Author: APT

I coached volleyball and track for nearly ten years at both the junior high and high school levels. The beginning of the season always brought a new energy and a renewed passion for the sport. However, that was tempered by the seed of fear in the back of your mind about what if _____ got hurt, what would happen to your season. We all have those athletes, the super star scorer, the team leader, the one with blinding speed, the motivator. And, when those people get hurt it can devastate your season. So how do you prevent it? There are several pre-season cues that you can look for to tell you who has the greatest potential for injury and what type of injury that may occur. Let’s start at the bottom and work our way up.

Foot Position

The position of a foot can predict a lot of injuries. If someone has a high rigid arch then they are more prone to ankle sprains. With a high arch the foot is carrying a majority of the weight on the lateral column (outside) and has greater ease of rolling. If you have a flat foot then you have less shock absorption available which can set you up for stress fractures, back pain, knee injuries, etc. If you have a good arch when sitting but it flattens when you stand then that is a sign that you have a weak glut medius. This is a glut muscle that supports all single leg activity. It is responsible for your ability to run, jump, cut, and land on one foot. Athletes with a strong glut med have less knee and ankle injuries, they are faster and have better reaction time on the run and off the jump. If this muscle is weak then the athlete has poor balance on one or two feet, puts more stress through their medial column (inside). This puts them at risk for ACL tears, ankle sprains, SI joint dysfunctions, patellar tendonitis, and plantar fasciitis, and stress fractures.

Knee Position

Genetics determines a lot about the position of your knee. If you have a strong valgus or knock knee-d posture then you are more at risk for ACL tears and typically have greater difficulty with jumping and cutting as a valgus knee position is less biomechanically efficient. If you add glut med weakness and a collapsing arch then your chances of injury are exponentially increased. Those with varus knee position or a bow legged appearance are at more risk for lateral ankle sprains, illiotibial band syndromes, hip bursitis, and have a difficult time with shock absorption with jumping. Knee position is directly effected by the strength of the gluts and the position of the foot.

Back Position

There are 3 load bearing curves in the spine: the neck curves in, upper back curves out and low back curves in again. These curves need to be in a good balance or you have an increased potential for injury as well as some pretty huge effect on performance. Chronic poor posture can effect these curves. If the upper back curve is excessive from chronic slumped positioning then the risk for shoulder impingements and neck pain is higher. Performance is effected as the athlete cannot fully extend upper back and therefore throwing velocity, vertical leap, and lung capacity can all be effected. Low back curve plays a large role in injury potential and performance as well. If the curve is too flat then low back pain can be due to poor shock absorption with running and jumping. Running speed and vertical leap can be effected as the hip has difficulty extending for end range push off with jump and stride length. If the curve is excessive then stability can be effected and increased stress can be placed on the base of the spine with all athletic activities. Performance can be effected as excessive curve leads to decreased hip flexion with running, poor reaction time off of the jump to cutting activities, weakness with full body contact, as well as poor control when attempting to stop motion. So, armed with all of this knowledge how do you prevent injuries. Take a look at your players posture. What are their backs doing? How do their knees line up with their feet? Do they have flat feet or high arched feet? Can they stand on one leg without losing their balance—if they can’t it’s pretty much a given that they have glut med weakness. When they squat do they assume a valgus knee position? If they do then they are at higher risk for knee and low back injury. Not only can you assess what injuries you may have but you may be able to understand the athlete’s limitations. If someone has a knock kneed posture it’s a lot harder to cut laterally and to jump quickly due to the biomechanical inefficiency of their leg. If you specifically train improved posture and mechanics with the activity they will get better. But yelling at them to get up higher or faster will never get results based on their underlying weakness and posture. If you have questions about your potential for injury or want ideas for warm ups for work outs to prevent injuries in any sport feel free to contact Alyssa Subbert, PT at  Alyssa@absoluteperformancetherapy.com

I sit here on a Sunday night overwhelmed with the need to write this article. First of all because it’s important information that gets taken for granted and second of all because I am victim to what a brace can do. Ahhh…let’s go back a year. In February 2011 I broke my ankle while demonstrating push off during a running clinic I was hosting <—-I know that’s just sad isn’t it. I drove forward with my right leg and at the same time turned to answer a question. I rolled my ankle, only instead of a tolerable sprain I felt a nauseating crunch. With x-rays I found out I had an oblique fracture of my medial malleoli, a talar dome fracture, and at some point in my athletic history had avulsed my anterior talofibular ligament. I was put in a CAM walker for 6 weeks. I knew I hated boots after helping hundreds of patients rehab out of them, but I did not fully appreciate how much until I was in one. Now YES they are important, immobilization by the boot was preferable to fixation with a screw. I appreciate that. But what I want you to appreciate with this article is what the boot does that you don’t think about.

First, let’s talk about the height of the boot. It can cause at minimum a 1” leg length discrepancy depending on the height of the opposite leg shoe—and that’s when you are wearing shoes. That leg length discrepancy can wreak havoc on your sacroiliac joint. I have yet to have a patient come out of a boot that does not have a sacral torsion or inominate rotation and this is much more prevalent in females given increased ligamentous laxity. Patients assume their back pain is because of the boot—which it is—and that it will go away once the boot comes off—it does not. That rotation or torsion does not go away on it’s own. The body adapts to whatever position it is put in the most. That altered torque can cause a host of other problems. The pelvic obliquity causes a functional leg length discrepancy, and with that discrepancy comes compensation. The short leg can stay supinated trying to make up for the length loss. On the long leg the quadratus can shorten and the hip hikes up to try to accommodate for the length difference as well. This can cause increased torque in the spine and hip and lead to later disc issues or a higher risk for a labral tear in the hip.

And what about the foot and ankle? Ahhh..that’s where the most damage is done—all in the good name of healing. So, we immobilize your foot/ankle to let it heal. That is the correct thing to do. However, what else happens because of that bracing. When we walk we want a great deal of subtalar mobility. When my foot hits the ground my calcaneus inverts, my midtarsal joint unlocks to absorb shock, and my tibia and femur internally rotate. All of this happens so that I can absorb the shock of the weight of my body meeting the ground and so I can turn on my powerful hip rotators in order to propel forward. As my body moves over my foot the opposite happens—my femur and tibia externally rotate, my calcaneus inverts, and my midtarsal joint locks up so that I have a rigid lever to push off of. It’s truly a great system—when it works. When we immobilize with a boot we stop this process from happening. And that’s good because we are protecting structures from force. However, once healed we need to restore this motion. Typically, after immobilization – both due to the boot itself and the swelling/soft tissue restriction of the injury—we lose subtalar joint motion. Which means we lose the ability to absorb shock and the ability to push off. This can put increased stress on joints and soft tissue. This can cause meniscus tears, labrum tears, plantar fasciitis, Achilles injuries, and soft tissue injuries such as chronic muscle strains.

Now let’s go back to my story. So I fractured a year ago, in boot for 6 weeks and went back to work. I exercise daily for my job. And what a difference a brace makes. I had no balance with any single leg exercise, could not squat symmetrically, had teeth rattling stiffness with all landing from jump—and that’s when I could jump 8 weeks later. My hip was sore, my knee was sore, my SI joint was torque. I strained my calf about 100 times showing people exercises in those first few weeks back as my body tried to find the path of least resistance to move.

That’s the key. On a base level our bodies are lazy. Subconsciously we find the easiest way to move. My body had chosen to externally rotate my right femur to try to gain motion with gait since I could not move through my subtalar joint. However, this didn’t go well. I have a high rigid arch, a plantar flexed first ray, and a tight hip. So instead, I strained my calf a half dozen times before I got it worked out. And it took help. This isn’t “go home and stretch and feel better,” I needed someone to make my subtalar joint and hip work together the right way. Looking back, I had probably not moved well in a long time. That old ATF tear happened when I was in high school. Back then, we iced, we braced, and we played. We were dumb. That mentality lead me to an ACL tear—however helped me pick a career so it’s a wash—grin.

So my point in all this…please send your patients to physical therapy after they have been in any sort of boot or post op shoe, give them firm guidelines on how long to wear any type of brace, and ask them about pain in other joints. A brace can be cumulative trauma. Poor motion causes inability to load and unload every joint in the chain resulting in increased stress, torque, muscle strain, and joint dysfunction.

– Alyssa Subbert, PT, CSCS, FAFS, FMR, CFCE, CEAS, NG360 GPS

Questions: Contact us at 987-6267 or alyssa@absoluteperformancetherapy.com.