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Meniscus Injury – Russell Westbrook and Derek Rose
Mensical tears can vary extensively in their severity, but more so in their post operative management. Strength and improvement in knee mechanics are paramount moving forward and vital in the performance and health of any basketballer.
It’s topical at the moment as Derrick Rose remains side lined, and Russell Westbrook continues to go on a tear. How do these players differ? Usually I would suggest it’s related to players positions and requirements. A big man is less likely to perform sharp cutting movements, placing excessive stress on the knee, although their large frame places added strain onto the joint itself. Westbrook and Rose at face value hold too many similarities, so it would be thought that they differ in movement patterns and muscle imbalances.
The meniscus is a term we hear of so frequently in basketball, almost too frequently, but many people have minimal understanding of it’s structure, let alone it’s purpose. With the advancements in medicine, we have come to understand the meniscus far better than original thoughts. Many years ago, it was concluded, if it hurt, get rid of it, and your pain would be resolved. Years on, those who suffered meniscal tears are now requiring intervention due to the early onset of arthritis.
The meniscus can be simply viewed as a shock absorber, and is unique to the knee joint. We have a lateral meniscus but it is more common to damage the medial side due to anatomic structure. Tears can develop in all sorts of shapes and sizes, and fraying or degeneration of such structure is extremely common in athletes as they age. It is believed that the meniscus as such has very poor blood supply, and thus extremely slow (if any) healing capabilities. Thus when torn, the obvious option is surgical intervention. Previous surgical thoughts were to remove the entire structure, however medicine has advanced to recognize the importance of such anatomy. Depending on the location, size and direction of tear, will often influence how much of the meniscus is preserved. Preservation is argued to maintain joint integrity and prevent early onset of bone on bone arthritic change and also maintain joint proprioception.
I’ve heard the meniscus to be described as a piece of apple pie, and often pass on the analogy. The inner middle portion is often thinner and tears are cut out and removed, preserving any intact meniscus. Outer portion tears are considered thru a layer of the apple pie and can often be sewn up due to the thickness.
Accompanying surgical intervention, it is imperative to improve movement patterns to avoid further degeneration and deterioration as well as strengthen up specific quads and gluteal function to unload the specific knee joint. Such rehabilitation is thought to significantly improve longer term outcomes of knee preservation.
In a sport like basketball, twisting, cutting, pivoting and most importantly take off and landing are all extreme stresses going through the knee joint. It is thus explainable why athletes take extended periods off to rectify their strength and movement patterns. The body must be seen as a whole and it’s truly capable of learning new things, with landing technique and cutting imperative to reduce dynamic knee valgus angles. Rehabilitation also focuses around unloading the knee joint as the meniscus bears more load in a compressed environment, so open chain exercises are highly recommended. All of the rehabilitation goals and timeframes generally depend on the extent of injury and the surgical procedure performed. Preserving the integrity of more meniscus is great in the long run, but for short term recovery to see the star athletes back out on the court, a ‘cut it out and play’ can often be more desirable.
Despite being catastrophic for the knee, for anybody let alone a professional basketballer, it must be noted that it is however quite a simple injury, generally involving the one structure. Meniscal injuries however can accompany more serious diagnosis. Perhaps there was more to Derek Rose’s injury than we were led to believe?
The use of Orthokine and PRP – The great debate
Kobe Bryant. Greg Oden. Andrew Bynum. Derrick Rose. They all share dilemmas that have them on their knees looking for answers.
I remember back to Christmas a few years ago. During the Lakers vs. Bulls games the commentator began discussing Kobe’s knee treatment. The procedure involved centrifuging the patients blood and using the serum as an anti-inflammatory drug. Tracy McGrady reportedly recommended the therapy to Kobe who has now passed the knowledge on to Alex Rodriguez of the New York Yankees. Even before the season began I remember Derek Fisher at the time, mentioning that Kobe’s knee was better than ever. It’s very topical in the world of sports medicine, and has become a very popular intervention for tendon and joint injuries over the last five years. It is particularly popular in Melbourne. In fact there have been some sports medicine clinics open recently advertising this as one of their main intervention options! Now there is a mild difference between the infamous ‘orthokine’ used to treat Kobe and many other elite professionals knees and the now popularized PRP, but they follow similar principles.
Orthokine therapy was designed by Dr. Peter Wehling of Dusseldorf, Germany. He has treated numerous influential figures including Pope John Paul III (guess the holy powers didn’t work too well here). Dr. Wehling has reported a 90% success rate for the procedure, and proclaims it is a long term cure to inflammation and its resulting pain. On numerous accounts I’ve read him to state “I am the only one to have found a way to cure arthritis.” Along with his clinic in Germany, Wehling has also opened an outpost in Los Angeles, where he deals with ” a very small and exclusive clientele.” So how exactly does the procedure work? Well here I’ll do my best to break it down
Simply, the treatments involve your own blood being taken from you (normally from your arm) – then placed in a centrifuge and ‘spun down’ to separate the blood into 3 products – red blood cells, platelet poor plasma, and platelet rich plasma. The last item – the PRP – is kept, and injected into the affected tissue.
More to the point, the therapy focuses primarily on Interleukin-1. IL-1 plays a part in a wide variety of metabolic processes, specifically in immune and inflammatory response. IL-1 binds to specific cytokine receptors to induce inflammation. It is also known to play a role in disc degeneration, osteoarthritis, and the breakdown of the cartilage in joints. Thus, the primary focus is to stop this receptor mediated pathway via an antagonist protein where IL-1RA was that antagonist. The protein is produced by white blood cells (monocytes) and blocks Il-1 from binding to its receptor to significantly reduce inflammation.
In Dr. Wehlings procedure, blood is drawn from the arm by a special syringe in which glass beads induce monocytes to increase the growth of Il-1RA by up to 30 times. The solution is placed in an incubator to further induce protein synthesis and the final solution is centrifuged so that the serum of interest may be separated. In both cases the final solution is injected into the area of interest, and it seems to be working pretty well, at least for Kobe Bryant.
This entire process only differs from the more common treatment as the blood is stored and cultivated for a little longer in the glass beads, so that white blood cells produce a natural anti-inflammatory called IRAP.
Studies around Orthokine have largely been controversial with biased funding groups supporting affirmative outcomes. Comparing orthokine Therapy with PRP, it’s safe to say Orthokine lost badly in a head to head comparison of treating knee osteoarthritis.
Other studies have incomplete conclusions or are also questioned by scientific authorities. The anecdotal results are often very positive, but it is impossible to say that the treatments are de facto effective. At worst, there is no evidence that they have any sort of short- or long-term deleterious effects. Given most have severe degeneration at the time of treatment, it is hard to imagine much more damage could be done. Unfortunately unsuccessful treatments to Andrew Bynum and Peyton Manning in the NFL were less glorified or publicized.
Bearing in mind, the cost involved for such an injection is significant – anywhere from $200AUD up. The suggested number of injections varies but is normally two to four injections over a six to eight week period. This may be alright in an elite environment but can add up for the weekend warrior when we are truly unsure of strong positive outcomes.
With athletes and many individuals looking for a ‘quick fix’ we may see this trend of use continue to increase.
Tendons - What are they?
These hobbling images of a crippled Kobe, and him pushing through to shoot free-throws will forever remain in my head.
One of the most topical areas of sports medicine in Australia at the moment lies in the research and discoveries with regards to tendons and their properties. More so to these findings is the explanation behind the misunderstood tendon injuries and recurrence of problems in the past.
Basketball is a sport primed for tendon presentations following the recent discoveries behind the matrix of what a tendon is and how it responds and acts in accordance to load. To put simply, a tendon may be referred to as a ‘spring’ in the body. A tendon is put to use in bounding based sports, where the tendon matrix stores and expends energy on a repeated basis.
In an NBA review of injuries it was noted that ‘patellofemoral inflammation’ (which was a previous misconception) accounted for the greatest number of practices and games missed.
Traditionally, healthy tendons are densely packed collagen fibres, uniform in nature. They require mechanical stimulus to load, be that from compressive force or tensile stress, and with sufficient recovery time remodel to strengthen. Everybody is familiar with the DOMS feeling of muscle microtears. It has however been an area neglected as we don’t feel tendon DOMS and muscles have been shown to repair at somewhat of a faster rate than tendon tissue. Unfortunately, when we are younger, and older infact, we load these structures without the known required to for remodeling to finalise. This leads to slow degeneration of the matrix structure and it’s ability to withstand load. Further to this point, a bulk portion of tendon ruptures (namely Achilles) occur without prior onset of pain – indicating a swiss cheese or frayed rope analogy to a degenerated tendon and it’s declined ability to withstand load. To visualize a fresh healthy tendon, think of a brand new rope, and two people pulling in separate directions at each end. Repeated bouts of activity that places stress on to the tendon (‘high’ load – fast, bounding activity) slowly cuts away to fray the rope in the middle. Two people then pulling the rope from separate ends results in the rope snapping…
Pain presentation still is a interesting topic with regards to tendon management. Evidence suggests there are no internal inflammatory markers within the cellular matrix often rendering anti-inflammatory treatment as useless. It may be argued the external sheath to the tendon is stretched and becomes inflamed as the normally uniform collagen tendon matrix increases in diameter with the influx of tenocytes in normal response to load. Pain is present when a tendon becomes reactive due to it’s incompetence to tolerate the demands of the load that the body or athlete is placing on it. Rest previously and still does appear to settle basic tendons but this does not address or improve the tendons capability to tolerate higher or more demands. Thus recurring presentation of injury is extremely common if rest has been the only form of falsified ‘rehabilitation’. When the athlete places the same demands on the tendon in which it previously could not tolerate, the pain will return. Often presentations of onset occur at a reduced threshold because between painful events the individual has not allowed sufficient remodeling and further degeneration has taken place.
The greater debate now shapes around what’s considered ‘high’ load and who can tolerate what. Further studies and clinical experience will unveil a lot of these questions in the not too distant future. Understand now, that jumping places high demand on the Patella tendon, sprinting on your toes or up hills is high load on the Achilles tendon. Increased weight from bulking programs, or lazing about on the couch in the offseason adds demand to an underprepared tendon or simply sitting out missing games due to injury. Increased minutes or repeated days of activity also will see the quality of your tendon matrix suffer.
Moving forward I hope this helps every one of you to understand why you recurrently develop pain throughout certain times in season and from season to season this won’t go away. It can be fixed by the right practitioner, just unfortunately it has been poorly understood by the bulk portion of healthy professionals in the past. In 2007 Alonzo Mourning was a casualty of a patella tendon rupture and more recently everybody in the basketball world can recall Kobe going down with his Achilles.
Piece together Kobe’s rupture yet? Understand load and your body will be a happier machine.
Kevin Durant and his Jones Fracture
Welcome back NBA season! Well, before it all begins, we have seen our first casualty. Unfortunately for OKC it’s their main man, and what’s worse is the news I’m about to educate you with. Kevin Durant has suffered a Jones fracture, which is unfamiliar to most - this is because it is a very rare injury across the board. A Jones fracture is a fracture that occurs in the diaphysis of the fifth metatarsal in the foot, essentially at the base of the small toe. Often, these injuries remain undiagnosed as pain is very localized but as the fifth metatarsal doesn’t load excessively, and is only under extreme load through change of direction, it may be inconsistent in nature.
Other proximal fifth metatarsal fractures exist, although they are not as severe as a Jones fracture. If the fracture enters the intermetatarsal joint, it is a Jones fracture. If, however, it enters the tarsometatarsal joint, then it is an avulsion fracture caused by pull from the peroneus brevis.
A legitimate concern in any fracture is whether the fracture will heal quickly and without complication. If a fracture failure to join is it termed non-union and its frequency varies with the fracture site, some fracture sites being notorious for non-union. These are known sites due to their very low blood supply that in turn means slower healing capabilities. A pretty well understood injury in the general population example of such would be a scaphoid fracture of the wrist. Such a complication unfortunately for KD also involves fractures of the proximal end of the fifth metatarsal, such as the Jones fracture. This has been the subject of interest, and initially led to the description of three zones at the proximal end of the fifth metatarsal.
Zones I and II have been associated with relatively guaranteed union and this union has taken place with only limited restriction of activity combined with early mobilization. In other words, results tend to be good. On the other hand, zone III has been associated with either delayed or non-union and, consequently, it has been generally agreed that fractures in this area should be considered for some form of internal immobilization, such as internal screw fixation. Now, I’m led to believe KD will undergo surgical fixation, which should by all means increase his chances of union and optimal healing, but the timeframe will be around 8 weeks return to play.
8 weeks of minimal activity to an elite basketballer can be disastrous. They can lose their shooting touch, their feel for the game and a handful of idiosyncratic skills unique to the game. That’s not my concern. The bigger concern I have comes around sports medicine and understanding load management. I’ve had patchy spiels to you all about load and the load in which tendon and bones require. The body likes consistency. Significant prolonged periods of rest, coupled with being thrown into the deep end of the season, may be recipe for disaster. Periods of under loading of tendons and other bones and then returning to high level activity may see patella tendons blow up and other sequelae of injury. We know the best form of medicine is prevention, and I sure hope the OKC support staff have this is the back of their mind. To get a patella tendon under control mid-season can be disastrous, and I see Festus Ezeli’s year long PCL rehab result in ‘shin inflammation’ aka shin splints/MTSS upon return. Sitting extended periods of time out can result in disastrous sequelae, and more often than not it’s down to the time of season in which an injury occurs, not the management of the actual injury itself.
Ironically, Perry Jones III may have to take a bigger step up this year than we first expect.
Roller Techniques
The roller can be an athletes best friend. We see more and more people utilising these and is becoming an essential tool for most sportsmen in aiding self-management. Most beneficial in basketball is its ability to provide soft tissue release for the legs and low back. The other very significant use of a roller is seen for those with tendon pathology. It is very well recognized that in reactive tendon’s, stretching provides a compressive force that has proven to aggravate them and hinder their recovery. We know that unloading tight tissue and lengthening tight muscles is beneficial, and rolling provides a suitable alternative to when stretching is not advocated. Lengthening tissue allows for adequate range of motion and therefore improved or more normalized biomechanics.
Below are some basic recommended exercises with simple progressions to incorporate into your pre-game or training regime. Initially expect a fair bit of discomfort, however the more you do this, the easier it will all become.
Glute Rolling Basic
Glute Rolling Progression
ITB Rolling Basic
Rolling ITB Progression
Quad Rolling Basic
Quad Rolling Progression
Calf Rolling Basic
Calf Rolling Progression
In summary, a good rolling program saves many athletes heartache. It allows you to become far more aware of your body too and notice which parts are being overloaded or becoming tighter at any one period of time. It should be an essential in every player’s basketball bag to perform these simple exercises prior to and after any form of exercise session. It keeps the muscles and surrounding fascia at good length that can never be underestimated. Rolling program's can also be optimal in tendon management, which will be discussed in detail in the future.
Basketball Prehab
Ankles, Knees and Hips. They’re the most common presentations we see that can simply be avoided by a prehabilitation program – I can’t offer much advice on stopping the ball jamming down on your finger. So what is prehab? ‘Prehab’ is the process of improving mobility, flexibility and strength to reduce injuries in troublesome areas.
Ankles: I’ve mentioned the need for 12-14cm worth of knee to wall to ensure the whole lower kinetic chain is moving efficiently, but I’ll state it again. Get mobilizing!
It is also important to progress thru an adequate ankle stability program, which allows the proprioceptive balance fibres to increase their ability to respond in certain settings. Start basic single leg standing and progress through tasks that may challenge this such as standing whilst throwing and catching a ball against the wall. You can also try shutting your eyes or standing on an unstable surface such as a folded pillow or wobble board. I see the last two as a bit dysfunctional to basketball, as we don’t require these skills, but they do take your balance to a higher level. I often like to challenge athletes into functional positions so I think single leg stance, standing sideways on a decline board is actually a great basketball specific ankle exercise (and one I’ve seen Steph Curry master over his ankle rehab program).
Hips: Hip strength is vital in any form of movement. It simple controls your body’s position and there is plenty of data stating that poor hip strength results in lateral ankle sprains, due to the position your centre of mass is when landing on one leg as a result of the lack of control. 3 very simple exercises to begin are basic clams, side lying leg lifts and glute bridges.
Clams – When lying on your side, slightly bend your knees and hips. Roll your hips forward and hold them there (rolling backwards is cheating). Keep your ankles together and lift your knees apart, changing the joint angle at your hip and feeling it work you glute medius (side glute) muscle.
Straight Leg Lifts – Again, when lying on your side, ensure you are dead straight this time. Take the top leg back slightly further so it is behind the bottom leg. Keeping the foot in somewhat of a neutral position, lift the leg up. Ensure it doesn’t kick out in front of your, nor do your turn your foot.
Bridge – This is an exercise many are familiar with but is performed relatively poorly. It is a great posterior chain strengthening exercise but athletes adopt a ‘strong get stronger’ approach and recruit the muscle dominant pattern they already have. A cue I often explain is “pee over your head” or “tuck your tailbone under”. It is simple a movement of lying flat on your back with you feet on the floor and knees slightly bent. Then you are to lift your bottom up, remembering to keep tucked under. If you arch your back too much, your hamstrings will cramp and you have probably performed this exercises incorrectly.
Progress from doing 3 x 30sec holds of these exercises, to 10 x 30sec holds. It’s then time to move to exercises that actually involve body weight, but you will be surprised at how weak most individuals are around the hips, and you’ll feel a burn!
Labral tears are a very common presentation in basketballers, due to the notion of cutting in the sport. They occur from ‘sloppy’ or ‘unstable’ hip joints due to lack of muscular control or strength around the hip socket itself. Quite frankly however, a bulk portion of the athletic population have underlying labral tears when imaged on MRI, however a smaller portion only present with pain. This is due to them having sufficient muscular stability and not relying on the inherent lack of passive stability. It is thus easy to see how a prevention strengthening program may eliminate your risk of hip pain.
NOTE: Many people have seen these generic exercises but have been poorly taught or perform them incorrectly. In the clinic, I've seen a variety of 'interesting' techniques. Remember, QUALITY OVER QUANTITY. Your strong muscles will get stronger if performed incorrectly.
Knees: The great news is a lot of knee pain comes from the lack of control from the proximal(hip) and distal(foot) parts of the body. One prehabilitation exercise important for the knees is landing strategy, in which I will discuss in far more detail in a subsequent post. Stay tuned. Basically the movement that is most toxic to the body is known as ‘dynamic knee valgus’, which is where your knees come together as you land or bend the knees. This places an athlete at severe risk to multiple injuries. Practice landing off a step where your knees go out towards your 2nd or 3rd toe and don’t trend in towards one another but ensure your knees do not go forward over your toes. Also add in hip and trunk flexion to absorb more through the hips to dissipate the load.
By performing these exercises daily, you’ve taken the right step towards body maintenance and keeping injury free.
Good Luck!
'Pray for PG'
After my previous post discussing the horrifics of Kevin Ware's injury, we unfortunately re-lived the memories when Paul George took off to block James Harden's transition basket in their USA basketball hit out. Nothing more than pure misfortune plays out in this incident, one I'll save you from graphically. Instead, I've posted something more heart-warming - Coach K embracing Paul George in his hospital bed. Sometimes in the NBA I feel players, teammates, coaches, support staff and front office staff alike, are caught up in the day-to-day winning and losing and the bottom line of producing a profit, that their compassion and respect for one another may not always shine through.
Thankfully, when they come together for USA Basketball, we see them at their best in every way shape and form.
Kevin Ware – Acute Trauma or Overload?
“Win for Kevin” or “Win for Ware”. We in the basketball world, unfortunately are all too familiar with the traumatic injury Kevin Ware suffered in Louisville's Elite Eight win over Duke back in March 2013, and images still haunt me of it today. He re-injured the same leg in December and did not appear in a game since a December 17’s victory over Missouri State and played only sparing minutes in nine regular-season appearances. Rightfully he was medically red-shirted and we keep our fingers crossed that we see him return to action in another prominent Louisville campaign in 2015. With such a traumatic leg break still paramount in all our memories, it leads me to question how such an injury may happen. Was it a freak accident or could this have been prevented? Do elite athletes push well and beyond points of pain and discomfort not notifying medical professionals around them, just so they can showcase what they perceive to be their best, neglecting any effect injury may have or increase further catastrophic disaster?
Having recently returned from this environment, the words of a very prominent orthopaedic surgeon ring in my head every day – “To play at the elite level… It’s not ones ability over another, it’s their ability to perform in the same capacity throughout or enduring pain. It’s their ability to not falter or let pain hinder their impact”. In a case like Kevin Ware, it makes me question this even more. Did Ware suffer from mild shin pain, even moderate shin pain in the matches leading up to the Duke game? Was he putting on a brave face, just to be there at the end of March Madness holding that trophy, trying to showcase his skills on the elite stage to be picked up by an NBA team to fulfill a childhood dream? All these are questions we never will know answers to… It is my personal opinion that Kevin Ware probably ignored warning signs. He no doubt would have been suffering some form of shin discomfort leading in to that ever so gruesome leg break. Yes, he is in an athletic population we know are slightly more susceptible to bone damage than another, but nothing to which I would feel a standard landing routine would crack a bone to that extent. It is more plausible in my opinion that due to the increase in scheduling of March Madness, his bone did not have sufficient time to remodel. Unfortunately, leading to a stress reaction in the bone, of which progressed further into the events we saw that took place. It is probably a pessimistic view, but one I’d like to share with everybody, and give insight from being in the health industry. Having seen the elite setting and the pain and suffering they put their body’s through, it is sometimes not well publicized. I guess it’s like comparing the glitz and glamour of Hollywood to the actual reality of it all. Battered and bruised these athletes are required to fight or some may term it play, day in day out, to generate revenues and wins for their respective teams. At the end of the day, money is the real issue, with players playing for minutes, stat lines and ultimately contracts. Unfortunately, from a medical perspective, we see bodies trashed in the process, and I try and keep the sane thinking, that unfortunately you can’t play for money if you’re broken. Learn to listen to your body. Learn to respect your body. And in turn it will respect you.
https://www.youtube.com/watch?v=4qEIFmUOwd8
Ankle Injuries
I know I continue to harp on about the foot and ankle but the fact of the matter is ankle injuries are the most common of all basketball injuries, with an incidence of anything between 0.4% to 8.9% documented in medical literature. Falls accounted for most of these injuries (54%). The average time loss for ankle injuries has been recorded as just over 5 days per injury, however in another study indicated 45.9% of athletes missed 1 week or more with the injury. Ankle sprains are more common in female athletes, although this applies mostly to basic mild ankle sprains which are classified medically as ‘grade 1’; the incidence of more severe ankle sprains is similar in male and female players, and the incidence of ankle fractures is higher in male players.
Most ankle sprains are non-contact injuries, and the highest incidence occurs when rebounding during practice. Ankle sprains are more common in athletes with a high body mass index (BMI). Importantly, the incidence of ankle sprains is much higher in athletes who have had a prior ankle sprain; therefore, rehabilitation after an ankle sprain should be directed not only at resolving current symptoms but at preventing future ankle sprains. This makes me question our ability to rehabilitate and our commitment to taking ankle sprains to higher level function. A common question I pose to patients is why do we neglect the ankle, when we care so much for our knees and backs. Following ACL rupture and reconstruction, it’s well understood and accepted that we rehabilitate for anywhere up to 24 months, even though we commence running as early as 6 months. Unfortunately with ankles, it is not uncommon that people fail to continue their rehabilitation once they’ve returned to pain free running. The reduction in muscle control and proprioception in ligaments and muscles of the local area then lead to recurring injury and often the player to just resign to the fact “they have weak ankles”. It shouldn’t be the case!
Because of the anatomy of the ankle joint, the talar dome is held more tightly between the distal tibia and fibula when the ankle is dorsiflexed (toes pulled up). For this reason, ankle sprains are more likely to occur when the ankle is plantarflexed (toes pointed down). Furthermore, because of the relative strength of the deltoid ligament on the medial (inside) aspect of the ankle, the lateral ligaments of the ankle are much more likely to be injured.
Athletes with an ankle sprain typically present with lateral ankle swelling and tenderness shortly after inversion of the plantarflexed ankle. The anterior talofibular ligament (ATFL) is the most commonly injured ligament of the lateral ankle complex, and athletes may present with point tenderness along the path of the ATFL. In addition, they may have pain and laxity (looseness) with provocative testing of the ankle ligaments. Imaging is not necessary after most ankle sprains. It may be important to rule out fractures, however, which would require more restrictive management. For this reason, the Ottawa ankle rules were developed to determine which subset of patients with lateral ankle pain require an x-ray to rule out the possibility of a fracture. Under these guidelines, radiographs are only ordered for those ankle injuries that are accompanied by tenderness along the distal 6 cm of the posterior (back) edge of the medial or lateral malleolus (ankle bone) or at the base of the fifth metatarsal (little toe) or navicular bone and for which athletes are unable to bear weight for four steps at the time of the injury and at the time of evaluation. The Ottawa ankle rules were developed with adults, and are therefore not appropriate when applied to the pediatric population. When ordering radiographs of the ankle, it is important to consider weight-bearing films to evaluate the functional alignment better.
Here is a picture demonstrating the Ottawa ankle rules.
When a fracture is cleared, a lot of the population think it is great news. From where I stand, sometimes it is the worst news. Patient's think they have the green light to load as tolerated, and it is why I've been referred several chronic ankles who've been managed exceptionally poorly. They mobilise excessively and avoid any further rehabilitation, expecting it to heal on it's own as there is no break and "it's only just rolled". Contrary, those who fracture require the use of a CAM boot to immobilise the ankle. not only does the bone heal, but the often severely damaged ligamentous tissue is given a chance to scar and heal as well. Correct return to sport protocol and loading programs will optimise the ankles performance in the future and also prevent future ankle sprains.
Don't say you haven't been informed..
Marfan Syndrome - Is Isaiah Austin really a basketball outlier?
Isaiah Austin's basketball career is finished. The former Baylor center who declared for the 2014 NBA draft has Marfan syndrome, a genetic disorder that affects about one in 5,000 people, including men and women of all races and ethnic groups. About 3 out of 4 people with Marfan syndrome inherit it, meaning they get the genetic mutation from a parent who has it. But some people with Marfan syndrome are the first in their family to have it; when this happens it is called a spontaneous mutation. There is a 50 percent chance that a person with Marfan syndrome will pass along the genetic mutation each time they have a child.
Austin was diagnosed during genetic testing in preparation for the draft, where he was expected to be a second-round pick. Austin was measured out as just over 7 foot and 220 pounds at the draft scouting combine in Chicago. He also had the longest wingspan of any prospect there, at 7-4½. He revealed last season, as a sophomore at Baylor, that he is blind in his right eye as a result of a detached retina.
A classic demonstration of people with Marfan syndrome are that they are usually tall and thin with disproportionately long arms, legs, fingers and toes. It is often something that occurs to me when thinking of basketballers, as it’s very typical that many of the athletes demonstrate many of the characteristics especially in the elite setting.
Marfan syndrome is a genetically inherited disorder that commonly affects the body’s connective tissue. Connective tissue holds all the body’s cells, organs and tissue together. It also plays an important role in helping the body grow and develop properly. The damage caused by Marfan syndrome can be mild or severe and varies throughout the spectrum. If your heart or blood vessels are affected, the condition can become life-threatening. Connective tissue is made up of proteins. The protein that plays a role in Marfan syndrome is called fibrillin-1. Marfan syndrome is caused by a defect (or mutation) in the gene that tells the body how to make fibrillin-1. This mutation results in an increase in a protein called transforming growth factor beta, or TGF-β. The increase in TGF-β causes problems in connective tissues throughout the body, which in turn creates the features and medical problems associated with Marfan syndrome and some related disorders.
Because connective tissue is found throughout the body, Marfan syndrome can affect many different parts of the body, as well. Features of the disorder are most often found in the heart, blood vessels, bones, joints, and eyes.
Below is a short summary of Marfan syndrome features:
Heart and blood vessels (cardiovascular system)
Enlarged or bulging aorta, the main blood vessel that carries blood from the heart to the rest of the body (aortic dilation or aneurysm)
Separation of the layers of the aorta that can cause it to tear (aortic dissection)
“Floppy” mitral valve (mitral valve prolapse-MVP)
Bones and joints (skeletal system)
Long arms and legs
Tall and thin body type
Long, thin fingers
Curvature of the spine (scoliosis or kyphosis)
Chest sinks or sticks out
Flexible joints
Flat feet
High-arched palate
Teeth that are too crowded
Eyes (ocular system)
Severe nearsightedness (myopia)
Dislocated lens of the eye
Detached retina
Early glaucoma
Early cataracts
Lungs
Sudden lung collapse
Emphysema
Asthma
Sleep apnea
Other body systems
Stretch marks on the skin that aren't explained by pregnancy or weight gain or loss
Swelling of the sac around the spinal column (dural ectasia, found with CT or MRI scans of the back)
I often wonder in the elite basketball population if some of the athletes are very mild sufferers of Marfan syndrome, and to what degree it may affect them. It poses many questions when thinking about it’s physiological impact on the body. We see remarkable turn around on some athletes and others take excessively long periods to rehabilitate following what originally appear to be minor injuries. In the elite environment of the NBA, players battle through pain on a constant basis and so I sometimes question those stuck in long rehabilitation processes. Are these mild Marfan syndrome sufferers whose connective tissue and structures take longer time to remodel than those who do not possess this trait? I leave you with unanswered questions, as I’m yet to discover the answers but we wish Isaiah Austin all the very best in his future and I’ll keep eagle eyes on him and any injury he has in the future and what may be a lengthy road to recovery for him.
Medical Redshirt
‘Redshirt-ing’ is a term we hear thrown about all the time when Australian athletes embark on their college careers.
College athletes across all sports, have four years of eligibility to play varsity sport, where they may compete during a 5-year span, except in very rare circumstances where some athletes have 6 years to complete their four years of eligibility.
It’s not uncommon for an athlete to take what is called a ‘redshirt’ year as a freshman, in which the athlete practices with the team, lifts weights and is involved in all the teams scheduling, but doesn’t physically compete in any games. Many Australians take this year to adapt to college life but to also bulk up in the weights room as many are undeveloped comparatively when hitting American shores due to the inadequate systems or lack their of in place to maximize athletic potential at an earlier age. Utilising a redshirt season is usually to avoid wasting a year's eligibility on a season that would otherwise be spent on the bench.
Additionally, if an athlete competes in some games but misses a substantial part of the team’s season due to injury or illness, they can petition the NCAA for a hardship waiver – commonly known as a ‘medical redshirt’ – meaning that the abbreviated season doesn’t count against their four years of eligibility.
If a player sustains an “incapacitating injury or illness” then they qualify under NCAA ruling. The injury or illness does not have to be related to basketball, but must take place after the first day of classes in the athlete’s senior year of high school. To gain a medical redshirt for a specific season, the athlete’s illness or injury must occur before the first game of the second half of the team’s schedule. If the team plays an odd number of games, the exact midseason contest is considered part of the second half. Games played in postseason tournaments, such as a conference tournament or the NCAA or NIT tournaments, count among the team’s total games played.
More specifically, to gain a medical redshirt, the athlete cannot compete in more than 30 percent of their team’s games within a season, which does not include contests officially designated as scrimmages or exhibition games. When such computations are made, fractions are rounded up. For example, if a team plays 27 games, the exact 30 percent mark is 8.1. For the purposes of medical redshirt eligibility, therefore, the player may compete in nine games and still be eligible for a medical redshirt.
As mentioned, in special and somewhat rare circumstances where a player takes a standard, nonmedical redshirt season, then later is granted a medical redshirt, the player has six years in which to complete their four seasons of basketball eligibility.
Medical documentation is of course required with every medical redshirt request.
What is ‘Core’?
The constant discussion over ‘core’ and what is ‘core’ can often be gear grinding. From couch potatoes, everyday gym junkies, personal trainers right through to qualified health professionals, everybody has their own two cents of knowledge and opinion of what actual ‘core’ is.
I believe the best example of athletes with ‘core’ are 100m sprinters. Their ability to look effortless whilst sprinting is second to none. This however still doesn’t answer the question I pose of “what is ‘core’?” but gives us an ability to break down each aspect far better to then understand Michael Jordan's 'core' and his ability to maximise hang-time.
Well, look at a 100m sprinter, running straight at you, and cover up their torso or upper body. You will see their legs turning at a rate of knots, spinning like they are trying to ride a bike. Now, cover their legs. Negating all forms of facial expressions and tongue waving antics, you may mistake these athletes for sitting on a chair. They’re practically stationary. This is core.
Glutes, abs, lumbo-pelvic stability. It’s all incorporated into one. Core, is ones ability to control their pelvis on their hip and spine. When you stand on one leg, you should not drop through the pelvis, or shift your weight, or lean overtly to one side. These compensatory mechanisms means that our buttocks are underactive and not holding ourselves on our pelvis, so we move about to reduce moment arms (sorry, we are getting into physics) to provide the muscle with mechanical advantage.
Many patients come to me and tell me they have poor balance. Unfortunately it’s more often than not, a lack of gluteal strength and ‘core’ control. Balance, I explain, comprises of vision, vestibular function and then muscle mass and function. Generally, the first two are in fine working order, and we lack the latter component. The good news is it’s easily re-trainable and can improve quickly with the right forms of activity. It is here where I see Pilates or Yoga as a good activity as a lot of poses are based on single leg stance and gluteal activation and control of the pelvis on hip. In a future post I will discuss the use and benefits of Pilates or Yoga into an athletes program.
Another great example of athletes with amazing ‘core’ are Tour de France cyclists. You can often hear the commentators predict who is fatiguing and will be dropped over the next few kilometers and it used to amaze me how accurate they were. Now as a professional, I too can see those struggling. Their hips start to shake and twist from side to side when out of the saddle, rather than staying flat and stable as they cycle away. Much like the 100m sprinters described earlier, however throughout the many hours of racing, the levels of fatigue demonstrate noticeable change. There’s always one exception to every rule. Alberto Contador. He’s the ‘Dancing Spaniard’ because of his style as he shakes his hips from side to side. It therefore makes it extremely challenging for other cyclists to pick when he is fatiguing.
The correlation of this and basketball may be puzzling to most, however a stronger core, results in more efficient movement and biomechanics which no doubt aids injury prevention. It also is considered to have benefit to your agility and maximum vertical leap, because no energy or movement pattern is wasted in pelvic dip. Instead, structurally strong throughout the decline movement of a squat and can power straight up into a leap rather than at all sorts of dysfunctional vectors. It's probably safe to assume Jordan's hang-time was associated with maximum efficiency in his movement patterns.
I hope this uncovers a lot of the misunderstanding of ‘core’ and inspires you to all begin a glute stability program to maximize your efficiency.
Occlusion Training
Just moments before the NBA Finals kick off, I’d like to share this with everybody reading. It’s pretty eye-opening and a groundbreaking phenomenon. I saw it used hours before games to get the full hormonal influence ideally in the latter half of games. I question whether the Spurs or the Heat have been exposed to it and if they’ve implemented it for the game today. Considering Lebron's athletic ability, perhaps he knew something well before we did. Well… It is pretty common medical as well as general knowledge that blood is responsible for the transport of oxygen, nutrients, and many other molecules crucial for sustained life. Most bodybuilders will also tell you that blood is important for gaining muscle, blood flow to be more specific. Not surprisingly, an entire category of supplements has emerged in the past decade (for good or bad – I’m yet to conclude), focused on increasing blood flow and thus purporting to enhance anabolism. But what if I told you that the opposite may be true? What would you say if I told you that occluding blood flow to muscles can have an anabolic effect? You would probably tell me I’m not getting enough blood flow to my brain but you would be wrong. Most recently, I was exposed to this form of training, whilst over in the USA and it intrigued me enough to start to research further into its origins and possible uses. I’ve seen it first hand have incredible results in a sports medicine setting, returning athletes in ridiculously fast times and have set about to further my understanding to this phenomenon.
Blood Flow Restriction (BFR) or sometimes referred to as Occlusion training has years of research to support its effectiveness and in this article I will explain what it is and how to use it to augment your training.
Quite simply, BFR training involves restricting the venous return of blood flow from the muscle. The goal is not to restrict blood flow to the muscle, but instead prevent blood flow return from the muscle, i.e. you do NOT want to restrict the arterial blood flow to the muscle, only the venous return from the muscle, causing the blood to pool in the muscle. The purpose of this technique is to increase the accumulation of local metabolic byproducts. These compounds include lactate, IL-6, IL-15, and other “muscle molecules”. They are not simply waste material, but are now understood to be potent stimulators of muscle growth and fat loss through intracellular and hormonal mechanism. This is accomplished by use of some form of constriction around the limbs from theraband to compression sleeves and some literature also describes blood pressure cuffs.
This form of occlusion when performed properly, allows you to use much lower weights than normal training protocols and still achieve sizable anabolic training responses. In fact, studies have shown that occlusion training can increase muscle size and strength using training loads as light as 20% of a 1 rep max. This is especially useful for individuals who are injured and can only use very light weights or for trainers who are undergoing a de-load phase in their training cycle – highly recommended in any sport. Blood Flow Restriction training allows you to still make gains using light weights while giving your joints, ligaments, and tendons a break from heavy lifting. In a high impact and high load sport like basketball – I will discuss tendons and loading in a future article, I see it as ground breaking that we can utilise such a technique. Following NBA games is the only suitable time to lift weights with their heavy schedule. Due to the high frequency of games and very few nights off, it was often the only practical time to lift, as we are all aware of the following day soreness heavy lifting sessions has, and don’t want to risk this impact on performance as well as risk it may place to injury.
Suitably, BFR training induces an anabolic response through various pathways perhaps the most important of which is by preferentially targeting the large fast twitch muscle fibers. Fast twitch fibers are the biggest muscle fibers and have the most potential for growth. These fibers are recruited last during contractions and are mostly anaerobic (don’t use oxygen) whereas the smaller slow twitch fibers are recruited first during contractions and are aerobic (use oxygen). Slow twitch fibers have a much smaller potential for growth compared to fast twitch fibers. By restricting blood flow to muscles, pre-fatiguing the slow twitch fibers and forcing the anaerobic fast twitch fibers to handle the load even at low intensities your muscle is getting a similar effect to lifting heavy loads but using much lighter weights. Not only does occlusion training preferentially activate fast twitch muscle fibers, it has been shown to cause a fiber type shift from slow to fast, thus increasing the potential for muscular growth and size which should inevitably increase power output.
Metabolic by-product accumulation is the primary mechanism by which occlusion training produces hypertrophy and other questionable sports medicine benefits. These metabolic by-products would normally be ‘washed out’ by normal blood flow, but occlusion allows them to accumulate near the muscle. Lactate accumulation in particular seems to have an effect, presumably by increasing growth hormone concentrations. In fact, one study found that BFR training caused a growth hormone increase 290 times above baseline! This is a twofold greater increase in growth hormone than what is produced by normal heavy resistance training. It is here where there is no further research into sports medicine or rehabilitation, but where we can logically conclude that additional growth hormone would result in faster recovery and remodeling of damaged tissue.
If those reasons weren’t convincing enough to try occlusion training, consider that it has also been shown to increase muscle protein synthesis, mTOR signaling, and the expression of NOS-1 that has been shown to increase muscle growth through increased satellite cell activation. Perhaps even more impressive, forms of this training has been demonstrated to reduce myostatin concentrations. For those of you who aren’t familiar with these cellular names, myostatin is considered to be a big time inhibitor of muscle growth and is thought to limit the muscle potential of muscle gain. Perhaps occlusion training may be able to increase the overall potential of muscle gain through slow to fast fiber shifts and reductions in myostatin.
It is important to realize this form of training isn’t a replacement for heavy gym sessions, it is a supplement to all your hard work. It is also very useful for people who can’t train heavy due to injury or de-loading and where I have included it into my rehabilitation and prehabilitation of athletes. However, occlusion provides several long-term benefits that regular heavy training doesn’t, including slow to fast fiber transitions and a greater hormonal response. It would be nice to think these hormonal responses are building sturdier, more resilient tissue in these athletes, making them less prone to injury because of stronger structures. Unfortunately there is no research that has explored such avenues of use but what’s not gained is lost when we are always looking for that competitive edge.
Before proceeding further, and occluding all blood supply to every part of your body, all day every day, please keep in mind that this form of training is very difficult even though the loads are very light, and it has not been researched extensively to be fully aware of medical risks. It is easily the most painful form of training I have ever performed. As always, before starting any kind of new training protocol, you should talk with a medical professional but remember it’s an area poorly understood by most general practitioners. Blood Flow Restriction can be performed for the thighs, calves, upper arms, and forearms using a blood pressure cuff, theraband or tightly wrapped knee wraps (more practical). To occlude the thighs and upper arms, wrap at approximately 70% of maximum tightness around the uppermost part of the muscles. To occlude the calves or forearms wrap at approximately 70% of maximum tightness just below the knee or elbow.
Perform 3-5 sets to muscular failure with 20-50% of your 1 rep max on a given exercise with the muscle occluded the entire time. Rest periods should be 30-60 seconds between sets. After the final set remove the wraps and restore blood flow to the muscle. It is important to never exceed 15-20mins of any form of occlusion.
A word of advice, be prepared for a lot of pain and if you do not find yourself in excruciating pain, the odds are the wraps are not tight enough. Try blood flow restriction training and take your training to another hypertrophic dimension!
Knee To Wall
When we think of load going through the body it’s pretty simple to understand that the body does a good job absorbing ground reaction force by spreading it through different joints of the body. Effectively, each joint of the body has the capacity to absorb some form of shock and dissipate it. Unfortunately in sport, or basketball more specifically, following insufficient rehabilitation, we start to load our body in abnormal biomechanical patterns. I say basketball more specifically, because in our sport, we have a high incident of ankle injuries. Here, we often take a few days off, can walk again and return to running with pain as our guiding factor. When this doesn’t fit into our self-proclaimed medical rehabilitation time frame, we may seek further medical assistance in returning us to sport. Even here, unfortunately I’ve seen ankles exceptionally poorly rehabilitated, and recurrent ankle sprains are high. It’s a pet hate, hearing “ahh I just have weak ankles” and patients accepting defeat that there is minimal they can do.
Strengthening and rehabilitating an ankle is one of the more simplistic things, but is so commonly neglected. I never ban my athletes from returning to sport when pain free, but I do make a conscious effort to never allow another rolled ankle to occur by equipping them with the tools to wean out of bracing or taping, into basic basketball shoes. Yes, I’ll educate them on shoes, and that’s been discussed previously. Yes, I’ll educate them on hip strength, and that will be discussed in future. But more importantly, it’s important to return to adequate ankle range of motion. There is plenty of literature to support this, and my simple explanation lies in the body’s ability to shock absorb.
The figure lies at 12-14cm. This is an iPhone length. Place the phone there and start stretching, until your heel remains on the ground and you have sufficient range, so that your knee hits the wall comfortably. Only once this range has been restored will you be loading your body in a more appropriate manner.
Good Luck!
Our final day with the Warriors. RIP Season 2013-14..
Happy Feet?
We've seen big changes in footwear over the decades and basketball shoes have been no exception. We've seen chucks, Jordan's of all varieties, to low cut Kobe’s, and more recently differing shoes in the KD’s and Lebron’s. Nike and other brands are constantly evolving to produce different shoes. I was a sucker over the years trying to chase the latest and greatest and went through multiple pairs of shoes. But which ones are right for you??
Many questions surrounded Adidas in the 'season of ACLs' where the bulk of players who required knee reconstructions had been under Adidas contract and wearing their shoes (Rose, Rondo, Gallinari to name a few).
The more common question raised is which shoe will give me the most support?
High top vs low top actually hasn't produced substantial evidence to support either way. We do know taping and braces help but the cut of the shoes is thoughts to contribute very little. What evidence has found is that more expensive footwear has placed athletes at higher risk of injury. This study was conducted in the days of Nike Shox and Air Max bubbles. Analysing this data and we can conclude that these added features impact our ability to respond to landing. With a firm shoe surface the body may respond at a faster rate, to counter any ankle inversion (the position of rolling) initiation.
If you've sprained your ankle or feel weak through your ankles – you may wish to stay tuned as I talk about ankle strengthening exercises – it is best you avoid an elevated heel or any addition into the heel. The air cushioning or ‘Shox’ systems delay the proprioceptive response of the ankle as discussed and place you at further risk of re-doing your injury. There was a trend away from using this technology when the studies were published, but we see the air cushioning returning in the latest KDs…
As also stated, it is best to ensure that the ‘pitch’ of the shoe is relatively neutral. This means that the heel sits as similar level to that of the toes. This avoids the plantarflexed (toes pointed) position in which the ankle is often injured in, as the small ligament at the front of the ankle is on stretch here and deemed one of the weaker ligaments in the body. It must be understood that these flatter style shoes are appropriate for recurrent ankle-sprainers and cant be suited to everybody. The real trade off then lies with those who have suffered patella tendon problems or shin splints as these conditions generally prefer a more elevated heel ‘pitch’. A shoe must always suit the individual but at least this puts you on the right path in your selection. It’s also important to look good as when you start draining buckets, start crossing up ankles, or explode down the lane to throw it down, your feet are what are left dangling at head height for your opponent to look at. KG still has nightmares over these Lebron’s. https://www.youtube.com/watch?v=Tag9UmmFfY8