One of the Weirdest Injuries... In the World

I'm fascinated with the British TV show, Top Gear.  I gave the American version a shot but it just fails in comparison.  The BBC hosts and all of the British idiosyncrasies and slang are what makes the show for me.  It's got all sorts of unique and bizarre little segments.  Today, I saw some more video about racing in Britain, but this one results in something far more interesting.

Take a look...

Big thanks to Jim Rome for showing a brief clip of this on The Final Burn today.  I love a good rant about how much he hates soccer or NASCAR or arrogant, overpaid athletes as much as anyone, but today we got to see a cyclist take a shard of wood through his calf.

My friends and I have been looking for all kinds of injury videos throughout the years.  There are a few good ones, but the majority are some dumb rednecks doing professional wrestling moves off of their roof or cell phone videos of stunts gone wrong.

If anyone knows of some other than the usual Willis McGahee and Kickboxing Tib/Fib Fracture video, I'd like to check them out and will share them here.

It's honestly a good way to practice some evaluation.  We often times have the advantage of seeing the injury occur.  Observing a mechanism of injury is invaluable in evaluating an injured person.  I have a lot of examples but one sticks out in my memory the most.  At one of baseball games I covered at Memphis, one of our players made a great diving play but injured his shoulder.  As I ran out in the freezing rain that was falling I realized that he did brace his dive with an outstretched hand (FOOSH!) and then fell in a manner that put his shoulder into flexion.  With this info, I quickly made sure that it wasn't dislocated and he didn't report any of the standard signs of a subluxation.  I was able to then move on to my next thought which was a posterior labrum, capsular sprain or rotator cuff injury.  At the time, he was in considerable pain so he was removed from the game.  For days, I continually evaluated this shoulder convinced that I would find a positive test for a labral tear.  Even our other ATC's and Physicians and an MRI couldn't find it.  We moved on with the treatment but a full recovery just didn't happen right away.  Later, an arthroscopy revealed a Kim Lesion, which I had never heard of.  However, it turned out that my initial suspicion of a labral pathology was correct.  It goes to show that seeing the MOI is invaluable and to trust your instincts!

This is REAL Core Stability

"Core Stability" was all the rage not too long ago and to some extent, it still is.  Unfortunately, so many people thought that doing thousands of crunches meant that you'd have a strong core.  In my experience, this has gotten somewhat better lately, especially in organized athletics.  There are a lot of good Strength and Conditioning Specialists (CSCS) that are taking a broad scoped and all incorporating approach to "core strength".  Even the heavily marketed, but actually useful, P90X takes a pretty good shot.  If you follow Tony Horton's 90 day program, you will definitely be stronger, leaner and more fit.  However, I'm not sold on how actually stable the core is in so many of our athletes.  Up until a few months ago, I likely would have said differently.

As I've mentioned before, I was fortunate enough to attend the PBATS Sports Medicine conference in January.  One of many great presentations was given by PJ Mainville, Assistant Athletic Trainer with the Arizona Diamondbacks.  He spoke on an integrated approach to rehabilitating shoulder injuries.  A main topic of this integrated approach centered around Dynamic Neuromuscular Stabilization (DNS).  Of all of the presentations during the three-day conference, DNS stood out to me as the most interesting.  It is logical, applicable to a broad population and cutting-edge.  A 20 minute lecture that briefly touched on DNS was enough to pique my interest.  I've researched it a good bit and thought about its concepts even more.  I'm excited to learn more about this approach because of its growing use in professional baseball and because it makes much more sense as "core stability".

I can do no justice to thoroughly explaining DNS here.  I honestly don't have a strong enough grasp of the concepts and have never actually practiced it yet.  Hopefully that will change soon though.  In the meantime I'll do my best to give a brief summary and provide links to the information I've found.

DNS has been developed by Associate Professor Pavel Kolar, P.T., Paed. Dr., Ph.D. from the Prague School in Prague, Czech Republic. "DNS is designed to stimulate movement control centers in the brain in order to activate the body's "stabilizing system". This allows for improved body awareness, posture and respiration, improving the quality of specific and general exercises. DNS techniques stimulate the brain, which controls all muscles, and the muscles in turn move and protect all joints. DNS stabilizes the body by re-establishing the precise postures the child utilizes as it matures to crawl and upright itself in order to stand and walk. The method helps to restore the structural and postural alignment of the body's neuromuscular skeletal system by invoking a full body "global" motor pattern."

Basically, by placing patients in the postures of an infant learning to crawl, reach and walk, and initiating resisted movements from there, DNS stimulates the central nervous system to retrain the spinal stabilizing muscles.  Every movement made by the head or an extremity is preceded by a group of muscles activating to provide a stable base.  These muscles are the multifidi, deep neck flexors, diaphragm, muscles of the abdominal wall and muscles of the pelvic floor.  The activation of these muscles is automatic and they act as a functional unit.  Over time, the CNS takes over and the spine is stabilized subconsciously.

At PBATS, Mainville described it in a practical way that made a lot of sense.  I'll try to do it justice here.

Imagine a basic, empty bottle of water.  If you squeeze it on the sides, it's pretty easy to bend the bottle in half in any direction.  Now, squeeze it by the top and bottom.  The bottle is now much harder to bend.  When the diaphragm and other muscles contract, your spine becomes like the water bottle squeezed by the top and bottom and is much more stable.

As we know, a lot of injuries are caused by disfunction or compensation.  DNS is being used to not just rehabilitate but also in injury prevention.

There is so much more to this amazing concept.  I hope you will take a look at the links and read some of the articles or watch the videos.

Here is the site for the Prague School: http://www.rehabps.com/REHABILITATION/Home.html  From here you can follow the links to research articles, videos and power point presentations detailing the development and practice of DNS.

This is another site with some descriptions of DNS and testimonials from top professionals including Athletic Trainers. http://www.rehabfai.com/index.html

Steve Smith, of Athlete's Performance in Florida, wrote a guest post on mikereinold.com about it too.  He has some good practical application of what he learned at one of Kolar's seminars.  http://www.mikereinold.com/2009/05/dynamic-neuromuscular-stabilization.html

Another Ignorant Person... Except This One Has a Newspaper Column

I saw a link on the NATA's twitter feed today about the president of the Pennsylvania Athletic Trainer's Association responding to an opinion column in a newspaper.  Mr. Greg Janik wrote a pretty basic response detailing the education and certifications of Athletic Trainers and their competence in evaluating and treating concussions.  A response was certainly justified in setting the record straight and correcting the original columnist, Paul Carpenter.

You can read Carpenter's column here: http://www.mcall.com/news/local/carpenter/mc-paul-carpenter-concussions-20110201,0,5280899.column

You can read Janik's response here: http://articles.mcall.com/2011-02-07/opinion/mc-concussions-janik-20110207_1_concussions-pennsylvania-athletic-trainers-society-interscholastic-athletes

This Carpenter guy clearly has no clue.  It drives me crazy that ignorant fools like this get paid to share their "opinions" and spread false information.  If you don't want to read the whole thing just know that Mr. Carpenter feels that "trainers" are not qualified to evaluate a concussion and decide if a student-athlete is fit to return to play because they are "nothing but flunkies for coaches, some of whom are willing to do anything to win."  Read that again. "FLUNKIES FOR COACHES." Apparently we all work for Bud Kilmer. Go Coyotes...

The newspaper, the Morning Call, claims that Carpenter will be responding to his apparently numerous critics tomorrow.  I'll be waiting to see what he writes and will post what I find.  Hopefully the critics have corrected him and a full apology is issued.

If being called a "flunkie" doesn't inspire you to do your part to promote this profession, I don't know what will. Please share those links to other Athletic Trainers.

Yo Bartender! Jobu Needs a Refill!

I love movies.  I love baseball.  An obvious conclusion? I've seen all of the movies in the Major League series multiple times.  Not always the most baseball accurate films (Eddie Harris' pitching mechanics MIGHT get the ball to the plate) they are quotable, hilarious and have withstood the test of time so far.  My roommate in college would constantly hit me with one of Harry Doyle (Bob Uecker) or Rube Baker's quotes.  The other night, I put the original on before bed.  An hour and 45 minutes later, there was a smile on my face and a ton of excitement for baseball season to be here.  Like I said, I've seen these movies countless times so I knew everything that was in there but this time I did happen to notice there are quite a few instances of an Athletic Trainer making an appearance or times when an Athletic Trainer is needed.  Let's take a look at a few...

As we all know, Charlie Sheen is a stand up guy and a moral citizen.  He'd never do anything to end up in jail...  ummm.... However, his character Rick "Wild Thing" Vaughn was signed from the California Penal League and is having a little problem controlling his high 90s fastball.  Just as he is about to be sent down, manager Lou Brown stumbles upon the source of this problem.  Rick has horrible vision.

Willie Mays Hayes might have a point, but they do solve Rick's control issue.  While a yellow legal pad with 4 letters scribbled on it got the job done here, it's not the most scientific approach to determining an athlete's visual acuity.  What they need here is a Snellen eye chart.  Most Athletic Training rooms have one of these and the lucky ATC's can book a same day appointment with an optometrist or ophthalmologist.  Sometimes we might not have the best facilities or may be traveling and might need to come up with our own solution similar to Lou.  There is a chart for making your own Snellen eye chart based on the height of the letters and the correlating distance. You can find that grid many places, including here.

Continuing with the Wild Thing example, think about this.  We should always be searching for and treating the cause of problems.  Yes it is important to break the pain cycle and treat the symptoms but that won't solve the problem.  In the real world, before the vision problem was found, this athlete's pitch counts would be exceptionally high due to throwing so many balls.  He probably wouldn't stay in the game long, but these Indians were a sad bunch so maybe that's not true.  The Athletic Trainer would likely have been seeing Rick about some overuse conditions soon.  You might not think that poor eyesight could cause shoulder or elbow problems but it is our job to find the cause, no matter how unrelated or bizarre it may seem.

I had one pitcher who came to me early in his time with this team complaining of diffuse shoulder pain.  This particular exam revealed a lot.  Poor posture and upper cross syndrome were present.  Positive Hawkins-Kennedy and Impingement sign tests were elicited.  Manual Muscle Tests revealed weakness in most planes.  Already this seemed a daunting rehab but I jumped right in and began postural correction exercises, scapular stabilizing and rotator cuff strengthening programs.  In my excitement to get started tackling all of these problems, I forgot to truly figure out the cause.  Being a former pitcher myself, I've had lots of training regarding pitching mechanics and its intricacies.  After watching this young man throw, it appeared to me that he was rushing and was inconsistent at his balance point.  I had him do some basic single leg stands which showed incredibly poor balance.  After working with the pitching coach to correct and fine tune his throwing mechanics and correcting his other issues with me, he went on to have some success and remained healthy.

Let's take a look at one more clip for today.  As I mentioned before, there are a lot of these little instances in these film (including one where they mount an outboard boat motor in a whirlpool. not safe but funny)  This article would be too lengthy to go over them all so I'll hit the one that covers the hot topic of 2010 and continuing into 2011, concussions.

While no research will show voodoo magic as a cause of concussion, 'tis very bad to steel Jobu's rum. 'Tis very bad.

This weekend featured a couple of all star games.  We had the laughable NFL Pro Bowl and the NHL All-Star Game.  Defense was not present much in either game.  Unfortunately, the NHL's biggest star, Sidney Crosby, wasn't present at all.  Crosby is still recovering from a concussion.  This NFL season brought a lot of attention to the issue and now Crosby's All-Star absence is making the NHL pay more attention as well.  Athletic Trainers and Team Physicians have been paying attention to these serious injuries for a lot longer.

There is a lot of attention and new research into concussion right now.  I'd say that most ATCs are keeping a close eye on this and some are doing the research themselves.  There were two such articles in the latest edition of the Journal of Athletic Training.  As important the research is, I think that most of our focus should be on properly dealing with the concussions that we could see at any moment while on the job.  While this article isn't here to rehash evaluation protocols, knowing your concussion evaluation protocol is a must.  Hopefully it entails more than a bag of ice on the head like our friend Eddie Harris.

At the PBATS conference in January, I got to see a good presentation on emergency care.  Richie Bancells, the Orioles Head Athletic Trainer touched on some generalities and some of the new equipment they had.  His focus was on being prepared though.  He reiterated several times the importance of practicing your emergency action plans and taking an honest look at what your strengths and weaknesses are.  I'd like to convey that here as well.  Take out your concussion evaluation form tonight and look it over.  Go through it in your head a few times and even ask the questions out loud.  Make some changes if necessary.  I will be doing the same.

Rhabdomyolysis at Iowa

There's a lot of things I want to write about but when things are in the news, it seems more appropriate and relevant to go off of that.  The breaking news last night came from the University of Iowa, where 12 football players developed cases of "exertional rhabdomyolysis".  Apparently, these athletes were participating in the football team's winter workouts.  A bunch of athletes coming down with muscle soreness after a winter workout isn't that rare. Many of them probably took it relatively easy or completely rested over their holiday break and jumped into a high level strength training session.  However, this case caught my eye as a bit strange.  First, rhabdomyolysis is not regular muscle soreness or DOMS.  Rhabdomyolysis is rare and is a very serious condition that can cause kidney damage and other serious complications. It was actually discovered during World War II in bombing victims that had muscles crushed. Over 70 years, there has been extensive research so I won't go into all of the details but you can read more about it here.  Secondly, this past fall, 19 members of a high school football team in Oregon were stricken with the same disease.  Within 6 months, 2 football teams have had several young, healthy athletes suddenly develop a very serious muscle condition.  After the first scenario there was some debate about if creatine supplementation was a factor.  It appears that the jury is still out on that one. I'm guessing there will be more investigating about what exactly is causing this now that a second case has occurred.  I'll keep an eye on it but if you have more information or research please share it with us all in the comments.

While I am definitely interested in the findings there's a few other things going on here.  Nowhere in these articles is "Athletic Training" or "Athletic Trainer" mentioned.  As someone who has worked Div. 1 football, I can assure you that this directly affects the Athletic Trainer.  When these football players were having trouble walking, who do you think was getting called at midnight or later? The Athletic Trainer. Who do you think is visiting these guys in the hospital and contacting their families? The Athletic Trainer.  A lot of these issues they are likely dealing with in Iowa today falls under the area of the hypothetical course I want to teach some day, The Things They Don't Teach You in College. 

One thing that this originally made me think of was my old medical terminology class.  It was something I reluctantly decided to take as an elective but it has proved useful time and time again. In this case, Lysis = breakdown and Rhabdomyo = striated muscle.  If you're a student reading this, I can't encourage you to take a medical terminology course enough.  It's helped me figure a lot of things out as a trainer and answer a lot of questions on Jeopardy!

1/27/11
Here is the latest: http://sports.espn.go.com/ncf/news/story?id=6065314

Sounds like they are going to try and blame the Strength & Conditioning staff for the workout. The workout has been reported by the players themselves to be 100 squats at 50% of their max and then pushing sleds. Is this a difficult workout? Yes, but don't kid yourself to think that this is out of the ordinary in high level collegiate athletics.  If it was just one case I might believe this to be a "freak" occurrence. 13 cases makes it seem that there is still something else playing a big role in this.

Ah Hah Moments and Their Close Relative, the "Doh!"

Everybody loves when they have one of those "Ah Hah!" moments. Some people may call it something different, but when you are able to put two and two together and get a grasp on something it can be very rewarding.
On the other hand, these are closely related to the "Doh!" moments, when you feel rather stupid for not knowing or not being able to remember something.  Some of you who know me probably know how much I love game shows. While Wheel of Fortune isn't one of my favorites it does provide great examples of each!

Ah Hah: http://www.youtube.com/watch?v=pMzNeTVCNIM&feature=related

Doh!: http://www.youtube.com/watch?v=NLdZ9AhPCEQ

No matter which of one of these paths you take to realizing something, to me it seems like all that matters is that you do know the answer.

The first case in Athletic Training that I can personally remember something like this happened over the span of my first fall semester at Memphis and culminating at a conference I was attending that Winter. At first, I had my "Ah Hah" moment but I was quickly hit with my "Doh!" moment.

All throughout fall baseball season, I kept noticing a lot of my athletes were coming in with complaints of shoulder pain.  Being a freshly certified trainer, I was more than happy to get to practice all of my shoulder special tests. (For those of you reading who may not be an AT, there are a LOT of shoulder examinations)  After a few lengthy exams resulting in not a lot of clear answers, I was admittedly frustrated. I knew that something was causing these athletes to have repeated cases of impingement and rotator cuff tendonitis, but I couldn't figure it out.  One day during treatment, 3 of my pitchers were in for treatment when I realized they all looked a lot alike.  Rounded shoulders? check.  Forward Head? Check.  Tight Pectoralis groups? check.  I thought that I had discovered this major combination of postural conditions that would lead to shoulder pain and injury. Now maybe I wasn't paying attention as well as I should have back in Upper Extremity Eval class one day because it turns out I was simply noticing the very common "Upper Cross Syndrome".  When I saw a presentation on this syndrome that Winter, I thought to myself "Not as brilliant as you thought? Huh Scott?".  But as Lee Corso would say... Not so fast my friend!  While I did not immediately recognize a phenomenon first described in 1979, I recognized common signs, symptoms and conditions and then used what I knew to make a logical and educated conclusion about the cause of our team's problem.    We were able to treat the effected athletes and begin a preventative course of action for the rest of the team.  Most trainers and coaches will put that in our proverbial win column.

If you're working with or plan on working with athletes, you will probably see Upper Cross Syndrome. Obviously, I know baseball the best and it can cause a lot of negative effects in the rotator cuff in those athletes.  However, I became even more versed in it's causes, effects and treatments this summer working with a Titelist Performance Institute trainer. Upper Cross Syndrome adversely effects many golfers as well.  A quick search will also bring back results relating Upper Cross Syndrome to MMA Fighters, Swimmers and even a cause of headaches.  Even if you think you know about this condition, take a few minutes to research it and read about it's potential effects.  I was rather astonished at how much it plays a role in.

Have there been any times in your career or studies when you had a similar situation?
Know of a good treatment for Upper Cross Syndrome?
Please share in the comments.

Dream Jobs and Where I've been

Somehow, as a 17 year old high school senior, I made a decision about what I wanted to do with my life. That decision has certainly been the right one so far. I consider myself lucky.  However, getting to do what you love everyday isn't the same kind of luck as hitting the lottery.

"Luck is when preparation meets opportunity." - Seneca, Roman Philosopher 5 BC - 65 AD

I saw this quote a while back in a great article by Mike Reinold about landing his dream job on his website.  If you are an ATC, PT or CSCS and don't know about Mike and his work, you are missing out.  Mike is the Head Athletic Trainer for the Red Sox and has done an extensive amount of work and research on the athlete's shoulder.  He's a pretty big inspiration for me and this tiny endeavor you are reading.  I see him as a pioneer in our field because he is using the technology we have today to educate ATCs and PTs and foster discussion on hot topics in our field.  Here is the link to that article: 5 Tips for Landing a Sports Medicine Job in Professional Sports 

I'd certainly echo everything he discusses in that article. As for me personally though, I'll share some extra info.

My #1 piece of advice that I could give based on my experience is to be willing to step out of your comfort zone. Personally, I've done this 3 times and it has worked out each time.  As a member of a graduating HS class of 175, I could have went to one of many colleges with a lot of classmates and friends.  However, I went to the small, yet highly respected, Wilmington College.  People still think I went to school in Delaware or North Carolina.  False.  Now, I know I'm not the first kid to go to college knowing nobody, but at the time it was a big step.  I can't speak highly enough about Wilmington.  I'm very proud to be an alumnus and would recommend it to anyone interested in Athletic Training.  It surrounds its students with great faculty and puts them in many career growing opportunities. It has great internships available including one with the Cincinnati Reds. Easily, this was their selling point to me and it was the highlight of my undergrad experience.

The next time was also a choice of college.  Graduation was fast approaching and I needed to make a decision about where to go next.  A very big part of me wanted to take one of a few opportunities to stay in Ohio. It was a complicated and difficult decision but in the end I decided to head south to Memphis, TN because of the chance to be the sole ATC with a Div. 1 baseball team. Once again, it worked out.

While at the University of Memphis, I saw Coach John Calipari give a speech.  He was a captivating and charismatic speaker.  It's not hard to see why he is a great recruiter in NCAA Basketball.  He was talking about his life and how it wasn't always as good as it was for him then (and now...) His main advice was when you feel stuck and aren't sure what to do, ask for help.  The timing of this was pretty good as I was nearing the point of having to do a summer internship as part of my Master's program and was having some difficulty.  At the time, my advisor and the other faculty were hoping to have me do an internship in the compliance department or somewhere else internally in the Memphis athletic department.  While those were more applicable to my degree (Sport & Leisure Commerce), I did not see it as a step toward my goal of being in pro baseball.  At that time, I reached out to one of our team physicians, Dr. Barry Phillips, who was also the team physician for the Cardinals' AAA team, the Memphis Redbirds.  Dr. Phillips got me in touch with their trainer, Chris Conroy.  I'm now happy to call Chris a good friend and a colleague with the Cardinals.

Another graduation was coming quickly and the fact that I didn't have anything in mind for what to do next was staring me in the face.  Enter the Cotuit Kettleers of the Cape Cod Baseball league.  I was offered the position and accepted.  I would definitely put leaving on a two-day drive with no idea about my housing situation outside of the comfort zone.  As a fan of baseball alone, it would have been worth it.  4,000 educated, opinionated and enthusiastic baseball fans is a sight to see.  As a bonus, it was good experience too.  I had the opportunity to have my first intern.  It is easy to see why so many people love being an AT instructor and working in an ATEP.

While there are a lot of important details and personally influential people left to tell, I don't mean for this to be my life story.  At the recommendation of a good friend, I just wanted to share a little about where I'm coming from.  I'll work on some applicable things to post tomorrow.

As always, comment or send me a message with ideas of things you'd like to see in the future.

Lots of ideas, big plans and starting small

As I sit here in Cincinnati watching it snow, I am confident that I am ready to head to Florida for Spring Training.  Ohio is a beautiful place and has been my home forever.  However, I'm ready to trade snowmen for palm trees and snow shovels for baseball bats.

It is my first Winter as an Athletic Trainer in Minor League Baseball. I don't have enough words (and any potential readers don't have enough time) to begin to get into how excited I am for this opportunity.  I've been blessed with a lot of great mentors, coworkers and friends that were a huge part of me getting this job.   Although I've been an Athletic Trainer for just over 2 1/2 years, I know without a shadow of a doubt that this is what I'm meant to do.  It's been an eventful career for such a short period of time.  I've been in Division 3 and Division 1 NCAA Football and Baseball, Minor League Baseball, Major League Baseball and this summer I was proud to be the ATC with the 2010 Cape Cod Baseball League Champion Cotuit Kettleers.  Though many days didn't even seem like "work" to me, I was a very busy person.  However, now as I'm about halfway through my first offseason, I've had a lot of time for reflection, thought and even brainstorming.

This blog is step one in implementing some of those thoughts, etc.  Where is this going? I'm not sure, but I have a lot of ideas.  I plan on sharing products, articles, concepts, personal stories and anything else that I think is helpful or interesting.  I would love for it to become a forum of discussion by ATC's and anyone interested or involved in the care, training and rehabilitation of athletes.  At the very least, it will be an outlet for my thoughts.  Perhaps it will become more or be a stepping stone to something bigger.

So for now, I will promise to write regularly at least until Spring Training.  In return, I ask that you all share this with your coworkers and colleagues.  Also, feedback from you all will certainly steer this blog in the direction that will be enjoyed by (and maybe even helpful to) the most people.