal results and professional endeavors.

If you've ever done a Mavenaction workout, you'd know what I mean. There are triathletes, runners, and other endurance specialists who could do laps around me till kingdom come, but if I were to have them do...say...10 minutes of burpees, mountain climbers, jumping jacks, squats, they'd be screaming for mercy (which used to be me, by the way)....if I had them attempt a few sets of pull ups and push-ups, they'd be a goner.

I think you get the drift.

In essence, to be the best triathlete you want to be next season, you MUST be fitter. How do you become fitter? Add cross-training (functional resistance training) as PART of your triathlon training, not as something separate; as a soon-to-be certified USAT level 1 coach, this is how I intend on program designing and mapping out your best tri performance next season.

What do I mean by adding in cross-training? Instead of 7 days a week of all cardio or multisport activities during the season, 3-4 days would be dedicated to your sport, and the other 2 days would involve functional, resistance training or a combo of activities; for example, drop and do 20 burpees or 20 push-ups every 100m of running around a track at your 5k pace for 2 laps x 4 sets...try it, I dare you, then come back and visit my blog for more). Of course, remember that you need to make rest a part of your training as well, and for longevity in the sport, 1-2 days/wk is necessary.

We'll get more into the specifics as we move along in this multi-part series.

Maven PT Guidelines for Running in Minimalist Shoes

In your daily pursuits towards improving your fitness level or running ability, you have probably come across the oft controversial topics of "forefoot strike running," "barefoot running," or "minimalistic shoes" (yes, you've seen shoes like the Vibrams I'm sure- the not-so-pretty running sneakers that resemble fingered gloves for feet). 

So, where do we stand on the topic?  Well, as an endurance athlete and rehab professional, I had been totally against the idea of running in sneakers with a "0mm drop" or flat-bottomed, no-heel rise from an injury point of view.  I had also been against changing the way you run, taking on the "if it ain't broken, don't fix it" perspective, not seeing a benefit in changing running technique, especially as an adult.

Recently, some of my running friends began adapting their running to the Pose method and were really getting some positive gains.  My curiosity was piqued.  I dabbled with it myself, watching YouTube clips here and there, reading about Pose running, and for me the real kicker was the research.  Some of the big guns in the rehab and biomechanics world (notably, Irene Davis), who had been preaching for years about the benenfits of the forefoot (ball of foot) strike....and finally gaining traction in the mainstream (thanks to folks like Chris McDougal), led me to fully embrace the switch.  Preventing injury, improving running economy, AND getting faster...I was sold. I then became certified as a Crossfit endurance coach where most of the course focused on learning the Pose technique and integrating Crossfit principles into endurance as well. 

How has it worked for me?  I have not been able to get under a 20 min 5K (7 min/mi pace) ever.
After the past 6 months of transitioning to/training in Pose style running, I PR'd at the Dumont 5K- 19:41 (6:20 min/mile pace).  So, the evidence for effectiveness for me was clear.  Of course, incorporating consistent speed work on the track and clean nutrition helped A LOT as well, but no doubt, the running technique change was a primary factor in my recent performance.

Is it better to run in the 0 drop sneakers??  Well, yes...and no.  If you have bad running form/technique and you add in shoes with bare minimal support, you would be compromising the well-being and longevity of your feet/lower extremities.  However, running with proper technique, such as the Pose Method, which we subscribe to at Maven, utilizes the minimalist shoes and will enhance your running experience and performance...BUT, it takes a serious committment and investment in time and patience to do this SAFELY.  We take a very conservative approach to introducing our runners to changing their running form/shoes.

First steps to take:
1) Decide if you really care or want to change your running form.  If you're a sub-3 hour marathon runner or elite level runner, and you've had no injuries (which is rare), I would consider keeping things the way they are.  You're gifted.  However, if you've had recurring injuries to the lower extremities (which is the majority of us), consider making a change and continue reading.  Contrary to popular belief, you CAN teach an old dog new tricks!

2) Decide on when or if you will seriously commit to changing your running technique.  Committing to make the change to a ball-of-foot/forefoot srike-to-heel landing from a heel-to-toe landing during running will take a while for your body (especially your Achilles and feet) to adjust to the new stresses.  Perhaps making the change during your running season will not be the best time to devote your efforts.  In any regard, you WILL get injured if you progress yourself too quickly. Trust me.  I have come across one too many eager novices or seasoned runners desiring to run in Pose immediately, who end up getting injured.....you know, though- it certainly would be a profitable move for Maven Sports Medicine to promote an accelerated Pose running program for people who want to learn it in a day. Hmmm...

If you're a seasoned runner, you'll have to accept the fact that you will not be able to run at your usual pace for any races using this technique during the season without the risk of injury (and don't blame the new shoes...or barefeet!).  Think about it.  You've probably been running the heel-toe way for MOST of your life and for you to transition to running on a forefoot to heel running style....it will take months of practice if you want to do it right and SAFELY.

Once you've decided that you're fully on board about the duration and committment level required to take the next steps, so to speak, here's our (conservative) transition protocol:

Recommended transition to forefoot to heel strike (Pose running):  This is subject to change as we continue refining the process, so we'll keep you informed!

Neuromuscular and Tissue Adaption Phase I (two to three months)

1. Practice running in place with barefeet and "quiet feet" running
Slowly work up to 5 minutes x 12 rounds,  2-5 times a week.
Expect some soreness in your calves, in particular, and a bit in your hamstrings during the first few weeks.  The emphasis must be on "pulling" your foot up to towards your butt.  Plenty of drills to practice that we'll be posting up on our YouTube site (search: "MavenPT" channel).  If you're doing things the right way and your form is correct, you will notice immediately that you almost automatically land on the ball of your foot and then on to the heel (let the heel "kiss" the floor). Keep your foot loose.  Also, try some short distance "quiet feet" running.  If you're running quietly, you're naturally engaging the gravity dampeners (your muscles).  Try running in place, heels first for a second. It doesn't feel good to pound your heels on the ground, does it?   If you're feeling soreness in your hip flexors the next day, your technique is incorrect.  Contact our office if you would like some help on your technique.

Ice your calves, take a day off (or two or three) if your perceived soreness is greater than a 5/10.  Basically, if you're gimping around, take the extra time off. Another activity you can add during this transition if you're thinking about barefoot running (particularly for the barefoot folks) to toughen up your feet is to run in place on asphalt or lay out a pile of gravel or pebbles and do the same (reflexology, anyone?). 

I know, two to three months seem like an awfully long time. Right?  This time period will allow for you to be generous to your feet and your body; Your limbs will work better for you as a result.  You have to get your running form to change and your body to adapt. Check out some of our basic Pose running demonstrations on Youtube (Maven PT channel). www.Posetech.com is also a good site to visit. 

Again, we're conservative about this transition, but if you feel like you require less or more time than we suggest, do what feels right for your body. You will appreciate it, trust me.  Everyone adapts differently to stresses on their bodies. 

2. Buy the 0mm or minimalist (4-7mm) drop shoes...but only use them for walking and drills.  Again, performing many repetitions over time is the best way for the necessary adaptations in length to occur in your tendons.  Getting your feet, ankles, tendons used to this feel will only help you ease into the transition. 

Neuromuscular and Tissue Adaptation Phase II (one month):
Transition to practice running short distances with your minimalist shoes or 0 drop shoes for one month.  Attempt distances of 50m, 100m, 150m, 200m, 400m on the track or flat road for another month.  You can attempt a combo of running the "old" way and every few minutes, switch over to Pose running for a mile or so and then back to your old way or running.  You will start to feel the difference and your body will start to get used to running for distance in Pose.

Reintegration Phase I (two to three months):
1.  Now it's time to transition running with a lower heel drop (Nike Free run have been my favorite, but look for a 4mm drop) for two to three months, keeping the mileage around 3-6 miles every other day at a slow pace (I know, this is relative).  Build your mileage up slowly, but steadily.   

Reintegration Phase II (two to three months):
2. Transition to running in a 0 drop shoe for two months.  Keep your mileage around 3-6 miles a day or every other day.  Some short distance speed work on the track can be done once a week, but be aware of how you feel the next day.

All in all, we believe a 5-9 month transition (again, people adapt differently) is a safe duration of time to make the slow and steady transition to a minimalist sneaker or barefoot running.  Depending on your body's ability to adapt, age, weight, flexibility, or running level, this transition time can either be lengthened or shortened. 

For more information on Pose running, check out www.posetech.com.  Contact Dr. Yoo at mavenoffice@gmail.com if you have questions or would like to be coached on running technique or how to succeed in your first sprint or olympic distance triathlon.