Last week, Skyd introduced our panel of training professionals and elite level athletes (Tyler Kinley, Lindsay Hack, and Jamie Nuwer – who will be getting her answers in soon) for our training topic of the month. If you have follow up questions, please ask them in the comments. We have encouraged our panelists to respond there.
And now for the questions and responses:
1. Stephen Hubbard asks – How do you convince college kids to take the appropriate rest after an injury? It seems that “coming back to early” happens way too often. How can players and coaches figure out when its ok to venture back on the field?
LINDSAY HACK, Orthopedic Physical Therapy
- Let’s remember that rest is not synonymous with doing nothing. Rehabilitation can be a workout in itself. And, a necessary workout.
- Be creative in figuring out ways to rehabilitate on the sideline so the player feels like he/she is continuing to somewhat “suffer” with the team.
- Injuries not properly addressed turn into injuries that are very difficult or impossible to come back from in one season.
- Rule of thumb that I use for all my players/patients…if you can perform the activity without compensation (i.e. no limp or weird movement patterns because of pain or to avoid the pain) you can come back. If you are compensating, you are out.
- GET PHYSICAL THERAPY!!!!!!! STOP LETTING YOUR PLAYERS GO TO ONLY THEIR PRIMARY CARE DOCTORS!
TYLER KINLEY, Captain of Seattle Sockeye
This is just a great, tough question. The finite period of time kids have for college makes them that much more aggressive about returning to play too early, and I’ve rarely seen success preventing a kid from doing what he or she wants to do. You need to figure out who that player will “believe,” be it a doctor, or someone in the ultimate community they look up to / trust (a star, perthaps, on the local club team). As for when to return, that’s a case by case basis, and I’d leave it up to a professional (not me).
JAMIE NUWER, Sports Medicine
Published rehab protocols exist in physical therapy and sports medicine text books. A good general principle is to gradually return to sport in a pain-free and function oriented fashion. For example after an ankle sprain: step 1 (20 min light jogging), step 2 (20 min running), step 3 (sprinting in a straight line), step 4 (running with direction changes), step 5 (sprinting with direction changes), step 6 (jumping on two feet), step 7 (jumping on injured foot). At any point if there is pain, stop. If pain persists more than 24 hours then go back a step and do more rehab before repeating the painful step.
From a NCAA D1 and Professional sports perspective, sport is their job or payment for school so many of our sport role models return to play way too early. For juniors players, coaches should be very conservative about returning athletes to play too early. Consider getting a doctor’s note to return. Athletes under the age of 18 should at least have their parent’s permission before returning to play. This protects the coach’s liability.
For college students, coaches may choose to follow the above recommendations for juniors players, though most of the athletes are adults. Coaches should avoid pressuring an injured athlete to return. The option of not playing should always be offered as a acceptable alternative.
Athletes will frequently want to play through an injury. The coach and athlete should have a private discussion about risks and benefits of playing. The more a coach is educated on rehab protocols and injury management, the better adviser she or he can be. More information can be obtained at www.injurytimeout.org, Web MD, and other sites.
2. It appears that several of our readers have experience with this problem:
I am having issues with one of my hamstrings (left) but not the other, tightness, or slight ache when I try to extend it fully, or a just lack of power in general. After considerable warmups it finally loosens up, usually about halfway into practice though. I’ve tried icing it, frankenstein dynamic stretches, bending at the waist static stretches. Ideas for what I could do to help it warm up faster? Its been suggested to have a teammate lean on the leg while I lay on my back to push the stretch further – is there danger doing this?
LINDSAY HACK, Orthopedic Physical Therapy
- Read the attached article on hamstring rehabilitation. In general, we have been going about hamstring rehabilitation incorrectly for too long.
- Many times a hamstring is tight because it is overworked because something else in your body is being “lazy.” Usually it is lazy because something else is tight inhibiting it. usually, with a hamstring, I have found that patients clinically present with a very tight hip flexor on that side, a glute on that side that can not fire independently of your unaffected side (NECESSARY for running), and a hamstring that is freaking out because it is doing the work of a large glute max muscle.
- Long and short of it…stop treating your hamstring and venture to other areas of your body that may not be doing their job.
- Pulled hamstring? Gently stretch to help new muscle fibers grow back in the right direction. But, you don’t want to stretch so aggressively that you actually break these new bonds.
TYLER KINLEY, Captain of Seattle Sockeye
I have this same problem, and it always comes from not stretching enough. Whenever I go to the gym and get lazy about stretching, everthing tightens up. And, it’s often from stretching everything surrounding my hamstrings, especially calves, hips, and even back. Stretch stretch stretch. Especially on off days when your muscles aren’t tired from a workout. This will make warming up far easier. As for the meanwhile, start your warmup earlier and build very gradually in intensity. I sometimes start my warmup before games 20 minutes before our team warmup.
JAMIE NUWER, Sports Medicine
In the last USA Ultimate magazine, I published an article on managing chronic hamstring strains. This is likely what you have. Rehab will certainly help you. In the mean time progressive neuromuscular facilitation (PNF) stretching that you described above will help relax the muscle spasm that occurs with chronic strain. To perform this stretch properly look up “PNF stretching” on YouTube. There are a bunch of videos.
3. Ryan asks: As professionals in sports medicine, do you have any suggestions to help navigate finding the best practitioner for the best price covered by your insurance?
LINDSAY HACK, Orthopedic Physical Therapy
- This is a tough one. I have had many problems trying to help a friend not located near me (Raleigh/Durham, NC) find the appropriate help.
- For physical therapy…try and find a board certified specialist. Orthopedic Certified Specialist or a Manual Therapy Fellow or a Sports Medicine Resident
- In general, I find that teaching hospitals and their ancillary services are the best and practice using the latest evidence/technology.
TYLER KINLEY, Captain of Seattle Sockeye
To find the best doctor for an injury, I simply ask around. Ultimate players get injured a ton and there is a wealth of knowledge in every community. When I tore my ACL I got like 5 recommendations within a day. As for whether they’re covered by insurance, you’ll have to check on that yourself.
JAMIE NUWER, Sports Medicine
For HMO insurance, call the number on your card and ask for a list of providers covered in your area. Call or make an appointment with your primary care doctor for a referral to one of these doctors. Your primary care doctor may be able to help you with choosing a doctor for your specific needs.
For PPO insurance, you can go to any doctor. Google doctors in your area. Read their websites to learn about their expertise. Narrow down a few and call their office to see if they accept your particular PPO insurance.
For POS (this is a combined HMO and PPO plan) you may choose to go to the lower priced HMO doctor or the higher priced PPO doctor. See above on choosing.
Choose a doctor with a specialty in Sports Medicine. This could be an orthopedic surgeon, family medicine, internal medicine, physical medicine and rehabilitation, or pediatrics trained doctor. They would have either a board certification or a certificate of added qualification in Sports Medicine.
If you want to find the most experienced, highly-qualified doctor in your area, you’ll have to ask around and use the web.
Non-surgery trained sports docs: http://www.amssm.org/Find-a-Doc.html
Surgery trained sports docs: http://www.sportsmed.org/tabs/findadoc/membersearch.aspx
4. Three weeks ago on the last play of the last day of tryouts I had to reach extra far for a layout score (didn’t even catch it, fml). severe pain initially in the right shoulder. and now I cant raise my hand over my head without severe discomfort. what’s the prognosis? I know I have to see a PT soon so hopefully answering my first question will help me and others more.
LINDSAY HACK, Orthopedic Physical Therapy
- I would need to ask about 100 more questions before giving you a solid answer here:) If you can raise your hand all the way over your head, you are in luck…but, I still have no idea what you look like doing that motion. My best piece of advice, get it looked at asap.
- In most states, you do not need a referral from a MD to see a physical therapist. See a physical therapist (which usually requires a lot less wait) and if they think your shoulder warrants an MRI/surgical consult, they will get you that appt with a orthopedic MD.
5. Mr. Anonymous wonders: Foam rollers – so hot right now – but are they actually that beneficial? any risks with using them?
LINDSAY HACK, Orthopedic Physical Therapy
- My clinical experience says yes.
- I wonder if there is actually any research on this…
TYLER KINLEY, Captain of Seattle Sockeye
100% benefit, zero risk to my knowledge. Every single tournament I use one after playing and sometimes before. I can immediately tell a difference in muscle tension and flexibility after foam rolling and highly encourage them.
JAMIE NUWER, Sports Medicine
Foam rollers are a convenient way to do deep tissue massage to yourself. Make sure you are warmed up before stretching. Stretching for the purpose of flexibility is the best at the end of practice when you are thoroughly warm. Stretching excessively before playing can actually decrease your performance by decreasing the contraction speed of your muscle. Excessive stretching would occur when stretching one muscle for more than 5 minutes in a static pose. This effect probably wears off in 10 – 15 minutes, but you may not want to spend 5 minutes on a roller and then jump back in to playing right away.
Do not ever stretch an acutely pulled or re-pulled muscle! Do not static stretch, dynamic stretch, or massage stretch. The muscle is literally ripped apart and bleeding in even a minor muscle pull. As you could image anything that stretches that tissue would cause more damage. You should stop immediately, apply pressure with a wrap over a pair of socks laid right over the area of maximal pain (where the tear is) for focal compression, and apply ice over the wrap. Wait 24 hours (when the swelling and bleeding has stopped) before started with gentle massage and stretching. Avoid aggressive massage or stretching until gentle feels normal. Foam rollers are aggressive massage.
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